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International Journal of Developmental Disabilities logoLink to International Journal of Developmental Disabilities
. 2021 Sep 27;68(6):889–899. doi: 10.1080/20473869.2021.1917109

Self-regulation predicts companionship in children with autism

Heather J Nuske 1,✉, Wendy I Shih 2, Nicole Sparapani 3, Lauren Baczewski 2, Amanda Dimachkie Nunnally 2, Samantha Hochheimer 4, Consuelo Garcia 2, Fernanda Castellon 2, Lynne Levato 4, Erin Fischer 4, Zabryna L Atkinson-Diaz 1, Jennica Li 3, David S Mandell 1, Connie Kasari 2; the Autism Intervention Research—Behavioral 1 team
PMCID: PMC9788710  PMID: 36568619

Abstract

 Self-regulation is associated with many positive outcomes in children with and without autism, including increased mental health and academic achievement, and decreased problem behavior. Less is known regarding whether and how self-regulation and symptoms of mental health challenges (internalizing and externalizing problems) relate to social outcomes, such as friendship quality and loneliness. Parents and teachers of 106 children with autism aged 5–12 reported on children’s self-regulation difficulties and externalizing and internalizing symptoms. Four-to-five months later, children reported on the quality of their friendship with their best friend (companionship, conflict, helpfulness, sense of relationship security, closeness), and their feelings of loneliness. Linear regression was used to examine the effects of self-regulation and symptoms of mental health challenges on friendship quality and loneliness. Less self-regulation difficulties predicted stronger companionship and girls had better quality friendships with their best friend than did boys, in terms of companionship, helpfulness, security and closeness, confirming that they have a protective advantage in friendship development. Autism symptoms, IQ, and age were not associated with friendship quality or loneliness. Results highlight the importance of self-regulation and mental health interventions for school-aged children with autism.

Keywords: autism, self-regulation, friendship, loneliness, depression, mental health: internalizing problems, externalizing problems

Introduction

Throughout early to middle childhood, typically developing children become increasingly attuned to their peers and skilled at connecting with them in a coordinated, meaningful way. This supports social learning, provides emotional support and security, and creates templates for later affiliative experiences and intimacy in relationships (Hartup 1984, 1992). During this developmental period, children are better able to identify best friends, as well as reflect and report on the quality of their friendships and feelings of loneliness (Hartup 1992, Ladd 1988, 1999, Sullivan 2013). In typically developing children, high rates of loneliness during elementary school predict more depressive symptoms at the end of elementary school (Qualter et al. 2013). Not only are friendships integral to children’s social skill development and their mental health (Howes 2009, Woods et al. 2009), but mental and emotional health also impacts friendship outcomes (Cardoos and Hinshaw 2011, Leflot et al. 2011, Manfro et al. 2017, O’Driscoll et al. 2015, Patalay and Fitzsimons 2018, Pamela Qualter et al. 2010, Silke et al. 2016, Wood 2006). Therefore, the relationship between mental health and friendship is bi-directional (e.g. Mundt and Zakletskaia 2014).

Although most children with autism spectrum disorder (ASD) report having friends, many youth with ASD exhibit challenges developing and maintaining friendships (Bauminger-Zviely and Kimhi 2017). Compared with their neurotypical peers, children with ASD report having fewer friends and poorer quality friendships, specifically in terms of companionship, security, and helpfulness (Bauminger and Kasari 2000, Calder et al. 2013). Low friendship quality is associated, in turn, with greater loneliness and lower self-worth among children and adolescents on the autism spectrum (Bauminger et al. 2004, Whitehouse et al. 2009)—putting them at a greater risk for experiencing mental issues later in life. In fact, recent reports illustrate that individuals with ASD experience considerable mental health challenges throughout their lifespan (Benevides et al. 2020, Gotham et al. 2020, Jackson et al. 2018), and this is, in part, due to difficulties with friendship development earlier in life. Not only is there a bi-directional link between childhood social experiences and later mental health status in typically developing children, as mentioned above, these reciprocal associations over development are also true in children with ASD, although much more work has been done predicting mental health outcomes from friendships, rather than the other way around (Chiang and Gau 2016, Cotugno 2009). Hence, it is critical that we cultivate a greater understanding of how to help children with ASD develop and maintain strong, positive friendships within early and middle childhood to improve their social outcomes overall and resilience to later mental health challenges.

Individual characteristics, family factors, and environmental contextual features help to determine whether children with ASD will successfully develop and maintain friendships with their peers (Bauminger et al. 2010b, Calder et al. 2013). For example, studies examining children with ASD have documented the impact that sex has on friendship development (Dean et al. 2014, Sedgewick et al. 2016). Both girls and boys with ASD have fewer peer nominations and social relationships than their neurotypical peers, but boys with ASD are more overtly rejected by their peers than are girls with ASD (Dean et al. 2014).

Another important but less-studied child characteristic that may have an effect on friendship formation in children with ASD is self-regulation—the ability to control, monitor, and manage emotion, cognition, and behavior for the purposes of pursuing a goal (Blair and Diamond 2008, Kopp 1982, Robson et al. 2020). Self-regulation has been conceptualized as an overarching construct that includes control over a variety of processes, such as emotional experiences and expressions (i.e. emotion regulation), cognitive processes (i.e. executive function), and approach/withdrawal behavior (i.e. effortful/behavioral control (e.g. Jahromi 2017). Individuals may exhibit adaptive responses to environmental stimuli, which helps them to successfully accomplish a goal, or they may respond with maladaptive behaviors, which interfere with accomplishing a goal. In typical development, children show evidence of self-regulation as early as five months-of-age (Stifter and Braungart 1995) and become increasingly sophisticated and effective at using emotion regulation strategies with age (e.g. Morris et al. 2011). As described in the conceptual framework outlined in Mazefsky et al. (2013), children with ASD may experience a limited capacity to regulate their emotions and behaviors due a host of factors associated with the ASD phenotype related to self-regulation (i.e. cognitive inflexibility, differential information processing, perseveration, atypical neural circuitry) and mental health symptoms (i.e. psychiatric conditions such as mood and/or anxiety disorders). Together, these factors make students with ASD more susceptible to episodes of dysregulation than their typically developing peers (Mazefsky et al. 2013). Studies have documented that young children with ASD are less likely to use adaptive self-regulatory strategies and tend to express more negative affect than their non-spectrum peers (e.g. Jahromi et al. 2012, Konstantareas and Stewart 2006, Nuske et al. 2017). Difficulties with self-regulation are common in ASD; a population-based sample identified emotion regulation problems in 74% of children with ASD, compared with 42% in children with intellectual disability and 18% of typically developing children (Totsika et al. 2011). In fact, research suggests that difficulty with emotion regulation may be a core feature of ASD (Mazefsky et al. 2013, Mazefsky and White 2014, Prizant et al. 2006). Difficulties with the cognitive and behavioral aspects of self-regulation in children with ASD have been well-documented in the research literature (e.g. Bachevalier and Loveland 2006, Geurts et al. 2004, Gilotty et al. 2002, Gomez and Baird 2005, Jahromi 2017, Loveland 2005).

In both typical development and individuals with ASD, the ability to self-regulate has been linked to a host of positive outcomes, including better mental health (e.g. less anxiety and depression), decreased problem behavior (e.g. aggression) and higher academic achievement (Ashburner et al. 2010, Bauminger et al. 2010a, Berthoz and Hill 2005, Duckworth and Carlson 2013, Gross and Muñoz 1995, Mischel et al. 2010, Ponitz et al. 2009, Rieffe et al. 2011, Robson et al. 2020, Trentacosta and Izard 2007, Villavicencio and Bernardo 2013). Additionally, in children with ASD, recent evidence suggests self-regulation difficulties are bi-directionally linked to cognitive development (Nuske et al. 2020). In typically developing children, self-regulation skills have been linked to positive social outcomes (Berkovits and Baker 2014, Blair et al. 2015, Chang et al. 2012, Chervonsky and Hunt 2019, Dollar and Stifter 2012, Spinrad et al. 2006, Spritz et al. 2010). In children with ASD, initial evidence suggests that self-regulation predicts later social skills (Berkovits et al. 2017) and less social impairment (Goldsmith and Kelley 2018). However, less is known on how self-regulation and symptoms of mental health challenges affect social relationship (e.g. friendship) outcomes. To our knowledge, no research has examined how they affect friendship formation, maintenance or quality, or loneliness in children or adolescents with ASD (though work has begun on this topic in adults; see Mazurek 2014).

The aim of this exploratory study was to examine the impact of self-regulation difficulties and symptoms of mental health challenges (externalizing and internalizing behavior) on friendship quality and loneliness in school-age children with ASD. Based on the aforementioned literature from typical development (e.g. Berkovits and Baker 2014, Blair et al. 2015, Chervonsky and Hunt 2019) and adults with ASD (Mazurek 2014), our main working hypotheses were that: 1) friendship quality would be negatively associated with self-regulation difficulties and symptoms of mental health challenges, and 2) loneliness would increase with self-regulation difficulties and symptoms of mental health challenges.

Methods

Setting

The current study comprised a secondary analysis from a larger randomized controlled trial (et al., 2016). Study participants from the original study included school-aged children with ASD recruited across four sites (Los Angeles, Baltimore, Ann Arbor, or Seattle) over the course of two years. The trial was registered (clinical.trials.gov) and approved by each site’s Institutional Review Board. Families gave written consent and children assented. The sample comprised of children who were randomized into the two intervention conditions (ENGAGE vs SKILLS; see Kasari et al. 2016 for intervention and randomization details). The children included in this study had a diagnosis of ASD and an IQ of at least 65 (confirmed by the abbreviated Stanford Binet-5; Roid 2003; i.e. children were moderately to high functioning), were between the ages of 5 and 12 years, in elementary school (grades 1–5), and educated in a general education classroom for a minimum of 80% of the school day (due to the focus of the larger study context of an intervention focusing on social skills with typical peers (Kasari et al. 2016). More than half of children were of ethnic/racial minorities. See Table 1 for participant characteristics.

Table 1.

Participant characteristics.

    Frequency % Mean SD
Gender Female 18 17.0    
  Male 88 83.0    
Age Years     8.11 1.50
Grade 1st 20 18.9    
  2nd 30 28.3    
  3rd 23 21.7    
  4th 11 10.4    
  5th 13 12.3    
  Missing/not reported 9 8.5    
IQ ABIQ     89.73 15.46
SCQ Autism symptom severity     15.6 7.47
Ethnicity African American 8 7.5    
  Caucasian 39 36.8    
  Hispanic 17 16.0    
  Asian 24 22.6    
  Other 5 4.7    
  Missing/not reported 13 12.3    
Site Los Angeles 46 43.4    
  Baltimore 33 31.1    
  Ann Arbor 8 7.5    
  Seattle 19 17.9    
Mother’s education Less than 7th grade 3 2.8    
  Junior High 4 3.8    
  Some High School 3 2.8    
  High School Graduate 10 9.4    
  Special training after high school 6 5.7    
  6 = Some college 15 14.2    
  7 = College Graduate 39 36.8    
  8 = Graduate/professional training 21 19.8    
  Missing/not reported 5 4.7    
Family income Less than $10,000 5 4.7    
  $10,000–$15,000 9 8.5    
  $15,000–$20,000 3 2.8    
  $20,000–$25,000 6 5.7    
  $25,000–$30,000 2 1.9    
  $30,000–$35,000 3 2.8    
  $35,000–$40,000 1 0.9    
  $40,000–$45,000 3 2.8    
  $45,000–$50,000 4 3.8    
  $50,000–$55,000 9 8.5    
  $60,000–$65,000 1 0.9    
  above $60,000 50 47.2    
  Missing/not reported 10 9.4    
BRIEF (T1) BRI     64.25 11.07
  Emotional control     60.28 10.75
  Inhibit     61.12 11.10
  Shift     66.64 12.48
BASC (T1) Externalizing problems composite     156.35 25.82
  Aggression     52.05 9.95
  Hyperactivity     54.98 10.97
  Conduct     49.37 8.60
  Internalizing problems composite     160.82 26.92
  Depression     57.15 11.41
  Anxiety     54.37 12.96
  Somatization     49.65 9.69
FQS (T2) Companionship     13.31 4.16
  Help     15.11 5.35
  Security     13.87 4.16
  Closeness     18.82 4.16
  Confidence     8.33 3.64
CLS (T2) Loneliness     38.81 14.50
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Note. ABIQ = Stanford Binet Abbreviated IQ; BASC = Behavior Assessment System for Children; BRI = Behavioral Regulation Index (BRIEF sub-scale); BRIEF = Behavior Rating Inventory of Executive Function; FQS = Friendship Quality Scale; LS = Loneliness Scale; SCQ = Social Communication Questionnaire (SCQ; Rutter et al. 2003); T1 = Time 1; T2 = Time 2, 4–5 months after T1.

Recruitment

The eligibility criteria were explained to school personnel, who identified potential students for the study. A recruitment packet to the parents of the potential students was sent home. Once parents returned the signed consent forms to the school, the research team communicated directly with the parents to commence study participation.

Participants

In total, 106 participants of the 148 from the original study were included in the present study (34 had missing outcome measures, one had missing Autism Diagnostic Observation Schedule (ADOS; Lord et al. 1999) data, (we were unable to verify ASD diagnosis), and seven did not meet criteria for ASD on the ADOS. Compared to the included participants, the sub-group with missing outcome measures were more likely to be from the Baltimore or Seattle sites (χ2 = 33.73, p < .001), and had a higher IQ, though their mean was still within the average range (t = −1.989, p = .049; included M [SD] = 89.73 [15.46]; missing outcome measures = 95.97 [17.96]). See Table 1 for participant characteristics.

Measures

Friendship quality

Friendship quality was measured using the Friendship Quality Scale (FQS; Bukowski et al. 1994), in which children report on the extent to which the statements are true regarding the quality of their friendship with their best friend, ranging from 1 (not at all true) to 5 (really true). The FQS has 23 items across five subscales, with the first four measuring positive aspects of friendship quality: 1) companionship (i.e. “Sometimes my friend and I just sit around and talk about things like school, sports, and things we like”), 2) help (i.e. “If other kids were bothering me, my friend would help me”), 3) security (i.e. “If there is something bothering me, I can tell my friend about it even if it is something I cannot tell to other people”), and 4) closeness (i.e. “I think about my friend even when my friend is not around”). The fifth sub-scale measures one negative aspect of friendship quality, conflict (i.e. “I can get into fights with my friend”). Internal consistency reliability of the measure for our sample was moderate to high across sub-scales (Companionship α = .72; Help α = .71; Security α = .53; Closeness α = .73; Conflict α = .57).

Loneliness

Loneliness was measured using the Asher Children’s Loneliness Scale (CLS; Asher et al. 1984). The CLS is a 24-item self-report questionnaire that measures feelings of loneliness and social dissatisfaction in children. Sixteen of the 24 survey items assess feelings of loneliness, social dissatisfaction, and/or evaluations of the child’s social status in reference to their peers (e.g. ‘I have lots of friends’). The remaining eight items are filler questions designed to allow the child to become comfortable with the structure of the measure (e.g. ‘I like playing board games a lot’). Items are measured on a 5-point Likert scale (1= always true, 5= not at all true). A total loneliness score is derived by reverse coding negatively phrased items and summing the responses to the loneliness-related items. Responses to the hobby items are not included in the total score. Higher scores indicate greater feelings of loneliness and social dissatisfaction. For the current study, participants with ASD completed the measure. Internal consistency reliability of the measure for our sample was high (α = .87).

Self-regulation

Self-regulation was measured with selected sub-scales of the BRIEF, the Behavioral Regulation Index, and its subscales: Emotion Control, Inhibit, and Shift. The BRIEF (Gioia et al. 2000) is a standardized, empirically validated caregiver/teacher questionnaire designed to measure executive functioning behaviors for children aged between 5 and 18 years. The questionnaire is composed of 86 questions in total, scored on a 3-point Likert scale: 1 = never, 2 = sometimes, 3 = often, and produces T scores per sub-scale (M = 50, SD = 10). Higher scores indicate more difficulties. For the current study, caregivers completed this questionnaire. Although this measure was originally validated using samples of typically developing children and children with ADHD, the BRIEF has been widely used to measure executive functioning in children with ASD, and has been found to be effective in detecting executive dysfunction in this population (Gilotty et al. 2002, Gioia et al. 2002, Kenworthy et al. 2005, Rosenthal et al. 2013). Internal consistency reliability of the measure for our sample was high (Behavioral Regulation Index α = .93; Emotion Control sub-scale α = .87; Inhibit sub-scale α = .87; Shift sub-scale α = .79).

Internalizing and externalizing problems

Internalizing and externalizing problems, symptoms of mental health challenges, were measured with selected sub-scales of the Behavior Assessment Scale for Children, Second Edition (BASC-2; Reynolds and Kamphaus 2004). The BASC-2 was used because data were collected prior to the release of BASC-3. The BASC-2 is an individually administered behavior rating scale that helps to identify emotional and behavioral difficulties in children. It assesses for both internalizing (depression, anxiety, and somatization) and externalizing (aggression, hyperactivity and conduct) problems. Items are scored on a 4-point Likert scale: 0 = never, 1 = sometimes, 2 = often, and 3 = almost always. T scores for each sub-scale are produced; higher scores indicate more difficulties. For the current study, teachers completed this measure to assess functioning in the school setting. Internal consistency reliability of the measure for our sample was low to high (Internalizing scale α = .63; Depression sub-scale α = .21; Anxiety sub-scale α = .21; Somatization sub-scale α = .51; Externalizing scale α = .77; Aggression sub-scale α = .75; Hyperactivity sub-scale α = .03; Conduct sub-scale α = .85).

Autism symptoms

Children were included in the current study if they had an ASD diagnosis confirmed by trained (i.e. research-reliable) clinicians using the Autism Diagnostic Observation Schedule (ADOS; Lord et al. 2000), a semi-standardized play assessment of ASD symptoms. In addition, the Social Communication Questionnaire (SCQ; Rutter et al. 2003) was administered to parents. The SCQ is a 40-item questionnaire used to evaluate social communication and social functioning in children four years and older. The SCQ yields a total score, with a recommended cut-off score of 15 or greater indicating possible ASD.

Data analysis

Variables were analyzed for skewness, kurtosis and outliers. As all variables of interest were normally distributed, parametric analyses were conducted. Linear regression models were conducted to examine the impact of self-regulation (BRIEF sub-scales) and symptoms of mental health challenges (BASC sub-scales), measured at time 1, on friendship quality (FQS sub-scales) and loneliness (CLS), measured at time 2, four to five months later. We examined bivariate associations between dependent variables and potential covariates, including age, gender, IQ, ASD symptoms (SCQ total score), site and intervention group. Significant covariates that were bivariately associated in reduced models (only the covariates included) with the dependent variables (FQS sub-scales and CLS) at p <. 2 (gender, site and intervention group) were included in the corresponding BRIEF and BASC regression models, as per Hosmer and Lemeshow (2000). Due to the exploratory nature of this study and to avoid the issue of multi-collinearity across BRIEF and BASC sub-scales, regression models were run separately for each predictor variable with the corresponding covariates (i.e. sub-scale scores were not entered into the same model). Zero-order correlations amongst all continuous variables are also reported in the supplementary material.

Results

Friendship quality and self-regulation difficulties/symptoms of mental health challenges

Less frequent self-regulation difficulties (all BRIEF sub-scales) at Time 1 predicted stronger companionship with best friends at Time 2 (Behavioral Regulation: b = −.35, t = −2.79, p = .007, 95% CI [-.59, −.10]; Emotional control: b = −.29, t = −2.19, p = .03, 95% CI [−.52, −.02]; Inhibit: b = −.33, t = −2.48, p = .02, 95% CI [−.60, −.06]; Shift: b = −.38, t = −3.09, p = .003, 95% CI [−.60, −.13]). Self-regulation difficulties also explained a significant proportion of variance in companionship scores (Behavioral Regulation: R2 = .18, F = 5.73, p = .006; Emotional control: R2 = .14, F = 4.15, p = .02; Inhibit: R2 = .16, F = 4.80, p = .01; Shift: R2 = .20, F = 6.62, p = .003).

More frequent aggression at Time 1 predicted more interpersonal conflict with children’s best friends at Time 2 (b = .23, t = 2.12, p = .04, 95% CI [.01, .43]), however aggression did not explain a significant proportion of variance in conflict scores (R2 = .05, F = 2.26, p = .11). Symptoms of mental health challenges (internalizing or externalizing problem) did not predict any aspects of friendship quality. See Table 2 for all standardized regression coefficients.

Table 2.

Linear regression models predicting friendship quality and loneliness from self-regulation difficulties and mental health challenges.

  Outcomes
  Friendship Quality Scale
CLS
  Companionship Conflict Help Security Closeness Loneliness
BRIEF            
  Behavioral Regulation            
   Emotional control −.29* −.15 −.14 −.09 −.06 .11
   Inhibit −.33* .11 .03 −.04 −.13 −.01
   Shift −.38** .01 −.25# .22 −.18 .16
BASC            
  Externalizing            
   Aggression .04 .23* −.02 .08 −.03 .17
   Hyperactivity .06 .10 −.09 .04 .03 .19
   Conduct Problems .11 .10 −.08 −.08 .01 .22#
  Internalizing            
   Depression −.09 .16 −.01 .02 −.01 .25*
   Anxiety .03 −.02 .11 .08 .04 .04
   Somatization −.07 .03 −.04 .04 .02 −.01
Covariates            
Child Characteristics            
  Autism severity (SCQ) −.13 −.12 −.04 −.13 −.13 .05
  IQ −.09 −.12 .08 .01 .07 −.11
  Age −.08 −.11 −.08 −.12 .13 −.02
  Gender (0= Female, 1= Male) 83% Male −.36*** −.02 −.31** −.23* −.27** .15
Study Characteristics
  Site (reference = Los Angeles)
   Baltimore −.16+ −.23* −.07 −.17+ −.13 −.20+
   Ann Arbor −.20# −.09 −.07 −.05 .03 −.04
   Seattle −.05 −.09 . 25* .01 .13 −.05
  Intervention < −.01 −.06 −.02 −.15+ −.16+ .01
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Note. Standardized beta coefficients shown above. BASC = Behavior Assessment Scale for Children; BRIEF = Behavior Rating Inventory of Executive Function; CLS = Children’s Loneliness Scale; Intervention = ENGAGE vs. SKILLS (see Kasari et al. 2016 for more details); Site = Los Angeles, Baltimore, Ann Arbor, or Seattle; SCQ = Social Communication Questionnaire. For all BASC and BRIEF scales, the Conflict scale of the Friendship Quality Scale and the Loneliness scale, higher scores indicate more difficulties. In order to determine which covariate to include on each regression model, covariates as shown above were first tested in reduced models (with only the covariates included). As per Hosmer and Lemeshow (2000), the Friendship Quality Scale sub-scales and Children’s Loneliness Scale that were associated with covariates at p <. 2 (gender, site and intervention group), those significant covariates were adjusted for in the final BRIEF and BASC models. Each BRIEF and BASC sub-scale was entered, with the appropriate covariates, in separate regression models. ***p < .001, **p < .01, *p < 0.05, # p <.1, +p <. 2 (latter for covariates only as per Hosmer and Lemeshow 2000).

Loneliness and self-regulation difficulties/mental health symptoms

As shown in Table 2, more frequent depression symptoms measured with the BASC-2 in the children with ASD at Time 1 predicted greater feelings of loneliness at Time 2 (b = .25, t = 2.13, p = .04, 95% CI [−.02, .47]), however depression did not explain a significant proportion of variance in loneliness scores (R2 = .12, F = 1.87, p = .11). Self-regulation difficulties did not predict loneliness.

Friendship quality/loneliness and other child characteristics

Girls with ASD had stronger companionship (b = −.36, t = −3.80, p < .001, 95% CI [.55, .17]), security (b = −.23, t = −2.35, p = .02, 95% CI [−.45, −.04]), and closeness (b = −.27, t = −2.85, p = .005, 95% CI [−.48, −.09]) with their best friend, and rated their best friend as more helpful (b = −.31, t = −3.14, p = .002, 95% CI [−.51, −.12]) than did boys with ASD. ASD symptoms, IQ, and age were not associated with any aspects of friendship quality or with loneliness. See Table 2 for all standardized regression coefficients.

Discussion

The aim of the present study was to explore the impact of self-regulation difficulties and symptoms of mental health challenges (externalizing and internalizing behavior) on friendship and loneliness in school-age children with ASD. We found that children with ASD who have less self-regulation difficulties have higher quality companionship, indicating that using adaptive self-regulatory behaviors to successfully regulate emotions, cognitions, and behaviors affords children the psychological availability to connect with their best friends in a meaningful way. This study is the first to demonstrate a link between self-regulation and friendship in children with ASD, extending previous research showing this link in typically developing children (e.g. Berkovits and Baker 2014, Chang et al. 2012, Spinrad et al. 2006).

Interestingly, self-regulation predicted companionship in the children with ASD, but not the other aspects of their friendships measured (help, security, closeness, and conflict). This finding may reflect children’s preferences for sustained interactions, like those on which companionship is built, with others who express positive emotions (Halberstadt et al. 2001). By contrast, the need for self-regulation during other types of interactions with friends, such as those focused on gaining help or a sense of security, may not be as crucial. Further research is needed to elucidate this issue.

Children with ASD with more frequent teacher-reported aggression had greater interpersonal conflict with their best friends. This finding is consistent with previous work with children with ASD showing an association between higher self-control and decreased conflict on play dates (Frankel et al. 2010). Children with ASD who experienced more frequent teacher-reported depression symptoms had more loneliness in our study. This finding accords with a large body of work on depression in typical development (for review, see Heinrich and Gullone 2006) and is consistent with previous work in ASD (e.g. Mazurek 2014, Pouw et al. 2013). Given the established link between depression and self-regulation difficulties in ASD (e.g. Mazefsky et al. 2013, Pouw et al. 2013), this finding again underlines the significance of targeting self-regulation and mental health in interventions for school-aged children with ASD, which may indirectly support friendship development and prevent loneliness. However, given the exploratory nature of this study, large number of variables explored, and non-significance of the variance explained, these findings warrant replication before any strong conclusions may be drawn.

The main results of an association of less self-regulation difficulties promoting higher companionship between the best friends reflects a the broader phenomenon of the inherent link between intrapersonal wellbeing promoting interpersonal wellbeing (Kitayama and Markus 2000), and broader still, between self-regulation and wellbeing (Chervonsky and Hunt 2019, Singh and Sharma 2018, van Genugten et al. 2017), given the background of the large body of research on self-regulation and positive outcomes (Duckworth and Carlson 2013, Mischel et al. 2010, Ponitz et al. 2009, Robson et al. 2020).

Some programs that have demonstrated success in targeting self-regulation and mental health in children with ASD include cognitive behavior therapy adapted for ASD (for review, see Keefer et al. 2018, Lake et al. 2020, Perihan et al. 2020), mindfulness-based interventions adapted for ASD (e.g. Hwang et al. 2015, Ridderinkhof et al. 2018), and self-regulation specific programs (Conner et al. 2019, Lee et al. 2019, Rispoli et al. 2019, Thomson et al. 2015). These programs have been tested only in home or in clinics, however (Reyes et al. 2019). To increase access, these programs could be delivered at school (Atkins et al. 2003). Many universal and targeted school-based programs incorporate cognitive, behavioral and/or mindfulness approaches for typically developing children, as we and others have found, there are few programs adapted for the unique support needs of children with ASD (Cannon et al. 2011, Christner et al. 2007, Durlak et al. 2011, Phan et al., under review; Taylor et al. 2017).

Although not within the scope of this study, there is also an emerging body of research demonstrating how peers can support self-regulation in children with ASD, such as acting as peer supports in educational settings or models for teaching self-regulation skills and appropriate behaviors (Jahromi et al. 2013, Kayne 2013, Pierce and Schreibman 1995, Weiss 2014). The link between self-regulation and friendship development may be bidirectional and needs further research. For example, some peer-mediated social-skills interventions have shown positive effects on friendship development; Kasari et al. (2016) found increased peer engagement and decreased isolation during school recess in children with ASD who took part of an intervention targeting social skills.

Autism symptoms, IQ and age were not associated with any aspects of friendship quality or with loneliness in our study, which contrasts with other research on children with ASD that has identified these links (Bauminger et al. 2010b, Bauminger and Kasari 2000, Lieb and Bohnert 2017). Our results call into question the consistency of these findings. We did find, consistent with previous research, that gender was associated with many aspects of friendship quality in our children with ASD. Girls had better quality friendships with their best friend in terms of companionship, helpfulness, security and closeness (Sedgewick et al. 2016, 2019). Factors such as earlier language development and the ability to integrate both nonverbal and verbal behaviors may be advantageous to girls with ASD in terms of friendship development (Hiller et al. 2014, Wallentin 2009). Girls show more social motivation when seeking friendships, often at levels similar to their peers without ASD (Cook et al. 2018, Dean et al. 2014, Sedgewick et al. 2016) and also present with greater skills in social and emotional reciprocity and empathy (Head et al. 2014, Hiller et al. 2014, Kreiser and White 2014, Sedgewick et al. 2019). In contrast to previous research, girls in the present study did not report significant conflict within their friendships; this is likely attributable to the age group investigated, as the theme related to conflict was most apparent among adolescent females (Head et al. 2014, Kreiser and White 2014, Sedgewick et al. 2016, 2019).

Limitations

This study is not without limitations. First, the sample included 5-12-year-old children with ASD with IQs > 65, and therefore, cannot address the association of self-regulation with friendship and loneliness outcomes in children with ASD who exhibit significant cognitive or language delays as well as preschool children and adolescents with ASD. Minimally verbal children with ASD have recently been found to have more self-regulation difficulties than children with ASD without delays (Nuske et al. 2020), hence should be a focus of future research. Second, the measurement of friendship quality and loneliness was completed by children with ASD and we cannot verify how realistic or self-reflective they were in their evaluations of their own friendships (Foley Nicpon et al. 2010). Therefore, future research should include another means of measurement, for example, by a different reporter via child observations. Third, although friendship quality was the focus of the current study, future research should include friendship network size, which has been found in previous research to be linked to loneliness in adults with ASD (Mazurek 2014). Fourth, some of the BASC sub-scales (Depression, Anxiety, and Hyperactivity) and FQS sub-scales (Security, Conflict) had low internal consistency reliability. This likely reflects that children with ASD were not included in the development of the measures and have not been validated with children with ASD, and, for the BASC sub-scales, is further evidence of the difference in such mental health symptoms in ASD as compared to non-ASD children, as reported elsewhere (e.g. Kerns et al. 2014). Nevertheless, results using these sub-scales warrant further scrutiny. Fifth, given the that this study was embedded in a larger study comparing two social skills interventions for children with ASD, no data from matched non-ASD comparison group was collected, and thus we cannot generalize our pattern of results to non-ASD populations. Future research should aim to include such comparison groups in order to assess the generalizability of these findings. Finally, as data were taken from a convenience sample, there might be some differences between those caregivers who decided to participate in the intervention study and those who felt their child did not need an intervention or for any other reason chose not to participate in the study.

Conclusion

The findings show that self-regulation skills promotes companionship and highlights the critical need of addressing self-regulation difficulties in children with ASD in schools in order to promote their development of meaningful peer relationships.

Acknowledgements

The information or content and conclusions are those of the authors and should not be constructed as the official position or policy of, nor should an endorsement be inferred by HRSA, HHS, NIH, or the U.S. government. First and foremost, the authors would like to thank the teachers, children, and parents who participated in this work.

Funding Statement

This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under award number UA3MC11055, the Autism Intervention Research Network on Behavioral Health. Dr. Nuske’s work on this study was partially supported by the National Institute of Mental Health (NIMH), under award number K01MH120509.

Disclosure statement

No potential conflict of interest was reported by the author(s).

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