Interoception refers to the perception of the physiological condition of the body, including hunger, temperature, and heart rate.  There is a growing appreciation that interoception is integral to higher-order cognition. Indeed, existing research indicates an association between low interoceptive sensitivity and alexithymia (a difficulty identifying one’s own emotion), underscoring the link between bodily and emotional awareness.  Despite this appreciation, the developmental trajectory of interoception across the lifespan remains under-researched, with clear gaps in our understanding.  This qualitative review and opinion paper provides a brief overview of interoception, discussing its relevance for developmental psychopathology, and highlighting measurement issues, before surveying the available work on interoception across four stages of development: infancy, childhood, adolescence and late adulthood.  Where gaps in the literature addressing the development of interoception exist, we draw upon the association between alexithymia and interoception, using alexithymia as a possible marker of atypical interoception.  Evidence indicates that interoceptive ability varies across development, and that this variance correlates with established age-related changes in cognition and with risk periods for the development of psychopathology.  We suggest a theory within which atypical interoception underlies the onset of psychopathology and risky behaviour in adolescence, and the decreased socio-emotional competence observed in late adulthood.

Background:  Although autistic adults often discuss experiencing "autistic burnout" and attribute serious negative outcomes to it, the concept is almost completely absent from the academic and clinical literature.  Methods:  We used a community-based participatory research approach to conduct a thematic analysis of 19 interviews and 19 public Internet sources to understand and characterize autistic burnout.  Interview participants were autistic adults who identified as having been professionally diagnosed with an autism spectrum condition.  We conducted a thematic analysis, using a hybrid inductive-deductive approach, at semantic and latent levels, through a critical paradigm.  We addressed trustworthiness through multiple coders, peer debriefing, and examination of contradictions.  Results:  Autistic adults described the primary characteristics of autistic burnout as chronic exhaustion, loss of skills, and reduced tolerance to stimulus.  They described burnout as happening because of life stressors that added to the cumulative load they experienced, and barriers to support that created an inability to obtain relief from the load.  These pressures caused expectations to outweigh abilities resulting in autistic burnout. Autistic adults described negative impacts on their health, capacity for independent living, and quality of life, including suicidal behavior.  They also discussed a lack of empathy from neurotypical people and described acceptance and social support, time off/reduced expectations, and doing things in an autistic way/unmasking as associated in their experiences with recovery from autistic burnout.  Conclusions:  Autistic burnout appears to be a phenomenon distinct from occupational burnout or clinical depression.  Better understanding autistic burnout could lead to ways to recognize, relieve, or prevent it, including highlighting the potential dangers of teaching autistic people to mask or camouflage their autistic traits, and including burnout education in suicide prevention programs.  These findings highlight the need to reduce discrimination and stigma related to autism and disability.

The term ‘pathological demand avoidance’ was first coined in 1983.  In recent years, diagnostic tools have emerged to enable practitioners to identify, name and treat pathological demand avoidance and, at least in the United Kingdom, there is an increasing number of children who attract this label.  In addition to what are defined as the core ‘deficits’ of autism, including assumed difficulties in social communication, difficulties in social interaction and restrictive interests, children with pathological demand avoidance are thought to have an extreme anxiety-driven need to control their environment and control the demands and expectations of others.  This article will argue that we must exercise extreme caution in accepting the validity of pathological demand avoidance and will suggest that it can be seen as an attempt to psychiatarise autistic children’s resistance, which, in so doing, restricts their agency.  First, it will draw on the arguments put forward by some autistic scholars who have claimed that pathological demand avoidance is better understood as rational demand avoidance – an understandable and rational response to the circumstances that one finds oneself in.  Second, it will consider the intersection between autism and childhood.  When one of the defining characteristics of pathological demand avoidance is an inability to recognise and, presumably, respect social hierarchy, children’s competencies as social actors and active meaning makers of their world can easily become pathologised as defiance.  Finally, the article will address the intersections of autism, childhood and gender.  Girls are much less likely to be diagnosed as having an autism spectrum condition than boys are, with a ratio traditionally estimated at approximately 1:4.  However, pathological demand avoidance diagnoses are fairly evenly spread between boys and girls.  It will be argued that it is girls’ resistance to the ordinary and everyday demands of her as a girl and her subsequent rejection or transgression of those expectations that is being pathologised.

Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorders (ASD) are two of the most represented neurodevelopmental conditions in childhood.  The diagnostic shift introduced by the DSM-5, allowing a combined diagnosis of ADHD and ASD, poses different clinical challenges related to diagnostic overshadowing, accuracy of clinical judgment and potential delay in an ASD diagnosis in children presenting with ADHD.  Here we tried to disentangle the clinical phenotype and specificity of the two co-occurring conditions in relation to autism traits and empathy, by comparing children with ASD with and without comorbid ADHD with children presenting ADHD only and children with typical development.  The child versions of the Autism Quotient (C-AQ) and Empathy Quotient (C-EQ) were administered to a total sample of 198 male children between 6 and 14 years old with age appropriate language skills and normal intelligence.  Univariate analysis demonstrated no significant differences in the C-AQ total and subscale scores as well as the C-EQ between children with ASD and children with ASD + ADHD, while children with ADHD alone presented an intermediate phenotype between ASD and TD.  Furthermore, a receiver operating characteristic (ROC) analysis was applied to discriminate among the different phenotypes. We found that the C-AQ and C-EQ were accurate at distinguishing with satisfactory reliability between: (a) ASD vs. non- ASD (N-ASD) groups comprising both ADHD and TD children (Area Under the Curve AUC 88% for C-AQ and 81% for C-EQ); (b) ASD and TD (AUC 92% for C-AQ and 95% for C-EQ); (c) ASD and ADHD (AUC 80% for C-AQ and 68% for C-EQ).  Our data confirm the reliability of the C-AQ and C-EQ as behavioral markers to differentiate ASD (regardless of comorbid ADHD) from an ADHD condition and TD.  Interestingly, in our sample an ADHD condition does not increase the severity of the clinical phenotype in terms of autism traits distribution and empathy, suggesting that the psychological measures detected by the two quantitative instruments are independent of ADHD traits.  This evidence will contribute to the translational efforts in developing better tailored treatments and preventive strategies.

Autism spectrum disorder (ASD) presents a diagnostic challenge due to its highly heterogeneous nature.  The most common clinical manifestations include difficulty with social interaction and the presence of repetitive sensory-motor behaviors.  Females are more likely to be misdiagnosed or have a delayed diagnosis compared to males.  Other factors that contribute to delayed diagnosis include low socioeconomic status and belonging to an ethnic minority.  In pediatrics, the goal of ASD screening is to diagnose ASD earlier, with timely referral to early intervention services, so that better long-term neurodevelopmental outcomes can be achieved.  Moreover, attention deficit hyperactivity disorder (ADHD) is the most common comorbidity in patients with ASD. While the Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-4) prohibited a co-diagnosis of autism and ADHD, the DSM-5 has modified exclusion criteria to allow such.  This case describes a minority adolescent male patient who presented initially with complex ADHD, who upon extensive evaluation, was ultimately diagnosed with co-existing autism.  This patient’s diagnosis of ASD at the age of 14 in the setting of a pre-existing complex ADHD diagnosis demonstrates how symptoms of inattention or hyperactivity may convolute underlying or newly emerging social interaction difficulties.  We highlight how children who are diagnosed with ADHD should be screened or evaluated for autism in the right clinical setting, such as evident persistence of social interaction impairment despite ADHD treatment.

Those with intellectual and developmental disabilities (I/DD), especially autism, represent an often misunderstood and underserved population. In order to address health disparities faced by those with I/DD in Washington state, the Extension for Community Healthcare Outcomes (Project ECHO) model was implemented to build capacity to serve these individuals and their families in their home communities. Through this year-long telementorship and learning community, expert teams lead clinics based on interdisciplinary case-based discussion and knowledge sharing with medical, behavioral, and mental healthcare providers. A cornerstone of these expert teams are autistic self-advocates, who provide insight into lived experience. In this paper, we will discuss how the inclusion of six autistic self-advocates across four different ECHO programs has allowed ECHO participants to broaden their horizons and gain new insight into supports for their I/DD clients across multiple aspects of care. In addition to the unique knowledge provided by self-advocates, their participation illustrates the potential for all people with I/DD to live rich and fulfilling lives. The initial implementation and on-going success of including lived experience within the ECHO model can be used as an example of how to create partnerships that meaningfully inform decisions and improve equitable outcomes in service provision.

Our ongoing systematic literature review of psychological well-being interventions for autistic adults highlighted that the concept of well-being has been poorly operationalized for autistic people in clinical literature.  Our investigation aims to contribute a novel review of how well psychological well-being interventions are designed for autistic adults.  While assumptions around the definition of autism have been critiqued extensively in literature (Heasman & Parfitt, 2023) our review of 69 studies found that the concept of “well-being”, as it applies to autistic people, has received comparatively little attention.  We raise three issues with the current oversimplification of well-being when it is understood as a return to “normal” functioning through the remediation of ill-being.  We suggest that a way forward is to embrace contemporary theorizing of both being autistic (Chapman, 2021; Kourti, 2021) and of experiencing wellness vulnerabilities (van Os et al., 2019).  A review of what is meant by autistic well-being would inform clinical and research practices.

Autism, attention deficit hyperactivity disorder (ADHD), and tic disorder (Tourette syndrome; TS) are neurodevelopmental conditions that frequently co-occur and impact psychological, social, and emotional processes. Increased likelihood of chronic physical symptoms, including fatigue and pain, are also recognized.  The expression of joint hypermobility, reflecting a constitutional variant in connective tissue, predicts susceptibility to psychological symptoms alongside recognized physical symptoms.  Here, we tested for increased prevalence of joint hypermobility, autonomic dysfunction, and musculoskeletal symptoms in 109 adults with neurodevelopmental condition diagnoses.  Rates of generalized joint hypermobility (GJH, henceforth hypermobility) in adults with a formal diagnosis of neurodevelopmental conditions (henceforth neurodivergent group, n = 109) were compared to those in the general population in UK.  Levels of orthostatic intolerance and musculoskeletal symptoms were compared to a separate comparison group (n = 57).  Age specific cut-offs for GJH were possible to determine in the neurodivergent and comparison group only.  The neurodivergent group manifested elevated prevalence of hypermobility (51%) compared to the general population rate of 20% and a comparison population (17.5%).  Using a more stringent age specific cut-off, in the neurodivergent group this prevalence was 28.4%, more than double than the comparison group (12.5%).  Odds ratio for presence of hypermobility in neurodivergent group, compared to the general population was 4.51 (95% CI 2.17–9.37), with greater odds in females than males.  Using age specific cut-off, the odds ratio for GJH in neurodivergent group, compared to the comparison group, was 2.84 (95% CI 1.16–6.94).  Neurodivergent participants reported significantly more symptoms of orthostatic intolerance and musculoskeletal skeletal pain than the comparison group.  The number of hypermobile joints was found to mediate the relationship between neurodivergence and symptoms of both dysautonomia and pain. In neurodivergent adults, there is a strong link between the expression of joint hypermobility, dysautonomia, and pain, more so than in the comparison group.  Moreover, joint hypermobility mediates the link between neurodivergence and symptoms of dysautonomia and pain.  Increased awareness and understanding of this association may enhance the management of core symptoms and allied difficulties in neurodivergent people, including co-occurring physical symptoms, and guide service delivery in the future.

Interoception is the perception of afferent information that arises from any point within the body. Individual differences in interoception have been associated with affective processing and decision-making processing.  The somatic marker hypothesis summarizes the potential effects of interoception on decision-making processes.  According to this theory, individuals with interoceptive dysfunction exhibit disadvantageous decision making.  Recently, enhancement of interoceptive accuracy, an element of interoception assessed by objective decision-making tasks, has been demonstrated using biofeedback.  Garfinkle et al. developed an interoceptive training task, modified from the heartbeat perception task, which enhanced interoceptive accuracy and reduced anxiety symptoms.  The purpose of this study was to determine the effects of interoceptive training on decision-making processes.  Based on improvements in interoceptive accuracy, we hypothesized that decision-making scores would change in a manner indicative of increased rationality.  This longitudinal interventional study was performed with interoceptive training.  Before and after the intervention, interoceptive accuracy and rationality of decision-making processes were assessed using a heartbeat perception task and rational decision-making tasks, respectively.  Fourteen healthy volunteers (nine women; mean age, 21.9 ± 4.5 years) participated. The analysis included data from 12 participants.  To detect individual differences in the effects of interoceptive accuracy on rationality of decision making, correlation analysis was conducted on change ratios of the indices of interoceptive accuracy and rationality of decision making.  Interoceptive training resulted in significant enhancement of interoceptive accuracy scores and significant reductions in somatic symptom and state anxiety scores. In contrast, interoceptive training did not cause significant changes in decision-making indices.  There was a significant positive correlation between change ratios of indices of interoceptive accuracy and rationality of decision making.  The results suggested a causal relation between interoception and rationality of decision making.  These findings will enhance the understanding of mechanisms underlying alterations of decision-making related to psychotherapy by focusing on interoception.  Trial registration number: UMIN000037548.

The way choices are framed influences decision-making.  These “framing effects” emerge through the integration of emotional responses into decision-making under uncertainty.  It was previously reported that susceptibility to the framing effect was reduced in individuals with autism spectrum disorder (ASD) due to a reduced tendency to incorporate emotional information into the decision-making process.  However, recent research indicates that, where observed, emotional processing impairments in ASD may be due to co-occurring alexithymia.  Alexithymia is thought to arise due to impaired interoception (the ability to perceive the internal state of one’s body), raising the possibility that emotional signals are not perceived and thus not integrated into decision-making in those with alexithymia and that therefore reduced framing effects in ASD are a product of co-occurring alexithymia rather than ASD per se.  Accordingly, the present study compared framing effects in autistic individuals with neurotypical controls matched for alexithymia.   Results showed a marked deviation between groups.  The framing effect was, in line with previous data, significantly smaller in autistic individuals, and there was no relationship between alexithymia or interoception and decision-making in the ASD group.  In the neurotypical group, however, the size of the framing effect was associated with alexithymia and interoception, even after controlling for autistic traits.  These results demonstrate that although framing effects are associated with interoception and alexithymia in the neurotypical population, emotional and interoceptive signals have less impact upon the decision-making process in ASD.

Some studies suggest that individuals with autism spectrum disorder have reduced emotional empathy while others do not.  The presence of co-occurring alexithymia in autism spectrum disorder and differences in interoception have been associated with reductions in empathic ability.  To fully explore the relationships between interoception, alexithymia, and emotional empathy, we collected self-report and interview data in 35 youth with autism spectrum disorder and 40 typically developing controls (ages 8–17 years).  The autism spectrum disorder sample had increased alexithymia and physiological hyperarousal compared to typically developing controls, but there were no group differences in interoception or emotional empathy.  Alexithymia severity correlated with higher personal distress in both groups and with lower empathic concern in the autism spectrum disorder group.  Within the autism spectrum disorder group, higher incidence of reports of bodily sensation when describing emotional experience correlated with lower personal distress and lower alexithymia.  In addition, although empathic concern was negatively correlated with alexithymia in the autism spectrum disorder group, across groups, the alexithymia hypothesis was supported in only the personal distress domain of emotional empathy.  These results suggest emotional empathy; personal distress, in particular, is not intrinsically impaired in autism spectrum disorder.  Empathy, the ability to understand and share the emotions of others, is a necessary skill for social functioning and can be categorized into cognitive and emotional empathy.  There is evidence to suggest that individuals with autism spectrum disorder have difficulties with cognitive empathy, the ability to imagine how another person is thinking or feeling.  However, it is unclear if individuals with autism spectrum disorder struggle with emotional empathy, the ability to share and feel emotions others are experiencing.  Self-report and interview data were collected to explore the relationships between interoception (individuals’ self-reported awareness of sensation from their body such as thirst, heartbeat, etc.), alexithymia (an individual’s ability to describe and distinguish between their own emotions), and emotional empathy in 35 youth with autism spectrum disorder and 40 typically developing youth.  Greater personal distress to others’ emotions and greater difficulty describing and recognizing self-emotions were associated with reporting fewer physical sensations in the body when experiencing emotion in the autism spectrum disorder group.  The results of this study suggest that while autism spectrum disorder youth with concomitant alexithymia may experience emotional empathy differently, it should not be characterized as an absence of a capacity for emotional empathy.

Autism Spectrum Disorder (ASD) is a complex neurodevelopmental disorder characterized by social deficits. Accumulated evidence has shown a link between alterations in the composition of gut microbiota and both neurobehavioural and gastrointestinal symptoms in children with ASD which are related to the genera Lactobacillus and Bifidobacterium. These genera have been recently categorized as “psychobiotics”. Moreover, this study aimed to compare the relative abundance of psychobiotics (L. plantarum, L. reuteri, and B. longum) to the total gut microbiome in typically developing (TD) children and those with ASD in order to correlate the distribution of psychobiotic with the severity and sensory impairments in autism. The ASD children were assessed using the Childhood Autism Rating Scale (CARS), while sensory impairments were evaluated using the Short Sensory Profile (SSP). Furthermore, the gut microbiome was analyzed using the quantitative real-time PCR. The study revealed a statistically significant increase in the relative abundance of L. reuteri and L. plantarum in the TD group in comparison to ASD children. Regarding the SSP total score of ASD children, a statistically significant negative correlation was found between both Lactobacillus and L. plantarum with the under-responsive subscale. For the Autism Treatment Evaluation Checklist (ATEC) score, B. longum and Lactobacillus showed a significant positive correlation with Health/Physical/Behaviour.