Motivation and emotion/Book/2020/Autism spectrum disorder and emotional regulation

Overview


""The emotional world on the spectrum can be very scary! Emotions are often, either turned off or coming on like a freight train! The emotions often come on without warning and are difficult to label and connect to a cause, which leaves the person unable to control them. You cannot control that which you cannot define, label, and understand."."

- (Larkey, n.d, p. 285.)

Modern society has been built for a neurotypical population leaving individuals with additional needs such as autism spectrum disorder (ASD) in an uncomfortable and overwhelming situation (see Figure 1). In a society built on the need for interactions and understanding peoples emotions, individuals with poor emotional regulation are often confused and misunderstood.

This chapter aims to explore this struggle between ASD and emotional regulation and assess the relationship between these two constructs. Through the exploration of emotion theories this chapter outlines how and why ASD impacts on emotional regulation. The chapter begins with outlining what ASD and emotional regulation is. Secondly, the relationship between ASD and emotional regulation is explored in relation to theories and research. Finally, techniques of how to support and encourage emotional regulation are identified.


 * What is autism spectrum disorder (ASD) and emotional regulation?
 * What is the relationship between ASD and emotional regulation?
 * What is the result of dysregulation for individuals with ASD?
 * How do theoretical frameworks suggest ASD impacts on emotional regulation?
 * What can be done to encourage and support emotional regulation?

Definitions
Autism spectrum disorder and emotional regulation are intertwined constructs that encompass a range of theory and research. Due to this it is important to gain an understanding of each term separately prior to evaluating their complex relationship.

What is autism spectrum disorder?


Autism spectrum disorder (ASD) is a neurodevelopmental disorder that is increasing worldwide. Within Australia, a study conducted in 2017 found that children born in 1999 to 2000 had a 2.4% prevalence rate of diagnosed ASD compared to a cohort of 2003 to 2004 of 3.9% (May et al., 2017). Within the DSM-5 (American Psychiatric Association, 2013) ASD is characterised by two core features:


 * 1) Deficits in social communication and social interaction: issues in understanding and interpreting nonverbal behaviours in others, relationship issues, and lack of enjoyment in social activities (Cotugno, 2009).
 * 2) Restricted, repetitive patterns of behaviour, interests or activities: preoccupation with narrow and rigid interests or ways of thinking, and communication deficits (Cotugno, 2009).

As seen through Figure 2, ASD encompasses a continuum of disabilities where each individual will have a different set of characteristics, challenges, and severity. It is also common for other neurodevelopmental disorders to co-occur with ASD as well as individuals to have struggles with intellectual impairment and/or language impairment.

What is emotional regulation?
Emotional regulation is an extensive, complex, and dynamic construct that's definition has caused much controversy overtime. A review by Djambazova-Popordanoska (2016) highlights that this debate has been centred around whether emotional regulation is something that occurs within a person or whether it is adaptation based off ones environment. Although there is debate and uncertainty surrounding the term, consensus throughout the literature describes emotional regulation as an individual's ability to manage, maintain, and adapt control of emotional states. A highly accepted definition of emotional regulation is from Thompson (as cited in Mazefsky et al., 2013, p. 680) describing emotional regulation as the “automatic or intentional modification of a person’s emotional state that promotes adaptive or goal-directed behaviour”. Building upon this Geller (2015) demonstrates that emotional regulation influences which emotions we have, when we have them, and how we experience and express them. It is also highlighted that the process of emotional regulation involves an individual's cognitive appraisal of the situation, physiological reaction, emotional expression (verbal or non-verbal), and past experiences. Thus, highlighting the complexity and collective processes involved in emotional regulation.

ASD and emotional regulation
Although not formally a part of an ASD diagnoses, the presence of emotional regulation difficulties is highly recognised in research, theory, and observations (Samson et al., 2014). Current literature has found that individuals with ASD have amplified emotional responses, poor emotional control, difficulties in understanding emotions in others, and difficulties understanding high emotion situations (Mazefsky et al., 2013). These examples of emotional dysregualtion have been found to lead to a range of behavioural difficulties including irritability, poor anger control, temper tantrums, self-injurious behaviour, aggression, and mood dysregualtion  (Samon et al., 2014). Hence, demonstrating the presence of emotional regulation deficits in ASD and the significant impact that this has on individuals.



Building upon this relationship, Samson et al. (2014) assessed the relationship between emotional dysregualtion and the DSM-5 characteristics of ASD. The study found that the core features of autism were significantly related to emotion dysregualtion, with the largest relationship found between emotional dysregualtion and repetitive behaviours (see Figure 3). This finding highlights not only the presence of emotional dysregualtion within ASD but an area of future research for the possibility of emotional dysregualtion  having an impact on the behavioural issues associated with ASD. However, future research is required in order to address the specificity between the found relationships as well as cross-sectional and longitudinal studies needed to assess if there are changes over a lifetime of the severity of the relationship. Although the study had a small sample size (56 participants with ASD) leading to the possibility that the found results are not comparable across the vastness of the spectrum, it does demonstrate a significant relationship between emotional regulation and ASD.

Furthermore, individuals with ASD have also been found to have differing coping strategies for emotional regulation in comparison to neurotypical peers. Konstantareas and Stewart (2006) uncovered that children with ASD had greater variability and less effective emotional regulation strategies compared to controls. Jahromi et al. (2012) assessed these differences further finding that children with ASD used greater venting and avoidance strategies and fewer constructive or instrumental strategies than neurotypical peers. As seen in Table 1 the findings highlight that children with ASD have less effective coping strategies than peers and thus demonstrates the impact that ASD has on emotional regulation.

Table 1.

Effect sizes (Cohen's d) for emotional regulation strategies between children with ASD and neurotypical children (adapted from findings from Jahromi et al., 2012)

Note: The effect size demonstrates the cohort with the higher use of a particular strategy in comparison to the other.

{Which one of the following is NOT associated with a ASD diagnoses? - a: issues with nonverbal behaviour - b: narrowed and rigid interests + c: issues with emotional regulation - d: restricted thoughts - e: lack of enjoyment in social activities
 * type="[]"}

{According to Jahromi et al. (2012) which of the following is an emotional regulation strategy that is used more by neurotypical children in comparison to children with ASD? + a: constructive and goal-directed strategies - b: venting - c: avoidance - d: resignation - e: vocalizations
 * type="[]"}

Theoretical frameworks
The clear relationship between ASD and emotional regulation has led to individuals proposing a range of theories into why and how this relationship exists. Due to this relationship being a growing area of interest, current theories are limited, leading to juxtaposing views and unclear conclusions. However, the current literature does suggest that the poor emotional regulation seen within the ASD population stems from cognitive, physiological, and neurological processes, demonstrating a combination of theories being proposed within the literature (White et al., 2014).

Cognitive theory: Process model of emotional regulation


One of the most recognised and developed models of emotional regulation is the process model by James Gross (Gross, 2002). This model views emotional regulation as a multicomponent and dynamic process between the individual and their context (Ying Cai et al., 2018). As seen in Figure 6 this model breaks down the process of emotional regulation into 5 strategies.

The 'cognitive change' component of the model has been of interest in relation to ASD. Due to this strategy including the ability to be cognitively flexible and have the ability to shift attention, it is a challenge for individuals with ASD (Berkovits et al., 2017). This challenge could hence reflect the poor emotional regulation that is seen within ASD population.

Furthermore, White et al. (2014) outlines that aspects of life that require emotional regulation are often unplanned, lack rules for how to handle the situation and require disengagement from the emotional trigger. These aspects are all challenges for individuals with ASD, making the appraisal of situations seen within the process model difficult and ultimately contributing to impaired emotional regulation.

 Sam is busy writing a story for school when his teacher continues to interrupt to show the class something new on the board. Sam begins to feel angry because this not only stops this concentration but wasn’t part of what the teacher said was going to happen.

Learning theory
 Although Sam struggles with stressful situations his teacher has started to give Sam a reward each time he uses an effective strategy to deal with his feelings. Through this Sam is learning ways to regulate his emotions.

The learning perspective of emotional regulation and ASD focuses on comparisons between neurotypical children and children with ASD. From this perspective typical emotional regulation skills are learnt automatically through social situations (Morris et al., 2007). However through the use of eye tracking studies, evidence has been found to suggest that the social deficits associated with ASD may interfere with this automatic process, leading to poor emotional regulation. A longitudinal study by Jones and Klin (2013) explored this theory, finding that by 6 months old, children who are later diagnosed with ASD have reduced eye contact. This highlights a key part of typical social development that is being missed, leading to the deficits seen later in life for emotional regulation.

Furthermore, the tendency for individuals with ASD too 'give up' due to poor emotional regulation has been found to be linked to learned helplessness. The significance of this relationship is demonstrated through the pivotal response treatment model, that accepts the relationship between failure and learnt helplessness and aims to maximise reinforcement after a child makes a reasonable attempt of treatment (Koegel & Koegel as cited in Jahromi et al.,2012). The success of this therapy to assist in behavioural change thus highlights the clear link between reinforcement learning principles and emotional regulation.



Biological theory
The biological perspective presents an inconclusive range of theories about emotional regulation and ASD. A review by White et al. (2014) highlights that the emerging view from this perspective is that individuals with ASD have neural anomalies that impact on downstream emotional regulation impairments. Although consensus on the exact deficits is lacking the current literature suggests that the challenges are associated with an overlap of deficits in the medial prefrontal cortex, amygdala, cingulate cortex, and orbitofrontal cortex.

The amygdala (Figure 7) is one of the most researched areas within this complex relationship. Dalton et al. (2005) assessed the functional brain activity of ASD individuals during emotional facial discrimination tasks and found that individuals with ASD showed greater activation in the amygdala than a control group. Due to this it is proposed that the struggles seen between ASD and emotional regulation is associated with an over arousal in limbic regions such as the amygdala. This over activation of the amygdala has also been linked to increased autistic symptom severity, demonstrating a clear link between ASD and the amygdala (White et al., 2014).

 Sam’s parents take him to the doctor due to worries about his behaviour. The doctor runs some tests and explains to his parents that Sam’s amygdala has greater activity than others his age which is why he struggles with emotional regulation.

{Which strategy of the process model of emotional regulation is the most difficult for individuals with ASD? - situation selection - attentional deployment - response modulation + cognitive change - situation modification
 * type="[]"}

{Which of the following is associated with the biological theories of emotional regulation and ASD? - medial prefrontal cortex - cingulate cortex - orbitofrontal cortex - amygdala + all of the above
 * type="[]"}

Consequences of poor emotional regulation in ASD
A study by Ying Cai et al. (2018) identities that adaptive emotional regulation strategies lead to reduced negative affect, improved memory, diminished cardiac reactivity, and lower levels of anxiety and depression. Above and beyond this the capacity in which children have to regulate their own emotions, has been found to play an important role in children's school engagement and achievements within the school environment (Djambazova-Popordanoska, 2016). In comparison due to individuals with ASD having poor emotional regulation strategies, research suggests that this has led to a range of difficulties and challenges within day to day activities.

Meltdowns
"He has very fixed ideas with what he wants and if something isn’t exactly how he wants it he can have huge meltdowns just the slightest thing like the internet going off for a couple of minutes can produce huge violent outbursts" (Pru as cited in Montaque, Dallos, & McKenzie, 2018, p.129)



A meltdown (see Figure 4) is a common behavioural response to poor emotional regulation, seen within children with ASD. A meltdown is similar in resemble to a tantrum but is longer in duration, more intense and potentially physically and emotionally dangerous (Montaque et al., 2018). A study by Mazefsky et al. (2013) highlights that meltdowns are a strong indicator for impaired emotional regulation. However, empirical research on meltdowns and emotional regulation is limited demonstrating a discrepancy between the perceived importance of this relationship and research.

Aggression
During normal development, as children learn to regulate emotions, associated aggression tends to also improve (Kaartinen et al., 2012). In contrast, individuals with ASD have been found to carry aggressive behaviours forward, as a response to struggles with emotional regulation. Although limited by a small sample size a study by Kaartinen et al. (2012) revealed that this response is more common in boys and suggested that this response was linked to poor emotional regulation strategies.

The problematic behaviour of aggression is highlighted through the overrepresentation of adults with ASD as adult violent offenders, within the criminal justice system. A study by Soderstrom et al. (2004) assessed 100 offenders and found that 55%, had childhood onset neuropsychiatric disorders such as ASD. Although future research is needed to assess how the development of effective emotional regulation strategies can assist in lowering this statistic, the importance of emotional regulation skills, to lower the problematic behaviour of aggression is clear.

Schooling


A major struggle for children with ASD is schooling. A study by Ashburner et al. (2010) assessed children with ASD within mainstream classrooms and found that teachers reported them to have significantly higher levels of behavioural and emotional difficulties than typically developing peers. Due to these difficulties it was reported that 54% of students with ASD were underachieving academically compared to 8% within typically developing peers. The study assessed difficulties in emotional regulation such as meltdowns, crying, frustration and mood changes and found each to be a strong predictor for poor academic achievement. The findings from this study are also supported elsewhere with research highlighting that students with ASD exhibit higher levels of emotional difficulties at school than peers (Knott et al., 2006).

These difficulties within school environments has also been extended outside of the classroom, finding that children with ASD are often subject to exclusion and bullying (Knott et al., 2006). A study by Humphrey and Lewis (2008) interviewed 20 students with Asperger's syndrome and high functioning autism and revealed that almost all experienced bullying and teasing to varying degrees while attending mainstream school. Thus, demonstrating the downfall of poor emotional regulation within current mainstream education systems.

Mental health
Anxiety and depression are one of the most prevalent disorders associated with ASD (American Psychiatric Association, 2013). This prevalence has been found to be associated with lower life satisfaction, social difficulties, externalising problems, loneliness and insomnia (Ying Cai et al., 2018). Due to these challenges, research has started to look at the potential importance of emotion regulation as a mental health risk factor, for individuals with ASD.

A self-report study by Bruggink et al. (2018) uncovered that individuals with ASD use less adaptive cognitive emotion regulation strategies and instead use more “other-blame” and less “positive reappraisal” strategies. These less adaptive strategies were found to have a positive relationship to anxiety and depression, demonstrating a direct link between poor emotional regulation strategies, seen in ASD individuals and mental health problems such as anxiety and depression.

Building upon this, White et al. (2014) assessed the relationship between ASD and anxiety by presenting a developmental model of emotional regulation. It is suggested that the neural, physiological and socio-cognitive mechanisms associated with ASD leads to impaired emotion regulation. This impairment combine with moderators such as struggles in socialisation, executive function, emotional awareness, and recognition skills, is the cause of anxiety in ASD. Although the model hasn't been tested, other research has confirmed a link between the restricted and repetitive behaviours seen in individuals with ASD and anxiety (Joyce et al., 2017). Hence demonstrating a relationship between anxiety as an indicator for poor emotional regulation.

{Which of following is NOT a consequence of poor emotional regulation in ASD?} - a: poor academic achievement - b: aggression - c: anxiety and depression + d: emotional wellbeing - e: meltdowns

Supporting and encouraging emotional regulation
Although individuals with ASD struggle with emotional regulation, strategies have been developed in order to support and encourage effective emotional regulation. The enhancement of adaptive forms of emotion regulation has been suggested to have the potential to decrease emotional problems and optimize long term outcomes for individuals with ASD (Samson et al., 2014). Table 2 highlights some key strategies and therapies that can assist in supporting and encouraging emotional regulation within schools, at home, and professionally.

Table 2.

Ways to support and encourage emotional regulation and practical examples based off a fictional character 'Sam' who is a child with ASD.

Conclusion
This chapter demonstrates that the relationship between ASD and emotional regulation is complex and highly important. Although not recognised within the DSM-5, emotional regulation is a characteristic within the disorder that is highly recognised in research, theory and observations (Samson et al., 2014). The presence of this construct within ASD is also highlighted through research highlighting that the core features of autism are significantly related to emotion regulation, and the clear differences in coping strategies between children with ASD and neurotypicals (Samson et al., 2014; Jahromi et al., 2012). Although future research is needed to assess the juxtaposing views and unclear conclusions, the current cognitive, learning and biological perspectives demonstrate a clear consensus of how ASD impacts on emotional regulation. The behavioural consequences of meltdowns and aggressive behaviour as well as educational and mental health struggles, indicates that there are clear negative consequences associated with emotional regulation and ASD. These consequences highlight the importance of supporting and encouraging effective emotional regulation strategies (Table 2). Hence, although future research is needed to assess the relationship between ASD and emotional regulation over time as well as greater studies looking into adults with ASD, the current theory and research concludes that ASD has a clear impact on emotional regulation.


 * 1) Although not mentioned in the DSM-5 emotional regulation is a significant deficit in ASD that needs to be recognised and understood.
 * 2) The behavioural deficits seen in ASD have a deeper psychological reasoning linking to emotional dysregualtion.
 * 3) The impacts of emotional dysregualtion  can be seen in a range of situations, causing impairments for individuals with ASD.
 * 4) There are a range of support services and ways to encourage effective emotional regulation.