Transdiagnostic Processes On Anxiety And Depression In Autistic Youth: The Role Of Emotion Dysregulation

Emotion dysregulation (ED) in autistic individuals involves intense emotional reactions, difficulty modulating responses, and challenges communicating feelings. This can exacerbate anxiety and depression symptoms.

Signs include meltdowns, transition difficulties, intense anxiety or frustration, trouble recognizing emotions, rigid thinking, sensory-related outbursts, and poor self-soothing.

Heightened reactivity may increase anxiety in social or uncertain situations, while persistent negative affect can contribute to depression.

These difficulties significantly impact daily functioning and mental health, underlining the importance of understanding ED’s role in autism and its relationship to anxiety and depression.

Barnes, G. L., Ozsivadjian, A., Baird, G., Absoud, M., & Hollocks, M. J. (2024). Investigating the effects of transdiagnostic processes on anxiety and depression symptoms in autistic young people: The mediating role of emotion dysregulation. Journal of Autism and Developmental Disorders. Advance online publication. https://doi.org/10.1007/s10803-024-06246-0

Key Points

• Emotion dysregulation (ED) mediates the relationship between some transdiagnostic processes (cognitive inflexibility, intolerance of uncertainty, alexithymia) and anxiety/depression symptoms differently in autistic and non-autistic youth.
• Intolerance of uncertainty (IU) directly predicted anxiety and depression symptoms in autistic youth, while cognitive inflexibility (CI) and alexithymia did not.
• ED mediated the relationship between CI/alexithymia and depression symptoms only in non-autistic youth.
• The study highlights the importance of investigating ED as a potential mediator between transdiagnostic processes and internalizing symptoms in autistic populations.
• Findings suggest the need for targeted interventions addressing specific transdiagnostic processes and ED in autistic youth with co-occurring mental health difficulties.

Rationale

Autism is associated with elevated rates of internalizing difficulties, particularly anxiety and depression, compared to the general population (Lau et al., 2020; Bougeard et al., 2021).

Recent research has highlighted the role of emotion dysregulation (ED) in pathways to anxiety and depression in autism (Connor et al., 2021).

Additionally, transdiagnostic processes such as intolerance of uncertainty (IU), cognitive inflexibility (CI), and alexithymia have been linked to internalizing symptoms in autistic populations (Jenkinson et al., 2020; Hollocks et al., 2019; Milosavljevic et al., 2016).

However, the interactions between these transdiagnostic processes, ED, and internalizing symptoms in autism remain unclear.

Furthermore, it is uncertain whether these relationships are unique to autism or present in non-autistic populations as well. Understanding these relationships is crucial for developing effective interventions for autistic individuals with co-occurring mental health difficulties.

This study aimed to investigate the associations between key transdiagnostic processes (IU, CI, alexithymia) and anxiety/depression symptoms in autistic youth, explore ED as a potential mediator of these relationships, and compare the effects with a non-autistic comparison group.

Method

Procedure

The study used a cross-sectional design. Participants were young people referred to a UK specialist neurodevelopmental service for a comprehensive autism assessment. Parents/carers completed questionnaires as part of routine clinical evaluation.

Sample

175 young people aged 5-18 years (M=10.6 years, SD=3.1) were included. 94 children (54%) received an autism diagnosis, while 81 (46%) did not and served as the control group.

Measures

• Development and Well-Being Assessment (DAWBA): Assesses autism symptoms and provides probability bands for autism diagnosis.
• Revised Child Anxiety and Depression Scale (RCADS): Measures anxiety and depression symptoms in children and adolescents.
• Children’s Alexithymia Measure (CAM): Evaluates difficulty identifying and describing emotions in young people.
• Intolerance of Uncertainty Scale (IUS): Assesses the tendency to respond negatively to uncertain situations or events.
• Flexibility Scale-Revised (FS-R): Measures cognitive flexibility and rigidity in day-to-day functioning.
• Emotion Dysregulation Inventory (EDI): Evaluates difficulties in regulating emotions, including reactivity and dysphoria.

Each measure was completed by parents/carers and provided quantitative scores for the respective constructs, allowing for statistical analysis of the relationships between these variables.

Statistical measures

Structural equation modeling (SEM) was used to investigate process-symptom links and test ED as a potential mediator. Linear regressions were employed to test associations between IU/CI/Alexithymia and ED.

Separate models were run for each cognitive process to test associations with depression and anxiety, controlling for age, sex, and autism symptoms.

Results

1. CI and ED:
   • Significant effect of CI on ED in both groups
   • No direct effect of CI on depression in either group
   • Indirect effect of CI on depression via ED only in non-autistic group
   • Direct effect of CI on anxiety only in non-autistic group
   • No indirect effect of CI on anxiety via ED in either group
2. IU and ED:
   • Direct effect of IU on ED in both groups
   • Direct effect of IU on depression only in autistic group
   • Indirect effect of IU on depression via ED only in non-autistic group
   • Direct effect of IU on anxiety in both groups
   • No indirect effect of IU on anxiety via ED in either group
3. Alexithymia and ED:
   • Direct effect of alexithymia on ED in both groups
   • No direct effect of alexithymia on depression or anxiety in either group
   • Indirect effect of alexithymia on anxiety via ED only in autistic group
   • Indirect effect of alexithymia on depression via ED only in non-autistic group

Insight

This study provides novel insights into the interplay between transdiagnostic processes, ED, and internalizing symptoms in autistic and non-autistic youth.

The finding of a direct pathway from IU to anxiety and depression in autistic youth is consistent with previous literature (Cai et al., 2018; Hollocks et al., 2014).

However, the lack of association between CI and anxiety/depression in autistic youth is a novel finding, as is the mediating role of ED in the relationship between alexithymia and anxiety/depression symptoms in both samples.

The study extends previous research by comparing these relationships between autistic and non-autistic youth, revealing different patterns of associations.

For instance, ED mediated the relationship between CI/alexithymia and depression only in non-autistic youth, suggesting that the pathways to internalizing symptoms may differ between these populations.

These findings highlight the importance of considering ED and specific transdiagnostic processes when developing interventions for autistic youth with co-occurring mental health difficulties.

Future research could explore more specific cognitive, emotional, and behavioral processes that may mediate the relationship between IU and depression in autistic youth, as ED did not explain this relationship in the current study.

Strengths

This study had several methodological strengths, including:

1. Use of a comparison group with comparable levels of social communication difficulties, allowing for more confident inferences about diagnosis-related differences.
2. Utilization of a measure of ED (EDI) specifically developed and validated for use in autistic populations.
3. Investigation of multiple transdiagnostic processes and their relationships with both anxiety and depression symptoms.
4. Use of sophisticated statistical methods (SEM) to examine complex relationships between variables.

Limitations

This study also had several methodological limitations, including:

1. Cross-sectional design limits conclusions about the direction of relationships between variables.
2. Clinically selected sample may not be generalizable to the general population or the full autism spectrum.
3. Reliance on parent-reported measures for all variables, which may introduce common-method variance and limit insight into young people’s internal experiences.
4. Lack of access to item-level data for some measures, preventing calculation of internal reliability for the study sample.

Implications

The findings have important implications for clinical practice and intervention development:

1. IU emerged as a strong predictor of anxiety and depression in autistic youth, suggesting it may be a primary target for intervention.
2. The differential patterns of associations between transdiagnostic processes, ED, and internalizing symptoms in autistic and non-autistic youth highlight the need for tailored interventions for each population.
3. The mediating role of ED in some relationships suggests that addressing emotion regulation skills may be beneficial in reducing internalizing symptoms, particularly in non-autistic youth.
4. The lack of association between CI and anxiety/depression in autistic youth challenges previous assumptions and may inform the focus of interventions for this population.

These results underscore the importance of considering multiple factors and their interactions when assessing and treating internalizing symptoms in autistic youth.

Clinicians should be aware of the potential differences in pathways to anxiety and depression between autistic and non-autistic individuals and tailor their approaches accordingly.

References

Primary reference

Barnes, G. L., Ozsivadjian, A., Baird, G., Absoud, M., & Hollocks, M. J. (2024). Investigating the effects of transdiagnostic processes on anxiety and depression symptoms in autistic young people: The mediating role of emotion dysregulation. Journal of Autism and Developmental Disorders. Advance online publication. https://doi.org/10.1007/s10803-024-06246-0

Other references

Bougeard, C., Picarel-Blanchot, F., Schmid, R., Campbell, R., & Buitelaar, J. (2021). Prevalence of autism spectrum disorder and co-morbidities in children and adolescents: A systematic literature review. Frontiers in Psychiatry, 12, 744709. https://doi.org/10.3389/fpsyt.2021.744709

Cai, R. Y., Richdale, A. L., Dissanayake, C., & Uljarević, M. (2018). Brief report: Inter-relationship between emotion regulation, intolerance of uncertainty, anxiety, and depression in youth with autism spectrum disorder. Journal of autism and developmental disorders, 48, 316-325. https://doi.org/10.1007/s10803-017-3318-7

Conner, C. M., Golt, J., Shaffer, R., Righi, G., Siegel, M., & Mazefsky, C. A. (2021). Emotion dysregulation is substantially elevated in autism compared to the general population: Impact on psychiatric services. Autism Research, 14(1), 169-181. https://doi.org/10.1002/aur.2450

Hollocks, M. J., Jones, C. R., Pickles, A., Baird, G., Happé, F., Charman, T., & Simonoff, E. (2014). The association between social cognition and executive functioning and symptoms of anxiety and depression in adolescents with autism spectrum disorders. Autism Research, 7(2), 216-228. https://doi.org/10.1002/aur.1361

Hollocks, M. J., Lerh, J. W., Magiati, I., Meiser-Stedman, R., & Brugha, T. S. (2019). Anxiety and depression in adults with autism spectrum disorder: a systematic review and meta-analysis. Psychological medicine, 49(4), 559-572.

Jenkinson, R., Milne, E., & Thompson, A. (2020). The relationship between intolerance of uncertainty and anxiety in autism: A systematic literature review and meta-analysis. Autism, 24(8), 1933-1944. https://doi.org/10.1177/1362361320932437

Lau, B. Y., Leong, R., Uljarevic, M., Lerh, J. W., Rodgers, J., Hollocks, M. J., … & Magiati, I. (2020). Anxiety in young people with autism spectrum disorder: Common and autism-related anxiety experiences and their associations with individual characteristics. Autism, 24(5), 1111-1126. https://doi.org/10.1177/1362361319886246

Milosavljevic, B., Carter Leno, V., Simonoff, E., Baird, G., Pickles, A., Jones, C. R., … & Happé, F. (2016). Alexithymia in adolescents with autism spectrum disorder: Its relationship to internalising difficulties, sensory modulation and social cognition. Journal of autism and developmental disorders, 46, 1354-1367. https://doi.org/10.1007/s10803-015-2670-8

Keep Learning

Socratic questions for a college class to discuss this paper

1. How might the relationship between transdiagnostic processes, ED, and internalizing symptoms differ in adults with autism compared to the youth population studied here?
2. What additional measures or methods could be employed to gain a more comprehensive understanding of the internal experiences of anxiety and depression in autistic individuals?
3. How might cultural factors influence the relationships between transdiagnostic processes, ED, and internalizing symptoms in autistic and non-autistic populations?
4. Given the direct relationship between IU and anxiety/depression in autistic youth, what specific intervention strategies might be most effective in addressing IU?
5. How might the findings of this study inform the development of transdiagnostic interventions for autistic youth with co-occurring mental health difficulties?
6. What neurobiological mechanisms might underlie the differences in associations between transdiagnostic processes, ED, and internalizing symptoms in autistic and non-autistic youth?
7. How might the inclusion of self-report measures, in addition to parent-report measures, have impacted the study’s findings?
8. In what ways could longitudinal research designs extend our understanding of the causal relationships between transdiagnostic processes, ED, and internalizing symptoms in autism?