Browsing by Author "Mazefsky, Carla A."
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Item Assessment and Treatment of Emotion Regulation Impairment in Autism Spectrum Disorder Across the Life Span Current State of the Science and Future Directions(WB Saunders, 2020) Beck, Kelly B.; Conner, Caitlin M.; Breitenfeldt, Kaitlyn E.; Northrup, Jessie B.; White, Susan W.; Mazefsky, Carla A.; University of Pittsburgh; University of Alabama TuscaloosaEmotion regulation (ER) is the ability to modify arousal and emotional reactivity to achieve goals and maintain adaptive behaviors. ER impairment in autism spectrum disorder (ASD) is thought to underlie many problem behaviors, co-occurring psychiatric symptoms, and social impairment, and yet is largely unaddressed both clinically and in research. There is a critical need to develop ER treatment and assessment options for individuals with ASD across the life span, given the multitude of downstream effects on functioning. This article summarizes the current state of science in ER assessment and treatment and identifies the most promising measurement options and treatments.Item Assessment and Treatment of Emotion Regulation Impairment in Autism Spectrum Disorder Across the Life Span: Current State of the Science and Future Directions(Elsevier, 2020) Beck, Kelly B.; Conner, Caitlin M.; Breitenfeldt, Kaitlyn E.; Northrup, Jessie B.; White, Susan W.; Mazefsky, Carla A.Emotion regulation (ER) is the ability to modify arousal and emotional reactivity to achieve goals and maintain adaptive behaviors. ER impairment in autism spectrum disorder (ASD) is thought to underlie many problem behaviors, co-occurring psychiatric symptoms, and social impairment, and yet is largely unaddressed both clinically and in research. There is a critical need to develop ER treatment and assessment options for individuals with ASD across the life span, given the multitude of downstream effects on functioning. This article summarizes the current state of science in ER assessment and treatment and identifies the most promising measurement options and treatments.Item Development of a College Transition and Support Program for Students with Autism Spectrum Disorder(Springer, 2017) White, Susan W.; Elias, Rebecca; Capriola-Hall, Nicole N.; Smith, Isaac C.; Conner, Caitlin M.; Asselin, Susan B.; Howlin, Patricia; Getzel, Elizabeth E.; Mazefsky, Carla A.Empirically based, consumer-informed programming to support students with Autism Spectrum Disorder (ASD) transitioning to college is needed. Informed by theory and research, the Stepped Transition in Education Program for Students with ASD (STEPS) was developed to address this need. The first level (Step 1) supports high school students and the second level (Step 2) is for post-secondary students with ASD. Herein, we review the extant research on transition supports for emerging adults with ASD and describe the development of STEPS, including its theoretical basis and how it was informed by consumer input. The impact of STEPS on promotion of successful transition into college and positive outcomes for students during higher education is currently being evaluated in a randomized controlled trial.Item Development of the Emotion Dysregulation Inventory: A PROMIS®ing Method for Creating Sensitive and Unbiased Questionnaires for Autism Spectrum Disorder(Springer, 2016) Mazefsky, Carla A.; Day, Taylor N.; Siegel, Matthew; White, Susan W.; Yu, Lan; Pilkonis, Paul A.The lack of sensitive measures suitable for use across the range of functioning in autism spectrum disorder (ASD) is a barrier to treatment development and monitoring. The Emotion Dysregulation Inventory (EDI) is a caregiver-report questionnaire designed to capture emotional distress and problems with emotion regulation in both minimally verbal and verbal individuals. The first two phases of the EDI’s development are described, including: (1) utilizing methods from the Patient-Reported Outcomes Measurement Information System (PROMIS®) project to develop the item pool and response options; and (2) assessment of the EDI in psychiatric inpatients with ASD. The results suggest that the EDI captures a wide range of emotion dysregulation, is sensitive to change, and is not biased by verbal or intellectual ability.Item Efficacy of the Emotion Awareness and Skills Enhancement (EASE) Program in Autism: A Randomized Controlled Trial(Elsevier, 2025) White, Susan W.; Conner, Caitlin M.; Beck, Kelly; Mazefsky, Carla A.Autistic adolescents and adults often struggle with emotion dysregulation, and advocates consistently encourage more research on mental health. This study aimed to establish efficacy for psychotherapeutic intervention for emotion dysregulation for autistic adolescents and young adults. In this multisite randomized controlled trial, a primarily mindfulness-based intervention called the Emotion Awareness and Skills Enhancement (EASE) Program, developed to improve emotion dysregulation in autistic adolescents and young adults, was compared to a rigorous active control condition (ACC) that allowed for personalized and evidence-based intervention as long as it did not include EASE core elements. It was hypothesized that the EASE group would demonstrate a steeper decline in emotion dysregulation, as well as decreased mental health problems, compared to those in ACC. A total of 109 participants were randomized, 102 began treatment, 89 participants completed all treatment sessions. intent-to-treat (ITT; n = 109) analyses were conducted, with supplemental per protocol analyses (PP; n = 76). Primary outcomes included emotion dysregulation severity and its interference with daily functioning, whereas secondary outcomes assessed mental health symptoms. Condition-naive interviews, which gauged impairment related to dysregulation, showed that the EASE group had more treatment responders (63%) compared to ACC (44%) (p = .052, odds ratio = 2.85), but this difference was not statistically significant. EASE participants demonstrated greater declines in emotion dysregulation than those in ACC (Reactivity, b = − 0.168, p = .017; Dysphoria, b = − 0.182, p = .010) at endpoint. EASE participants demonstrated improvement in internalizing and externalizing symptoms, relative to baseline, based on self and caregiver-report, whereas ACC participants showed improvement only in caregiver-reported externalizing symptoms. All effects were stronger in PP analyses, suggesting the possible importance of treatment dosage. Findings suggest that EASE improves emotion dysregulation for autistic adolescents and young adults.Item Emotion Dysregulation is Substantially Elevated in Autism Compared to the General Population: Impact on Psychiatric Services(Wiley, 2021) Conner, Caitlin M.; Golt, Josh; Shaffer, Rebecca; Righi, Giulia; Siegel, Matthew; Mazefsky, Carla A.; University of Pittsburgh; University of Alabama Tuscaloosa; Cincinnati Children's Hospital Medical Center; University of Cincinnati; Brown University; Maine Medical Center; Tufts UniversityEmerging evidence suggests that emotion regulation (ER) impairment in those with ASD is associated with poor mental health. This study used the Emotion Dysregulation Inventory, a new norm-referenced ER measure with clinical cut-offs, developed and validated in ASD and non-ASD samples, to establish rates of ER impairment and understand its association with psychiatric service use in ASD. Parents of 6-17 year olds in three well-characterized samples (nationally representative US n = 1,000; community ASD n = 1,169; inpatient ASD n = 567) completed a battery of questionnaires about their child. The prevalence of ER impairment was significantly higher in the ASD groups compared to the nationally representative sample and highest in the psychiatric Inpatient ASD group. The community ASD and inpatient ASD samples were four and seven times more likely, respectively, to exceed clinical cutoffs for emotional reactivity than the general US sample. Similarly, history of psychiatric hospitalization, recent emergency services use (police contact, emergency room visits, or in-home crisis evaluations for emotional or behavioral concerns in the past 2 months), and psychotropic medication prescriptions were significantly higher in the ASD groups. ER impairment was significantly associated with all forms of psychiatric service use, after controlling for demographics (age, sex, race), co-occurring intellectual disability, and ADHD symptoms. This is the first large-scale study to document substantially higher rates of ER impairment in youth with ASD compared to the general population. The importance of ER impairment is underscored by its association with higher utilization of inpatient, emergency, and medication services in ASD, after accounting for demographics and ADHD-related symptoms. Lay Summary This study compared problems with emotion regulation in large samples of youth with and without ASD. An ASD community sample had two to four times more youth with clinically elevated regulation impairments compared to youth without ASD. Emotion regulation impairment was also related to using psychiatric hospitalizations, emergency services, and medications in the ASD group. This study suggests that screening for emotion regulation difficulties in ASD is important and treatment may have a wide ranging impact.Item Emotion Regulation: Concepts & Practice in Autism Spectrum Disorder(Elsevier, 2013) Mazefsky, Carla A.; White, Susan W.The purpose of this article is to describe emotion regulation, and how emotion regulation may be compromised in autism spectrum disorder (ASD). This information may be useful for clinicians working with children with ASD who exhibit behavioral problems. Suggestions for practice are provided.Item Neural features of sustained emotional information processing in autism spectrum disorder(Sage, 2020) Mazefsky, Carla A.; Collier, Amanda; Golt, Josh; Siegle, Greg J.; University of Pittsburgh; University of Alabama TuscaloosaEmotion dysregulation is common in autism spectrum disorder; a better understanding of the underlying neural mechanisms could inform treatment development. The tendency toward repetitive cognition in autism spectrum disorder may also increase susceptibility to perseverate on distressing stimuli, which may then increase emotion dysregulation. Therefore, this study investigated the mechanisms of sustained processing of negative information in brain activity using functional magnetic resonance imaging. We used an event-related task that alternated between emotional processing of personally relevant negative words, neutral words, and a non-emotional task. A priori criteria were developed to define heightened and sustained emotional processing, and feature conjunction analysis was conducted to identify all regions satisfying these criteria. Participants included 25 adolescents with autism spectrum disorder and 23 IQ-, age-, and gender-matched typically developing controls. Regions satisfying all a priori criteria included areas in the salience network and the prefrontal dorsolateral cortex, which are areas implicated in emotion regulation outside of autism spectrum disorder. Collectively, activity in the identified regions accounted for a significant amount of variance in emotion dysregulation in the autism spectrum disorder group. Overall, these results may provide a potential neural mechanism to explain emotion dysregulation in autism spectrum disorder, which is a significant risk factor for poor mental health. Lay abstract Many individuals with autism spectrum disorder struggle with emotions that are intense and interfering, which is referred to as emotion dysregulation. Prior research has established that individuals with autism may be more likely than individuals who are not autistic to have repetitive thoughts. It is possible that persistent thoughts about negative or distressing stimuli may contribute to emotion dysregulation in autism spectrum disorder. This study aimed to identify areas of the brain with evidence of persistent processing of negative information via functional magnetic resonance neuroimaging. We used a task that alternated between emotional processing of personally relevant negative words, neutral words, and a non-emotional task. Criteria were developed to define heightened and persistent emotional processing, and analyses were conducted to identify all brain regions satisfying these criteria. Participants included 25 adolescents with autism spectrum disorder and 23 typically developing adolescents who were similar to the autism spectrum disorder group in IQ, age, and gender ratios. Brain regions identified as having greater and continued processing following negative stimuli in the autism spectrum disorder group as compared with the typically developing group included the salience network and the prefrontal dorsolateral cortex. These areas have been previously implicated in emotion dysregulation outside of autism spectrum disorder. Collectively, brain activity in the identified regions was associated with parent-reported emotion dysregulation in the autism spectrum disorder group. These results help to identify a potential process in the brain associated with emotion dysregulation in autism spectrum disorder. This information may be useful for the development of treatments to decrease emotion dysregulation in autism spectrum disorder.Item Psychosocial Treatments Targeting Anxiety and Depression in Adolescents and Adults with Autism Spectrum Disorder: Review of the Latest Research and Recommended Future Directions(Springer, 2018) White, Susan W.; Simmons, Grace Lee; O'Gotham, Katherine; Conner, Caitlin M.; Smith, Isaac C.; Beck, Kelly B.; Mazefsky, Carla A.This synthesis of treatment research related to anxiety and depression in adolescents and adults with autism spectrum disorder (ASD) focuses on the scientific support for various forms of psychosocial interventions, useful adaptations to standard interventions, and engagement of candidate therapeutic mechanisms. There is considerable evidence for the efficacy of cognitive-behavioral therapy (CBT) to treat co-occurring problems with anxiety, but there has been relatively little research on treatment of co-occurring depression. Multiple mechanisms of treatment effect have been proposed, but there has been little demonstration of target engagement via experimental therapeutics. Comorbidity between ASD and anxiety and/or mood problems is common. Although there is evidence for the use of CBT for anxiety, little work has addressed how to effectively treat depression. There is emerging support for alternative treatment approaches, such as mindfulness-based interventions. We encourage rigorous, collaborative approaches to identify and manipulate putative mechanisms of change.Item Social-Cognitive, Physiological, and Neural Mechanisms Underlying Emotion Regulation Impairments: Understanding Anxiety in Autism Spectrum Disorder(Wiley, 2014) White, Susan W.; Mazefsky, Carla A.; Dichter, Gabriel S.; Chiu, Pearl H.; Richey, John A.; Ollendick, Thomas H.Anxiety is one of the most common clinical problems among children, adolescents, and adults with autism spectrum disorder (ASD), yet we know little about its etiology in the context of ASD. We posit that emotion regulation (ER) impairments are a risk factor for anxiety in ASD. Specifically, we propose that one reason why anxiety disorders are so frequently comorbid with ASD is because ER impairments are ubiquitous to ASD, stemming from socio-cognitive, physiological, and neurological processes related to impaired cognitive control, regulatory processes, and arousal. In this review, we offer a developmental model of how ER impairments may arise in ASD, and when (moderating influences) and how (meditational mechanisms) they result in anxiety.Item Students with Autism Spectrum Disorder in College: Results from a Preliminary Mixed Methods Needs Analysis(Elsevier, 2016) White, Susan W.; Elias, Rebecca; Salinas, Carlos E.; Capriola, Nicole; Conner, Caitlin M.; Asselin, Susan B.; Miyazaki, Yasuo; Mazefsky, Carla A.; Howlin, Patricia; Getzel, Elizabeth E.Background—There is a growing call for empirically based programming to support the success of students with autism spectrum disorder (ASD) as they transition to college. Aims—The purpose of this study was to identify the needs and challenges faced by adolescents and young adults with ASD in postsecondary education. Methods—A mixed methods approach was taken to explore the needs of college-bound and college-enrolled students with ASD. Primary stakeholders (i.e., parents, educators/support staff from secondary and postsecondary institutions, and students) participated in an online survey (n = 67) and focus groups (n = 15). Results—Across the stakeholder groups, commonly identified areas of difficulty included limited interpersonal competence, managing competing demands in postsecondary education, and poor emotional regulation. There was a high degree of agreement across stakeholders in the identified needs and challenges. Implications—Findings from this preliminary needs analysis will inform the development of programming to support students with ASD.Item The Emotion Dysregulation Inventory: Psychometric Properties and Item Response Theory Calibration in an Autism Spectrum Disorder Sample(Wiley, 2018) Mazefsky, Carla A.; Yu, Lan; White, Susan W.; Siegel, Matthew; Pilkonis, Paul A.Individuals with autism spectrum disorder (ASD) often present with prominent emotion dysregulation that requires treatment but can be difficult to measure. The Emotion Dysregulation Inventory (EDI) was created using methods developed by the Patient-Reported Outcomes Measurement Information System (PROMIS®) to capture observable indicators of poor emotion regulation. Caregivers of 1,755 youth with ASD completed 66 candidate EDI items, and the final 30 items were selected based on classical test theory and item response theory (IRT) analyses. The analyses identified two factors: 1) Reactivity, characterized by intense, rapidly escalating, sustained, and poorly regulated negative emotional reactions, and 2) Dysphoria, characterized by anhedonia, sadness, and nervousness. The final items did not show differential item functioning (DIF) based on gender, age, intellectual ability, or verbal ability. Because the final items were calibrated using IRT, even a small number of items offers high precision, minimizing respondent burden. IRT co-calibration of the EDI with related measures demonstrated its superiority in assessing the severity of emotion dysregulation with as few as seven items. Validity of the EDI was supported by expert review, its association with related constructs (e.g., anxiety and depression symptoms, aggression), higher scores in psychiatric inpatients with ASD compared to a community ASD sample, and demonstration of test-retest stability and sensitivity to change. In sum, the EDI provides an efficient and sensitive method to measure emotion dysregulation for clinical assessment, monitoring, and research in youth with ASD of any level of cognitive or verbal ability.Item The Role of Emotion Regulation and Core Autism Symptoms in the Experience of Anxiety in Autism(Sage, 2020) Conner, Caitlin M.; White, Susan W.; Scahill, Lawrence; Mazefsky, Carla A.Youth with autism spectrum disorder (ASD) are at elevated risk for impaired emotion regulation (ER) and clinically impairing anxiety. A prior developmental framework posited that impaired ER leads to co-occurring psychiatric conditions such as anxiety, with outcome determined in part by ASD-specific moderating factors. Using measures developed and validated in ASD, this study evaluated: 1) the association between ER and anxiety in a large, community-based sample of youth with ASD and a wide range of intellectual and verbal abilities; and 2) whether greater core ASD symptoms strengthened the association between impaired ER and anxiety. Parents of 1,107 children with a community diagnosis of ASD (881 boys; age 6–17 years) participated in an online survey assessing their child’s ER, anxiety, and ASD symptoms. ER impairment significantly predicted whether participants had elevated levels of anxiety, after controlling for demographic variables and ASD symptoms; however, there was no interaction of ER and ASD symptoms. This study is the first to support the anxiety-ER association with measures developed and validated specifically for ASD, in a large sample with co-occurring ID and minimally verbal youth with ASD.Item The Role of Emotion Regulation in Autism Spectrum Disorder RH: Emotion Regulation in ASD(Elsevier, 2013) Mazefsky, Carla A.; Herrington, John; Siegel, Matthew; Scarpa, Angela; Maddox, Brenna B.; Scahill, Lawrence; White, Susan W.Objective—Autism spectrum disorder (ASD) is associated with amplified emotional responses and poor emotional control, but little is known about the underlying mechanisms. This paper provides a conceptual and methodological framework for understanding compromised emotion regulation (ER) in ASD. Method—After defining ER and related constructs, methods to study ER were reviewed with special consideration on how to apply these approaches to ASD. Against the backdrop of cognitive characteristics in ASD and existing ER theories, available research was examined to identify likely contributors to emotional dysregulation in ASD. Results—Little is currently known about ER in youth with ASD. Some mechanisms that contribute to poor ER in ASD may be shared with other clinical populations (e.g., physiological arousal, degree of negative and positive affect, alterations in the amygdala and prefrontal cortex), whereas other mechanisms may be more unique to ASD (e.g., differences in information processing/perception, cognitive factors (e.g., rigidity), less goal-directed behavior and more disorganized emotion in ASD). Conclusions—Although assignment of concomitant psychiatric diagnoses is warranted in some cases, poor ER may be inherent in ASD and may provide a more parsimonious conceptualization for the many associated socio-emotional and behavioral problems in this population. Further study of ER in youth with ASD may identify meaningful subgroups of patients and lead to more effective individualized treatments.Item Therapeutic Alliance Formation for Adolescents and Young Adults with Autism: Relation to Treatment Outcomes and Client Characteristics(Springer, 2021) Brewe, Alexis M.; Mazefsky, Carla A.; White, Susan W.; University of Alabama Tuscaloosa; University of PittsburghTherapeutic alliance may influence treatment outcomes for individuals with autism spectrum disorder (ASD). The present study examined the trajectory of alliance, observationally-measured at four timepoints during a 16-week mindfulness-based treatment targeting emotion regulation problems in adolescents and young adults with ASD (n = 37, mean age = 15.28, 78.40% male). Variability in alliance as a function of client characteristics and the degree to which alliance predicted emotion regulation outcomes were assessed using parent-report forms. Results demonstrate that alliance fluctuates throughout treatment. Moreover, stronger alliance predicts decreased dysphoria at posttreatment. Results also suggest that increased ASD symptom severity and depression predict weaker alliance early and throughout treatment. Findings highlight a need for clinicians to consider the importance of developing strong alliance for clients with ASD.Item Trial by trial EEG based BCI for distress versus non distress classification in individuals with ASD(Nature Portfolio, 2021) Eldeeb, Safaa; Susam, Busra T.; Akcakaya, Murat; Conner, Caitlin M.; White, Susan W.; Mazefsky, Carla A.; University of Pittsburgh; University of Alabama TuscaloosaAutism spectrum disorder (ASD) is a neurodevelopmental disorder that is often accompanied by impaired emotion regulation (ER). There has been increasing emphasis on developing evidence-based approaches to improve ER in ASD. Electroencephalography (EEG) has shown success in reducing ASD symptoms when used in neurofeedback-based interventions. Also, certain EEG components are associated with ER. Our overarching goal is to develop a technology that will use EEG to monitor real-time changes in ER and perform intervention based on these changes. As a first step, an EEG-based brain computer interface that is based on an Affective Posner task was developed to identify patterns associated with ER on a single trial basis, and EEG data collected from 21 individuals with ASD. Accordingly, our aim in this study is to investigate EEG features that could differentiate between distress and non-distress conditions. Specifically, we investigate if the EEG time-locked to the visual feedback presentation could be used to classify between WIN (non-distress) and LOSE (distress) conditions in a game with deception. Results showed that the extracted EEG features could differentiate between WIN and LOSE conditions (average accuracy of 81%), LOSE and rest-EEG conditions (average accuracy 94.8%), and WIN and rest-EEG conditions (average accuracy 94.9%).