"an urgent need for autism treatment pathways in mental health services"

Of the many and varied important clinical and research areas connected to a diagnosis of autism or autism spectrum disorder (ASD), the provision of services to manage and treat mental health issues in the context of autism must rank high on the list of needs and priorities.

It's with this in mind that I turn my blogging attention to the findings reported by Louise Camm-Crosbie and colleagues [1] and their findings observing three important themes around the issue of mental health and (adult) autism: "(1) difficulties in accessing treatment and support; (2) lack of understanding and knowledge of autistic people with co-occurring mental health difficulties and (3) appropriate treatment and support, or lack of, impacted autistic people’s well-being and likelihood of seeing suicide as their future." All of this is set within the idea that various mental health issues seem to be over-represented when it comes to autism (see here and see here and see here  and see here for examples) and the lack of support and management of such issues can sometimes have devastating consequences (see here).

So: "In partnership with a steering group of autistic adults, an online survey was developed to explore these individuals’ experiences of treatment and support for mental health problems, self-injury and suicidality for the first time." The partnership bit ties in with the increasingly discussed 'participatory research' theme in some autism research circles (see here), where stakeholders are seen as partners driving a study or research agenda rather than just passive participants who are the topic of a particular study. The 'online survey' bit also continues a theme where technology means that participation doesn't mean having to be questioned face-to-face. Said survey was completed by 200 autistic adults ("122 females, 77 males and 1 unreported") and results covered an array of different issues, including some previously discussed by some authors on the Camm-Crosbie paper on other [important] research occasions (see here).

Alongside those three themes that emerged from the data, researchers also reported that: "In relation to treatment for mental health, self-injury and suicidality (n = 197), 164 participants (83.2%) were currently receiving/had previously received treatment, 29 participants (14.7%) needed/currently needed treatment but had not received it and 4 participants (2%) did not need treatment." As you can see from the figures, particularly that 2% not needing treatment, mental health issues (including self-injury and suicidality under that banner) are very much present when it comes to a diagnosis of autism, at least in this cohort.

Various other observations were reported on in the study; many of them pertinent to the another important theme coming from the article: "although participants reported experiences of being excluded from mental health services, with potentially tragic consequences for their well-being, there are also examples of participants benefitting from tailored support and treatment, which had a positive effect on their well-being." In other words, look to the individual and their wants, needs and wishes, and adapt accordingly. Not exactly rocket science.

So, what can be done to help ameliorate the issues identified by Camm-Crosbie et al and ensure that suitable 'tailored support and treatment' is offered? Well, the short answer is investment. Monetary investment. I could go for the 'low-hanging fruit' by saying that awareness of mental health issues in relation to autism needs to be improved among professional bodies, but the core material to aid such awareness is money. I could also go on about further dedicated resources needing to be put in place to support autistic adults (and children) with mental health issues, but the core material to get such resources is, once again, money. Money. And unfortunately in these austere times that we continually live in, where social care funding in particular, seems to have been cut to the bone, money for such issues is seemingly in short supply. Indeed, it seems that only when a crisis point is reached by an individual is anything actually done about something like mental health issues. And with all due respect to the hard working people who work in the mental health sector, after a crisis has been reached and 'managed', normal service seems to resume until another crisis comes along. The reason? Money yet again. The solution: put more money into this important issue. It will definitely help.

And whilst the focus of the Camm-Crosbie paper was adults with autism "without co-occurring intellectual disability", I also have to ask the question: what about those autistic people who are not able to complete online surveys and their mental health needs? Who's taking an interest in them? Are they, yet again, the understudied and underrepresented in autism research (see here)? There may be quite a bit to see [2]...

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[1] Camm-Crosbie L. et al. 'People like me don't get support': Autistic adults' experiences of support and treatment for mental health difficulties, self-injury and suicidality. Autism. 2018 Nov 29:1362361318816053.

[2] Baudewijns L. et al. Problem behaviours and Major Depressive Disorder in adults with intellectual disability and autism. Psychiatry Res. 2018 Dec;270:769-774.

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Participatory research in autism continued

Consider this post discussing the findings reported by Gregory Hollin & Warren Pearce [1] a continuation of some previous chatter on the topic of participatory research and autism (see here). Participatory research means just that: meaningful engagement of "users, publics, and stakeholders with scientific research." It's something that has come further and further to the forefront in recent years, as the term 'Nihil de nobis, sine nobis' ('Nothing About Us Without Us') has steadily moved from the textbook to real life.

The tone of the Hollin & Pearce article is somewhat different from that of the Fletcher-Watson article [2] which was covered in my last post on this topic. That previous article was heavy on themes derived from some seminars on how participatory research with autism in mind should look including: "Respect, Authenticity, Assumptions, Infrastructure and Empathy." The latest article deals more with the practicalities of such participation, warts and all, from the sole perspective of [assumed] non-autistic autism researchers.

Before heading into the Hollin & Pearce article, I should warn viewers that this is not going to be one of those 'everything's rosy' kinda discussions. There are some uncomfortable results reported as part of the Hollin/Pearce qualitative analysis as per their talking to various research persons about their experiences of participatory research. Their cohort: "The sample consisted of seven Professors, two Readers, one Senior Lecturer, one Associate Professor, two Lecturers, and seven Postdoctoral Researchers." All held academic posts at a British university and all "had self-declared interests in psychology, neuroscience, and autism."

Warts and all is a good description of the findings discussed by the authors. They mention two key themes relating to the experience of participatory research and autism in their cohort. First: "disagreements within the autistic community are caused, in part, by the heterogeneity of the autistic condition." An example: "During the debate one individual stands up and says ‘I am a neurodiverse person and you must respect me’. At this point another autistic individual invariably rises and says ‘if I could throw a switch tomorrow and get rid of it I would’." I've previously talked about the idea that a singular 'autism community' is wishful thinking at best, despite such a term being thrown about willy-nilly in all-manner of different circumstances. There is no 'autism community' in the same way that there is no 'schizophrenia community' or 'depression community'. The label(s) just cover too much ground to describe anything other than an overarching diagnostic code. Such a label says nothing about the life, views, opinions and politics of an individual in receipt of the diagnosis.

Second: "the socio-communicative impairments typical of autism... make any form of rapprochement or compromise particularly difficult." Some people will take offence to that last sentence. They'll take offence by the use of the word 'impairments'. They'll take offence at the idea that some of the features of autism *might* not be 'all positive' and on occasion, might make ideas like 'compromise' particularly difficult for someone. And to prove a point, the authors cited one viewpoint: "I mean I got in trouble with a lot of autism advocates for suggesting that having specialist interests wasn’t always a great thing. You know, they came down on me like a ton of bricks but, you know, then this is it, they can’t sometimes see that it’s not." I'm not a great fan of concepts like 'theory of mind' and how it's been almost universally applied to autism down the years (see here). But when reading such viewpoints, it is kinda hard to say that 'perspective' and specifically 'taking another's perspective' might not be an issue for some people. And just before anyone gets a bee in their bonnet about the focus being just on those with autism, I do have a great deal of time for the idea of a double-empathy issue in relation to autism and not-autism too.

Onward: "scientists consistently said that they valued the input of autistic individuals and advocates." Hollin & Pearce mention how, despite the inherent difficulties in ensuring that participatory research in autism is truly participatory across the spectrum, researchers do value the input from those on the autism spectrum. Terms like 'inner experience' and 'shaping research priorities' are mentioned in their paper, and how autism research is all the better for engaging with the autism communities (plural). I agree.

They also go on to suggest a few ways in which participatory research could be improved: "it is important that dissensus is recognized and embraced." What this means is that autism researchers shouldn't set out to 'please all of the people all of the time' when it comes to their professional interests and study of autism. Acknowledge that their research will pretty much always have a mixed reception but at least serve one part of the heterogeneous autism spectrum, hopefully in terms of improving quality of life. I'd also highlight the idea that social media is not necessarily representative of real life or any particular diagnostic group, so don't also go looking for Twitter appreciation either. Next: "far greater effort needs to be invested in developing mechanisms and venues which allow fruitful dialogue." Employ strategies such as focus groups and round table discussions by all means; talk to people, listen to people and learn from people. But bear in mind that for some on the autism spectrum, such discussion are in reality going to be a very distant prospect as things currently stand, as their 'disabilities' will undoubtedly affect their participation (see here). Indeed, as I mentioned in my last post on participatory research and autism, one of the big research priorities coming from the joint research and autistic communities should perhaps be moves to providing a voice to all of those on the autism spectrum, particularly those who seemingly don't have a voice (see here). Oh, and bear in mind that parents are often the biggest advocates for their autistic children so be a little careful before disregarding their important input too.

What else? Well, I'm inclined to add that participation from those on the autism spectrum shouldn't just be taken as being voluntary. Pay people. Pay people for their time and effort. And pay them as you would anyone else who involves themselves in research.

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[1] Hollin G. & Pearce W. Autism Scientists’ Reflections on the Opportunities and Challenges of Public Engagement: A Qualitative Analysis. J Autism Dev Disord. 2018. Oct 24.

[2] Fletcher-Watson S. et al. Making the future together: Shaping autism research through meaningful participation. Autism. 2018 Aug 10:1362361318786721.

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Participatory research in autism: some good ideas but who gets to participate?

I was genuinely pleased to read the article published by Sue Fletcher-Watson and colleagues [1] talking about how the incorporation of views and opinions from people with autism / autistic people can hopefully improve the relationship between autism research and clinical practice. Pleased because, as autistic voices become more prominent in many walks of life including important research agencies, so such voices can help both guide research priorities and also aid in the the important translation of research findings from dusty science books/journals to [positively] affecting real lives.

The Fletcher-Watson paper recalls the results of a "shaping autism research seminar series" held here in Blighty. We are told that the "overarching goal was to examine how autism research could become more participatory in nature" where the 'target group' aids in making research "more meaningful – that is, relevant to the community, consistent with their values, and not tokenistic in delivery." 'Nihil de nobis, sine nobis' so the [important] saying goes.

Some key themes emerged from the initiative: "Respect, Authenticity, Assumptions, Infrastructure and Empathy." All of these points serve to enhance autism research and move it away from issues like 'research solely for the benefit of researchers careers' and/or 'research for the benefit of just getting further research grants/money' which probably feature in at least some circumstances. Instead the message is about moving towards a research strategy that has tangible real life impact for those on the autism spectrum, also trying to be sensitive to the numerous wants, needs and desires. All those sweeping psychobbable explanations of autism from yesteryear really haven't served anyone well in terms of enhancing quality of life and so people want something different...

The authors accept that alongside the strengths of such an approach there are also challenges. So for example, we are told that under the category of 'authenticity' where "autism communities can shape a research agenda", one challenge is going to be that "merging perspectives of a diverse group into homogeneous outcomes can result in under-specified priority research topics." Indeed it can, and it has been talked about before in the context of consumers/producers of autism research (see here).

Whilst noble in sentiment, I have some cautions and caveats about this area; not least around the question of exactly how participatory such initiatives truly are and can be when it comes to the very heterogeneous autism spectrum and the multitude of voices to be included (see here). Are voices from the autism spectrum who for example, are critical of the concept of neurodiversity likely to be invited to participate? What about those who don't see their autism or its effects in as positive a light as others? Who are the gatekeepers deciding who is involved in "shaping autism research through meaningful participation" and what is the criteria for participating aside from a diagnosis of autism? What happens also when there are disagreements in research direction between 'professionals' and the communities they serve?

The oft-used term 'if you've met one person with autism, you've met one autistic person' always figures in my mind. It denotes that within such a heterogeneous label/diagnosis, there is huge variation in the presentation of autism and the impact that core and related symptoms have on day-to-day living, alongside lots of different views and opinions about autism and what the label means to people. And in this context, terms like 'relevant to the community' and 'consistent with their values' are difficult concepts to entertain in any universal sense because there really is no single 'autistic community' or universally shared values. Remember: if you met one person with autism... Indeed, their meaning may also likely be something slightly different to the 'under-studied' parts of the autism spectrum for example (see here), where voices seem to be currently less well heard in many different scenarios (see here).

I was also a little confused to read the word 'allies' multiple times in the Fletcher-Watson paper, denoting those who are not autistic but share the various views and opinions of those on the spectrum particularly included in the article. 'Allies' is typically a word used in the context of combat and warfare. I appreciate that there are debates/arguments on-going in the autism 'community' that sometimes look and feel like warfare. But the implication from the use of such a 'them-and-us' term, particularly in the context of a research paper, is that if you're 'for' participatory research of the specific type highlighted by the authors, you're an ally. If you're not, or if your opinion differs in terms of possible research priorities (whether you are autistic or not), then by definition, you're not an ally. This is important. Words matter, particularly in the context of 'participatory' research. I say all this also acknowledging that science should really be allegiance-free...

Without wishing to continue too much with the cautions and caveats when such inclusion efforts have noble goals, I have further points. Appreciating that some important research goals have already been published (see here) and with the rapid development of the ICF core sets for autism (see here), there are already plenty of research directions that need to be taken which prioritise people with autism / autistic people and the day-to-day challenges they face; all already including input from people on the autism spectrum. In this respect, participatory research is nothing new to autism.

Insofar as that research 'relevant to the community' (or should that be 'communities') opinion, I'd also advance the idea that 'life-saving' should perhaps represent the first tier of autism research importance to any participatory strategy, as issues such as wandering, suicide risk and early mortality (see here, see here and see here respectively) continue to remain ever-present and significantly impact on many peoples' lives - again, particularly among those who perhaps fall into that 'under-represented' categorisation of autism (see here). The alleviation of pain and suffering, whether physical (see here for one example) or otherwise (see here), should probably form the next tier of research importance. And perhaps another tier of participatory research could be devoted to giving those with autism who seemingly don't have a voice, the means to communicate their wants, needs and desires and thus enable themselves to participate further in such participatory schemes. Just my observations...

A final question I have for such participatory research is an ethical one in the context of some likes and dislikes voiced by some on the autism spectrum: if for example, by tackling such primary issues such as depression and anxiety that plague many people on the autism spectrum and often severely impact on quality of life, it actually means having to intervene on the core presentation of autism (see here and see here for other research in these areas), would such participatory research 'alliances' be brave enough to take on such an option? If for example, it mean't that something like the presence of social-communication issues showed a *connection* to the experience(s) of depression for example (see here), would such participatory research look to evidence-based strategies and possibilities to try and 'change' such core issues and behaviour? Or would the conversations just revert back to something like the tenets of the social model of disability as being the primary reason for such issues as per other examples (see here)?

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[1] Fletcher-Watson S. et al. Making the future together: Shaping autism research through meaningful participation. Autism. 2018 Aug 10:1362361318786721.

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Autistic adults as critical autism experts (with research caveats)

"Findings suggest that autistic adults should be considered autism experts and involved as partners in autism research."

That was the conclusion reached in the paper by Kristen Gillespie-Lynch and colleagues [1] (open-access) reporting on the results of an online survey assessing "autism knowledge and stigma among 636 adults with varied relationships to autism, including autistic people and nuclear family members." Among the various groups of people who contributed to the survey, several viewpoints emerged. The message primarily however was that: "autistic people are autism experts through their lived experiences." I don't think many people would quibble with such findings.

A few other details emerged from the Gillespie-Lynch study that merit discussion. Many participants showed a "reduced tendency to view autism through a deficit-defined medical model compared with non-autistic people." This is perhaps not an unexpected finding given the history of applying the medical model to autism and the rise and rise of the neurodiversity movement that "challenges the medical model" in particular respect over the question of deficit vs. difference and implications thereof. Although the medical model provides the means to identify and diagnose autism or autism spectrum disorder (ASD) (on the basis of deficits), it's not unexpected that for some, once those tasks have been completed, the 'treatment' side of the model is not necessarily a top priority; or at least not as important as addressing the various inequalities that seem to stem from a diagnosis. That being said, I do agree with the authors sentiments that: "the neurodiversity movement and the medical model overlap in recognizing that supports are needed to ameliorate challenges associated with autism." Those challenges are variable and person-dependent but include the effects of both core and peripheral signs and symptoms and the various over-represented comorbidities that seem to follow a diagnosis of autism (see here). I would, at this point, also caution on using the words 'biopsychosocial model' in the context of autism as the authors have included in their discussions, given what it has meant for other labels (see here) and the potential 'psychologising' of some important medical symptoms.

I added the words 'with research caveats' to the title of this post to ensure that such a positive message about autism and the autism spectrum is not just given a 'free pass' when it comes to scrutiny of the scientific method, the way the study was carried out and the applicability of the results to the entire autism spectrum. This was an online survey not a face-to-face piece of research (other related research has similarly used such a method and on more than one occasion) and the authors acknowledge that they: "did not verify diagnosis of participants who self-identified as autistic" for example. Given what we are beginning to see when it comes to some of the 'self-screening' instruments out there regarding possible autism or not (see here), I'm always a little cautious that self-diagnosis / self-identification does not necessarily mean [eventual] clinician-diagnosed autism and how important this is when it comes to correctly ascertaining the wants and wishes of those diagnosed as being on the spectrum.

On the point about the representativeness of this research, the authors also note: "Findings may not generalize to autistic participants who lack the verbal and computer skills needed to complete the survey." Yet another example it seems of this important issue.

I have to say that I'm also a little disheartened that yet again an important group that was once very firmly on the autism spectrum aren't really given the credit they deserve according to the Gillespie-Lynch findings: "Autistic participants were more likely to recognize that most children cannot outgrow autism." The 'optimal outcome' children and adults it seems, still represent one of the most maligned groups associated with the autism spectrum (assuming that optimal outcome occurring in up to 9% of the autism population is not an insignificant figure). This despite the fact that even the diagnostic stability of the most 'high-functioning' cases of autism can wobble it seems (see here) even into adulthood. One of the premier experts on autism also seems to agree according to some recent media (see here). I often wonder if the seeming lack of acceptance of this group/feature might have something to do with the 'identity' side of autism and the idea that within the vast heterogeneity of autism (or the plural autisms if you prefer) the use of 'them and us descriptions' like 'neurotypical' are perhaps not as binary or long-lasting as many would believe or want to believe?

Within the context of [approximate] phrases such as 'if you've met one person with autism, you've met one autistic person' there is caution in over-generalising these latest results but they are nonetheless important. I think it would be rather fitting to end with a few choice phrases from the Gillespe-Lynch paper: "As many of our survey respondents indicated, each person, regardless of whether or not they are autistic, is unique" and: "Some autistic people seek out factual knowledge about autism while others believe that they can only be experts in their own particular form of autism." Either way, the insights provided by people on the autism spectrum (all parts of the autism spectrum and indeed, across the age ranges) should be valued, and where possible, incorporated into research and practice.

And one voice from the autism spectrum carries some rather sensible messages...

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[1] Gillespie-Lynch K. et al. Whose Expertise Is It? Evidence for Autistic Adults as Critical Autism Experts. Front. Psychol. 2017. March 28.

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Gillespie-Lynch, K., Kapp, S., Brooks, P., Pickens, J., & Schwartzman, B. (2017). Whose Expertise Is It? Evidence for Autistic Adults as Critical Autism Experts Frontiers in Psychology, 8 DOI: 10.3389/fpsyg.2017.00438