Article summary with The role of emotion regulation in autism spectrum disorder by Mazefsky a.o. - 2013

Summary of the article The role of emotion regulation in autism spectrum disorder - Mazefsky et al. (2013)

What is the role of emotion regulation in Autism Spectrum Disorder (ASD)?

Autism spectrum disorder (ASD) is a neuro-developmental disorder which is characterized by difficulties in social behavior and the presence of restrictive, repetitive behavior. There are some disruptions in the connections and processes of different brain areas. ASD is often accompanied by increased irritation, aggression, self-damaging behavior, anxiety and impulsiveness. Emotion regulation (ER) is a construct that can help to explain the problems that people with ASD experience. ER is defined as the automatic or intentional adjustment of one's emotional state to promote goal-directed behavior.   

What are terms and concepts related to emotion regulation (ER)?

The definition of ER is not that clear. To understand ER better, it is important to distinguish between mood and emotion. Mood refers to a stable, long-term state, while an emotion is a reaction to a specific situation.  

What are methods to study ER?

It is recommended to use different methods to study ER. Often, behavioral methods are  used. For example, children have to wait for a reward or they are observed while they play together. However, this does not measure internal ER components. To measure internal ER components, interviews or self-reports (questionnaires) are used. Little research has been done into the psychometric quality of self-reports. Nor are self-reports suited for individuals who cannot speak, young children and people with intellectual disabilities. Biological measurements are also used to measure ER. For example, sometimes the heart rate variability is looked at, as well as fMRI. In the scanner, however, it is difficult to distinguish between an emotion and an attempt to regulate that emotion.

ER research at ASD

Research into ASD has focused more on emotional experiences than on ER. The results of the studies showed that ASD is associated with a poorly differentiated emotional response, more negative emotions, and limited cognitive insight. Children with ASD often use visible cues to determine their emotion (for example: I was sad because I was crying). Research suggests that there is not enough emotional insight to reach effective ER in ASD.

Conceptualizing bad ER in ASD

A possible explanation for the deficienties in ER in ASD could be the presence of another psychiatric disorder which causes the difficulties in ER. This explanation is plausible, because there is a reciprocal relationship between ER and psychiatric disorders: inadequate ER increases the chance of a psychiatric disorder, and having a psychiatric disorder interferes with emotion regulation. In addition, deficienties in ER are prevalent among many psychiatric disorders. However, it could also be the case that psychiatric disorders are too often diagnosed together with ASD. Another explanation is the presence of common risk factors. Deficienties in ER often goes together with anxiety, depression and borderline. Some mechanisms that can explain problems with ER in these disorders are also relevant for ASD. The tripartite model states that general stress is a shared risk factor between the disorders, but that physiological arousal is specific to anxiety, and anhedonia specific to depression. General stress also plays an important role in ASD, as well as physiological arousal. Therefore, treatments for ASD that focus on reducing this physiological excitement could be effective.

Normally, ER activates different areas of the prefrontal cortex (PFC). Research has shown that the PFC does not function normally in people with ASD. However, it is not yet clear whether there are any flaws in the connectivity between the PFC and the amygdala. It is clear that defects in the medial prefrontal cortex probably contribute to defects in ER in ASD. In the normal population, anxiety is associated with increased amygdala activity. With ASD, however, there is anxiety and reduced amygdala activity. However, other studies have shown increased activity of the amygdala. So, it is clear that the amygdala and the PFC are involved with deficienties in ER in ASD, but it is still not clear what the exact mechanisms are.

Which characteristics of ASD influence ER?

The functionalistic perspective states that someone is always consciously trying to regulate positive and negative emotions in order to achieve goals. Clinical observations in ASD show a tendency for people with this disorder to respond to emotional stimuli in a very intense manner. In ASD, there seems to be a lack of motivation for ER, which probably consists of poor emotional insight and self-monitoring. Adaptive ER strategies depend on the context, and are applied selectively. People with ASD also often experience problems with cognitive flexibility and behavioral adjustment, so it is not surprising that they make less use of adaptive ER strategies. Differences in information processing and perceptions in ASD can also contribute to this.

Discussion

There are still many questions about the mechanisms that lead to deficienties in ER in people with ASD and therefore it is still unclear what the implications for treatment should be. The author of the article states that neural mechanisms that are shared with other psychiatric disorders in combination with ASD-related behavioral and cognitive characteristics together provide heterogeneous manifestations of ER problems in ASD. The author states that ER problems may be intrinsic to ASD, but that this may increase the risk of developing a comorbid psychiatric disorder. Research into ER must be done with the use of different methods, which preferably consists of a combination of physiological, neurological, and behavioral measurements. To understand ER in ASD, representative samples are needed with a variety of emotional expressions. Samples must also have different language and intellectual skills. Behavioral measurements are the most suitable for assessing ER in a clinical context, since this is independent of someone's language skills or cognitive functioning. These measurements can be looked at in combination with reports from parents or self-reports. Psycho-education about emotion regulation can also help to accept someone's problems and acknowledge someone's powers. There is some evidence that psychosocial interventions aimed at erupting ER outbreaks and negativity in children can be reduced, but much research is still needed. Measurements of ER that are reliable and valid for the full range of young people with ASD and that are sensitive to change have yet to be developed.