Improving Care for Autistic Youth in Correctional Settings.

Safety Planning for Suicidality in Autism: Obstacles, Potential Solutions, and Future Directions.

Why is this topic important?: Alcohol is the most commonly used substance among adolescents, and marijuana is the most commonly used illicit drug. Previous studies suggest that at least some autistic individuals may be at increased risk of substance use disorder compared with allistic counterparts, potentially to control social anxiety or facilitate social interaction. However, to the best of our knowledge, estimates of substance use by autistic youth in the United States are limited.What is the purpose of this article?: This study was performed to highlight the lack of data sets that collect information about alcohol and/or marijuana use by autistic youth in the United States. We systematically reviewed U.S. data sources on child and/or adolescent health, disability, and/or substance use to identify sources that could generate estimates of the prevalence of substance use among autistic adolescents in the United States, even if those estimates may not be stable due to small sample sizes or other methodological weaknesses.What is the perspective of the authors?: The authors are a team of allistic researchers. M.B.-M. and S.B.-F. are pediatricians. E.F.R. and A.A. are public health researchers. S.B.-F. has an extensive background in providing clinical health care services to children with autism and is an autism researcher. R.A.N.P. and A.C.S.-R. are master's level public health research assistants. E.F.R., A.A., and M.B.-M. are adolescent health research experts. E.F.R. has an adolescent daughter on the autism spectrum. Our collective positionality is that we identify as people who are not autistic and who select to focus on research that we hope will benefit autistic people and society in general.What did the authors find?: Based on our four-step investigation, we identified 19 U.S. data sources that had the potential to generate estimates of the prevalence of alcohol and/or marijuana use in autistic youth. Only one included information about both autism and substance use.What do the authors recommend?: The National Institutes of Health (NIH), and the National Institute of Alcohol Abuse and Alcoholism (NIAAA) and National Institute of Drug Abuse (NIDA), specifically, should prioritize funding data collection from autistic youth and adults on alcohol and marijuana use, misuse, hazardous use, dependence, and use disorders. In addition, it is critical that nationally representative surveys and data sources include robust questions on autism and substance abuse. This includes assessing autism status in multiple ways (e.g., self-report, diagnosis by a clinician, neuropsychology reports). Substance use questions should include age of first drink or use, frequency of use, quantity of use per day or within a certain number of hours, expectancies, consequences of use, and indicators of alcohol use disorder.How will these recommendations help autistic individuals?: These findings highlight a critical gap in the literature on substance use among autistic youth. Substance use is recognized as a pressing adolescent health problem, and autistic youth deserve evidence-based substance use prevention strategies. Without an estimate of substance use by autistic youth, it is difficult to justify to funding entities the expenditure of resources on the development of evidence-based substance use prevention strategies to benefit them.

Autistic youth experience higher rates of peer victimization than their non-autistic peers. While there is some evidence that friendships may protect against the negative mental health effects of peer victimization in the general population, these protective effects have not been examined in autistic youth. The current study explored whether satisfaction with friendship support is associated with depressive symptoms among autistic youth, and whether satisfaction with friendship support buffers against the negative effects of peer victimization on mental health. Autistic youth (N = 224) between the ages of 15 and 25 years (M = 18.68 years) completed questionnaires measuring frequency of peer victimization, satisfaction with friendship support, and depressive symptoms. Satisfaction with friendship support was not associated with depressive symptoms; however, the effect of peer victimization on depressive symptoms was attenuated for youth who were more satisfied with their friendship support compared to youth who were less satisfied with their friendship support. The results of the current study therefore highlight the potential for promoting mental health of autistic youth through reducing peer victimization and increasing satisfaction with peer relationships.Lay Autistic youth are more likely to be bullied than youth who are not on the autism spectrum. Youth in the general population who are bullied experience poor mental health, but those who are satisfied with their friendships may be protected from these negative outcomes. No studies have looked at how friendships affect the mental health of autistic youth who are bullied by their peers. Autistic youth completed questionnaires that asked them to report how frequently they were bullied, whether they were satisfied with the support they received from friends, and depressive symptoms they experienced. Depressive symptoms did not differ between youth who were more satisfied and youth who were less satisfied with their friendship support. However, among youth who were frequently bullied, depressive symptoms were lower for those who were more satisfied with their friendship support compared to those who were less satisfied with their friendship support. This study shows that interventions are needed to support the mental health of autistic youth by decreasing bullying by peers and increasing positive peer relationships.

Compared to their nonautistic peers, lower levels of life satisfaction have been reported by autistic individuals. It is unclear, however, whether autistic individuals with intellectual disability report similar levels of life satisfaction as autistic individuals without intellectual disability or which characteristics are associated with life satisfaction. This study sought to examine differences in levels of self-reported life satisfaction across those with and without intellectual disability and explore correlates of life satisfaction in a sample of 35 autistic youth with intellectual disability and 99 autistic youth without intellectual disability. No difference in self-reported life satisfaction was detected between autistic youth with and without intellectual disability. Greater self-reported life satisfaction was associated with higher self-determination for autistic youth without intellectual disability. For autistic youth with intellectual disability, greater self-reported life satisfaction was related to more frequent social participation, lower parent stress, and fewer unmet service needs. Unmet service needs and parent stress were significantly stronger correlates of life satisfaction for youth with intellectual disability compared to youth without intellectual disability. Although the sample size of autistic youth with intellectual disability was small, these findings suggest the importance of considering heterogeneity among individuals on the autism spectrum when seeking to understand their well-being.Lay abstractAutistic people report lower life satisfaction compared to people without autism. It is unclear whether autistic people with intellectual disability report similar levels of life satisfaction to autistic people without intellectual disability. In this study, we did not find a difference in levels of life satisfaction for autistic youth with intellectual disability compared to autistic youth without intellectual disability. We also identified factors that might promote better life satisfaction. Higher self-determination was related to higher life satisfaction for autistic youth without intellectual disability. For autistic youth with intellectual disability, more frequent social participation, lower parent stress, and fewer unmet service needs were associated with higher life satisfaction. Unmet service needs and parent stress were more strongly related to life satisfaction for youth with intellectual disability compared to youth without intellectual disability. Our findings suggest that taking a more individualized approach to support the well-being of autistic youth is important.

Purpose Transition to adulthood is a complex process that involves important life domains such as education, work, independent living, community, health, and social relationships. Autistic youth face the transition with greater challenges than their peers, and there continues to have significant gaps in the services as they approach young adulthood. The study was conducted to understand the complex interplay between supports and barriers to participation in the transition process. Method Data was collected through six focus groups with 24 participants (7 parents, 11 practitioners, 6 autistic youth), digitally audio-recorded, transcribed, and analyzed using thematic analysis. Results Four themes were reported: Inadequacy of Services, Ambivalence about Formal Services and Support, Understanding Good Partnership, and Evolving Parental Involvement. While parents and practitioners see the fragmented services and lack of comprehensive support as the most prominent challenge, autistic youth feel ambivalent about the type of services they need. Practitioners address the importance of establishing an appropriate level of engagement with parents in the transition process. Autistic youth expect their parents to set a boundary that affirms their independence. Conclusions Our study highlights the need to elicit input across different stakeholders to make transition services centralized, easily accessible, and individualized. Implications for Rehabilitation It is important to have a systematic road map, early preparation of families and autistic youth about the array of adult transition services, and a centralized hub of information to be disseminated. Disability service agencies should develop and implement plans for enhancing outreach and services to transition youth on the autism spectrum and their families. Practitioners need to identify locally available resources and channels for outreach and make available service more visible by producing transition-related materials with examples of current legislative information, problem solving, and best practices. Practitioners should consider how autistic youth identify their needs and wants may be different than how service providers and parents conceptualize them. It is critical to capitalize appropriate levels of caregivers/family support and engagement by provision of education about policies and guidelines for communication and collaboration.

Research consistently show that autistic youth are less physically active compared to their neurotypical peers. However, there is limited understanding of how gender influences physical activity (PA) patterns among neurodiverse youth compared to the general population. This study aims to examine 24-hour movement behaviors - PA, sedentary behavior (SB), and sleep duration - among autistic youth (n = 71) in Norway, in comparison to peers with Attention-Deficit/Hyperactivity Disorder (ADHD) (n = 411) and the general youth population (n = 3805). The data is from the Young-HUNT4 study, linked with diagnostic information from the Norwegian Patient Registry. Variables explored are objective accelerometer-measured PA, SB, and sleep duration, self-reported participation in organized and unorganized physical activities, and screen activities. Results confirms that autistic youth engage in lower levels of moderate-to-vigorous PA, while demonstrating similar levels of light PA. They also spend more time sitting and comparable time sleeping. Autistic youth participate less in sport and were less likely to use commercial gyms. However, their participation in outdoor activities were similar to their peers. Regarding screen activities, autistic youth spent more time playing video games, while youth with ADHD were more engaged in social media. Among autistic youth, the only gender difference found was in video games. In conclusion, autistic youth are less physically active overall and spend significant time in SB. However, their comparable participation in light PA suggests opportunities for promoting further participation. Additionally, exergaming could offer a promising avenue to increase PA in this population.

PurposeAutistic youth face higher risks for experiencing mental health crises. To develop and test a county-level social network measure of care coordination between police departments and other systems that support autistic youth experiencing suicidal crisis.Design/methodology/approachTo measure the structure of care coordination for autistic youth experiencing suicidal crisis, the authors created a roster of all police departments and youth servicing organizations in two East Coast counties in the United States. They met or exceeded the whole network recruitment threshold of 70% completion in both counties. From the data, the authors created a directed matrix for each county of all reported connections, which they used to create sociograms and calculate standard network measures, including indegree, outdegree and total degree for each organization in the network. Data management and processing were done using R-programming and ORA.FindingsSocial network findings indicated that about half of all police departments surveyed coordinate care for autistic youth in suicidal crisis. Coordination varied by county, with nonpolice organizations acting as connectors between police and other nonpolice organizations. Two structural configurations were found, including a nonpolice organizational hub structure and a lead police structure. More research is needed to determine how different police integration structures shape care coordination for autistic youth.Research limitations/implicationsLimitations include the small number of counties included in the study. A larger sample of counties is required for generalizable results.Practical implicationsThis article introduces new tools and approaches to assist police in building their capacity to measure and improve their coordination of care with other community systems during crisis situations for youth on the autism spectrum. Network science (e.g. matrix and graph theoretic algebra methods) can be used to measure the configuration of relationships police departments have with complex multi-level healthcare systems.Social implicationsImplications for findings include the consideration of police integration across systems in ways that produce new collaboration possibilities to support autistic youth experiencing suicidal crisis.Originality/valueWhile police departments play a critical role in coordinating care for youth in suicidal crisis, little is known if or how police departments collaborate with other systems to provide assistance for autistic youth during a suicidal crisis. Improving care continuity within and between systems could potentially address clinical and structural challenges and reduce risk for autistic youth experiencing a suicidal crisis.

Autistic children and adolescents experience high rates of co-occurring mental health conditions, including depression and suicidality, which are frequently identified by stakeholders as treatment priorities. Unfortunately, accessing community-based mental health care is often difficult for autistic youth and their families. The first obstacle families confront is finding a provider that offers mental health treatment to autistic youth within the many service systems involved in supporting the autism community. The mental health and developmental disability systems are two of the most commonly accessed, and previous work has shown there is often confusion over which of these systems is responsible for providing mental health care to autistic individuals. In this study, we conducted a telephone survey to determine the availability of outpatient mental health services for autistic youth with depressive symptoms or suicidal thoughts or behaviors in New York City across the state's mental health and developmental disability systems. Results showed that while a greater percentage of clinics in the mental health system compared with in the developmental disability system offered outpatient mental health services to autistic youth (47.1% vs 25.0%), many more did not offer care to autistic youth and there were very few options overall. Therefore, it is important that changes to policy are made to increase the availability of services and that mental health care providers' knowledge and confidence in working with autistic youth are improved.

The implementation of evidence-based practices (EBPs) for autistic youth is a critical concern worldwide. Research examining factors facilitating the implementation of EBPs found that providers’ attitudes are an important factor. In this study, we evaluated cross-cultural differences in attitudes toward and use of EBPs. We tested socio-demographic factors as predictors of attitudes, and attitudes as predictors of EBPs use among mental health professionals working with autistic youth in Bangladesh and Germany. We used purposeful sampling. Two-hundred-ninety-two professionals who worked in a clinical setting responded to the survey and fulfilled the inclusion criteria (101 in Bangladesh, 191 in Germany). Participants were asked to respond to nine subscales of the Evidence-Based Practice Attitude Scale-36 (EBPAS-36), to indicate which of nine types of treatments they used, and to provide sociodemographic data. Measurement invariance across countries could be established for four subscales of the EBPAS-36. Comparative analyses of attitudes showed that professionals in both countries were open to using EBPs, but German practitioners were more likely to use EBPs when they appealed to them. By contrast, Bangladeshi professionals claimed to be more likely to adopt an EBP when required and to be more willing to learn EBPs to enhance job security. The relationship between caseload and attitudes varied between countries. A broader variety of EBPs was used in Germany. The findings highlight the importance of considering country-specific factors when implementing EBPs. Directions for conducting comparative studies on mental health professionals’ attitudes towards EBP including methodological considerations are discussed.

It has been suggested that the sequelae of trauma are under-recognized in youth on the autism spectrum. We aimed to generate expert consensus regarding important trauma indicators, including but not limited to traumatic stress symptoms, in autistic youth. We recruited 72 experts in autism and/or childhood trauma. Via a 2-round Delphi survey, experts commented on and rated the importance of 48 potential indicators, drawn from PTSD criteria and a broader literature on traumatic sequelae in autism. A revised list of 51 indicators, 18 clinical guidelines developed from expert comments, and summaries of expert qualifications and ratings from Round 1 were submitted to a second round (n = 66; 92% retention) of expert review and rating. Twenty-two indicators reached consensus (>75% round 2 endorsement). Many, but not all, reflected PTSD criteria, including intrusions (e.g., trauma re-enactments in perseverative play/speech), avoidance of trauma-reminders, and negative alterations in mood/cognition (e.g., diminished interest in activities) and in arousal/reactivity (e.g., exaggerated startle). Experts also identified increased reliance on others, adaptive and language regressions, self-injurious behavior, and non-suicidal self-injury as important indicators. Consensus guidelines emphasized the need for tailored measures, developmentally informed criteria, and multiple informants to increase diagnostic accuracy. Expert consensus emphasizes and informs a need for tailored diagnostic guidelines and measures to more sensitively assess traumatic reactions in autistic youth.

Autistic youth visit the emergency department (ED) for psychiatric concerns, including suicidal ideation and behavior, at elevated rates. However, clinicians often report low levels of training and confidence in addressing suicide risk in autistic youth. In this pilot study, clinicians in a pediatric psychiatric emergency service were trained on community- and evidence-informed recommendations to improve suicide-related care for autistic youth and provided with resources to use with autistic youth for a 3-month period. Ratings on attitudes and confidence were obtained from ten providers before and after the training/implementation period and compared. Ratings of feasibility and utility of strategies and resources were obtained from 15 providers after training/implementation and analyzed. While no changes were found across attitudes items, confidence scores were significantly higher after the training/implementation period than before, particularly in the area of suicide risk assessment. Feasibility and utility ratings were generally high, with endorsement patterns aligning with common organizational and systems-level barriers. This pilot study demonstrated that targeted training and evidence-informed recommendations to improve suicide-related care for autistic youth were associated with increased clinician confidence. As research continues in the development of adapted suicide risk assessment tools and management strategies for autistic youth, it is important that both clinical guidance on best practices is provided and that systems-level barriers are addressed.

BackgroundAnxiety is common in youth on the autism spectrum and cognitive behavioural therapy (CBT) has been adapted to address associated symptoms. The aim of the current systematic review and meta-analysis was to examine the efficacy of CBT for reducing anxiety in autistic youth.MethodSearches of PubMed and Scopus databases were undertaken from January 1990 until December 2020. Studies were included if they consisted of randomised controlled trials (RCTs) using CBT to reduce anxiety in autistic youth. Separate random effects meta-analyses assessed anxiety ratings according to informant (clinician; parent; child), both at end-of-trial and at follow-up.ResultsA total of 19 RCTs met our inclusion criteria (833 participants: CBT N = 487; controls N = 346). Random effects meta-analyses revealed a large effect size for clinician rated symptoms (g = 0.88, 95% CI 0.55, 1.12, k = 11), while those for both parent (g = 0.40, 95% CI 0.24, 0.56; k = 18) and child-reported anxiety (g = 0.25, 95% CI 0.06, 0.43; k = 13) were smaller, but significant. These benefits were not however maintained at follow-up. Moderator analyses showed that CBT was more efficacious for younger children (for clinician and parent ratings) and when delivered as individual therapy (for clinician ratings). Using the Cochrane Risk of Bias 2 tool, we found concerns about reporting bias across most trials.ConclusionsThe efficacy of CBT for anxiety in autistic youth was supported in the immediate intervention period. However, substantial inconsistency emerged in the magnitude of benefit depending upon who was rating symptoms (clinician, parent or child). Follow-up analyses failed to reveal sustained benefits, though few studies have included this data. It will be important for future trials to address robustness of treatment gains overtime and to further explore inconsistency in efficacy by informant. We also recommend pre-registration of methods by trialists to address concerns with reporting bias.

Anxiety commonly occurs among youth on the autism spectrum, yet measurement of anxiety in this population is complicated by a number of factors, including potentially overlapping symptomatology, the child's intellectual functioning, and changes in anxiety across development. Moreover, few studies have examined the psychometric properties of anxiety measures in this population, and no study to date has tested whether there are systematic differences in the measurement of anxiety, or differential item functioning (DIF), across the high degree of heterogeneity and the developmental course of autism. To test this possibility, data were combined across multiple studies using the National Database for Autism Research, an NIH-funded data repository. Parent-report on the Screen for Child Anxiety Related Disorders (SCARED) and Social Communication Questionnaire (SCQ) were used as measures of anxiety and autism features, respectively. A confirmatory factor analysis indicated good fit of the literature standard five-factor structure. Moderated nonlinear factor analysis (MNLFA) revealed multiple items with intercept and loading DIF based on level of autism features, IQ, and age, especially for items related to social behavior. Therefore, although the measure's factor structure is consistent with that found in the general population, the SCARED may not capture differences in anxiety equivalently for all children on the spectrum and across their development. Clinicians and researchers need to be especially vigilant in measuring anxiety symptoms in children with autism by removing items flagged for DIF from the SCARED and/or by using multiple measures and informants. LAY ABSTRACT: Autistic youth often experience clinical levels of anxiety. Many tools used to measure anxiety were developed for the general population, but not for use with autistic youth. This study found that the Screen for Child Anxiety Related Disorders (SCARED) measures the same five dimensions of anxiety as in the general population. Parents, however, may respond differently to questions on the SCARED based on their child's autism features, intellectual functioning, and age, which impacts our ability to accurately measure anxiety among autistic youth.

There are many established evidence-based practices (EBPs) for autistic youth which facilitate wellbeing and skill development across a range of domains. However, individuals on the autism spectrum are consistently underserved in mental health settings, limiting their access to these EBPs. Positive provider attitudes toward EBPs may increase their uptake or use. The current mini-review seeks to synthesize the literature regarding attitudes toward EBPs among providers working with autistic youth across a variety of settings (i.e., school, early intervention, and general mental health). Fifteen quantitative studies were included. The majority of studies (n = 13, 87%) utilized the Evidence Based Practice Attitudes Scale (EBPAS) or a variation of this scale. Attitudes toward EBPs were primarily used as a correlate or covariate, although some studies reported descriptive statistics of provider attitudes. When available, the reported results suggest that attitudes toward EBPs are moderately positive at baseline, although they vary between provider types. Two studies (13%) examined change in attitudes toward EBPs and suggested that they may be responsive to intervention. However, findings were mixed as to whether attitudes toward EBPs are predictive of EBP use/uptake. Implications and future directions are discussed.

Autistic youth frequently experience anxiety that can negatively affect them at home, with friends, and at school. Autistic youth have difficulty accessing mental health care, and this is particularly true for youth from traditionally underserved backgrounds. Providing mental health programs in schools may increase access to care for autistic youth with anxiety. The purpose of the study was to train interdisciplinary school providers to deliver school-based Facing Your Fears, a cognitive behavior therapy program for anxiety in autistic youth. Seventy-seven interdisciplinary school providers across 25 elementary/middle schools were trained by their colleagues and members of the research (train-the-trainer approach). Eighty-one students with autism or suspected autism, ages 8-14 years, were randomly assigned to either school-based Facing Your Fears or usual care. Students in school-based Facing Your Fears showed significant reductions in anxiety compared to students in usual care according to caregiver and student report. Other measures involved examining change in provider cognitive behavior therapy knowledge after training and determining how well interdisciplinary school providers were able to deliver school-based Facing Your Fears. Results indicated that interdisciplinary school providers showed significant improvements in cognitive behavior therapy knowledge after training. Interdisciplinary school providers were able to deliver most of school-based Facing Your Fears activities and with good quality. The positive outcomes in this study are encouraging. Training interdisciplinary school providers to deliver school-based Facing Your Fears may increase access to care for anxious autistic students. Future directions and limitations are discussed.