Anxiety Symptom Structure in Youth with ASD Receiving Residential Care Is Distinct and Varies By Informant

Background: Anxiety in youth with autism spectrum disorder (ASD) is highly prevalent and impairing (Kerns et al., 2015). In recent years, there has been significant progress in accurate assessment of anxiety in non-treatment seeking as well as outpatient samples of youth with ASD (e.g., Kerns et al., in press). However, a large proportion of youth with ASD have profound challenges that necessitate care in residential treatment settings (Siegel at al., 2015). While such challenges are likely to alter expression of co-occurring psychopathology, resulting in different symptom presentation compared to that seen in non-treatment seeking and outpatient youth, little is known about internalizing symptom presentation in this population (Rosen et al., 2018). Moreover, obtaining reports from multiple informants is necessary to fully understand context differences of symptom presentation within clinical samples (De Los Reyes, 2013).

Objectives: The present study explored the structure of anxiety symptoms in a sample of ASD youth living in three residential settings, and whether structure differed as a function of residential manager or teacher report.

Methods: The Child and Adolescent Symptom Inventory (CASI-5; Gadow & Sprafkin, 2013) was administered for 146 youth (M_age = 15.27, SD_age = 3.12; 119 male) with severe intellectual (IQ ≤ 70) and adaptive functioning (M_Vineland = 43.25, SD_Vineland = 14.11) difficulties, receiving care in state-funded residential facilities across NY. Classroom teachers completed the CASI teacher version, whereas residential managers who provided intensive, around-the-clock behavioral support, completed the CASI parent version. An exploratory factor analysis (EFA) of the CASI-20 anxiety scale, an adapted, reliable, and valid measure of anxiety symptoms in ASD (Lecavalier et al., 2014), was conducted separately for residential manager and teacher report. Maximum Likelihood estimation and Geomin rotation were utilized, and separation anxiety items were removed for analyses. Standard fit indices were used to evaluate model fit (Table 1).

Results: Residential manager report yielded a 3-factor structure accounting for 63% of item variance, whereas teacher report yielded a 2-factor structure accounting for 52% of item variance (Table 1). Residential manager factors were over-arousal, performance fears/physical symptoms, and social fearfulness; teacher report factors were social fearfulness/generalized anxiety disorder (GAD) and GAD/physical symptoms/obsessions (Table 2).

Conclusions: Non-treatment seeking ASD youth show distinct factors of social anxiety and GAD (Hallett et al.); in the present study, this differentiation was evident from residential manager report, but not teacher-report. Such informant differences bear consideration for measurement design, such as adapting measures to each informant accordingly. Moreover, anxiety structure in ASD youth in residential facilities differs from that of outpatient youth with ASD, as outpatient youth have GAD symptoms that load on to one unitary factor (Lecavalier et al., 2008). Further, all CASI anxiety symptoms in ASD youth receiving residential care do not form one unitary construct, which contradicts current conceptualizations and CASI-informed anxiety measurement approaches for ASD (e.g., Scahill et al., in press). It may be that increased challenges lead to more complex and nuanced symptom presentation for youth receiving residential care, which might not be adequately captured even by anxiety instruments adapted for ASD.