Abstract
Increasingly research is highlighting the differences between autistic and neurotypical (NT) emotional development. Cibralic et al (2019) conducted a systematic literature review around emotional regulation (ER) and autism, highlighting clear differences to NT development.
Background
“…70.8% of [autistic] children had at least one current psychiatric disorder…”
(Simonoff et al. 2008 p. 926)
A higher prevalence of mental health difficulties for autistic people has been demonstrated, we need to ask ourselves why. We know autism is diagnosed when difficulties lie across two areas, namely social communication/interaction and restricted/repetitive behaviours (American Psychiatric Association, 2013). Adults on the spectrum of describe life in a NT world using words such as lonely, challenging and stressful. This observation is often used as a causal hypothesis to explain the increased chance of a mental health difficulty. Anxiety is commonly reported by autistic people, many describing a constant feeling of flight or fight as their body responds to their struggles to identify what is safe. The diagnostic criterion refers to a ‘deficit in social-emotional reciprocity’, for example ‘reduced sharing’ of emotions. The focus reads primarily as though the differences in emotions stem from the difficulties with social interaction/communication.
For a number of years now I have worked with children and young people in a specialist school for those with an autism diagnosis. I have seen first-hand the effect anxiety can have, and the challenge it can present, for example when trying to engage with learning and in social interactions. Over the years, I have seen the benefits of offering explicit teaching, and learning to improve emotional literacy for autistic children and young people. Developing their understanding of their own emotional states, as well as the emotional states of those around them.
The question I would like to ask is, should this difference in emotional literacy and understanding be more readily recognised for autistic individuals? Maybe this could help to reduce the frequency and distress those affected by mental health difficulties in the long run?
Main content
First let’s take a brief moment to consider normative development; it is known that facial recognition plays a significant role in learning about emotions (Sroufe, 1996). When Gaigg (2012) reviewed the literature around autism and emotions, he highlighted autistic individuals show difficulties in facial recognition. It is not unreasonable then to suggest that an autistic individual does not follow the same path for their emotional development as a NT individual. Gaigg suggests that the difference in the way they process faces impacts on their ability to understand the emotional expression of others, and consequently their ability to learn about their own emotions. Unlike previous reviews, Gaigg’s review included functional brain imaging based research, and showed there were observable differences in brain function around the facial recognition of emotion. When observing solely for behavioural differences, a difference was often not seen (despite the underlying difference in brain function). This observation suggests that perhaps the individuals had perhaps developed coping strategies that masked the impact on them of the observed functional brain imaging differences.
If we therefore accept a difference in emotional development, we need to consider what this means for the autistic population, and why it may lead to an increased prevalence in mental health difficulties. Cibralic et al (2019) proposed that emotional regulation may be a factor at play, and reviewed the research around emotion regulation (ER) and autism. Identifying differences in ER could offer specific strategies that could improve the well-being of the autistic population longer term. By ER they mean the ability to ‘monitor, evaluate and modify one’s emotional state’.
As we have already highlighted, there is a difference in the way someone with autism learns about their emotions, therefore, I think it stands to reason that ER may also be affected in autistic individuals. Cibralic et al (2019) found evidence that the research suggests that children with ASD had poorer ER than typically developing peers. They are more likely to employ simpler strategies, for example verbal reasoning was less effective (most likely linked to their ability to understand language). Their findings support the idea that ER development is delayed in autistic children.
The focus of Cibralic at al’s (2019) review was to identify the benefit of early intervention, using the inclusion criterion of children aged 12 to 72 months. It would be interesting to review how and if differences remained or changed overtime. Is the development of ER skills simply delayed or does it track an entirely different path for those with autism? Cibralic et al reflect that their findings cannot be assumed to remain throughout their lives. Whilst they cannot state this difference in ER is a direct link to the elevated rates in mental health difficulties, they do propose that increasing our understanding of ASD may help find a way to reduce the rates. They do suggest that ER difference may be a risk factor, and that early intervention would be helpful.Further research is needed to assess whether better ER strategies support better mental health outcomes for autistic individuals. Cibralic et al (2019) recognises that the research into this area is in its infancy, with only 15 articles meeting the inclusion criterion. There is scope for this to extend in the future, and I hope it might further solidify the importance of improving ER through early intervention to improve well-being for the autistic population. One direction for future research would be to focus on what helps, what style of support is beneficial in developing supportive ER strategies for the autistic population? Cibralic et al (2019) highlight important differences in the ER skills of autistic young people, but it is clear there is a need for future research to develop strategies for early intervention and improve the mental health outcomes for the autistic population.
Going forward
The current criterion for an ASD diagnosis span difficulties across two areas (American Psychiatric Association, 2013). What I would like to suggest, and the research to date supports, is that perhaps we need to consider including greater emphasis on the differences in emotional understanding or development? This could be, similar to the acknowledgment of sensory differences being common in autism.
Gaigg (2012) suggests that ASD is a different developmental path that occurs when an infant experiences differences in the interplay between emotion and cognition at a very young age. If emotion and cognition are both so central to the differences presented in ASD should this have greater emphasis at the early diagnostic stage.
The reason that I feel there could be benefit from these changes is the impact it could have on people’s perception and focus in supporting autistic individuals. For example, I know a parent whose child recently received a diagnosis of autism. The first advise and support they have been given focusses on the dyad; supports for developing social interaction and around inflexibility of thought. There is far less focus on emotional understanding of the young person. If, at this early stage of support there was advice around emotional development, not only would it increase the parents understanding, but also it would ensure more effective early intervention. I also find this interesting as without an individual being able to regulate their emotion states, how can they engage with learning around their social communication? In many cases individuals will not be able to make the desired progress on their social communication because they are unable to understand their emotional states. The research outlines an evidence base that helps to explain a difference in the development of emotions in the autistic population, however our practice has not caught up.
The children with whom I work each have an Education and Healthcare Plan (EHCP). The professionals writing these plans are well versed in documenting the need for speech and language therapy and increasingly occupational therapy. However, often there can be a complete lack of reflection of the need for these children to learn about their emotions or the emotions of others. Similarly I have observed a lack of focus on learning needed around their emotion regulation skills. This is something that we are striving to amend for those accessing our provision, but really, there is a need for systemic changes to improve everyone’s understanding. The hope would then be that over time, with more consistent supports in place, we would see a reduction in the prevalence of mental health difficulties
Conclusion
There is more research needed to truly support this change, however I believe it is such an important step forward, which could improve the well-being of the autistic population in the future. When I say this, I do not want to sound like I am approaching things from a ‘medical-curative’ approach, and that we need to change or cure people with autism. Instead it is my hope that we can develop approaches that support people with autism to learn about their emotions, in a way that is most natural to them, in order to avoid significant mental health difficulties later in life.
Caption text: Autism is increasingly being viewed as transactional, and with the right supports and approaches we can make a positive impact.
Conflict of interest statement: The author declares no conflicts of interest in relation to this blog on clinical experience
Primary Reference
Cibralic S, Hohlhoff J, Wallace N, Mcmahon C and Eapen V (2019) A systematic review of emotion regulation in children with ASD Research in Autism Spectrum Disorders 68
https://doi.org/10.1016/j.rasd.2019.101422
Other References
American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders. 5th edn. Arlington: VA: American Psychiatric Publishing
Gaigg, S. B. (2012) The interplay between emotion and cognition in autism spectrum disorder: implications for developmental theory Frontiers in Integrative Neuroscience, 6 (113) pp. 1 – 35
https://doi.org/10.3389/fnint.2012.00113
Simonoff, E., Pickles, A., Charman, T., Chandler, S., Loucas T and Baird G. (2008) Psychiatric Disorders in Children With Autism Spectrum Disorders: Prevalence, Comorbidity, and Associated Factors in a Population-Derived Sample Journal of the American Academy of child and adolescent psychiatry 47 (8) pp. 921 – 929
https://doi.org/10.1097/CHI.0b013e318179964f
Sroufe, A. L. (1996) Emotional Development: The organization of emotional life in early years. Cambridge: Cambridge University Press
Discussion
Thank you for your article Jody, an important area for clinicians and educators to focus on.
Brilliant & timely article Jody & my sentiments exactly! I am a psychologist/psychotherapist & an independent practitioner. I work privately with children diagnosed ASD and my work focuses primarily on psychoeducation. Helping children to identify different emotional states initially in others – feelings faces & body language, then in themselves via social stories with personal questions.
I agree that this is an area of support that is lacking. It is a time consuming intervention but one that I believe will have very positive effects in the longer term both for children with ASDs and their parents, carers, educators & peers.
Hi,
I’m not sure how aware you or not, but a lot of what you are talking about is a condition known as a Alexithymia. Alexithymia is a personality dimension (common in people with ASD) that is characterized by difficulty labeling emotions, describing emotions, and externally oriented thinking. In a study done in 2005, researchers tested patients with High Alexithymia scores ability to accurately label negative and positive emotional facial expressions over 1 sec and 3 sec intervals. There were significant deficits in emotional labeling among HA patients in the 1 sec labeling and not 3 sec. Pairing this finding with the difficulty people with ASD face in making eye contact and it makes a lot more biological sense why people with ASD struggle in emotional development. I question your statement “They are more likely to employ simpler strategies, for example verbal reasoning was less effective (most likely linked to their ability to understand language).” As there are a number of studies out there that highlight Cognitive Behavioral Therapies effectiveness time patients with an IQ of 70 or higher. Additionally consider reviewing the work of Dr. Tony Atwood or Dr Judy Reaven, both of which promote use of CBT to treat patients with ASD and Anxiety or Depression. Comorbid psychiatric disorders in people with ASD have a lot more to do with schema than an employing simpler pathways. In addition to the work of CBT, I’d encourage patients to see a pediatric speech pathologist because they can increase language acquisition (or emotional language). Emotional development due to deficits in speech, ability to make eye contact inevitably leads to difficulty with social communication because so much of reading people is done in the face, eyes, and body language. If people with ASD make eye contact less frequently then they are learning to read social cues using very different senses like sound, or observation of body position. I’m not sure that difference in emotional development accounts for the higher comorbidity, rather negative schemas May have more to do with the higher prevalence.
Thank you Michael-I think it is happening in some places, but my experience is that it is often forgotten and not highlighted on EHCPs. I suppose practice is not always aligned with research. With greater emphasis at diagnosis perhaps it would be a focus for all.
I wish therapy was already doing this! A great article. This ties in with my clinical observations as both the mother of an (adult now) with ASD and a Child Psychiatrist working with children and their families. Much of the work that we did with my son was to teach him what emotions are and how to apply that vocabulary to himself as well as others – he was 11 and a half when he first showed empathy and an intuitive, rather than scientific analytical, understanding of sorrow – and I wept for joy (which really confused him – another teaching moment!)
You have put my thoughts into words!
Do you suggest any literature or emotional regulation curriculum that support this idea?