Response to the Emotion Awareness and Skills Enhancement (EASE) Program: Emotion Dysregulation and Intolerance of Uncertainty As Potential Mechanisms

Background:

Adolescents with autism spectrum disorder (ASD) often have co-occurring anxiety or depression. Recently there has been an emphasis on transdiagnostic processes that may contribute to risk for psychopathology and serve as potential modifiable treatment targets. A growing body of literature suggests that emotion dysregulation (ED) may underlie a range of psychiatric and behavioral problems in ASD. Intolerance of uncertainty (IU) has been established as a mechanism underlying anxiety in and outside of ASD, but its association with depression and other manifestations of ED has received relatively little attention. IU may decrease in response to interventions that target acceptance and awareness through techniques such as mindfulness.

Objectives:

This study aimed to: 1) Establish the association between IU, depression, and ED in adolescents with ASD; 2) Explore whether IU decreases in response to a new mindfulness-based psychosocial treatment for ED in ASD; and 3) Determine whether change in IU is associated with change in anxiety, depression, and ED in response to treatment.

Methods:

Participants included 17 12- to 17-year-olds (IQ > 80) with ADOS-confirmed ASD who participated in an open trial of the Emotion Awareness and Skills Enhancement (EASE) Program. EASE is a 16-week manualized individual therapy intervention that teaches mindfulness, distress tolerance, and emotion regulation strategies to decrease ED. Participants and their parents completed a battery of questionnaires before and after treatment including the Intolerance of Uncertainty (IUS) Scale, the Emotion Dysregulation Inventory (EDI), and PROMIS Anxiety and Depression Scales. A larger, two-site randomized controlled trial of EASE with the same battery is on-going (current completed n = 13, currently on-going n = 10, with continuous enrollment); additional analyses will explore whether IU and ED decrease more in EASE compared to individual supportive therapy.

Results:

At baseline, IU was correlated with parent-reported anxiety as expected (r = .576, p = .006), but correlations with ED (EDI Reactivity scale) and depression were not significant. After completion of EASE, there was a significant decrease in IU (t₍₁₅₎= 3.26; p= .005; effect size .69). The magnitude of change was comparable to previously reported decreases in parent-reported anxiety (effect size = .59), depression (effect size = .96), and ED (effect size = .69) following EASE (Conner et al., 2018). IU change was significantly associated with a reduction in ED (r = .502, p = .047) and parent-reported depression change (r = .756, p = .001). IU change was approaching a significant correlation with parent-reported anxiety change (r = .485, p = .057).

Conclusions:

A new ED-focused intervention produced parent-reported improvements in psychiatric symptoms (depression, anxiety) as well as IU and ED. Although previously studied in the context of anxiety predominately, change in IU was associated with a decrease in depression and ED. IU may serve as a potentially modifiable transdiagnostic treatment target in ASD.