The use of punishment to treat severe behavioral challenges in autistic children was first introduced nearly 60 years ago. Although most people in the autism community strongly disagree with using any form of punishment as a therapeutic approach, aversives continue to be a source of discussion and controversy. Recently, the Association for Behavior Analysis International, a renowned professional organization established in 1974, asked its members to vote on whether contingent electric shock should be entirely ruled out or be appropriate in some cases. Given the recent renewed interest in aversives, I thought it would be timely to share my thoughts on this topic.

Over the past 50+ years, much has been written about using aversive interventions to treat those on the autism spectrum. Aversives involve mild to severe degrees of discomfort or pain, from saying the word “no” or making a loud noise to more extreme forms such as forced ammonia inhalation, blindfolding, and electric shock [1-3].

Although aversives can be moderately effective in reducing challenging behaviors, such as self-injurious behavior (SIB) and aggression toward others, critics often use the words “cruel” and “torture” to describe extreme forms of aversives. However, some forms of aversives are currently accepted by the general professional community. For instance, aversives, including contingent electric shock (CES), are sometimes employed to treat addictions in the general population, including alcoholism, gambling, and smoking [4-6].

In this editorial, I will address CES given a legal decision rendered last year (July 2021) [7]. Basically, a judge allowed the utilization of CES for clients who engaged in severe challenging behaviors potentially leading to harm to others or to themselves. This ruling applies only to clients at the Judge Rotenberg Educational Center in Canton, Massachusetts. The ruling affects about one-fifth of the approximately 300 clients at the center. However, this decision can now be referred to in other legal cases involving similar situations.

CES should not be confused with electroconvulsive therapy (ECT). The former is applied immediately, usually within seconds, after a challenging behavior, such as self-harming behavior or aggression. The latter, ECT, involves administering electric current into the brain to induce a brief seizure. ECT has been given to some individuals on the spectrum to treat severe self-injurious behavior [8] and catatonia [9].

Research on CES started in the mid-1960s, soon after autism was recognized as a biological condition as opposed to a condition caused by emotional neglect by parents. Early studies typically involved single-subject controlled experiments. Over the years, few studies have been reported in the literature.

Today, CES is, for the most part, not considered a viable form of intervention within the autism community. In addition, the Food and Drug Administration banned CES in the United States [10], and the United Nations has stated that CES is dehumanizing and abusive [11].

The use of CES over the decades was never widespread; however, it was sometimes employed as a last resort since SIB can lead to severe self-inflicted harm, such as lacerations, bone fractures, and concussions. There are also reports of individuals blinding themselves in addition to biting off their fingers or part of their tongue. One rationale people have used when condoning CES is to avoid other “less desirable” options, including long-term sedation or restraint.

Several methods have been used to deliver CES, including (1) an electrical prod, (2) an electrical grid embedded in the floor, (3) a remote-controlled device activated by a therapist, and (4) an automated movement sensor. Regarding the latter, the Self-Injurious Behavior Inhibiting System (SIBIS) was created to control head-banging by placing a sensor on the child’s head that would deliver a signal to activate a shock to the arm or leg [12].

How should we approach the treatment of severe challenging behaviors?

Edward Carr, one of the leading experts in treating challenging behaviors, would often tell a heart-wrenching story about the time he attempted to treat a young man on the spectrum who engaged in severe SIB [13]. Dr. Carr’s team developed a behavioral strategy that involved giving CES immediately after the man engaged in head-hitting. The intervention was moderately successful in that the frequency of head-hitting decreased but was not entirely eliminated. Later, the team learned that the man suffered from migraine headaches. One could imagine how an individual would feel when experiencing both a severe head pain and electric shock.

In a recent interview in the Boston Globe, a father described his son who had blinded himself in one eye and exhibited numerous challenging behaviors (August 1, 2021) [14]. After receiving CES, he stopped poking his other eye. Other benefits seen in the child were also attributed to the CES, including improvements in communication and self-help skills.

However, it is important to mention that one research study demonstrated a dramatic reduction in eye-poking behavior in a group of autistic children after receiving liquid calcium [15]. This is because some-to-many individuals who exhibit this type of behavior suffer from hypocalcemia. One possible explanation for eye-poking is that low calcium levels are associated with dry eye syndrome, which may lead to inflammation on the surface of the eyes and/or the eyelids as well as cause a burning sensation [16, 17]. Thus, giving an individual a simple nutritional supplement may be beneficial when treating behavior directed toward the eyes. Unfortunately, this treatment is not well-known among clinicians.

The use of CES, as almost always argued, is considered after attempting all other possible options for intervention. Although this may sound convincing and commendable, the term “all” can be considered a misnomer because this really depends on the knowledge-base as well as the training of the members of the clinical team as well as outside consultants. Given the limited amount of research and the lack of widespread knowledge about the biology of challenging behaviors, one can easily question whether the decision to administer electric shock is truly reasonable and thorough.

There is mounting evidence indicating that internal discomfort or pain may be associated with SIB. Unfortunately, many individuals on the autism spectrum have impaired communication skills. As a result, they often cannot express their feelings of discomfort and pain. Comorbidities associated with SIB include gastrointestinal problems [18], immune system issues [19], metabolic problems [20], seizures [21], abnormal sensory processing [22], nutritional issues [23], anxiety [24], and sleep problems [25].

Obviously, it can be a daunting task to assess all possibilities when determining the underlying reasons for a severe behavior, but it is crucial that an all-out effort be made.

The Autism Research Institute recently launched a new webpage, www.Self-InjuriousBehavior.com, designed to assist professionals and parents in identifying treatments that may reduce or eliminate self-injurious behavior. After answering questions regarding the location of the injury as well as related factors, users are directed to a description of possible underlying causes for the behavior. In addition, online links are presented with respect to understanding and treating the behavior.

A large parent survey that collected data on almost 40,000 individuals with ASD indicated that 9% engaged in SIB, 19% engaged in aggression, and 19% engaged in both behaviors (data collected by the Autism Research Institute between 1964 and 2006). Given that nearly half of individuals on the spectrum exhibit one or both of these challenging behaviors, we urge the autism community to work collaboratively to establish a consensus report on treating challenging behaviors. The goal of such an effort would be to recommend a number of behavioral, sensory, medical, and biomedical approaches that could help to identify the underlying reasons for the behaviors of interest, pointing to the most appropriate treatments. We hope that the autism community will welcome such a challenge and support such an endeavor.

References are available at www.ARRIReferences.org.

This editorial originally appeared in Autism Research Review International, Vol. 36, No. 4, 2022

Many teens and young adults who seek treatment for a substance use disorder (SUD) exhibit previously unidentified traits characteristic of autism spectrum disorder (ASD), according to a new study.

James McKowen and colleagues asked parents of 69 adolescents or young adults who were visiting a SUD clinic for the first time to evaluate their children using the Social Responsiveness Scale-2 (SRS-2). This form is designed to measure social awareness, social cognition (thinking about other people and interactions with them), social communication, social motivation, and restricted interests and repetitive behaviors. It has been shown to reliably identify the presence and severity of social impairment in individuals with ASD, and to distinguish autism from other disorders.

“Usually, studies of substance use disorder in autism are done in those with an autism diagnosis already,” McKowen says. “We have looked at this question from the other side, asking how many people with substance use disorder have autism.”

The researchers found that 20% of the teens and young adults had elevated scores on the SRS-2. They say the findings highlight the importance of assessing patients in a SUD treatment setting for autistic traits.

For parents of children with a SUD, McKowen adds, “the big takeaway is that if you suspect that your child may have an autism spectrum issue or if school personnel have suggested that your child may have autistic traits, you should certainly get that assessed, and let your clinicians know whether your child has had a prior diagnosis
of ASD.”

—

“Characterizing autistic traits in treatment-seeking young adults with substance use disorders,” James McKowen, Diana Woodward, Amy M. Yule, Maura DiSalvo, Vinod Rao, Julia Greenbaum, Gagan Joshi, and Timothy E. Wilens, American Journal on Addictions, December 2021 (online). Address: James McKowen, Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital, 15 Parkman St., Wang Bldg., Suite 805, Boston, MA 02114, jmckowen@mgh. harvard.edu.

—and—

“Undiagnosed autistic traits common among youths with substance use disorders, study finds,” news release, Massachusetts General Hospital, January 24, 2022.

This article originally appeared in Autism Research Review International, Vol. 36, No. 1, 2022

Adolescents with autism spectrum disorders (ASD) may have difficulty understanding other people’s emotions because they do not use contextual clues, a new study suggests.

The study, by Steven Stagg and colleagues, compared 20 teenagers with ASD to 20 neurotypical teens. All participants were between 13 and 15 years of age.

In the first part of the experiment, the groups viewed photos of people displaying static emotions (fear, anger, happiness, sadness, disgust, and surprise). The teens with ASD and the neurotypical controls identified the emotions in the images equally well.

In the second part of the experiment, the groups watched six short videos. In the first part of each video, a main character displayed an emotion that matched the context of the scene. Later in each video, the character displayed a feigned emotion masking his
or her true feelings.

For example, one video showed an individual buying a cup of coffee and then being bumped into by another individual, making him spill his coffee. The main character first appeared angry, but after receiving an apology, he displayed a forced smile. The researchers found that while the teens did not differ in their ability to identify the emotions being displayed on the faces of the characters in the videos, those with ASD could not correctly identify how the characters actually felt. For example, they identified the feigned smile of the man in the coffee video as happiness.

Stagg comments, “Our findings suggest that children with autism may misjudge the feelings of others due to an over-reliance on facial cues to the detriment of contextual cues, rather than an inability to recognize facial emotion. In fact, we found that children with autism are just as capable as their typically developing peers at recognizing static images of facial emotion. However, in everyday life facial expressions are not presented in a vacuum. People commonly attempt to hide their feelings, and therefore accurate recognition of emotion involves processing both facial expressions and contextual cues.

In this study, he says, “the children with autism struggled when asked to describe how the actors were feeling. We believe this is because these children have difficulties integrating the narrative with the facial expressions, and instead their judgments are guided only by the visible emotion on display. In part, this may be due to the higher cognitive demand that more complex stimuli, such as context, place on processing capacity.”

—

“Emotion recognition and context in adolescents with autism spectrum disorder,” Steven Stagg, Li-Huan Tan, and Fathima Kodakkadan, Journal of Autism and Developmental Disorders, October 7, 2021 (epub prior to print publication). Address: Steven Stagg, Anglia Ruskin University, East Road, Cambridge, CB1 PT1, UK, steven.stagg@aru.ac.uk.

—and—

“Autistic children struggle with hidden emotions,” news release, Anglia Ruskin University, October 8, 2021.

This article originally appeared in Autism Research Review International, Vol. 35, No. 4, 2021

Mothers of children with autism spectrum disorders (ASD) may reduce their odds of having another child with ASD if they time a second pregnancy to occur 2.5 to 3 years after the birth of the child with ASD, according to a new study.

Gavin Pereira and colleagues studied data from more than 925,000 births in Denmark, Finland, and Sweden. More than 9,300 of the children in the birth cohort were later diagnosed with ASD.

The researchers found that the association between ASD and the intervals between pregnancy was U-shaped for all three countries. Pereira says, “Our research found that the siblings of children with autism were less likely to be diagnosed on the spectrum if there was a 30- to 39-month gap between both pregnancies.

Across the general population, this study also showed that children born to mothers who became pregnant again three months after giving birth had a 50 percent higher chance of being diagnosed with autism, and those born five years later had a 24 percent greater chance.”

Pereira comments, “The results of this large-scale, multi-country research may help to inform family planning counseling, particularly for those families that are already at a higher risk because of a genetic history of neurological disease.” He and his team speculate that “about 5% to 9% of autism cases might be avoided by optimizing birth spacing.”

—

“Optimal interpregnancy interval in autism spectrum disorder: A multi-national study of a modifiable risk factor,” Gavin Pereira, Richard W. Francis, Mika Gissler, Stefan N. Hansen, Arad Kodesh, Helen Leonard, Stephen Z. Levine, Vera R. Mitter, Eric T. Parner, Annette K. Regan, Abraham Reichenberg, Sven Sandin, Auli Suominen, and Diana Schendel, Autism Research, August 23, 2021 (online). Address: Gavin Pereira, School of Public Health, Curtin University, Perth, WA 6102, Australia, gavin.f.pereira@curtin.edu.au.

—and—

“Sibling’s likelihood of autism diagnosis impacted by age gap,” news release, Curtin University, August 25, 2021.

This article originally appeared in Autism Research Review International, Vol. 35, No. 4, 2021

A new study indicates that rates of depression rise significantly in individuals with autism spectrum disorders (ASD) if they experience a job loss or reduction in hours or pay.

“Though unemployment has been linked to mental health problems in the general population,” Julie Lounds Taylor and colleagues say, “this relationship is seldom considered among adults with autism.” The COVID-19 pandemic, the researchers say, provided a natural opportunity to study this issue.

The researchers used online surveys to collect data from individuals with ASD at two times: just before widespread social distancing took place, and again ten weeks later. At both points, the researchers also measured participants’ depressive symptoms.

Of the 144 young adults who were employed at the first point, the researchers say, more than one-third reported employment changes during the first two months of the pandemic. In most cases, these involved losing a job or having their hours or pay reduced.

“Controlling for Time 1 depressive symptoms,” they say, “young adults who experienced job loss/reduction had significantly higher depressive symptoms at Time 2 than those without an employment change.”

The researchers say, “Our study is the first to find that employment changes— particularly job loss or reduction—had a significant negative effect on the mental health of young adults with ASD compared to stable employment. This association suggests important directions for future research and practice—both as the economy recovers from COVID-19 and likely beyond. Better supporting adults with ASD in the workplace may not only decrease the likelihood of job loss, but also combat the exceedingly high rates of depression in this group.”

The researchers also note that currently, treatments for individuals with ASD who are diagnosed with depression focus almost exclusively on psychotropic medications or cognitive behavioral therapy, while the role of day-to-day issues such as unemployment is rarely taken into account. “Findings from this study,” they say, “suggest that employment changes (and likely other daily experiences) may need to be considered when treating depression in this population.”

As part of their study, the researchers asked participants about their perceptions concerning the impact of job changes. Interestingly, they say, “we observed that perceived negative impact and perceived positive impact were associated with higher depressive symptoms, relative to those who perceived that the employment change had no impact on their wellbeing.” This suggests, they say, that any perceived impact of a job change—either positive or negative— may increase the risk of depression for individuals with ASD.

The researchers conclude that “targeting the employment situations of adults with ASD may represent a critical avenue for improving their psychological health.” However, they note that their findings need to be replicated because their study group was fairly small and the study focused solely on short-term job changes.

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“Job loss predicts worsening depressive symptoms for young adults with autism: A COVID-19 natural experiment,” Julie Lounds Taylor, Ryan E. Adams, Florencia Pezzimenti, Shuting Zheng, and Somer L. Bishop, Autism Research, October 2021 (free online). Address: Julie Lounds Taylor, Vanderbilt Kennedy Center, PMB 40-230 Appleton Pl., Nashville, TN 37203, julie.l.taylor@vanderbilt.edu.

This article originally appeared in Autism Research Review International, Vol. 35, No. 4, 2021