Fatemeh Hosseinjani; Mehdi Zemestani
Abstract
Abstract
Autism spectrum disorder (ASD) is one of the important neurodevelopmental disorders that always has a high comorbidity with other psychiatric disorders. One of the ways to investigate this comorbidity is to identify the underlying mechanisms involved in this association. The aim of the present ...
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Abstract
Autism spectrum disorder (ASD) is one of the important neurodevelopmental disorders that always has a high comorbidity with other psychiatric disorders. One of the ways to investigate this comorbidity is to identify the underlying mechanisms involved in this association. The aim of the present study was to explore the mediating role of emotion regulation and intolerance of uncertainty in the development of externalizing disorders in children with ASD. The current research was a correlational study using structural equation modeling (pathway analysis). The statistical population included all children and adolescents with ASD in the age range of 8 to 18 years from autism schools and the autism society in Tehran, Tabriz, and Mianeh province. Using a convenience sampling method, a sample of 117 children was selected and the data were collected online from parents. Pearson correlation coefficient and pathway analysis were used for the statistical analysis of data by SPSS and AMOS software. The results of the present study showed that the symptoms of autism directly and significantly explain the symptoms of externalizing spectrum disorders. Also, emotion dysregulation and intolerance of uncertainty as mediating factors explain the severity of externalizing spectrum disorders impairments in children with autism disorder. According to these findings, it can be concluded that emotion dysregulation and intolerance of uncertainty as pathological transdiagnostic factors play an important mediating role in the exacerbation of the symptoms of externalizing disorders in children with ASD.
Keywords: Autism spectrum disorder, Transdiagnostic factors, Emotion regulation, Intolerance of uncertainty, Externalizing disorders.
Extended Abstract
Introduction
Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by marked social and communication deficits, fixed interests, and repetitive behaviors (American Psychiatric Association, 2022). Children with ASD often have comorbid psychiatric disorders, including internalizing and externalizing disorders (Kaplan, Sadock, & Ruiz, 2019). Co-occurring externalizing problems (e.g. aggression, outburst behaviors, hyperactivity, and irritability) are very common in ASD across the lifespan and are often associated with poorer quality of life over and above the impact of ASD itself (Vaillancourt et al., 2017; Miller et al., 2019).
Considering the high prevalence of comorbid externalizing problems with ASD, the negative consequences of this comorbidity, identifying the underlying mechanisms involved in this comorbidity have important implications. Identifying and understanding the possible role of transdiagnostic mechanisms in the development and maintenance of externalizing pathologies in children with ASD have implications in the better explanation of the nature of comorbid disorders with ASD as well as in the modeling and developing effective treatment protocols for these children (Ozsivadjian et al., 2020).
Various transdiagnostic factors may play a mediating/moderating role in the development or maintenance of the symptoms of comorbid externalizing problems in children with ASD. Limited research has been conducted on transdiagnostic factors underlying the comorbidity of externalizing disorders in children with ASD. There is emerging empirical support for a number of cognitive-emotional mechanisms being implicated in the development and maintenance of high rates of externalizing problems in ASD (Mazefsky et al, 2013).
Among the important transdiagnostic factors that have been highly emphasized in recent studies on the externalizing problems in ASD, we can mention emotion regulation (Mazefsky et al, 2013; Morie et al., 2015) and intolerance of uncertainty (Neil, Olsson, & Pellicano, 2016; Vasa et al., 2018). These two constructs are among the important underlying transdiagnostic factors that have been emphasized in recent research on their influential and mediating role in the creation and continuation of comorbid disorders with autism spectrum disorder (Say et al., 2017; Saiz-Souanes et al., 2020).
The present study was conducted to explain the mediating role of emotion dysregulation and intolerance of uncertainty as transdiagnostic mechanisms in the development and maintenance of externalizing problems in children with ASD. The main question of the research was to what extent the two underlying and transdiagnostic constructs of emotion dysregulation and intolerance of uncertainty as mediating variables can explain the symptoms of externalizing symptoms in children with ASD?
Literature Review
Limited studies have been conducted on the role of emotion dysregulation and intolerance of uncertainty in the development of internalizing and externalizing problems in children with ASD. In this regard, Mazefsky et al. (2011) showed that children with ASD have problems in using adaptive emotion regulation strategies and they use maladaptive strategies to deal with negative daily tensions, which makes them prone to a wide range of internalizing psychopathologies including depression and anxiety. Morie et al. (2015) also showed that defect in emotion regulation plays an important role as a mediator in the development and exacerbation of anxiety and depressive symptoms in youth with ASD. Neil et al. (2016) and Vasa et al. (2018) showed that the high level of intolerance of uncertainty in children with ASD increases the level of tension and anxiety in them, and this tension in turn leads to the possibility of disruptive behaviors in them. Therefore, previous evidence shows that intolerance of uncertainty is an important element in the development and maintenance of internalizing pathologies in them. Therefore, previous pieces of evidence show that emotion dysregulation and intolerance of uncertainty in youth with ASD are among the important mediating risk factors for the development and maintenance of comorbid psychopathologies in them.
Methodology
A descriptive correlation research approach (structural equation model) is adopted in this study. The statistical population included all children and adolescents with ASD who were referred to exceptional children schools and autistic centers in Tehran, Tabriz, and Mianeh cities in 2019-2020. A convenience sampling method was used to select 117 children and adolescents with ASD as the study sample. The inclusion criteria were receiving ASD diagnosis based on the pediatric psychiatrics interview, ability to write and read, having ages between 8 and 18 years, and willingness to participate in the study. All participants were assessed by the Gilliam Autism Rating Scale-second edition (GARS-2), Strengths and Difficulties Questionnaire (SDQ), and Intolerance of Uncertainty Scale for Children (IUSC). To analyze the data, descriptive statistical metrics such as mean, standard deviation, and Pearson correlation and pathway analysis were employed using the SPSS-22 and Amos-24 software.
Results
The results of the matrix correlation showed a significant relationship between ASD symptoms, externalizing problems, emotion regulation strategies, and intolerance of uncertainty dimensions. The standardized direct effect of ASD symptoms on externalizing problems, emotion regulation strategies, and intolerance of uncertainty dimensions was significant (p> 0.05). Moreover, evaluation of indirect effects using the bootstrap method showed that the indirect effects of ASD symptoms on conduct problems, hyperactivity, emotion regulation strategies (i.e., suppression, reappraisal), and intolerance of uncertainty dimensions (prospective and inhibitory) were significant. Therefore, the indirect relationship between ASD symptoms and externalizing problems through emotion regulation and intolerance of uncertainty is significant (p> 0.05).
Conclusion
This study aimed to investigate the mediating role of transdiagnostic factors of emotion dysregulation and intolerance of uncertainty in the association between ASD symptoms and externalizing problems. The results of the present study showed that the symptoms of autism directly explain the externalizing problems in children with ASD. Also, emotion regulation and intolerance of uncertainty as mediating factors explain the severity of externalizing problems in children with ASD.
According to these findings, it can be said that emotion dysregulation and intolerance of uncertainty as pathologic transdiagnostic mechanisms probably play an important mediating role in explaining the development and maintenance of externalizing problems in children with ASD. Based on the results of this research, it can be said that the defect in emotional regulation and also the inability to tolerate ambiguous situations in autistic children and adolescents probably lead to the development of externalizing symptoms (conduct problems, hyperactivity) in them.
This study has limitations that should be considered in future research. Limitations related to the cross-sectional nature of the study, geographical region, small sample size, sampling method, and using self-reporting questionnaires as a data collection tool.