Matthew J. Hollocks

Extreme/pathological demand avoidance (EDA) is a behavioral profile characterized by the avoidance of everyday demands, with significant impact on the individuals and those around them. Little is understood regarding the correlates and drivers of EDA; understanding these better may lead to targeted interventions and support strategies. Cross‐sectional data from parent‐rated measures were analyzed for 63 children referred to a specialist neurodevelopmental clinic in the United Kingdom. The relationship between EDA traits and a number of psychological (intolerance of uncertainty, anxiety, emotional dysregulation [reactivity and dysphoria], cognitive inflexibility, alexithymia [i.e., difficulty identifying emotions]), and neurodevelopmental (autistic and ADHD) traits was tested. No differences in EDA traits were found by diagnostic group (autistic vs. not‐autistic) or gender (male and female). Across the whole sample, EDA traits were negatively correlated with age and positively correlated with emotional dysregulation reactivity, ADHD traits, cognitive inflexibility, intolerance of uncertainty and alexithymia. EDA was not associated with autistic traits or anxiety. Path models were used to identify which cognitive and behavioral features predicted EDA scores, once inter‐correlations among predictors were controlled for. Only emotional dysregulation, ADHD traits and age predicted EDA‐Q scores. Further research is needed to assess how these variables contribute to EDA in larger more diverse samples, capturing potentially unmeasured variables, and exploring possible mediation pathways.

Background: Cultivating a positive identity may buffer against the adverse mental health outcomes often experienced by autistic individuals. Group settings can provide valuable spaces for identity consolidation. This study evaluated the feasibility and acceptability of a co-designed group intervention promoting positive identity and self-esteem among autistic adolescents. Methods: A six-week group intervention was co-developed with eight autistic adolescents. Sixteen autistic adolescents (13–16 years; 10 females, 5 males, 1 non-binary) and their caregivers participated. Psychometric measures were collected pre- and post-intervention to assess self-esteem (Rosenberg Self-Esteem Scale), wellbeing (Warwick–Edinburgh Mental Wellbeing Scale), and autistic identity (Multidimensional Social Identification Scale). Feasibility was assessed through recruitment, retention, attendance, and data completeness; acceptability was evaluated via session ratings and post-group interviews analysed using inductive thematic analysis. Results: The intervention showed high feasibility (6.25% attrition) and acceptability, with positive feedback on content and facilitation. Themes highlighted the importance of shared experience, social connection, and adaptive delivery. Conclusions: This novel co-designed intervention was feasible and acceptable for autistic adolescents and caregivers, supporting identity-affirming, post-diagnostic approaches within clinical services.

Autistic individuals are at increased risk of developing mental health difficulties. Self-esteem has been found to be a significant indicator of mental health in the general population yet remains underexplored in autistic adolescents. This review aimed to explore rates of low self-esteem in autistic versus non-autistic adolescents (10–19 years of age) and examine the relationship between self-esteem and mental health symptomatology. A comprehensive literature search was conducted across four databases to identify relevant studies published until March 2025. The systematic review included 30 studies of self-esteem in autistic adolescents, including 15 studies with a non-autistic comparison group, and 16 studies with measures of both self-esteem and mental health. Autistic adolescents reported significantly lower levels of self-esteem compared with non-autistic adolescents, with a moderate weighted pooled effect size (g = −0.47). Group differences were maintained when considering measure variance in self-esteem tools but observed to be greater when using the Self-Perception Profile (g = −0.55) in contrast to the Rosenberg Self-Esteem Scale ( g = −0.33). Lower self-esteem was associated with greater depressive symptomatology in autistic adolescents, with large effect ( r = −.59). These findings highlight the need for targeted self-esteem interventions in autistic adolescents as a potential means to address co-occurring mental health difficulties. Lay Autistic adolescents are more likely to experience mental health difficulties than their non-autistic peers. One factor that may influence mental health is self-esteem, which refers to how positively or negatively a person views themselves. This review looked at how self-esteem differs between autistic and non-autistic adolescents, and whether low self-esteem is linked to mental health problems such as depression and anxiety. The review included 30 studies, some of which compared self-esteem levels between autistic and non-autistic adolescents and others explored how self-esteem relates to mental health symptoms. The findings showed that autistic adolescents tend to have lower self-esteem than non-autistic adolescents. In addition, lower self-esteem was linked to higher levels of depression in autistic adolescents. These results suggest that supporting self-esteem in autistic adolescents may be an important way to help improve mental health difficulties. The studies in this review included mainly male participants and used different ways to measure self-esteem and mental health, so more research is needed to better understand these relationships and how best to support a diverse range of autistic adolescents.

This Response addresses methodological and conceptual issues raised in a Letter to the Editor concerning our recently published network analysis of autism characteristics and anxiety symptoms in autistic children and youth. We clarify concerns related to potential conceptual overlap between autistic characteristics and anxiety‐related symptoms and address questions concerning the multinational nature of the dataset. We also summarize sensitivity and stability analyses showing that the identified bridge nodes are robust to variation in regularization parameters and operational definitions. Together, these clarifications support the interpretation of the reported network findings.

The social motivation theory hypothesizes that autistic individuals' experience diminished social motivation due to reduced social reward, social orienting, and social maintaining. Low social motivation has been linked to increased vulnerability to internalizing difficulties within this population. This systematic review and meta‐analysis examined the relationship between social motivation and internalizing symptoms across the lifespan in autistic individuals. Relevant research papers until February 2025 were identified by searching EMBASE, PsycINFO, PubMed, and Web of Science databases (PROSPERO protocol: CRD42024547863). The systematic review included 14 studies ( n = 4590). A total of three meta‐analyses were run using Pearson's correlation coefficients between social motivation and (1) anxiety, (2) depression, and (3) social anxiety, and the moderating effect of age, sex, and study quality were assessed using meta‐regressions. Sensitivity analyses were run to assess whether one study was influencing the results of the meta‐analysis. Greater difficulties with social motivation are associated with increased anxiety, depression, and social anxiety, with a moderate pooled effect size across all domains. Sensitivity analyses did not significantly alter any of the results. Age, sex, and quality of study were nonsignificant moderators. Reduced social motivation may be associated with an increased vulnerability to internalizing difficulties in autistic individuals. The stability across age, sex, and study quality highlights social motivation as a potential transdiagnostic target for intervention in autistic individuals.

Autistic people are known to demonstrate greater difficulties with cognitive flexibility. These difficulties are associated with a range of poor outcomes, including elevated rates of anxiety and depression. Current intervention approaches fail to account for these specific mechanisms. In this study, we address this by piloting a new intervention which aims to specifically target cognitive inflexibility. The ‘Thinking Flexibly’ intervention has been co-designed with autistic youth based on previous work, including cognitive remediation therapy. Twenty autistic adolescents were recruited from clinical services and offered the eight-session intervention. Acceptability was assessed through participant drop-out and session completion. Participants (and their parents) also completed questionnaire measures of cognitive inflexibility, anxiety, depression and functional outcomes before and after the intervention. Our results indicated good acceptability with 19/20 participants completing the intervention and session attendance was high, with a single missed session. We found significant increases in flexibility across both parent- and self-report of a moderate effect. Participants reported significant reductions in symptoms of anxiety and depression. We conclude that ‘Thinking Flexibly’ is acceptable for use with autistic adolescents and shows promise as a standalone or adjunct therapy. Changes on outcome measures are promising and warrant further investigation in a larger trial. Lay Autistic people often have greater difficulties with flexible thinking when compared to those without autism. People with difficulties in this area often appear to be ‘stuck’ in their style of thinking or in their way of behaving. This can have a negative impact on several areas of life, including on their mental health. In this study, we developed and tested an intervention designed to help autistic individual think flexibly. We showed that the intervention was acceptable (people were able to attend and complete the intervention) and some improvements in cognitive flexibility and mental health symptoms were reported.

Background: Autistic children experience significantly higher rates of anxiety compared to nonautistic children. The precise relations between autism characteristics and anxiety symptoms remain unclear in this population. Previous work has explored associations at the domain level, which involve examining broad categories or clusters of symptoms, rather than the relationships between specific symptoms and/or individual characteristics. We addressed this gap by taking a network approach to understand the shared structure of autism characteristics and anxiety symptoms. Method: Data were pooled from five studies from Canada, Singapore, the UK, and the USA, totaling 623 autistic children (17% female sex; aged 6–18 years), for whom the parent‐report Spence Children's Anxiety Scale (SCAS‐P) was available. We derived two undirected regularized networks, first from the SCAS‐P items only, and then by adding autism characteristics pertaining to social communication, highly focused and repetitive behavior, and sensory hypersensitivity. From these models' metrics, we extracted nodes' predictability, key bridging nodes, and community detection. Results: The anxiety‐only network was highly connected and consisted of four key clusters: General Anxiety, Social Anxiety, Separation Anxiety, and Panic/Agoraphobia. These broadly aligned with the existing SCAS‐P structure based on DSM‐IV‐TR criteria. In the autism‐anxiety network, the structure of anxiety remained mostly stable, with autism features forming their own community. Preference for predictability (i.e., sameness) and sensory hypersensitivity were key nodes that linked autistic features and anxiety symptoms, primarily through generalized anxiety. Conclusion: This study identified some of the key characteristics that bridge the broadly independent structures of autism characteristics and anxiety symptoms. The findings are discussed in the context of guiding the assessment, prevention, and treatment of anxiety in autism.

Autistic people are at an elevated risk of experiencing co‐occurring anxiety and depression. The contributors to this are likely multifaceted and complex and remain poorly understood. Cognitive flexibility, social camouflaging, and perceived stress provide useful indices of the interacting neurocognitive, behavioral, and environmental factors that have been associated with anxiety and depression in autistic individuals. Here, we test if cognitive flexibility, as the factor most closely related to individual differences in thinking styles, mediates the relationships between social camouflaging, perceived stress, and anxiety/depression. This study included 806 autistic individuals aged between 18 and 83 years (Mean age = 40.2), recruited through the Research Match service of the Simons Powering Autism Research (SPARK) participant registry. Participants completed an online battery of questionnaires measuring cognitive and social flexibility, social camouflaging, perceived stress, anxiety, and depression. Parallel mediation analyses were used to test the mediating effect of cognitive and social flexibility. Across separate parallel mediation analyses, cognitive flexibility was found to significantly mediate the relationships between both social camouflaging and perceived stress with anxiety and depression. This was contrasted with social flexibility, which showed a lower magnitude mediating effect for perceived stress and no mediating effect of social camouflaging. Cognitive flexibility plays an important mediating role between the impact of both perceived stress and social camouflaging on greater symptoms of both anxiety and depression in autistic adults.

Although autism is a childhood‐onset neurodevelopmental disorder, its features change across the life course due to a combination of individual and contextual influences. However, the influence of contextual factors on development during childhood and beyond is less frequently studied than individual factors such as genetic variants that increase autism risk, IQ, language, and autistic features. Potentially important contexts include the family environment and socioeconomic status, social networks, school, work, services, neighborhood characteristics, environmental events, and sociocultural factors. Here, we articulate the benefit of studying contextual factors, and we offer selected examples of published longitudinal autism studies that have focused on how individuals develop within context. Expanding the autism research agenda to include the broader context in which autism emerges and changes across the life course can enhance understanding of how contexts influence the heterogeneity of autism, support strengths and resilience, or amplify disabilities. We describe challenges and opportunities for future research on contextual influences and provide a list of digital resources that can be integrated into autism data sets. It is important to conceptualize contextual influences on autism development as main exposures, not only as descriptive variables or factors needing statistical control.