Denis G. Sukhodolsky

Purpose: Autism spectrum disorder (ASD) presents challenges for public health systems due to its heterogeneity and complexity. The Step-by-Step Program was developed as an innovative, community-based mentalization-based intervention for autistic children aged 5–7 and their families. This study aims to evaluate the feasibility of implementing this program within existing systems of care and to examine its preliminary effects. Design/methodology/approach: An open trial was conducted with 16 autistic children and their families who participated in the Step-by-Step Program, a two-year intervention integrating weekly group therapy for children with alternating multi-family and parent sessions. Outcome measures included standardized assessments of child emotional and behavioral functioning, autism symptom profiles and parental satisfaction. Data were collected at baseline, midpoint, endpoint and one-year follow-up. Findings: Findings indicated high feasibility, treatment adherence and strong family satisfaction ratings. Children demonstrated significant improvements in social communication, symbolic play, flexibility and emotional/behavioral regulation. These gains were not only maintained but further consolidated at the one-year follow-up. Families also reported reduced stress and increased capacity for understanding and supporting their child’s development. Research limitations/implications: This pilot study supports the feasibility and preliminary effectiveness of the Step-by-Step program; however, several limitations should be considered. The open, uncontrolled design precludes causal attribution of observed changes to the intervention rather than to time or nonspecific therapeutic effects. This limitation will be addressed in future randomized controlled trials, for which the present findings provide essential pilot data. Additionally, due to the COVID-19 pandemic, the final three months of treatment were delivered via telehealth, although outcome assessment and treatment procedures were maintained. Finally, parental perceptions of children’s mentalizing abilities were not assessed. Future studies should include measures of parental reflective functioning, a key treatment target of mentalization-based therapy for children. Practical implications: This is a pilot study that describes the development and implementation of the mentalization-based treatment for autistic children in the context of the community mental health case system in Catalonia, Spain. Social implications: The Step-by-Step Program appears to be a promising, feasible and effective early intervention model for autistic children and their families. Its integration into community mental health services suggests potential for sustainable, family-centered approaches that enhance social development and well-being. Originality/value: The authors believe that the innovative aspects of this study include the adaptation of mentalization-based therapy for autism, long-term treatment and implementation in the local Catalone system of care.

Sensory processing differences are a core feature of autism, yet mechanisms underlying sensory distress remain incompletely understood. Emerging work suggests that interoceptive difficulties and alexithymia, reflecting uncertainty about bodily and emotional states, may be associated with sensory responsivity. The present study examined the independent and shared associations of interoceptive confusion and alexithymia with sensory processing differences in 69 autistic adolescents and young adults (M age = 20.92 years). Participants completed self-report measures of sensory responsivity (Glasgow Sensory Questionnaire; GSQ), interoceptive confusion (ISQ-8), and alexithymia (GAFS-8). In multiple regression analyses, both alexithymia (B = .42, p < .001) and interoceptive confusion (B = .36, p = .001) were independently associated with greater sensory processing differences, together accounting for approximately half of the variance (R² ≈ .49). Commonality analyses indicated that most explained variance was shared (~58%), alongside unique contributions from alexithymia (~24%) and interoceptive confusion (~18%). Associations were largely domain-general across sensory modalities and hyper- and hypo-responsivity dimensions. To our knowledge, this is the first study to partition shared and unique contributions of interoceptive confusion and alexithymia to sensory responsivity in autism. These findings support integrative accounts linking sensory processing differences to internal state uncertainty and highlight interoceptive and emotional awareness as dimensions relevant to sensory experience in autism.

Conduct disorder (CD) is the leading global cause of mental health burden in children and adolescents and has recently been hypothesized to be a neurodevelopmental disorder. Although prior research has identified neuroanatomical differences associated with CD, it remains unclear whether these differences reflect atypical brain development. Here, we investigated the difference between an individual’s brain age and chronological age as a proxy for variations in brain maturation. Using a pretrained model, we estimated brain age from structural neuroimaging data obtained from 1,119 youth with CD and 1,183 typically developing controls across 14 international cohorts participating in the ENIGMA-Antisocial Behavior Working Group. Youth with CD exhibited a statistically robust but small acceleration in brain age compared to typically developing youth (around 0.50 years), which was restricted to the adolescence-onset subtype of the disorder. Our large-scale, coordinated analysis provides the first evidence of accelerated neurodevelopment as a potential mechanism underlying CD.

Reinforcement-driven learning involves processing feedback signals to optimize future actions and decision making. This feedback can be discrete, occurring as a separate event from action or anticipation, or continuous, occurring constantly and concurrently with ongoing decision-making. Despite the real-world relevance of continuous feedback, most research paradigms investigate feedback processing as a discrete process. To address this, we analyzed fMRI data from four neurofeedback studies in which participants engaged in continuous feedback learning. Neural responses to the most positive, most negative, and the weakest feedback signals were compared. Our results show that nucleus accumbens activity tracked with feedback valence, and specifically, was greater in response to success than to failure during neurofeedback. Medial prefrontal cortex (mPFC), posterior cingulate cortex (PCC), hippocampus, supplementary motor area (SMA) and superior temporal gyrus (STG) were more activated in response to weak feedback than to strong feedback. Our findings suggest that during continuous feedback learning, weak feedback (more than strong feedback) increases activity in brain regions previously implicated in self referential thinking, decision-making under uncertainty, and referencing past experiences. These data suggest the ambiguity inherent in weak feedback may result in engagement of these processes to support context-dependent interpretations of the feedback signals.

Although affective irritability is a common and concerning problem for autistic youth, limited research has examined relations among core autism characteristics and irritability. Therefore, this study investigated potential associations among types of restricted/repetitive behaviors (RRBs) and social communication challenges and irritability in autistic children and adolescents. Participants were 107 autistic youth recruited from a university-based autism clinical research program. Two hierarchical multiple regressions were conducted with Affective Reactivity Index as the dependent variable. Covariates were entered at step 1, followed by the independent variables of interest at step 2. For the first model, independent variables of interest were Repetitive Behavior Scale-Revised subscales: stereotyped behavior, self-injurious behavior, compulsive behavior, ritualistic behavior, sameness behavior, and restricted behavior. For the second model, independent variables of interest were Social Responsiveness Scale, Second Edition subscales: social awareness, social cognitive, social communication, and social motivation. Irritability was significantly associated with several categories of RRBs (i.e., insistence on sameness, stereotypic behavior, and restricted interests/activities). Nonetheless, irritability was not associated with categories of social communication and interaction challenges in autistic youth. Results from this study indicated differing associations between core autism characteristics and affective irritability. Findings highlight the importance of differentiating types of restricted, repetitive behaviors and social communication and interaction challenges in conceptualizing mental health concerns in autistic youth.

Depression is common among autistic youth and is associated with worse quality of life in this group. Despite significant need for high-quality efficacious treatments, there has been very limited research on interventions for depression in autistic youth. This single-arm pilot study examined the feasibility and preliminary efficacy of a novel, behavior-based approach for treatment of depression symptoms in autistic adolescents without intellectual disability (i.e. Behavioral Activation for Autistic Adolescents, BA-A). BA-A is an individually delivered manualized 12-session treatment that utilizes established BA strategies and incorporates common mental health treatment adaptations for autistic young people. Of the 18 youth (11–16 years old) who enrolled, 15 completed all 12 treatment sessions, as well as pre-treatment, post-treatment, and follow-up assessment visits. Clinician treatment fidelity was quite high. Paired sample t-tests found that depression symptoms decreased pre- to post-BA-A according to multiple informants (i.e. self, caregiver, and independent evaluator), and treatment gains were maintained at 1-month follow-up. Paired sample t-tests also found that caregiver-reported anxiety symptoms and social skills improved pre-treatment to post-treatment. The results, although preliminary, indicate that BA-A may improve depression symptoms in autistic youth without intellectual disability. Furthermore, these promising findings suggest that a randomized controlled trial of BA-A is warranted. This trial was pre-registered at ClinicalTrials.gov (NCT05018169). Lay Depression is common among autistic youth and has a significant negative impact on quality of life and day-to-day functioning. Despite great need for efficacious treatments, there are currently limited research-supported interventions for depression symptoms in autistic young people. This study tested a novel, behavior-based approach or psychotherapy for treatment of depression symptoms in autistic adolescents without intellectual disability (i.e. Behavioral Activation for Autistic Adolescents, BA-A) with 15 youth (11–16 years old). BA-A is an individually delivered 12-session therapy that was developed for and to meet the needs of autistic youth with depression. Results found that autistic youth and their caregivers were able to participate in BA-A therapy sessions, and clinicians were able to deliver BA-A in accordance with the treatment manual. Notably, results demonstrated that autistic youth depression symptoms significantly improved after participating in BA-A. Furthermore, anxiety symptoms and social skills significantly improved following BA-A.