Assessment and Treatment of Emotion Regulation Impairment in Autism Spectrum Disorder Across the Life Span

As eloquently summarized by Thompson,¹ emotion regulation (ER) is a complex, multifaceted, and interactive process. Involving one’s neurobiology, cognition, behavior, affect, and context, ER is the ability to monitor and modify arousal and reactivity to engage in adaptive behavior. ER involves intentional and automatic attempts to manage affect, as well as internal (acquired) and external (imposed by others) strate-gies.^1,2 Finally, ER is usually viewed functionally, meaning in relation to the degree that it is effective in facilitating goal attainment. In this review, we adopt a fully inclusive definition of ER that encompasses both reactivity (the speed and intensity of felt emotion) and the strategies (internal, external, intentional, automatic) applied to manage emotions.^3,4

Although ER impairment in autism spectrum disorder (ASD) and its adverse influence on outcome has been acknowledged for several years (eg, Kanner’s⁵ mention of “disturbances of affective contact”), research on this phenomenon has been slow to develop. Herein, we offer readers a synthesis of extant research on both assessment and treatment of ER problems in ASD. This review is neither exhaustive nor is it an attempt to compare differential effectiveness of approaches. Rather, our goal is to summarize the advances made over the past decade with respect to assessment and treatment of ER problems in people with ASD across the life span. In so doing, we identify what appear to be the most promising ER measures for this population and consolidate the extant scientific literature on interventions targeting remediation of ER impairment. We focus exclusively on ER and not on the myriad of related problems (eg, anxiety, aggression). We also offer suggestions for research that must be addressed for the field to advance.

CLINICAL VALUE OF ADDRESSING EMOTION REGULATION IMPAIRMENT

A mother of a 9-year-old verbal boy with ASD and extreme emotion dysregulation wrote this of her son:

My husband and I describe him as being at once the most capable and most disabled person we know; he can be the starting pitcher on his little league team without incident, participate and perform in a school-sponsored musical, all while not actually being capable of attending school (he is currently not at school at all, and is being referred by our local district for an out of placement evaluation). His dysregulation manifests in severe emotional outbursts, both verbal and physical; however, again, when regulated, he is more rationale, kind, and mature than his older neurotypical brothers…emotional dysregulation is absolutely his chief obstacle to living a full life and having the chance to enjoy his many talents (and they are many!).

This is, unfortunately, not an uncommon scenario. For many with autism, ER impairments are debilitating. As such, the top priorities for treatment trials identified by parents of young children with ASD are all related to problems regulating emotion (eg, distress, anxiety),⁶ which is consistent with priorities identified by parents of older children and adults and adults with ASD themselves.⁷ Indeed, people with ASD use psychiatric services at much higher rates than do individuals without ASD.⁸

Individuals with ASD may be predisposed to ER impairment due to differences in cognitive (executive functioning, abstraction, self-awareness) functioning, sensory sensitivities, and biological risks (Fig. 1) (see Ref.⁹ for a more thorough discussion). Accumulating evidence suggests that ER impairment is more common, and more severe, for individuals with ASD than neurotypical peers.^10,11 Even in the first few years of life, children with ASD are less easily soothed and use fewer adaptive/constructive ER strategies as compared with same-aged neurotypical peers.¹¹ Although most neurotypical children learn to manage emotions enough to facilitate goal achievement by the time they reach school-age, many individuals with ASD struggle with ER impairments well into adolescence and adulthood.⁹

Fig. 1.

Illustrative summary of the propensity for impaired ER in ASD, its common manifestations, and the resultant poor outcomes.

Impaired ER in ASD has been found to correlate with more problem behaviors (meltdowns, self-harm), co-occurring psychiatric diagnoses, and negative social outcomes for individuals with ASD.^12–15 Across the life span, ER impairment may present as aggression, more frequent and long-lasting negative emotions, and/or nervousness and social withdrawal.^7,16,17 In older ages especially, persistent rumination often days after an incident, intense reactions to social rejection, and continued reliance on parents or caregivers for calming (when no longer normative) is also commonly observed.^9,14,18 By adulthood, approximately 75% of adults with ASD in community samples have co-occurring diagnoses of either depression or anxiety, and ER impairment is believed to underlie these problems.¹⁹

Despite the varied manifestations of ER impairments in ASD and their presence across the life span, most psychosocial treatment research to address emotional problems has focused on children and the remediation of anxiety. These protocols generally do not address other common problems such as explosive behavior, meltdowns, irritability, anger, and depression. Although cognitive-behavioral therapy (CBT) has demonstrated potential for treating anxiety in children with ASD, response has been variable and effect sizes are lower than in youth without ASD.²⁰ Further, research suggests that these treatments are generally longer in duration than would be indicated for evidence-based therapies for similar conditions (eg, anxiety) in non-ASD populations, and that there is limited generalization of effects.²⁰ This suggests that it is important to try to remediate the causal processes.

Broader and more sustained clinical impact may be achieved by focusing on core processes that underlie a range of problems, such as ER. Focusing on ER may facilitate effective treatment by addressing multiple behaviors and symptoms simultaneously. Further, ER impairments have been linked to lower parental quality of life,²¹ suggesting that improving ER could have cascading positive benefits for the family system.

In sum, ER impairment underlies a variety of challenges faced by individuals with ASD and may present differently across the life span. For this reason, treatments that specifically address core ER impairments are likely to have a broader impact over a longer time horizon than treatments focused on secondary challenges arising from ER impairments (eg, behavioral problems in early childhood or anxiety in adolescence). Moreover, ER impairments are often cited as barriers to treatment focused on other ASD-related areas of need; thus, we recommend that (at least for some individuals) clinicians consider treating ER impairment before engaging in treatment for higher-level skills, such as social communication or social skills training.

EMOTION REGULATION MEASUREMENT IN AUTISM SPECTRUM DISORDER

The first step to improving ER is identifying it as an area of need. Screening to identify ER problems would be ideal to promote targeted prevention and treatment efforts. This is important, because although the ASD population as a whole is considered at high risk for ER impairment (as noted previously), there is wide variability. For example, even among psychiatric inpatients with ASD, there is a normal curve of ER severity.²² Likewise, heterogeneity is considered a challenge within treatment contexts, with vast variability observed in response to even evidence-based ASD treatments.²³ Therefore, frequent measurement of progress is needed to evaluate how well an intervention is working for a particular patient and to inform whether a change in approach, dosage, or otherwise is needed. Finally, the establishment of new treatments as evidence-based is dependent on the availability of psychometrically sound measures that will be sensitive to treatment effects. Taken together, ER measurement provides the foundation for ER-focused treatment success.

Types of ER measurement methods include direct observation and behavior coding, physiologic monitoring, informant-report, and self-report questionnaires.²⁴ Table 1 synthesizes the different ER measurement modalities, lists pros and cons to each modality, and references the most common measures used in ASD literature.

Table 1.

Measurement modalities and common measures to assess emotion regulation (ER) in autism spectrum disorder (ASD)

Method/Measure	ASD Studies that Used	Target Age
Self-report
Pros: Feasible; Direct report from individual; Incorporation of patient perspectives is helpful for rapport Cons: Reporting of internal emotional states difficult for some with ASD; No measures validated in ASD; Not applicable to all with ASD (eg, with more severe co-occurring intellectual disability)
1. Cognitive Emotion Regulation Questionnaire (CERQ25)	Rieffe et al, 201118; Bruggink et al68, 2016	Adults Also a youth version used in Rieffe et al., 201118
2. Difficulties in Emotion Regulation Scale (DERS26)	Conner & White,27 2018; Maddox et al,69 2017; Swain et al,70 2015	Adults Also an adolescent version not previously used in ASD
3. Emotion Regulation Questionnaire (ERQ28)	Samson et al,71 2012; Samson et al,14 2015; Cai et al,10 2018; Cai et al72, 2019; Goldsmith & Kelley,73 2018	Adults Also a youth version Emotion Regulation Question for Children and Adolescents (ERQ-CA) not previously used with ASD
4. Response to Stress Questionnaire (RSQ29)	Charlton et al,74 2019	Youth (developed on 11–19 y)
Parent-/Other-report
Pros: Some options developed and validated in ASD (Emotion Dysregulation Inventory and Emotion Regulation and Social Skills Questionnaire only); Can capture concerns across contexts Cons: Finding a consistent informant may be difficult (especially for adults who may not live with caregivers); Limited to observable indicators of ER
1. Child Behavior Checklist Emotion Dysregulation Index30–32	Samson et al, 2013; Samson et al,14 2015; Berkovits et al,33 2017; Keefer et al,75 2019; Joshi et al,76 2018	6–16 y
2. Emotion Dysregulation Inventory (EDI3,22,34)	Mazefsky et al,22 2018; Mazefsky et al,34 2018; Conner et al,35 2019	6–18 y
3. Emotion Regulation and Social Skills Questionnaire (ERSSQ36)	Butterworth et al,37 2014; Weiss et al,38 2018; Sofronoff et al,77 2017	Developed on 7–11 y
4. Emotion Regulation Checklist (ERC39)	Scarpa & Reyes,40 2011; Berkovits et al,33 2017; Thomson et al,78 2015; Jahromi et al,6 2013	6–12 y
5. Response to Stress Questionnaire (RSQ29)	Khor et al,79 2014; Mazefsky et al,9 2014; Conner White,27 2018; Charlton et al,74 2019	Developed on 11–19 y
Physiologic monitoring
Pros: Biological measure, may be more objective Cons: Expensive equipment; Requires expertise
1. Respiratory sinus arrythmia/heart rate	Bal et al,41 2010; Neuhaus et al,42 2014; Van Hecke et al,43 2009	Young child-adult
2. Skin conductance (electrodermal activity)	South et al,80 2012	11–16 y
Direct observation/behavior coding
Pros: Can be done in naturalistic situations or in response to structured tasks; Can be done with young children Cons: Coding can be challenging due to atypical emotional expressiveness; Time-intensive to train coders and complete coding
Observational tasks
1. Laboratory Temperament Assessment Batter (Lab-TAB; Goldsmith et al,81 1999)	Jahromi et al,11 2012; Nuske et al,44 2017; Hirschler-Guttenberg et al,45 2015	2–10 y
2. Unsolvable puzzle task	Jahromi et al,11 2012	3–7 y
3. Affect regulation manipulation (toy removal)	Konstantareas & Stewart,17 2006	3–10 y
Coding systems
1. Facial/body expressions (from Ekman & Friesen’s Facial Action Coding System)	Jahromi et al,11 2012	3–7 y
2. Coping strategies/ER (from Eisenberg et al, 1996; Calkins et al, 1999)	Jahromi et al,11 2012	3–7 y
3. Engagement/Disengagement Coping strategies (from Grolnick et al, 1996)	Konstantareas & Stewart,17 2006; Nuske et al,44 2017; Hirschler-Guttenberg et al,45 2015	2–10 y

ER measurement in young children with ASD has often relied on direct observation and behavior coding. Thus far, naturalistic, frustrating tasks meant to elicit emotional reactions have been used, such as unsolvable puzzles and removing access to a desired toy.^11,17,44,45 Several researchers have applied coding systems to samples of children with ASD to characterize reactions (facial/bodily negativity, resignation, negative/non-negative vocalizations, coping strategies) to ER tasks.^11,17,45 However, the challenge with observational ER assessment in children with ASD is properly coding the expressed emotional reactivity, given atypical nonverbal communication and varying verbal capacity. Reactions may need to be coded in context of baseline communication skills, verbal capacity, and behaviors.⁴⁶ Achieving reliable coders is also time-intensive and not ideal for clinical contexts especially.

Physiologic measurement of ER is limited but has been used in several studies.²⁴ Respiratory Sinus Arrhythmia (RSA), a measure of heart rate variability, was used by several researchers to capture changes in heart rate during different tasks.^41–43 However, this has primarily been used to capture heart rate correlations to social competence and has only been secondarily considered as a possible peripheral marker of ER impairment.⁴² Physiologic measures also typically require access to specialized sensors that can be expensive and thus are not regularly used in outpatient psychiatric care. However, an advantage of measures of physiologic arousal is that they can be used regardless of verbal ability, and emerging research has begun to explore how they can be applied to support clinical care. For example, Goodwin and colleagues⁴⁷ published promising proof of concept data on the use of physiologic data to predict imminent aggression onset, which may be effective in part due to its sensitivity to changes in overall arousal and reactivity.

Most research to date has used questionnaires to measure ER in individuals with ASD. ER assessment in school-aged children, adolescents, and adults typically consists of self-report and informant-report measures. This poses challenges given the limited psychometric research on the clinical utility of self-report ER measures in ASD samples, especially for individuals with limited verbal capacity.⁴⁶ This is complicated by inherent limitations in self-evaluation and awareness that is characteristic of ASD.^48,49 Further, informant-report assessment for adults with ASD are often not feasible or valid, especially for those who no longer live with parents. Thus, the options for ER measurement for adults with ASD are limited.

Researchers have primarily used existing parent-report assessments developed for general populations to assess ER.^6,33 The most commonly used informant-report assessments, typically completed by parents, include the Emotion Regulation Checklist (ERC)³⁹ and the Child Behavior Checklist (CBCL)^30,31 Emotion Dysregulation Index.³² The ERC is a 24-item parent-report measure that includes 2 subscales: ER subscale (appropriate emotional expression, empathy, and emotional self-awareness) and lability/negativity subscale (inflexibility, rigidity, and dysregulated negative affect). The CBCL is a 113-item parent-report measure of psychiatric symptoms and behavioral functioning. Samson and colleagues³² identified 18 items from the original CBCL that best characterize ER impairment, called the Emotion Dysregulation Index from the CBCL. In a study of 56 children, ages 6 to 16, they found greater ER impairment and severity than those without ASD.³² The Emotion Regulation and Social Skills Questionnaire (ERSSQ) is an informant measure developed specifically for youth and adolescents with ASD.³⁶ The ERSSQ is a 27-item questionnaire with parent and teacher (25 item) versions to measure social skills that includes a few items on ER control.³⁷

The Emotion Dysregulation Inventory (EDI) was specifically designed to measure ER impairments in youth and adolescents with ASD.^3,22,34 Mazefsky and colleagues²² developed the EDI using the National Institutes of Health Patient-Reported Outcomes Measurement Information Systems (PROMIS) methodology. This 30-item scale was finalized using factor analysis and item response theory analyses using data from 1755 youth with ASD (aged 4–20) with normative data from a general sample of 1000 youth matched to the US census on age, gender, race, ethnicity, and region of the United States. The EDI is composed of 2 scales, Reactivity and Dysphoria. The Reactivity scale can be assessed using a 24-item long form or 7-item short form, and it measures intense, rapid, sustained, and poorly regulated negative emotional reactions, whereas the Dysphoria scale includes 6 items that capture withdrawal, minimal motivation and positive affect, and sadness or nervousness. The EDI has good reliability and validity, as well as superior discriminability to the ERC and CBCL Emotion Dysregulation Index, as well as others, in both ASD and general samples. Importantly, none of the final EDI items had evidence of differential item functioning (eg, psychometric biases) by gender, age, intellectual ability, or verbal ability, making it suitable for use across heterogeneous populations. Finally, the EDI has evidence of change sensitivity and offers clinical cutoffs for screening and interpretation. Young child (for ages 2 to 5 years) and self-report (for adolescents and adults) versions of the EDI are in development (R01 HD079512).

The most commonly used self-report ER measures in ASD samples include the Difficulties in Emotion Regulation Scale (DERS),²⁶ Emotion Regulation Questionnaire (ERQ),²⁸ and Responses to Stress Questionnaire (RSQ).²⁹ The DERS²⁸ is an adult self-report measure originally developed for individuals without ASD. It has 36 items that yields 6 subscales: nonacceptance of emotional responses, difficulties engaging in goal-directed behaviors, impulse control difficulties, lack of emotional awareness, limited access to ER strategies, and lack of emotional clarity. The ERQ consists of 10 self-report items that make up Reappraisal and Suppression subscales.²⁸ Although not initially conceptualized as a measure of ER strategies, the RSQ-social stress version²⁹ is a 57-item self-report and parent-report measure of coping strategies based on a 5-factor model of coping that categorizes ER/coping skills based on awareness engaging in the strategy and approach/avoidance of the emotion-eliciting stimuli (ie, involuntary engagement, involuntary disengagement, voluntary disengagement, primary voluntary coping, and secondary voluntary coping). Although several studies in ASD samples have reported satisfactory internal consistency and expected patterns of correlations with measures of related constructs (in support of concurrent validity),¹³ none of these self-report measures were developed for ASD samples or have undergone thorough psychometric evaluation in ASD.

Ultimately, the research to establish the ideal means of measuring ER for individuals with ASD across the life span is in its infancy. The past 5 years has seen the application of newer coding systems²¹ as well as the development of questionnaires (eg, EDI)³⁴ with promise for the assessment of ER in ASD. It is recommended that ER measurement consists of a multimodal assessment approach,^46,50 although much published research incorporates only one method of assessment.²⁴ For children, combining observational coding with interviews or informant-based assessment may be promising. Jahromi and colleagues¹¹ have developed coding systems specific to ASD in response to ER tasks that have been used in several studies.⁵¹ For adolescents and adults, informant and self-report assessments may help to characterize ER impairments and improvements. Self-report ER measurement for individuals with ASD continues to be an area of need for future research, especially in transition-age and adult populations.

EMOTION REGULATION INTERVENTIONS ACROSS THE LIFE SPAN

Few interventions for very young children (preschool age or younger) with ASD include a component specifically aimed at improving ER, and none that we are aware of have measured change in ER as an outcome in a randomized control trial (RCT). The Social Communication, Emotional Regulation, and Transactional Support (SCERTS) model⁵² explicitly teaches both self-regulatory skills and mutual regulation within the parent-child relationship. SCERTS takes a developmental approach that recognizes the interdependence between social communication and ER skills and integrates treatment in these domains. The only RCT of SCERTS reports improvements in social communication, adaptive behavior, social, and verbal skills with small to medium effect sizes in a group of 16-month-old to 20-month-old children with ASD; however, this study did not measure ER as an outcome.⁵³ Therefore, the efficacy of SCERTS for improving ER specifically is unknown.

The Joint Attention, Symbolic Play, Engagement and Regulation (JASPER)⁵⁴ model is another intervention aimed at very young children that includes a theoretic link to self-regulation. JASPER is a parent-mediated treatment focused primarily on sustaining periods of joint engagement and improving joint attention and play skills. The investigators point to the connection between joint attention and ER to argue that improvements in joint attention and joint engagement will lead to improvements in ER. One study using growth curve analysis reported decreasing child negativity (although this trend did not reach significance) and increasing maternal emotional scaffolding during the course of the intervention; however, no control group was included in the study and so the efficacy of JASPER for ER remains unclear.⁵¹

In contrast to very young children, several ER interventions are available for school-aged children (5–12 years). Attwood⁵⁵ and Sofronoff and colleagues^56–58 developed the Exploring Feelings, a CBT-based group intervention designed for children with ASD ages 9 to 12 with problematic anger. Exploring Feelings teaches emotion recognition and awareness through the use of cognitive restructuring, an emotional toolbox and thermometer, and strategy application. In an RCT with waitlist control (n = 45), parents reported that children in the intervention group showed a significant decrease in anger on the frustration and authority relations subscale of the Children’s Inventory of Anger Parent.⁵⁸ Although this study did not use an ER measure, qualitative parent-report data showed that children receiving treatment reduced the number of anger outbursts and indicated that attending the sessions had been beneficial both for themselves and for their child.

Scarpa and Reyes⁴⁰ adapted the Exploring Feelings program for younger school-aged children (ages 5–7) experiencing problems with anger and ER, named the Stress and Anger Management Plan (STAMP). The STAMP program maintained the core components of Exploring Feelings with developmental adaptations appropriate for younger children (eg, shorter sessions, more games). Participants (n = 11) attended nine 1-h small group sessions while their parents attended a concurrent psychoeducation group. Pilot results indicated significant improvements of moderate to large effect in parent confidence in their child’s ability to manage anger (d = .63) and anxiety (d = .84). STAMP participants also demonstrate large effects in improved negativity and lability (d = .80) on the ERC and significantly decreased frequency and duration of emotional outbursts. In a subsequent waitlist control study, 67% of STAMP participants (n = 18) were designated as treatment responders, based on significant changes in lability/negativity and a 20% decrease in the frequency, intensity, or duration of emotional outbursts.⁵⁹ Parents of STAMP participants also reported a significant increase in confidence of child’s ability to manage anger.

The Secret Agent Society: Operation Regulation (SAS:OR) intervention targets ER in children with ASD through 10 sessions of manualized, individual CBT.³⁸ SAS:OR is based on the original Secret Agent Society, a social skills intervention designed for children with ASD.⁶⁰ SAS:OR was adapted to remove the social skills curriculum and replace it with ER (emotion awareness, mindfulness, acceptance) activities. This treatment also has a large focus on generalization of new ER skills to school and home environment through exposure activities and practice. Weiss and colleagues³⁸ conducted an RCT with a waitlist control on a sample of 68 children diagnosed with ASD. Moderate to large effect sizes of change were found over group and time in parent reports of ER skills (ERSSQ, d = 0.79; ERC, lability/negativity, d = 0.58), problem behaviors (BASC-2 Adaptive, d = 0.71).

The Intensive Outpatient Program for Emotion Regulation Treatment (IO-PERT)⁶¹ is another ER treatment designed specifically for youth (8–12 years) with ASD and ER impairment. IO-PERT is the only ER treatment reviewed in this article that was designed for individuals with ASD and co-occurring Intellectual Disability. IO-PERT sessions occur twice weekly for 5 weeks and include both a child treatment group and a simultaneous caregiver education group. The treatment incorporates CBT, mindfulness principles, mediation practice, and Applied Behavioral Analysis techniques. Forty participants were enrolled in the IO-PERT treatment and 85% completed the intervention with high satisfaction. Statistically significant changes were found between pretreatment and posttreatment in psychiatric symptoms and behaviors measured with the CBCL and Aberrant Behavior Checklist (ABC). Clinical severity and improvement ratings measured by the Clinical Global Impression (CGI) found 53% of participants to be responders, 24% minimally improved, and 21% no change. Primary outcomes were evaluated with parent-report scales of behavior (CBCL and ABC), limiting conclusions on the specific ER treatment effects.

Relatively few interventions for adolescents or adults with ASD target ER. The Emotional Awareness and Skills Enhancement (EASE) program was developed to target impaired ER in adolescents and adults with ASD and measured changes in ER following an open trial directly using the EDI.^34,35 EASE aims to teach awareness of one’s emotions and strategies to adaptively manage emotions by cultivating mindful awareness. Following increased awareness of internal emotional states, EASE participants learn cognitive skills (psychoeducation on thoughts, feelings, and behaviors, cognitive reappraisal, cognitive defusion), mindfulness-based distraction, and mindful breathing as a way to calm in heightened states of arousal. In an open pilot trial with 20 adolescents (12–17 years old) with ASD and IQ greater than 80, ER impairment, anxiety, and depression symptoms decreased with medium-to-large effect sizes. Participants and parents also indicated satisfaction with the intervention, including high ratings for helpfulness (M = 4.29 on 1–5 scale) and impact of the treatment in their lives (M = 4.18 on 1–5 scale). An RCT comparing EASE with individualized supportive therapy in adolescents and young adults with ASD and IQ >80 is ongoing.⁶²

The Resourceful Adolescent Program–Autism Spectrum Disorder (RAP-A-ASD) is a school-based intervention intended to prevent depression symptoms in adolescents with ASD.^63,64 The intervention combines CBT and Interpersonal Therapy components for an 11-week individualized intervention. Although RAP-A-ASD does not specifically target or measure ER, there is 1 week, “Keeping calm” that focuses on ER by increasing awareness to physical reactions of emotions during times of stress. Mackay and colleagues⁶³ conducted an RCT (n = 29) evaluating the effects of RAP-A-ASD on depression, coping self-efficacy, and functioning. Parent reports of coping self-efficacy were significant at post (P = .023) and 6-month follow-up, but no change was found on depressive symptoms. Qualitative analyses suggested that 80% of participants reported improved capacity to manage emotions by remaining calm and being more flexible. Participants cited examples of less aggression, navigating social conflict better, and coping with rejection. Similarly, 63% of parents reported that the intervention enhanced ER and confidence, citing examples of participants feeling happier, more relaxed, and calmer.

In adults, Conner and White²⁷ adapted mindfulness-based cognitive therapy for young adults with ASD who have ER impairment in an open pilot study. Nine adults age 18 to 25 with ASD and ER impairment completed a 6-session individual therapy, where each session focused on teaching mindfulness meditations and targeted discussion and practice of one typically “adaptive” ER strategy and discussion of one typically “maladaptive” ER strategy, which were determined by client self-report on the RSQ. Self-reported improvements in DERS subscales for emotional awareness, impulse control, and access to ER strategies were observed, as well as decreased negative affect on the Positive and Negative Affect Scale.

Beck and colleagues⁶⁵ sought to establish feasibility of using Mindfulness-Based Stress Reduction (MBSR) with a group of adults diagnosed with ASD without adaptation to the standardized intervention. A sample of 12 adults aged 22 to 63 completed the 8-week group intervention (100% retention) with high levels of satisfaction and large estimates of effect in positive outlook (d = 2.12), satisfaction with life (d = 1.08), and mindfulness (d = 1.10). Although ER impairment was not directly measured in the feasibility trial, posttreatment qualitative interviews suggested that ER and increased awareness were candidate mechanisms of MBSR in this sample. Specifically, 60% of participants indicated that improvements in ER were the primary benefit experienced from the intervention, which has been found to be a primary mechanism of change in a variety of samples.⁶⁶

Hartmann and colleagues⁶⁷ adapted Dialectical Behavior Therapy for adults with ASD in a small group study with 7 participants in which sessions targeted social communication challenges and ER impairment. The 12 group sessions included short mindfulness practices, identification of social situations that elicit emotional difficulties, and practicing social situations in session. Single-subject analyses on the 3-month group therapy indicated increased Social Cognition Index scores on the Social Responsiveness Scale-2 and ER improvement (decreased suppression and increased reappraisal on the ERQ) in most participants.⁶⁷

Overall, the evidence for ER-focused interventions in ASD is quite limited. Nearly all existing studies are preliminary open trials with small sample sizes. The only randomized trials included waitlist controls rather than an active treatment comparison group. Some interventions include ER as a theoretic target mechanism, but they do not include measurement of ER as an outcome. Other than IO-PERT⁶¹ and the interventions for young children, which to date have not measured effects on ER, most studies targeted children through adults who are verbal and/or have average cognitive ability. As such, the conclusions that can be drawn from the treatment research are limited. However, in general, the extant research suggests that ER can improve with treatment, with evidence for this from childhood (although not very early childhood yet) through adulthood.

SUMMARY

Nearly all ER research in ASD has occurred in the past decade. Although longitudinal studies to establish causation are lacking, the research overwhelmingly ties poor ER to a wide range of negative outcomes. This suggests that screening for ER impairment and the development and evaluation of ER-focused mechanistic treatments for individuals with ASD is an important direction for future research. Clinicians might consider focusing on treatment of ER as opposed to treatments for specific psychological symptoms or disorders. Further, treating ER impairment may be preferable before engaging in social skills training so that individuals can learn to manage emotions before engaging in stressful social demands.

Despite increasing appreciation of the importance of ER in ASD, treatment research for ER in ASD is in its infancy. The few clinical trials that have been done are preliminary in nature. For the most part, intervention studies have incorporated methods with efficacy outside of ASD, such as CBT and mindfulness, with promising results. This suggests that, in the absence of treatments with specific support of efficacy for ER in ASD, clinicians can use approaches to support ER outside of ASD with common modifications to support learning in ASD. It is also possible that approaches with efficacy for other treatment targets in ASD, such as CBT for anxiety or Functional Behavior Assessments and environmental supports for behavior, and so on, may be helpful for improving ER given that we know ER is strongly associated with these other concerns. However, measurement of ER outcomes is needed to better understand how other intervention approaches may impact ER.

Although there are very few measures that have been developed and validated for individuals with ASD, the recent development of 2 informant reports is promising.^24,46 More research is needed to develop sound self-report ER measures for adults with ASD. Although some studies have used biological indices such as measurement of RSA, this too, is in its infancy. Overall, the incorporation of technology into ER assessment in ASD has been very limited to date, although could be useful to consider more automated approaches to time-intensive forms of ER measurement, such as observational coding.

In sum, there is much to be done in terms of establishing empirically based approaches for ER assessment and treatment in ASD. More sophisticated clinical trials, such as sequential, multiple assignment, randomized trial (SMART) trial designs, integration of dissemination/implementation questions into trial designs, or comparison of multiple active treatments, may be useful to speed the state of the science. Although it may seem like a daunting amount of work remains to be done, we can continue steadfast with the potential for improved outcomes in mind. As stated by a parent of an adult woman with ASD, following initiating ER-focused treatment:

After 9 months of intensive sessions twice a week: results nothing short of miraculous. This, after trying every other type of therapy and medication out there. Without addressing her emotion regulation issues, nothing else was possible.

KEY POINTS.

• Research suggests that individuals with autism spectrum disorder (ASD) are more prone to have impaired emotion regulation (ER) than same-aged peers without ASD, beginning in early childhood and extending into adulthood.

• Cross-sectional research supports an association between impaired ER and more problem behaviors, aggression, co-occurring psychiatric diagnoses, and negative social outcomes in ASD.

• Broader and more sustained clinical impact may be achieved by focusing treatment on core ER impairments as opposed to a disorder-specific or problem-specific approach.

• A multimodal assessment approach to ER measurement in ASD is recommended, with priority placed on measures and coding systems developed specifically for individuals with ASD.

• Although the research is in its infancy with small open pilot or waitlist control trials, existing research on ER in ASD suggests that ER can improve with treatment.