Current Knowledge of Emotion Regulation: The Autistic Experience

Abstract

Autism spectrum disorder (ASD) is a heterogenous neurodevelopmental condition characterized by atypical social communication and restrictive and repetitive behavior. In recent years, researchers and clinicians have placed increased emphasis on emotional health, emotion regulation, and emotion dysregulation among individuals with ASD. A growing body of work in this field has documented individuals with ASD experience high rates of emotion dysregulation and impairment in adaptive functioning across the lifespan. However, methodological limitations, mixed results in the literature, and a dearth of studies centering autistic perspectives raise questions about the field’s comprehensive understanding of emotion in ASD. This chapter seeks to provide a broad overview of the current state of research examining emotion regulation among autistic individuals and highlight future directions toward comprehensive research and clinical practice.

1. Introduction

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by atypical social communication and restrictive, repetitive patterns of behavior, interests, or activities [1]. Autism was described in early research as disorder of “affective contact” [2], as clinicians observed children with ASD to have marked difficulties with social-emotional interactions and response. Over decades of study, research on emotional processes in ASD has yielded mixed results. While a large body of literature has identified increased emotion dysregulation and negative affectivity among individuals with ASD [3], more recent perspectives have explored the possibility that individuals with ASD utilize different mechanisms to make sense of their emotional world than their neurotypical peers [4]. With more and more individuals being diagnosed with ASD each year (current prevalence stands at 1 in 44 children; [5], there is a need to explore the extant literature on emotion in ASD. The current chapter provides a brief review of emotion and emotion regulation broadly and discusses implications for ASD research and clinical practice.

2. Role of emotion

Humans are inherently emotional creatures, hardwired to connect with others through their emotional expression. Emotional expression typically occurs early in infancy and will often continue to develop into adulthood via more complex mechanisms (e.g. crying vs. tantrums vs. pouting vs. arguing). At birth, infants possess reflexes that serve to illicit caregiving (e.g. crying), as they rely entirely on caregivers to regulate their physiological and emotional states [6, 7]. Infants can express their needs to caregivers with simple affective states; and when caregivers are responsive and sensitive to these needs through approach emotion regulation tactics (e.g. providing hugs and comfort), infants develop secure attachment [8]. Researchers Malik and Marwaha [9] posit that the expression of emotions begins when infants first reciprocate their caregiver’s gaze. Through simple expressions, newborns showcase their fear, joy, and frustration toward their caregivers as a means of communication [9]. Co-regulation in infant-caregiver dyads lays the foundation for emotion regulation development in children. Unfortunately, theorists believe this process may be disrupted among autistic youth [10].

Studies of emotional expression in early life have varied in their findings, supporting the theory that children with ASD display reduced positive emotionality compared to neurotypical peers (for a review, see [11]). Some studies have concluded that infants who were later diagnosed with ASD and their at-risk infant siblings displayed lower rates of social smiling [12, 13]. For children in preschool, autistic children were found to direct fewer positive facial expressions toward adults in the context of play [14] and had increased rates of distress, irritability, and negative affect [15]. However, these findings are inconsistent, particularly among studies using direct behavioral measures. Indeed, one recent study found no support for increased negative emotionality among youth with ASD. Specifically, Macari and colleagues [11] found that in response to emotional probes, toddlers with ASD demonstrated comparable positive affect to neurotypical peers. Thus, components of emotional experience and expression among individuals with ASD still need to be explored.

3. Emotion regulation overview

Emotion regulation has been characterized as the capacity to modulate, influence, and control one’s own emotional experiences [7]. Effective emotion regulation involves managing and responding to emotional states in a way that promotes adaptive functioning or desired behavior [7]. Discrete processes involved in emotion regulation include identifying and understanding emotions in the self, practicing present-moment awareness, accepting emotional experiences, and responding flexibly to stimuli all while balancing situational demands [16]. In contrast, emotional dysregulation involves managing emotions in ineffective or maladaptive ways that typically result in behavior that is at odds with an individual’s desired goals [17]. In a recent review, D’Agostino and colleagues [18] identified five related dimensions of emotion dysregulation: decreased emotional awareness, inadequate emotional reactivity, intense experience and expression of emotions, emotional rigidity, and cognitive reappraisal difficulty. Emotional dysregulation is a transdiagnostic risk underlying multiple mental health disorders and is linked to risky behaviors, such as aggression, substance use, and self-injurious behaviors [19]. Though not a core diagnostic feature of ASD, clinical research has consistently reported high rates of emotion dysregulation among autistic individuals [20]. For example, Samson and colleagues [21] found a significant association between increased emotion dysregulation and ASD symptom severity across domains of social functioning, repetitive behaviors, and sensory abnormalities. Whether a core feature or an associated symptom, emotion regulation is an important concern for autistic individuals, as it is has a demonstrated link to challenging behavior and co-occurring psychiatric conditions [22].

Recent perspectives suggest emotion dysregulation may emerge when autistic individuals apply emotion regulation strategies in maladaptive ways. Indeed, Cole and colleagues [23] conceptualize emotion dysregulation as a form of emotion regulation that is dysfunctional in the context in which it occurs, and thus, does not align with an individual’s goals or otherwise violates sociocultural expectations. Central emotion regulation strategies that individuals may use to manage their emotions include (a) avoidance (retreating or disengaging from emotional situations), (b) distraction (directing attention away from emotional situations), (c) rumination (repeatedly directing attention and thoughts toward the causes and consequences of emotions), (d) cognitive reappraisal (re-interpreting emotionally laden situations), (e) suppression (the process of inhibiting behavioral expressions of emotions), and (f) other physiological mechanisms, such as manipulating emotion-laden physiology by using substances [24]. Importantly, establishing an overall understanding of effective emotion regulation among autistic individuals poses a methodological challenge, as past research has used various types of instruments to measure emotion regulation, and many of these tools were not designed with ASD in mind [25]. Nonetheless, across both self-report and behavioral research, individuals with ASD appear to engage in a more dysregulated emotion regulation dynamic than their neurotypical peers [26].

Clinically, researchers have become increasingly interested in the distinction between adaptive and maladaptive emotion regulation strategies [27]. Generally, strategies are considered adaptive when they facilitate increased positive emotions and down-regulation of negative emotions and align with an individual’s goals and values [28]. However, certain strategies associated with decreased negative affect in the moment (e.g. avoidance, denial, and rumination) are associated with poor outcomes when used habitually [26]. A growing body of literature suggests that autistic individuals utilize strategies such as avoidance, rumination, and suppression more so than individuals without ASD [29, 30]. Yet, it is noteworthy to consider who is determining whether these strategies are adaptive or not and how are researchers and clinicians conceptualizing or defining “maladaptive” and “adaptive” strategies. Indeed, what is considered adaptive for neurotypical individuals may be deemed maladaptive for autistic individuals. In fact, while the literature suggests that the strategies most utilized by autistic individuals are maladaptive [29], it is more probable that autistic individuals have difficulties with responding to their emotions in a flexible manner [26, 31].

Adaptive emotion regulation or maladaptive emotion dysregulation can also be conceptualized outside of one’s own emotional experiences. In fact, modern theories have recognized that emotion regulation includes a significant social component [32, 33]. Specifically, extrinsic emotion regulation relates to how individuals influence how others respond to their emotions [34]. Since emotion regulation is an interpersonal process, individuals with ASD who misinterpret advanced social communication or emotion expression (e.g. sarcasm and laughing when angry) may then have difficulty responding appropriately in social situations, thus limiting the effectiveness of their own emotion regulation strategies. Researchers have found that autistic individuals with more social communication had a greater capacity for adaptive emotion regulation [35]. These findings further support the notion that social interaction plays an important role in emotion regulation. Importantly, recent literature has also revealed that neurotypical individuals often misinterpret the mental states, facial cues, and behavior (i.e. movement) of individuals with ASD [36, 37]. Thus, the broad social difficulties theoretically inherent to an ASD diagnosis may be due in part to neurotypical individuals misunderstanding their autistic peers. It stands to reason long-standing difficulties in social interaction, due in part ineffective interpretation from interaction partners, may prevent individuals with ASD from improving social communication, contribute to social isolation, and negatively impact emotion regulation abilities [38, 39].

4. Cultural considerations in emotion regulation

Though a growing body of literature has begun to demonstrate the important influence of cultural differences on emotion regulation [39], a substantial gap remains in understanding the intersection of culture, emotion regulation, and ASD. Generally, culture affects how one thinks, feels, and behaves as well how individuals choose to engage in emotion regulation strategies and the adaptiveness of emotion regulation [40]. Some countries promote collectivistic or interdependent values (e.g. Japan and China), while others promote individualistic principles (e.g. United States and Western Europe). Therefore, the function or adaptiveness of emotion regulation strategies (e.g. emotional suppression vs. emotional expression) may differ between cultural groups [41, 42]. Emotion regulation is further complicated in the context of societally based systemic oppression. For instance, Black Americans may regulate by suppressing their emotions in emotionally laden situations, limiting self-disclosure, or avoiding certain situations wherein they may be the target of racism or discrimination [43]. While the research on emotion regulation and ASD continues to develop, it is important to note that much of the literature reflects W.E.I.R.D societal ideals (Western, educated, industrialized, rich, and democratic; [3, 44]. The current state of the field limits generalizability and nuanced understanding of emotion regulation and ASD across cultures and racial-ethnic groups. Recognizing, appreciating, and centering the values and experiences of historically marginalized groups and how they choose to operate their emotional states in service of their values and goals are critical to disrupt the White, Western narrative and elevate the voices of those who have been historically and systemically oppressed—especially in the autistic community.

5. A further analysis of emotion regulation in ASD

Early ASD literature characterizing children as having an “affective disturbance” [2] likely contributed to decades of misconceptions about the emotional experience of this population. Namely, there is a myth that people with ASD do not have emotions or empathy. In contrast, current researchers regard this idea as a harmful oversimplification given the complex, heterogenous nature of ASD and the limited research efforts to understand empathy and emotion among autistic individuals [45].

Researchers, however, disagree on if emotional dysregulation is innate to ASD [3, 46]. In support of the notion, studies exploring ASD symptoms have shown their strong association with emotional dysregulation [47]. In particular, restricted and repetitive behaviors (RRBs) have been found to be the strongest predictor of emotional dysregulation in autistic individuals [21]. Arguments for this theory posit that emotion regulation challenges underlie and co-occur with other common presenting concerns, including other psychiatric conditions, sensory difficulties, and broad psychological rigidity [48, 49]. For instance, autistic individuals may be hypersensitive to sensory input which may trigger disruptions in their homeostatic state and result in intense reactions or dysregulated behaviors [49]. Similarly, autistic individuals with strong adherence to routines and resistance to change may experience intense distress and hyperarousal in response to minute changes in their environment [49]. Emotion dysregulation may also be compounded by poor perspective taking abilities and emotional organization, which may lead to misunderstanding and intense frustration in social interactions [20, 50]. As autistic individuals enter adulthood, they often present with high rates of internalizing symptoms (e.g. anxiety and depression), which may be also attributed to emotion regulation difficulties [51]. As such, emotion dysregulation is pervasive throughout the lifespan.

Other researchers argue that emotion dysregulation is not inherent, but instead that autistic individuals have a propensity to face emotion regulation challenges due to impairments in emotion identification, perspective taking and response inhibition in social situations [52]. For example, alexithymia, a trait characterized by impairments in emotional awareness, may be implicated in increased emotion regulation challenges [53]. Alexithymia is highly prevalent among individuals with ASD who may express difficulties identifying and describing their own feelings and distinguishing between emotional and bodily sensations [20, 54, 55]. In a sample of adult autistic women without intellectual disability, participants demonstrated elevated rates of alexithymia, which predicted greater emotion regulation challenges and increased anxiety and depression severity [56]. Indeed, alexithymia combined with difficulties recognizing emotions in others likely contribute to difficulties in both social interaction and emotion regulation [57].

In addition to the debate on the inherent nature of emotion dysregulation in individuals with ASD, further studies have explored causal factors outside of individual-related determinants. Specifically, parents have been a central research focus when understanding important contributors in the development of autistic children’s emotional regulation skills [58]. Generally, parents of children with ASD report greater levels of stress compared to parents of neurotypical children [59], and these increased levels of stress are associated with reduced caregiver use of adaptive coping skills—possibly limiting the child’s ability to witness effective emotion regulation modeling [60, 61]. Further, parents of autistic children have been shown to have fewer positive interactions with their autistic child, which was associated with increased child emotional dysregulation [62]. Lower use of mindful parenting (ongoing attunement to child’s emotional and behavioral needs, emotional self-awareness, acceptance, and responding thoughtfully to child’s emotions and behaviors; [63] has also been predictive of elevated dysregulation levels in children with ASD [58]. Alternatively, emotional scaffolding, parental sensitivity toward child emotions, and sharing in the child’s positive emotions have shown to be effective in reducing externalizing problems and psychological stress in children with ASD [64, 65, 66]. Therefore, parents may play an important role in an autistic child’s emotion regulation abilities beyond an individual child’s characteristics alone. When conceptualizing emotion regulation in individuals with autism, it is thus important to consider the emotional predisposition and mental health of their caregivers as well.

6. Emotion regulation and stereotyped behaviors

There is a plethora of unique factors to consider for individuals with ASD that may impact their experiences of emotion regulation as well as how they function within a neurotypical society. For example, complex, repetitive motor movements (e.g. hand flapping, finger mannerisms and full-body rocking) are a diagnostic feature of ASD categorized in the broader dimension of restricted and repetitive behaviors (RRBs [1]). Since the identification of these behaviors in early ASD literature, there has been a legacy of research pathologizing stereotyped mannerisms, known commonly as “stimming.” Earlier research reported the presence of these motor stereotypies primarily in youth with ASD and co-occurring intellectual disability and described these behaviors as negatively impacting adaptive functioning, child learning, and social engagement [67, 68]. More recent literature has found that autistic people without intellectual disability stim and stim often [69]. Nonetheless, behavioral interventions aimed at reducing stereotyped behavior remain common (for a review, see [70]), despite limited evidence suggesting these practices are helpful or effective [69].

Conflicting evidence has emerged on the relationship between stimming and social impairment. Several recent studies have revealed that repetitive motor characteristics observed in infants, toddlers, and young children were not associated with social withdrawal [71, 72]. Other research suggests that emotion dysregulation has a strong link to RRBs in ASD [3]. Researchers have posited that repetitive behaviors may either be the result of emotion dysregulation (e.g. RRBs are the application of ineffective emotion regulation strategies due to underlying emotion dysregulation) or the cause of increased emotional dysregulation [3, 73]. In one recent study, Martinez-Gonzalez and colleagues [35] demonstrated unique relations between stereotypic behaviors, social communication, and emotion regulation. Researchers found that individuals with more social communication displayed fewer stereotyped behaviors, and increased social communication was linked to increased emotion regulation capacity. RRBs may be linked between emotion regulation in a functional capacity.

Though not fully understood, several studies have suggested that stimming is a behavioral response to sensory experiences and function to provide a familiar motor sensation in the context of novel, overwhelming stimuli [74]. As such, research emphasizing qualitative reports from autistic individuals has begun to illuminate the ways in which stimming can serve an important role in self-regulation. In one qualitative study of adolescents with ASD, participants reported stimming as a means of managing sensory overload and coping with anxiety or uncertainty [75]. Stimming may also be implicated in emotion regulation through helping autistic individuals process and organize positive emotions, such as excitement [76]. In one of the first studies to explore the experience of stimming from autistic adults’ perspectives, a vast majority of participants identified stimming as a positive coping strategy to reduce anxiety and help self-soothe [77]. In an extension of this work, Kapp and colleagues [78] reported that the autistic adults in their sample overwhelmingly shared positive perceptions of stimming as a coping mechanism for managing emotion. Many autistic adults across these studies also reported they had been encouraged to stop stimming at some point in their lives. In the face of negative social judgment, adults reported making significant efforts to suppress or conceal stimming behavior, which left them feeling depleted, frustrated, ashamed, and confused [78]. Further, poor social interactions may perpetuate attempts to suppress stimming behaviors and contribute to increased emotion dysregulation. These accounts reveal a lack of understanding, and acceptance may be a substantial barrier preventing individuals with ASD from engaging in their own positive emotion regulation strategies—with neurotypically slanted studies ignoring adaptive coping mechanisms due to a theoretical or measurement limitations.

7. Assessing emotion regulation in ASD

Given the inherent limitations and narrow conceptualizations of emotion regulation in autistic individuals up to this point, innovative strategies to conceptualize, monitor, and improve emotion regulation in autistic individuals are needed. At this time, emotion regulation is assessed in ASD populations via behavioral observations and coding (e.g. Laboratory Temperament Assessment Battery and Ekman & Friesen’s Facial Action Coding System), self-report scales (e.g. Difficulties in Emotion Regulation Scale and Emotion Regulation Scales), caregiver report measures (e.g. Emotional Dysregulation Inventory and Emotion Regulation Checklist), and physiological instruments (e.g. heart rate and skin conductance; [73]). Unfortunately, many of these instruments were not developed for autistic populations. As Cai and colleagues reported in their review [26], the type of instrument used to measure emotion regulation characterizes this dynamic construct. Thus, using instruments that were not designed with or for autistic people may contribute to disparate conceptualization of emotion regulation in this population. Indeed, researchers must find ways to effectively identify and measure emotion regulation if our understanding of emotion regulation for ASD is to improve.

Recent developments demonstrate promise in effectively assessing emotion regulation in individuals with ASD. For instance, the Emotional Dysregulation Inventory, a caregiver-report questionnaire, was developed to assess emotional dysregulation impairment in verbal and nonverbal children and adolescents with ASD [79]. Further, behavior coding procedures during structured activities may provide important information about an individual’s naturalistic response to a situation [73]. However, both caregiver report and behavioral observation may be limited. Parent-report measures may be biased as they do not take an individual’s own perspective into account. Behavioral observation relies on reliable coders and may not be appropriate for adult clients who are less likely to display emotional dysregulation in a structured clinical setting [73]. Taken together, current assessment measures may be beneficial for conceptualizing emotion regulation/dysregulation, but further research is needed to develop comprehensive measures that assess and individual’s needs, functioning, and treatment goals. Improving assessment measures for emotion regulation lays the groundwork for improving and individualizing intervention for individuals with ASD.

8. Interventions for emotion regulation

Given the research presented, it is unsurprising that emotion-focused and emotion regulation interventions have garnered increased attention over the past decade. However, research on emotion regulation intervention remains in its infancy. In addition to limited clinical research investigating the efficacy of interventions, there remains a wide gap in understanding which treatment targets are most effective and helpful for autistic individuals. In line with recent qualitative studies [77, 78], future intervention research should emphasize treatments targets that align with what individuals value. This section presents a brief overview of current evidence-based interventions.

A majority of the ASD intervention research has focused on cognitive-behavioral therapy (CBT) approaches to treat co-occurring psychiatric conditions broadly (e.g. depression and anxiety), with far fewer emphasizing emotion regulation/dysregulation specifically. Exploring Feelings [80] is a CBT-based intervention targeting emotion regulation skills, such as anger and anxiety management. Initially designed for youth aged 9–12 years, this intervention consists of psychoeducation on why emotions exist and how to identify emotional expression. In the protocol, the client and therapist may explore one emotion at a time and discuss personal experiences that are connected to feelings and examine the sensations (e.g. sound, texture, and taste) that may elicit emotions. Additionally, therapists and clients practice cognitive restructuring to address distortions and maladaptive beliefs. Exploring Feelings also consists of discussion and practice of “tools,” or coping mechanisms, to help individuals with ASD navigate the social-emotional world [80]. Intervention studies have demonstrated improvements in emotion regulation abilities and reduction in anxiety symptoms [81, 82]. However, researchers have also suggested that autistic individuals may have difficulty accessing newer, learned emotion regulation strategies (e.g. emotional expression and problem-solving) in overwhelming situations [49]. Thus, mindfulness and acceptance-based approaches have been considered for enhancing adaptive emotion regulation among individuals with ASD.

While a CBT approach involves restructuring and reappraising maladaptive cognitions and beliefs, mindfulness-based approaches seek to change the relation to a thought, feeling, or belief, such that an individual can practice acceptance [83]. As such, mindfulness interventions have been used extensively to improve emotion regulation and awareness [84], and these approaches have been applied more recently to ASD populations. Mindfulness-based studies have often involved parents of young children and adolescents with ASD and aimed to reduce aggressive behavior and decrease parent stress [85, 86]. One mindfulness-based study found positive mental health impacts and decreased rates of rumination among adults with ASD [87].

Researchers have also postulated that Dialectical Behavior Therapy (DBT), an evidence-based intervention designed to treat emotion dysregulation, may be adapted to improve emotion regulation and distress tolerance among individuals with ASD [88]. However, DBT and mindfulness interventions are often time-intensive, requiring weeks of skill training for clients and more extensive training for clinicians [89]. Further exploration is needed to improve dissemination and access to evidence-based emotion regulation interventions.

Most evidence-based treatments for emotion dysregulation occur in traditional outpatient settings and are geared toward older adolescents and adults. However, over the past few decades, interventions designed to teach children social and emotional skills have become increasingly prevalent in schools. Social and emotional learning (SEL) interventions foster children’s ability to regulate their own emotions, use emotional problem-solving, and understand emotions in others [90]. RULER [91] is one such approach that has been adapted for youth with ASD [92]. Educators working with children with ASD may modify materials, such as the “Mood Meter” which displays simple images of emotional states, using visuals to support emotional learning. Additionally, evidence-based social skills interventions for children and adolescents with ASD have demonstrated promise in school settings. Social skills interventions may use a variety of strategies to teach social skills, support socio-emotional wellbeing, and reinforce social interaction with peers [93]. One review identified self-monitoring of emotions using an “emotion thermometer” as a method to help identify emotions and employ coping skills in the group setting [94]. Given the important role teachers and peers play in the lives of youth with ASD, further exploration is needed to integrate socio-emotional intervention into the classroom.

9. Conclusion

This chapter aimed to review the current literature examining emotion and emotion regulation among individuals with ASD. Importantly, this chapter is not an exhaustive review of all emotion in ASD research; rather, we aimed provide an overview of the current knowledgebase with particular emphasis on findings as they relate to neurodiversity and the autistic experience. Future reviews may benefit from expanding literature searches to more databases and critically examining emotion regulation assessment methods. To date, this body of work has not painted a clear understanding of emotions in ASD; while the bulk of the literature emphasizes increased negative affectivity in children and later emotion dysregulation among adolescents and adults [3, 12, 49] other studies have suggested that autistic individuals may develop adaptive emotion regulation mechanisms unique from neurotypical peers [4, 78]. Researchers’ interpretation of emotion regulation abilities among individuals with ASD may be shaped both by methodological challenges and narrow conceptions of adaptive and maladaptive emotion regulation strategies, with little current research emphasizing autistic individuals’ perspectives [78]. Nonetheless, researchers and clinicians should still consider the emotional health and wellbeing of autistic individuals, particularly given the transdiagnostic risk of emotional dysregulation. Future directions in the field should continue to examine individual and broader environmental (e.g. systemic and cultural) factors implicated in emotion regulation and work to provide thoughtful, strength-based approaches to address emotion regulation and dysregulation specific to ASD populations.