Is cognitive inflexibility a missing link? The role of cognitive inflexibility, alexithymia and intolerance of uncertainty in externalising and internalising behaviours in young people with autism spectrum disorder.
Autism
alexithymia
anxiety
autistic
emotional regulation
externalising
inflexibility
internalising
intolerance of uncertainty
mechanism
mediator
Journal
Journal of child psychology and psychiatry, and allied disciplines
ISSN: 1469-7610
Titre abrégé: J Child Psychol Psychiatry
Pays: England
ID NLM: 0375361
Informations de publication
Date de publication:
06 2021
06 2021
Historique:
accepted:
12
06
2020
pubmed:
23
8
2020
medline:
16
10
2021
entrez:
23
8
2020
Statut:
ppublish
Résumé
Internalising (anxiety and low mood) and externalising (aggressive or outburst behaviours, and irritability) difficulties are very common in autism spectrum disorder (ASD) across the life span, relatively stable over time and often associated with poorer quality of life. Understanding the cognitive mechanisms underlying internalising and externalising difficulties in ASD is essential for developing targeted supports and interventions. In the present study, we investigated established and less-researched cognitive factors hypothesised to contribute to internalising and/or externalising difficulties in ASD, namely cognitive inflexibility (CI), intolerance of uncertainty (IU) and alexithymia. Based on previous models and clinical experience, we hypothesised that IU would lead to internalising symptoms, with alexithymia contributing to this pathway, and that CI would have a direct effect on externalising behaviours and may indirectly contribute to internalising symptoms via increasing IU. Our sample consisted of 95 5- to 18-year-olds presenting to a specialist neurodevelopmental clinic and receiving a diagnosis of ASD. Parents/caregivers completed questionnaires assessing ASD symptomatology, internalising and externalising difficulties, CI, IU and alexithymia. Structural equation modelling was used to examine the hypothesised pathways and relationships between the main variables of interest. Cognitive Inflexibility played a significant direct role in the pathway from ASD symptoms to externalising symptoms in ASD, and indirect role via IU in the pathway to internalising problems. Relationships between alexithymia and both internalising and externalising symptoms were weaker, with alexithymia predicting internalising difficulties via IU only. The finding of a direct pathway from CI to externalising behaviours is novel, as is the indirect role of CI in internalising symptomatology. Of the three cognitive mechanisms examined, only CI significantly predicted externalising symptoms. Possible implications for interventions and supports targeting these cognitive processes in ASD are discussed.
Sections du résumé
BACKGROUND
Internalising (anxiety and low mood) and externalising (aggressive or outburst behaviours, and irritability) difficulties are very common in autism spectrum disorder (ASD) across the life span, relatively stable over time and often associated with poorer quality of life. Understanding the cognitive mechanisms underlying internalising and externalising difficulties in ASD is essential for developing targeted supports and interventions. In the present study, we investigated established and less-researched cognitive factors hypothesised to contribute to internalising and/or externalising difficulties in ASD, namely cognitive inflexibility (CI), intolerance of uncertainty (IU) and alexithymia. Based on previous models and clinical experience, we hypothesised that IU would lead to internalising symptoms, with alexithymia contributing to this pathway, and that CI would have a direct effect on externalising behaviours and may indirectly contribute to internalising symptoms via increasing IU.
METHODS
Our sample consisted of 95 5- to 18-year-olds presenting to a specialist neurodevelopmental clinic and receiving a diagnosis of ASD. Parents/caregivers completed questionnaires assessing ASD symptomatology, internalising and externalising difficulties, CI, IU and alexithymia. Structural equation modelling was used to examine the hypothesised pathways and relationships between the main variables of interest.
RESULTS
Cognitive Inflexibility played a significant direct role in the pathway from ASD symptoms to externalising symptoms in ASD, and indirect role via IU in the pathway to internalising problems. Relationships between alexithymia and both internalising and externalising symptoms were weaker, with alexithymia predicting internalising difficulties via IU only.
CONCLUSIONS
The finding of a direct pathway from CI to externalising behaviours is novel, as is the indirect role of CI in internalising symptomatology. Of the three cognitive mechanisms examined, only CI significantly predicted externalising symptoms. Possible implications for interventions and supports targeting these cognitive processes in ASD are discussed.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
715-724Commentaires et corrections
Type : CommentIn
Informations de copyright
© 2020 Association for Child and Adolescent Mental Health.
Références
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, 5th ed. Washington, DC: American Psychiatric Association.
Beck, A.T., Ward, C.H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571.
Bentler, P.M., & Chou, C.P. (1987). Practical issues in structural modeling. Sociological Methods & Research, 16(1), 78-117.
Boulter, C., Freeston, M., South, M., & Rodgers, J. (2014). Intolerance of uncertainty as a framework for understanding anxiety in children and adolescents with autism spectrum disorders. Journal of Autism and Developmental Disorders, 44, 1391-1402.
Buhr, K., & Dugas, M.J. (2002). The Intolerance of Uncertainty Scale: Psychometric properties of the English version. Behavior Research and Therapy, 40, 931-945.
Buhr, K., & Dugas, M.J. (2009). The role of fear of anxiety and intolerance of uncertainty in worry: an experimental manipulation. Behavior Research and Therapy, 47, 215-223.
Cachia, R.L., Anderson, A., & Moore, D.W. (2016). Mindfulness in individuals with autism spectrum disorder: A systematic review and narrative analysis. Review Journal of Autism and Developmental Disorders, 3, 165-178.
Cameron, K., Ogrodniczuk, J., & Hadjipavlou, G. (2014). Changes in alexithymia following psychological intervention: A review. Harvard Review of Psychiatry, 22, 162-178.
Carleton, R.N., Mulvogue, M.K., Thibodeau, M.A., McCabe, R.E., Antony, M.M., & Asmundson, G.J. (2012). Increasingly certain about uncertainty: Intolerance of uncertainty across anxiety and depression. Journal of Anxiety Disorders, 26, 468-479.
Carleton, R.N., Norton, M.A., & Asmundson, G.J. (2007). Fearing the unknown: A short version of the Intolerance of Uncertainty Scale. Journal of Anxiety Disorders, 21, 105-117.
Cassidy, S., Bradley, P., Robinson, J., Allison, C., McHugh, M., & Baron-Cohen, S. (2014). Suicidal ideation and suicide plans or attempts in adults with Asperger's syndrome attending a specialist diagnostic clinic: a clinical cohort study. Lancet Psychiatry, 1, 142-147.
Chorpita, B.F., Moffitt, C.E., & Gray, J. (2005). Psychometric properties of the Revised Child Anxiety and Depression Scale in a clinical sample. Behavior Research and Therapy, 43, 309-322.
Craig, F., Margari, F., Legrottaglie, A.R., Palumbi, R., de Giambattista, C., & Margari, L. (2016). A review of executive function deficits in autism spectrum disorder and attention-deficit/hyperactivity disorder. Neuropsychiatric Disease and Treatment, 12, 1191-1202.
Eack, S.M., Greenwald, D.P., Hogarty, S.S., Bahorik, A.L., Litschge, M.Y., Mazefsky, C.A., & Minshew, N.J. (2013). Cognitive enhancement therapy for adults with autism spectrum disorder: Results of an 18-month feasibility study. Journal of Autism and Developmental Disorders, 43, 2866-2877.
Ford, T., Last, A., Henley, W., Norman, S., Guglani, S., Kelesidi, K., … & Goodman, R. (2013). Can standardized diagnostic assessment be a useful adjunct to clinical assessment in child mental health services? A randomized controlled trial of disclosure of the Development and Well-Being Assessment to practitioners. Social Psychiatry and Psychiatric Epidemiology, 48, 583-593.
Fracalanza, K., Koerner, N., Deschenes, S.S., & Dugas, M.J. (2014). Intolerance of uncertainty mediates the relation between generalized anxiety disorder symptoms and anger. Cognitive Behaviour Therapy, 43, 122-132.
Gillott, A., Furniss, F., & Walter, A. (2001). Anxiety in high-functioning children with autism. Autism, 5, 277-286.
Gioia, G.A., Isquith, P.K., Retzlaff, P.D., & Espy, K.A. (2002). Confirmatory factor analysis of the Behavior Rating Inventory of Executive Function (BRIEF) in a clinical sample. Child Neuropsychology, 8, 249-257.
Goodman, R.(1997). The Strengths and Difficulties Questionnaire: A research note. Journal of Child Psychology and Psychiatry, 38, 581-586.
Goodman, R.(2001). Psychometric properties of the strengths and difficulties questionnaire. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1337-1345.
Greenberg, J., Reiner, K., & Meiran, N. (2012). “Mind the trap”: Mindfulness practice reduces cognitive rigidity. PLoS One, 7, e36206.
Griffin, C., Lombardo, M.V., & Auyeung, B. (2016). Alexithymia in children with and without autism spectrum disorders. Autism Research, 9, 773-780.
Hill, E., Berthoz, S., & Frith, U. (2004). Brief report: cognitive processing of own emotions in individuals with autistic spectrum disorder and in their relatives. Journal of Autism and Developmental Disorders, 34, 229-235.
Hollocks, M.J., Jones, C.R., Pickles, A., Baird, G., Happe, F., Charman, T., & Simonoff, E. (2014). The association between social cognition and executive functioning and symptoms of anxiety and depression in adolescents with autism spectrum disorders. Autism Research, 7, 216-228.
Hollocks, M.J., Lerh, J.W., Magiati, I., Meiser-Stedman, R., & Brugha, T.S. (2019). Anxiety and depression in adults with autism spectrum disorder: a systematic review and meta-analysis. Psychological Medicine, 49, 559-572.
Hu, L.T., & Bentler, P.M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal, 6, 1-55.
Kaat, A.J., Gadow, K.D., & Lecavalier, L. (2013). Psychiatric symptom impairment in children with autism spectrum disorders. Journal of Abnormal Child Psychology, 41, 959-969.
Keefer, A., Kreiser, N.L., Singh, V., Blakeley-Smith, A., Duncan, A., Johnson, C., … & Vasa, R.A. (2017). Intolerance of uncertainty predicts anxiety outcomes following CBT in youth with ASD. Journal of Autism and Developmental Disorders, 47, 3949-3958.
Kenworthy, L., Anthony, L.G., Naiman, D.Q., Cannon, L., Wills, M.C., Luong-Tran, C., … & Wallace, G.L. (2014). Randomized controlled effectiveness trial of executive function intervention for children on the autism spectrum. Journal of Child Psychology and Psychiatry, 55, 374-383.
Kester, K.R., & Lucyshyn, J.M. (2018). Cognitive behavior therapy to treat anxiety among children with autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders, 52, 37-50.
Lawson, R.A., Papadakis, A.A., Higginson, C.I., Barnett, J.E., Wills, M.C., Strang, J.F., … & Kenworthy, L. (2015). Everyday executive function impairments predict comorbid psychopathology in autism spectrum and attention deficit hyperactivity disorders. Neuropsychology, 29, 445-453.
Maisel, M.E., Stephenson, K.G., South, M., Rodgers, J., Freeston, M.H., & Gaigg, S.B. (2016). Modeling the cognitive mechanisms linking autism symptoms and anxiety in adults. Journal of Abnormal Psychology, 125, 692-703.
Mazefsky, C.A., & White, S.W. (2014). Emotion regulation: Concepts & practice in autism spectrum disorder. Child and Adolescent Psychiatric Clinics of North America, 23, 15-24.
McEwen, F.S., Stewart, C.S., Colvert, E., Woodhouse, E., Curran, S., Gillan, N., … & Bolton, P. (2016). Diagnosing autism spectrum disorder in community settings using the Development and Well-Being Assessment: Validation in a UK population-based twin sample. Journal of Child Psychology and Psychiatry, 57, 161-170.
Milosavljevic, B., Carter Leno, V., Simonoff, E., Baird, G., Pickles, A., Jones, C.R.G., … & Happé, F. (2016). Alexithymia in adolescents with autism spectrum disorder: Its relationship to internalising difficulties, sensory modulation and social cognition. Journal of Autism and Developmental Disorders, 46, 1354-1367.
Murray, D., Lesser, M., & Lawson, W. (2005). Attention, monotropism and the diagnostic criteria for autism. Autism, 9, 139-156.
Muthén, L.K., & Muthén, B.O. (1998-2007). Mplus User’s Guide, 5th ed. Los Angeles, CA: Muthén & Muthén.
Neil, L., Olsson, N.C., & Pellicano, E. (2016). the relationship between intolerance of uncertainty, sensory sensitivities, and anxiety in autistic and typically developing children. Journal of Autism and Developmental Disorders, 46, 1962-1973.
Ozonoff, S., Strayer, D.L., McMahon, W.M., & Filloux, F. (1994). Executive function abilities in autism and Tourette syndrome: An information processing approach. Journal of Child Psychology and Psychiatry, 35, 1015-1032.
Rodgers, J., Hodgson, A., Shields, K., Wright, C., Honey, E., & Freeston, M. (2017). Towards a treatment for intolerance of uncertainty in young people with autism spectrum disorder: Development of the Coping with Uncertainty in Everyday Situations (CUES(c)) Programme. Journal of Autism and Developmental Disorders, 47, 3959-3966.
Semple, R.J.(2019). Review: Yoga and mindfulness for youth with autism spectrum disorder: Review of the current evidence. Child and Adolescent Mental Health, 24, 12-18.
Shiri, V., Hoseyni, S.A., Pishyareh, E., Nejati, V., Emami, M., & Shiri, E. (2018). Is there any correlation between executive dysfunction and behavioral symptoms in autistic children? A systematic review. Archives of Neuroscience, 5, e64303.
Simonoff, E., Pickles, A., Charman, T., Chandler, S., Loucas, T., & 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, 921-929.
South, M., & Rodgers, J. (2017). Sensory, emotional and cognitive contributions to anxiety in autism spectrum disorders. Frontiers in Human Neuroscience, 11, 20.
Strang, J.F., Anthony, L.G., Yerys, B.E., Hardy, K.K., Wallace, G.L., Armour, A.C., … & Kenworthy, L. (2017). The Flexibility Scale: Development and preliminary validation of a cognitive flexibility measure in children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 47, 2502-2518.
Taylor, G. J.(2000). Recent developments in alexithymia theory and research. Canadian Journal of Psychiatry, 45, 134-142.
Tchanturia, K., Lounes, N., & Holttum, S. (2014). Cognitive remediation in anorexia nervosa and related conditions: A systematic review. European Eating Disorders Review, 22, 454-462.
Treanor, M.(2011). The potential impact of mindfulness on exposure and extinction learning in anxiety disorders. Clinical Psychology Review, 31, 617-625.
Trevisan, D.A., Bowering, M., & Birmingham, E. (2016). Alexithymia, but not autism spectrum disorder, may be related to the production of emotional facial expressions. Molecular Autism, 7, 46.
van Steensel, F.J., Bogels, S.M., & Dirksen, C.D. (2012). Anxiety and quality of life: Clinically anxious children with and without autism spectrum disorders compared. Journal of Clinical Child & Adolescent Psychology, 41, 731-738.
van Steensel, F.J., Bogels, S.M., & Perrin, S. (2011). Anxiety disorders in children and adolescents with autistic spectrum disorders: A meta-analysis. Clinical Child and Family Psychology Review, 14, 302-317.
van Steensel, F.J.A., & Heeman, E.J. (2017). Anxiety levels in children with autism spectrum disorder: A meta-analysis. Journal of Child and Family Studies, 26, 1753-1767.
Visser, E.M., Berger, H.J., Van Schrojenstein Lantman-De Valk, H.M., Prins, J.B., & Teunisse, J.P.(2015). Cognitive shifting and externalising problem behaviour in intellectual disability and autism spectrum disorder. Journal of Intellectual Disability Research, 59, 755-766.
Way, I.F., Applegate, B., Cai, X., Franck, L.K., Black-Pond, C., Yelsma, P., … & Muliett, M. (2010). Children's Alexithymia Measure (CAM): A new instrument for screening difficulties with emotional expression. Journal of Child & Adolescent Trauma, 3, 303-318.
White, S.W., Mazefsky, C.A., Dichter, G.S., Chiu, P.H., Richey, J.A., & Ollendick, T.H. (2014). Social-cognitive, physiological, and neural mechanisms underlying emotion regulation impairments: Understanding anxiety in autism spectrum disorder. International Journal of Developmental Neuroscience, 39, 22-36.
Wigham, S., Rodgers, J., South, M., McConachie, H., & Freeston, M. (2015). The interplay between sensory processing abnormalities, intolerance of uncertainty, anxiety and restricted and repetitive behaviours in autism spectrum disorder. Journal of Autism and Developmental Disorders, 45, 943-952.