“Keep Calm and Use Context Clues”: An Investigation into Interoceptive Awareness in Teens with Autism

Background: Interoceptive Awareness (IA) refers to the level in which one notices internal physiological signals (i.e., interoceptive sensations) and shapes our emotional experience. IA underlies the ability to clearly interpret emotions such as anger, calmness, distractibility, and fear (i.e., specific affective emotions) as well as hunger, thirst, and body temperature (i.e., specific homeostatic emotions). Given that autistic teens are often reported to have difficulty with emotional regulation, and the underlying reasons for this are poorly understood, it is possible that IA is a key factor. Our hypothesis was that autistic teens will report differences in IA as compared to neurotypical controls.

Objectives: The purpose of our study was to develop a novel approach to understanding IA in teens with and without ASD in order to facilitate targeted, effective interventions for emotional regulation.

Methods: Our study consisted of a 55-item Likert Scale survey administered to autistic and neurotypical teens, assessing general IA (12 questions), specific homeostatic emotions (14 questions), and specific affective emotions (19 questions). Possible responses for all questions were never, sometimes, and frequently/always. All questions were compared between groups using a Fisher’s Exact Test. A Bonferroni correction determined statistical significance, i.e., p-values <0.0009 were deemed significant.

Results: The study included 143 teens, 59 teens (41%) with ASD and 84 teens (79%) without. Autistic teens had a mean age of 14.5 years, and 75% were male. Teens without ASD had a mean age of 13.2 years, and 46% were male. Ten of the 12 items assessing general IA (83%), 4 of the 24 (17%) assessing specific homeostatic emotions, and 6 of the 19 (32%) items assessing specific affective emotions were significantly different between groups. Responses to questions assessing general IA were more likely to significantly differ between autistic teens and controls. For example, for the item, “Figuring out how I feel can be tricky,” 39% of teens with ASD endorsed “frequently/always” as compared to 6% of teens without ASD (p<0.0001). Responses to questions assessing specific homeostatic and specific affective emotions were less likely to significantly differ between groups. To illustrate, there were no significant differences between group responses for the two items: (1)“I can wear shorts or no jacket outside ... on a chilly winter day and not feel cold” (p = 0.070), i.e., assessing awareness of body temperature and (2)“I can feel changes in my muscles when I am angry” (p = 0.347), i.e., assessing awareness of anger. Open-ended and more abstract experiences appear to be challenging for teens with ASD to interpret as compared to the interpretation of IA when provided with context clues, perhaps making the experience more specific, detailed, and concrete.

Conclusions: Overall, autistic teens report differences in IA affecting interpretation of broad emotional states. This may play a key role in the emotional regulation challenges this population frequently experiences. In order to develop more robust IA, autistic teens may benefit from targeting the skills necessary to scaffold concrete details from their daily experiences onto more abstract emotional concepts, where inference and subtext analysis are required.