Emotion Regulation and Suicidality Publications

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Jessie B Northrup , Amy G Hartman , Kristen T MacKenzie , Shalini Sivathasan , Safaa Eldeeb, and Carla A Mazefsky

Autism Research. 2024.

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Abstract

Emotion dysregulation (ED) is common and severe in older autistic youth, but is rarely the focus of early autism screening or intervention. Moreover, research characterizing ED in the preschool years (when autism is typically diagnosed) is limited. This study aimed to characterize ED in autistic children by examining (1) prevalence and severity of ED as compared to children without an autism diagnosis; and (2) correlates of ED in autistic children. A sample of 1864 parents (Mean child age = 4.21 years, SD = 1.16 years; 37% female) of 2-5 year-old children with (1) autism; (2) developmental concerns, but no autism; and (3) no developmental concerns or autism completed measures via an online questionnaire. ED was measured using the Emotion Dysregulation Inventory-Young Child, a parent report measure characterizing ED across two dimensions: Reactivity (fast, intense emotional reactions) and dysphoria (low positive affect, sadness, unease). Autistic preschoolers, compared to peers without developmental concerns, had more severe ED (+1.12 SD for reactivity; +0.60 SD for dysphoria) and were nearly four and three times more likely to have clinically significant reactivity and dysphoria, respectively. Autistic traits, sleep problems, speaking ability, and parent depression were the strongest correlates of ED in the autism sample. While more work is needed to establish the prevalence, severity, and correlates of ED in young autistic children, this study represents an important first step. Results highlight a critical need for more high-quality research in this area as well as the potential value of screening and intervention for ED in young autistic children.

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 Kelly B. Beck, Kristen T. MacKenzie, Tanvi Kumar, Kaitlyn E. Breitenfeldt,  Judy C. Chang, Caitlin M. Conner, David L. Mandell, Susan W. White, and Carla A. Mazefsky

Autism in Adulthood. 2024.

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Abstract

Background: Emotion dysregulation is associated with mental health challenges and suicidality in autistic adults. Little is known about how emotion dysregulation manifests in adulthood and whether current services adequately support their needs. We explored autistic adults’ experiences of emotion dysregulation and identified key contributors to emotion dysregulation to inform future service development.

Methods: We performed qualitative semi-structured interviews with autistic adults, in which they shared emotion dysregulation stories. Three researchers developed the codebook using a consensus approach, coded interviews, and completed thematic analyses. Autistic adults were part of our study team and involved at every step.

Results: Fifteen autistic adults participated in the interviews. Emotion dysregulation was described in the context of a pervasive lack of control in various settings, most often experienced in health care settings. Limited awareness of internal states (i.e., emotions, sensory) until it was too late was a prominent theme. Many participants described emotion dysregulation as indistinguishable from sensory overload. Interpersonal conflict, largely social rejection because of being misunderstood by a neurotypical person, contributed to difficulty regulating emotions and low perception of self-worth. Participants described feeling powerless in health care settings and workplaces, where they experienced disproportionate and inappropriate responses to their emotion dysregulation, including involuntary sedation, termination of care, and job loss. Most participants described a lack of safety and supports for adaptively coping with emotion dysregulation, leading to tension between the personal costs of masking and the societal consequences of not masking.

Conclusions: Autistic adults attributed their emotion dysregulation to a lack of control across all contexts. It is important for autistic adults to develop emotion regulation skills, but more work is needed to understand and remediate the impact of social marginalization on autistic adults, as this directly contributed to instances of dysregulation.

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Kristen T MacKenzie, Mario J Crown, Jessie B Northrup, Elizabeth Rutenberg, Amy G Hartman, Carla A Mazefsky

Journal of Autism and Developmental Disorders . 2024.

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Abstract

The purpose of this project was to investigate potential correlates of family life impairment in families of young autistic children. This project incorporated measures of specific child and parent challenges in addition to a commonly used unidimensional measure of autism characteristics. In this way, we could assess whether such challenges explain variance in family life impairment, and whether their inclusion diminish associations between autism characteristics and family life impairment. Cross-sectional data were collected from 564 parents of autistic children aged 2 to 5 years who participated in a larger online study. Participants completed measures on child characteristics (autism characteristics, emotion dysregulation, speaking ability, flexibility, and sleep problems), parent depression, and family life impairment, using the Family Life Impairment Scale (FLIS). Multiple linear regression models were generated to examine whether any of the independent variables were associated with the four domains of the FLIS. Models controlled for child age and sex, parent education, and single-parent homes. All independent variables were associated with impairment in one or more FLIS domains. None of the primary independent variables were significantly associated with positive growth. More overt characteristics and behaviors (e.g., autism characteristics, reactivity, speaking ability, and flexibility) were associated with impairment in domains that reflected a family's ability to navigate the community. However, sleep challenges and parent and child emotional difficulties were most strongly associated with parent impairment. Findings suggests that families may have different needs across contexts and provide new avenues through which they might be better supported.

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Anne V Kirby , Caitlin M Conner , Carla A Mazefsky. 

Autism Res. 2024.

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Abstract

Understanding suicide risk is critical for supporting prevention. A growing body of evidence shows autistic people are at greater risk for multiple suicide-related outcomes than non-autistic people. This commentary is in response to an observed pattern of miscommunication in scientific and community spaces about autistic females having higher risk of suicide. However, it is not always clear who they are being compared with in these statements. To address this confusion, we summarize the current population-based evidence on autistic suicide risk, highlighting findings related to sex similarities and differences, which actually indicates comparable rates of suicide death among autistic males and females, and mixed findings related to sex differences in risk of other suicidal behaviors. We call for greater clarity in suicide risk communication moving forward focused on outcomes, measurement, sampling methods, and comparison groups to reflect accurate conclusions about existing evidence. Further research is needed about the full range of suicide-related outcomes for autistic people, including a greater understanding of sex differences as well as potential gender differences to include transgender and nonbinary autistic people. However, studies of sex and gender differences should not overshadow the compelling need for efforts to understand and address the elevated risk of suicidal thoughts, behaviors, and death among autistic people across sex and gender boundaries.

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Jessie B Northrup, Kaitlyn B Cortez, Carla A Mazefsky, and Jana M Iverson

Autism. 2024.

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Abstract

Managing negative emotion can be challenging for autistic individuals and their families from a young age. Parents help young children manage negative emotions by responding in comforting or supportive ways. Not much research has examined how negative emotions and parent responses to negative emotions are different in very young autistic children. This study used videotapes of 18-month-old toddlers and parents at home. We examined how much and how intensely toddlers expressed negative emotion in everyday situations, and how parents responded. Participants were younger siblings of autistic children, and we compared three groups—children that (1) later received an autism diagnosis; (2) had language delays but not autism; and (3) had no delays or autism. We found that autistic toddlers’ negative emotion was more likely to be intense and to continue once it started compared with children without delays or autism. Language-delayed toddlers also showed some, but not all these differences. Parents responded similarly to negative emotions in all groups. When parents used strategies to help, it reduced the chances of the negative emotions continuing, although it may have been less helpful for autistic toddlers. This study shows that autistic children may express more intense and long-lasting negative emotions from an early age. It also shows that parents of autistic children are very responsive to their children’s negative emotions, but these responses may not be as helpful to autistic children. While more research is needed, this study helps us understand how autistic toddlers may express and experience emotions differently.

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Jessie B. Northrup,  Carla A. Mazefsky &  Taylor N. Day 

Autism Dev. Discord. 2024.

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Abstract

Purpose: Differences in emotional experience and expression have long been recognized as common in the presentation of autism, yet research examining emotional expression in early childhood is limited, with mixed findings. Understanding emotional reactivity and expression in autism in early life is an essential step towards uncovering the mechanisms of these risks and identifying targets for intervention. 

Methods: The present study examined emotional expression in autistic (N = 17) and non-autistic (N = 20) toddlers (mean age = 25.27; SD = 1.88) during emotion elicitation tasks aimed at eliciting joy, frustration, and unease. Video recorded tasks were coded in ten second intervals for emotional valence and intensity, and the following variables were computed: proportion of time in positive, neutral, and negative affect; maximum intensity of positive and negative affect; and range of affect (i.e., most negative to most positive intensity). 

Results: Autistic toddlers spent more time in neutral facial expressions, less time displaying positive affect, and had somewhat less intense positive emotional expression than non-autistic peers. Small differences were apparent in intensity of negative affect expression, while no differences emerged in duration of time spent in negative affect. 

Conclusion: Findings emphasize that differences may be more apparent in duration, rather than intensity of emotional expression, and that it may be particularly important to examine periods of “neutral” affect in young autistic children. Future research should consider the best ways to understand emotional reactivity in this population considering their unique interests, challenges, and communication styles.

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Caitlin M Conner, Amy Ionadi , Carla A Mazefsky 

Pa J Posit Approaches. 2024.

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Introduction

Rates of death by suicide among teens and adults have increased more than 30% since 2000 in the United States, and an estimated 800,000 people die from suicide worldwide each year.^1,2 Even more people experience suicidal thoughts and/or make suicide attempts. The past several years of research have taught us that autistic people are more likely to die from suicide than non-autistic people.^3–5 Autistic people are also more likely to have suicidal ideation and to make attempts. Based on rates from a recent meta-analysis (statistical analysis to combine rates from published studies on the topic), 20% of autistic children and teens reported suicidal ideation in the past year, and 10% reported suicide attempts.⁶ Non-autistic children and teens comparatively report rates of 14.2% for suicidal thoughts and 4.5% for suicidal attempts.⁷ This suggests that the rates of suicide attempts are double in autistic children and teens compared to non-autistic children and teens. The comparisons for adults are even more striking. For autistic adults, 42% reported suicidal ideation in the past year, and 18% reported attempts.⁶ In studies of people who were first diagnosed as autistic in adulthood, over 60% reported having suicidal ideation.⁸ Comparatively, non-autistic adults reported rates of 4.8% for suicidal ideation and 0.7% for suicidal attempts.⁹ Therefore, available data suggests that autistic adults are 25 times more likely to make a suicide attempt than non-autistic adults.

An important limitation is that nearly all of the suicide research in autism has occurred in the past five years and the body of evidence remains limited in comparison to the general suicide literature. Further, it is important to note that there are large differences in suicide rates across different studies. Many studies have used online samples, and it may be possible that relying on online studies may result in higher rates. As a potential explanation, autistic adults might be drawn to participate in studies because of their personal experiences with suicidality. Furthermore, it can be hard to know if people in an online sample accurately represent the entirety of the autistic community. Regardless, these high rates are very concerning, and several autistic advocacy groups have identified suicide risk and prevention as top priorities for research and government efforts.^10,11

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Shalini Sivathasan, Safaa Eldeeb, Jessie B. Northrup, Ligia Antezana, Amy Ionadi, Lauren S. Wakschlag, Carla A. Mazefsky.

 JAACAP Open. 2024.

study link

Abstract

Purpose: Differences in emotional experience and expression have long been recognized as common in the presentation of autism, yet research examining emotional expression in early childhood is limited, with mixed findings. Understanding emotional reactivity and expression in autism in early life is an essential step towards uncovering the mechanisms of these risks and identifying targets for intervention. 

Methods: The present study examined emotional expression in autistic (N = 17) and non-autistic (N = 20) toddlers (mean age = 25.27; SD = 1.88) during emotion elicitation tasks aimed at eliciting joy, frustration, and unease. Video recorded tasks were coded in ten second intervals for emotional valence and intensity, and the following variables were computed: proportion of time in positive, neutral, and negative affect; maximum intensity of positive and negative affect; and range of affect (i.e., most negative to most positive intensity). 

Results: Autistic toddlers spent more time in neutral facial expressions, less time displaying positive affect, and had somewhat less intense positive emotional expression than non-autistic peers. Small differences were apparent in intensity of negative affect expression, while no differences emerged in duration of time spent in negative affect. 

Conclusion: Findings emphasize that differences may be more apparent in duration, rather than intensity of emotional expression, and that it may be particularly important to examine periods of “neutral” affect in young autistic children. Future research should consider the best ways to understand emotional reactivity in this population considering their unique interests, challenges, and communication styles.

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Carla A. Mazefsky, Caitlin M. Conner, Kaitlyn Breitenfeldt, Nina Leezenbaum, Qi Chen, Lauren M. Bylsma & Paul Pilkonis 

Journal of Clinical Child & Adolescent Psychology 2021

Free Access

Abstract

Objective: Emotion regulation (ER) is a multi-faceted and dynamic process relevant to both normative emotional development and transdiagnostic emotional dysfunction for a range of psychological disorders. There has been tremendous growth in ER research over the past decade, including the development of numerous new measures to assess ER. This Evidence Base Update included a systematic review to identify self- and informant-report questionnaire measures of ER for children and adolescents, including measures of ER strategies and effectiveness (or emotion dysregulation).

Methods: PubMed, PsycInfo, and Health and Psychosocial Instruments databases were searched using the terms emotion OR affect AND regulation OR control OR reactivity OR response, as well as terms related to questionnaires and psychometrics, restricted to articles on youth (< 18 years old). Each measure’s psychometrics was evaluated based on modified criteria by De Los Reyes and Langer (2018).

Results: Nine-hundred ninety-seven papers were identified yielding 87 measures that met inclusion for review. Although the majority (60%) of identified ER measures could not be recommended based on these criteria, 8% were Excellent, 14% were Good, and 17% were Adequate. The recommended measures included: 11 general ER measures (5 focused on strategies, 5 focused on dysregulation/ effectiveness), 13 measures of ER as it relates to specific emotions or contexts such as irritability or peer stress (4 focused on strategies, 9 focused on dysregulation/effectiveness), and 11 measures of other constructs that include an ER subscale (all focused on dysregulation). 

Conclusions: The characteristics, strengths, and weaknesses of the recommended ER measures are described in order to guide measure selection for clinical or research uses. A synthesis of themes identified during this review includes commonly observed areas of weakness and gaps in the literature to provide a foundation for future research and measure development.

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Jessie B. Northrup, Mark T. Patterson, and Carla A. Mazefsky

Journal of Clinical Child & Adolescent Psychology 2021

Abstract

Objective: Emotion dysregulation problems are prevalent and disruptive for many with autism spectrum disorder (ASD). This study compared severity and perceived change in emotion dysregulation in youth with and without ASD and probed correlates of emotion dysregulation (including possible two-way interactions) among youth with ASD.

Method: Participants were drawn from two large online samples (mean age = 12; range: 6–17) with (N = 1323) and without (N = 921) ASD. The study used the Emotion Dysregulation Inventory (EDI), a parent-report measure designed for youth with ASD. The EDI asks parents about current severity and perceived change (i.e. how current severity compares to lifetime severity) in emotion dysregulation, and includes two factors: Reactivity (rapidly escalating, intense negative affect) and Dysphoria (poorly upregulated positive affect, general unease).

Results: Results indicated that youth with ASD had greater Reactivity severity and also greater positive change in Reactivity than non-ASD peers. Furthermore, differences between youth with and without ASD in the relationship between Reactivity and Dysphoria suggest a distinct profile of emotion dysregulation in ASD. Within the ASD sample, age and severity of stereotyped behavior predicted Reactivity and Dysphoria severity and Reactivity change. Female gender, lower parent education, and fluent verbal ability were additional predictors of increased Reactivity severity, while intellectual disability predicted lower Dysphoria severity.

Conclusions: This study provides new insight into predictors of emotion dysregulation in youth with ASD and represents a first step towards identifying which children with ASD may be most vulnerable to severe emotion dysregulation problems.

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Caitlin M. Conner, Josh Golt, Rebecca Shaffer, Giulia Righi, Matthew Siegel, and Carla A. Mazefsky

Autism Research 2021

Free Access

Summary

This study compared problems with emotion regulation in large samples of youth with and without ASD. An ASD community sample had two to four times more youth with clinically elevated regulation impairments compared to youth without ASD. Emotion regulation impairment was also related to using psychiatric hospitalizations, emergency services, and medications in the ASD group. This study suggests that screening for emotion regulation difficulties in ASD is important and treatment may have a wide ranging impact.

Abstract

Emerging evidence suggests that emotion regulation (ER) impairment in those with ASD is associated with poor mental health. This study used the Emotion Dysregulation Inventory, a new norm-referenced ER measure with clinical cut-offs, developed and validated in ASD and non-ASD samples, to establish rates of ER impairment and understand its association with psychiatric service use in ASD. Parents of 6–17 year olds in three well-characterized samples (nationally representative US n = 1,000; community ASD n = 1,169; inpatient ASD n = 567) completed a battery of questionnaires about their child. The prevalence of ER impairment was significantly higher in the ASD groups compared to the nationally representative sample and highest in the psychiatric Inpatient ASD group. The community ASD and inpatient ASD samples were four and seven times more likely, respectively, to exceed clinical cutoffs for emotional reactivity than the general US sample. Similarly, history of psychiatric hospitalization, recent emergency services use (police contact, emergency room visits, or in-home crisis evaluations for emotional or behavioral concerns in the past 2 months), and psychotropic medication prescriptions were significantly higher in the ASD groups. ER impairment was significantly associated with all forms of psychiatric service use, after controlling for demographics (age, sex, race), co-occurring intellectual disability, and ADHD symptoms. This is the first large-scale study to document substantially higher rates of ER impairment in youth with ASD compared to the general population. The importance of ER impairment is underscored by its association with higher utilization of inpatient, emergency, and medication services in ASD, after accounting for demographics and ADHD-related symptoms.

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Kelly B. Beck, PhD, Caitlin M. Conner, PhD, Kaitlyn E. Breitenfeldt, BS, Jessie B. Northrup, PhD, Susan W. White, PhD, and Carla A. Mazefsky, PhD

Child and Adolescent Psychiatric Clinics of North America 2020

Abstract

As eloquently summarized by Thompson,¹ emotion regulation (ER) is a complex, multifaceted, and interactive process. Involving one’s neurobiology, cognition, behavior, affect, and context, ER is the ability to monitor and modify arousal and reactivity to engage in adaptive behavior. ER involves intentional and automatic attempts to manage affect, as well as internal (acquired) and external (imposed by others) strate-gies.^1,2 Finally, ER is usually viewed functionally, meaning in relation to the degree that it is effective in facilitating goal attainment. In this review, we adopt a fully inclusive definition of ER that encompasses both reactivity (the speed and intensity of felt emotion) and the strategies (internal, external, intentional, automatic) applied to manage emotions.^3,4

Although ER impairment in autism spectrum disorder (ASD) and its adverse influence on outcome has been acknowledged for several years (eg, Kanner’s⁵ mention of “disturbances of affective contact”), research on this phenomenon has been slow to develop. Herein, we offer readers a synthesis of extant research on both assessment and treatment of ER problems in ASD. This review is neither exhaustive nor is it an attempt to compare differential effectiveness of approaches. Rather, our goal is to summarize the advances made over the past decade with respect to assessment and treatment of ER problems in people with ASD across the life span. In so doing, we identify what appear to be the most promising ER measures for this population and consolidate the extant scientific literature on interventions targeting remediation of ER impairment. We focus exclusively on ER and not on the myriad of related problems (eg, anxiety, aggression). We also offer suggestions for research that must be addressed for the field to advance.

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Caitlin M Conner, Josh Golt, Giulia Righi, Rebecca Shaffer, Matthew Siegel, and Carla A. Mazefsky

Journal of Autism and Developmental Disorders 2020

Abstract

Evidence suggests increased rates of suicidality in autism spectrum disorder (ASD), but the research has rarely used comparison samples and the role of emotion dysregulation has not been considered. We compared the prevalence of parent-reported suicidal ideation and considered the role of emotion dysregulation in 330 psychiatric inpatient youth with ASD, 1,167 community youth with ASD surveyed online, and 1,000 youth representative of the US census. The prevalence of suicidal ideation was three and five times higher in the community and inpatient ASD samples respectively compared to the general US sample. In the ASD groups, greater emotion dysregulation was associated with suicidal ideation. Implications include consideration of emotion regulation as a potential mechanism and treatment target for suicidality in ASD.

Information

Carla A. Mazefsky and Susan W. White

Child and Adolescent Psychiatric Clinics of North America 2014

Synopsis

The purpose of this article is to describe emotion regulation, and how emotion regulation may be compromised in autism spectrum disorder (ASD). This information may be useful for clinicians working with children with ASD who exhibit behavioral problems. Suggestions for practice are provided.

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Carla A. Mazefsky, Xenia Borue, Taylor N. Day, and Nancy J. Minshew

Journal of Clinical Child & Adolescent Psychology 2014

Abstract

Autism spectrum disorder (ASD) is often associated with poor emotional control and psychopathology, such as anxiety and depression; however, little is known about the underlying mechanisms. Emotion regulation (ER) is a potential contributing factor, but there has been limited research on ER and its role in comorbid psychopathology in ASD. In this study, we compared self-reported ER with self- and parent reports of psychopathology in 25 high-functioning adolescents with ASD and 23 age- and Intelligence Quotient (IQ)-matched typically developing controls. Contrary to expectations, both groups reported similar levels of adaptive, voluntary forms of ER (problem solving, acceptance, etc.). However, the ASD group reported significantly greater use of involuntary forms of ER that are typically maladaptive, including remaining focused on the stressor (e.g. rumination and emotional arousal) and shutting down (e.g. emotional numbing and being unable to think or act). Associations between ER and psychopathology were generally more robust using self-report rather than parent report. For both groups, greater endorsement of involuntary ER strategies was associated with higher ratings of psychopathology, whereas voluntary ER strategies focused on changing or adapting to the situation were significantly associated with lower levels of psychopathology. The magnitude and direction of association between ER types and psychopathology were similar for measures of depression and anxiety. These findings can help guide the development of psychosocial treatments targeting dysfunctional ER in adolescents with ASD. Interventions focused on ER as a transdiagnostic process may be a more robust method to improve emotional control and decrease emotional distress in ASD than disorder-specific interventions.

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Carla A. Mazefsky, Ph.D., John Herrington, Ph.D., Matthew Siegel, M.D., Angela Scarpa, Ph.D., Brenna B. Maddox, M.S., Lawrence Scahill, MSN, Ph.D., and Susan W. White, Ph.D.

Journal of the American Academy of Child and Adolescent Psychiatry 2013

Abstract

Objective: Autism spectrum disorder (ASD) is associated with amplified emotional responses and poor emotional control, but little is known about the underlying mechanisms. This paper provides a conceptual and methodological framework for understanding compromised emotion regulation (ER) in ASD.

Method: After defining ER and related constructs, methods to study ER were reviewed with special consideration on how to apply these approaches to ASD. Against the backdrop of cognitive characteristics in ASD and existing ER theories, available research was examined to identify likely contributors to emotional dysregulation in ASD.

Results: Little is currently known about ER in youth with ASD. Some mechanisms that contribute to poor ER in ASD may be shared with other clinical populations (e.g., physiological arousal, degree of negative and positive affect, alterations in the amygdala and prefrontal cortex), whereas other mechanisms may be more unique to ASD (e.g., differences in information processing/perception, cognitive factors (e.g., rigidity), less goal-directed behavior and more disorganized emotion in ASD).

Conclusions: Although assignment of concomitant psychiatric diagnoses is warranted in some cases, poor ER may be inherent in ASD and may provide a more parsimonious conceptualization for the many associated socio-emotional and behavioral problems in this population. Further study of ER in youth with ASD may identify meaningful subgroups of patients and lead to more effective individualized treatments.

Information

Carla A. Mazefsky, Donald P. Oswald, Taylor N. Day, Nancy J. Minshew, Shaun M. Eack, and Janet E. Lainhart

Journal of Clinical Child & Adolescent Psychology 2012

Abstract

Objective: Varied presentations of emotion dysregulation in autism complicate diagnostic decision making and may lead to inaccurate psychiatric diagnoses or delayed autism diagnosis for high-functioning children. This pilot study aimed to determine the concordance between prior psychiatric diagnoses and the results of an autism-specific psychiatric interview in adolescents with high-functioning autism.

Methods: Participants included 35, predominantly Caucasian and male, verbal 10 – 17 year olds with a confirmed autism spectrum disorder and without intellectual disability. The average age of autism spectrum diagnosis was 11-years-old. Lifetime psychiatric diagnoses were established via the Autism Comorbidity Interview, developed to identify co-morbid conditions within the context of autism. Autism Comorbidity Interview results were compared to parent report of prior community psychiatric diagnoses.

Results: Approximately 60% of prior psychiatric diagnoses were not supported on the Autism Comorbidity Interview; the lowest diagnostic concordance was for prior bipolar disorder and obsessive-compulsive disorder diagnoses. While 51% of children met Autism Comorbidity Interview criteria for at least one psychiatric disorder, rates of prior diagnoses were much higher, with 77% having at least one prior psychiatric diagnosis and 60% having two or more.

Conclusions: Although many participants met criteria for comorbid psychiatric disorders, the majority of previous psychiatric diagnoses were not supported when autism-related manifestations were systematically taken into account. These findings require replication and may not generalize to lower-functioning and earlier diagnosed children with ASD. Results emphasize the importance of increasing awareness of the manifestations of high-functioning autism in order to improve accuracy of diagnosis and appropriateness of interventions.