Emotion dysregulation in autism: A meta-analysis

Abstract

Autism is associated with significantly higher rates of internalizing and externalizing disorders compared to neurotypical (NT) individuals. Emotion dysregulation (ED) is prevalent in autistic individuals and has been proposed to underlie both internalizing disorders and behavioral challenges in autism. This study sought to use a meta-analytic approach to examine the magnitude of ED severity in autistic samples compared to NT and other clinical (OC) samples. Following a review of the literature, a total of 35 studies were included in the analyses. In general, when comparing autistic to non-autistic individuals, findings suggest a medium magnitude of difference in ED severity between autistic and comparison groups overall. Subgroup analyses indicate that autistic individuals experience significantly higher ED severity when compared to NT peers. However, when compared to OC peers, the effect is small, suggesting the severity of ED may be more similar between OC and autistic groups. Moderators were also explored, including autistic traits, age, and sex composition. These findings provide integral information about the severity of ED in autistic populations compared to other non-autistic populations, assisting in further clarifying the presence of mental health challenges in autistic youth.

Lay Abstract

Autistic people often experience other mental health challenges, which makes it particularly important to understand factors that may contribute to the development of these conditions. Emotion dysregulation, or difficulties in effectively regulating one’s own emotions in response to a changing environment, is one factor that is experienced frequently by autistic and non-autistic people and is commonly related to a wide range of mental health conditions. This article represents a quantitative synthesis of the current state of the literature on emotion dysregulation, with a specific focus on how the severity of emotion dysregulation differs across autistic and non-autistic people across the lifespan. The findings suggest elevated emotion dysregulation in autistic individuals compared to both neurotypical and other clinical populations and provide insights into the experiences of emotion dysregulation in autistic people. Overall, this article underscores the importance of more research into emotion dysregulation in autistic people to inform areas of challenges related to emotion dysregulation that can be used to better inform treatment targets.

Keywords

adolescents adults autism spectrum disorders psychiatric comorbidity psychological theories of autism

Autistic¹ individuals experience significantly higher rates of internalizing (i.e. anxiety and depression) and externalizing (i.e. attention deficit/hyperactivity disorder (ADHD)) disorders across the lifespan than neurotypical (NT) populations (Bougeard et al., 2021; Hollocks et al., 2019; van Steensel & Heeman, 2017). Long-term experiences of both internalizing and externalizing disorders may exacerbate impairments in social functioning for autistic individuals and are frequently associated with social isolation and reduced number of friendships (Harkins et al., 2022; Kaartinen et al., 2019; Mazurek, 2014; Mazurek & Kanne, 2010). Furthermore, autistic adults with co-occurring mental health challenges report reduced overall quality of life and are at increased risk of suicidality (Kirby et al., 2019; Kuhlthau et al., 2018). Therefore, it is important to identify and characterize underlying mechanisms that may relate to the development of psychiatric and behavioral symptoms, which can, in turn, lead to difficulties across the lifespan (Benevides et al., 2020; Hollocks et al., 2019; Pazuniak & Pekrul, 2020).

Recent work has begun to conceptualize mental health conditions and neurodevelopmental conditions within a transdiagnostic framework (Astle et al., 2022). Specifically, the National Institute of Mental Health has suggested the use of Research Domain Criteria (RDoC), which is a cluster of six transdiagnostic factors that have been isolated to underlie biological and developmental mechanisms of multiple mental health and neurodevelopmental conditions (Insel et al., 2010). This framework provides understanding for biological mechanisms and insights into heterogeneity and co-occurrence across conditions. Since the development of this criteria, emotion regulation (ER) has been proposed to fall under the RDoC umbrella (Fernandez et al., 2016) and has been established across mental health conditions as an underlying mechanism leading to the development and maintenance of these conditions, rather than just a symptom of the condition (Cai et al., 2018; Conner et al., 2021; Conner, White, et al., 2020; Swain et al., 2015).

ER is defined as the modification of both the presence and intensity of emotional expressions and matching these to the environmental context (Gross & Thompson, 2007). Successful deployment of ER requires attention to the environment, accurate appraisal of situations, and appropriate responding, all of which represents effective and adaptive ER (McRae & Gross, 2020). On the other hand, emotion dysregulation (ED) occurs either when there are deficits in adaptive regulation strategies (e.g. cognitive reappraisal) or when ineffective responses are utilized, ultimately resulting in a mismatch between a person’s emotional expressions/experiences and the environment (Gross & Thompson, 2007). Ineffective regulation strategies or maladaptive responding can be either external (i.e. aggression) or internal (i.e. rumination) and frequently results in heightened emotional experiences. A large population-based study suggests that approximately 40% of autistic people experience ED, at a rate four times higher than their NT peers (Conner et al., 2021). Several studies have also reported higher prevalence rates of ED in autistic populations than those in other clinical (OC) populations, such as ADHD (Edmunds et al., 2023; Joshi et al., 2018) and developmental disabilities (Barnard-Brak et al., 2014). However, due to the emerging nature of this research, limited research has explored whether autistic people are not deploying the appropriate adaptive strategy or if they are relying on maladaptive responding. Some theoretical research suggests that both may occur, where autistic people are inaccurately appraising their environments, demonstrating reduced attention, and also responding in a maladaptive way (Mazefsky & White, 2014). Furthermore, empirical research has begun to measure ED across several approaches, such that elevated emotional dysregulation specifically may give some insight into maladaptive response patterns, while measures examining emotional control and self-regulation may better represent deployment of adaptive strategies.

ED appears to have significant impacts on global and specific (i.e. social communication) autistic traits, which may lead to compounding challenges for autistic individuals in psychosocial, behavioral, and cognitive domains (Sukhodolsky et al., 2016; Vine Foggo & Webster, 2017). ED can increase difficulties in social situations through misidentification of emotional experiences and increased reactivity to emotionally triggering events (i.e. aggressive outbursts; Conner et al., 2021; Goldsmith & Kelley, 2018; Swain et al., 2015). Furthermore, increased instances of repetitive behaviors have been linked to the presence of ED and have been theorized to be a method of coping with dysregulated emotions (Samson et al., 2015). ED has been established as a predictor of increased anxiety, suicidality, reduced social relationships, and reduced overall quality of life in autistic children and adults (Beck et al., 2020; Conner, Golt, et al., 2020; Conner, White, et al., 2020; Vasa et al., 2018). Despite this, autistic children with dysregulation were less likely to receive psychiatric treatment than their similarly dysregulated non-autistic peers (Vasa et al., 2022). Importantly, these findings provide evidence of significant associations and risk of psychopathology, reduced quality of life, and poor long-term outcomes in autistic individuals with a higher severity of ED. Much of the ED literature in autistic people has remained focused on the relationship between ED and internalizing and externalizing disorders. However, this research has focused mainly on the correlational and predictive relationships between mental health and ED, taking a symptom-based approach, which limits the ability to examine directional pathways, which have been established in other areas of ED research. ER research outside of autism has displayed provisional directional pathways among the presence of early difficulties modulating emotions and the development of multiple mental health conditions, including substance abuse, borderline personality disorder, anxiety disorder, among others, leading to the conceptualization of ED as a risk factor for these conditions (Aldao et al., 2016). However, recent work has proposed ED as a transdiagnostic mechanism of neurodevelopmental conditions more broadly, citing both the disruptions in emotional control, processing, and broader implications for co-occurring mental health conditions (England-Mason, 2020). Consequently, there is a growing body of, and an emerging interest in, research examining ED in autism; however, these findings have not yet been quantitatively synthesized. Synthesizing these findings can provide clinically important information on how autistic people experience ED compared to NT and OC peers, bolstering support for ED as a transdiagnostic construct in neurodevelopmental conditions.

Current study

The current project examined the difference in ED between autistic and NT or OC populations across the lifespan using meta-analytic procedures. Specifically, this meta-analysis examined whether the overall effect sizes differ between autistic individuals compared to both NT and OC comparison groups. Uniquely, this meta-analysis seeks to examine the magnitude of difference among specific OC and autistic populations, to provide better clarity surrounding global and specific differences between autism and OC populations.

The aims of the current project were as follows: (1) to assess the magnitude of difference in ED severity for autistic individuals compared to (1a) all comparison groups, (1b) NT samples only, and (1c) OC samples only. It was hypothesized that autistic groups will have significantly higher ED severity than all comparison groups overall, and NT comparison groups, in line with previous research showing consistently higher rates in autistic populations (Conner et al., 2021; Vasa et al., 2022). It was hypothesized that the severity of ED will also be higher in autistic populations than in OC groups, however, to a smaller magnitude than in NT groups due to variability among OC groups (Joshi et al., 2018). As specific OC samples may vary significantly in terms of ED presentation, the extent that ED may be more severe in autistic individuals may vary across OC conditions to which they are compared. (2) To understand the contribution of different study-level moderators, such as sex composition, mean age, mean level of autistic traits, informant (e.g. clinician-, parent-, self-report), measured construct (e.g. ER, ED, and emotional control), and mean IQ of the sample. It was hypothesized that samples that are younger, have more significant autistic traits, or have lower cognitive functioning will demonstrate greater differences in ED severity. While there is a lack of congruence in the literature relating to the impact of sex on ED severity, sex composition of the samples was explored as a moderator. In addition, no a priori hypotheses were proposed with regard to informant and measured construct as these moderators were explored as an exploratory aim.

Methods

Identification of studies

This meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Arya et al., 2021). The following Boolean string of search terms was used to identify articles that met inclusion criteria: (ASD OR autism spectrum disorder OR Asperger OR autis* OR pervasive developmental disorder) AND (emotion regulation OR emotion dysregulation OR dysregulation OR emotional disorders OR emotional problems OR emotional reactivity OR self-regulation). Rayyan reference manager and Microsoft Excel software were used to manage all data during the article identification and coding procedures.

Inclusion criteria

Studies were included in the meta-analysis if they met the following criteria: (1) included a sample of participants meeting Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM-V] or 4th ed. [DSM-IV]) criteria for autism diagnosed by either a clinician or a standardized measure for autism (including autism spectrum disorder, autism, Asperger’s disorder, pervasive developmental disorder–not otherwise specified); (2) included a comparison sample of either NT or OC participants; (3) included a measure for self-regulation or emotional regulation, emotional control, or ED; (4) original empirical research; (5) findings were reported in a peer-reviewed journal in the English language; (6) studies did not contain overlapping sample populations; and (7) included both means and standard deviations for group comparisons of ED, or authors provided these variables upon request.

Search and coding procedures

Two search phases were conducted using the identified search terms in PubMed, PsycINFO MEDLINE, and PsycArticles, the first of which was completed in March of 2022, and the second in March of 2023 (Figure 1). Following the initial identification, duplicates were removed from the included articles, and a title and abstract review was conducted by a team of six independent reviewers for the first phase, and a team of three (which were a part of the original review team) for the second phase. At the 2022 title and abstract review, reviewers had excellent inter-rater agreement (96%) for 20% of articles. Following the 2022 title and abstract review, a full-text review was conducted by three independent reviewers with excellent (93%) inter-rater agreement. For the 2023 phase of review, a team of three independent authors completed both the title and abstract and the full-text review with excellent inter-rater agreement (96%). Any discrepancies between reviewers were discussed and remediated by group consensus.

Figure 1.

Identification and selection of included studies.

Authors were contacted for multiple studies from the same research group to determine sample overlap or for additional data. After the final set of articles was established, two authors (RM and MIC) completed a quality assessment using the Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross Sectional Studies (Moola et al., 2020). Inter-rater reliability between the two coders was 98%. Disagreements between the reviewers were resolved by discussion. Data were extracted from the articles and synthesized for analysis by a team of two independent coders (RM and MIC), who had 100% inter-rater agreement. After the completion of article coding, analyses were conducted to address the aforementioned study aims. The final set of included articles included several well-established measures of (1) ER (Behavior Rating Inventory of Executive Function—Emotion Regulation Index; Cognitive Emotion Regulation Questionnaire; Difficulties in Emotion Regulation Scale; Emotion Regulation Checklist—Lability/Negativity Scale; Emotion Regulation Questionnaire; Mini PARS; NEPSY-II—Self Regulation Abilities; Self Report Emotional Ability Scale; Sense and Self Regulation Checklist; Scales of Independent Behavior -Revised), (2) ED (Child Behavior Checklist—Aggression/Anxiety—Depression/Attention; Child Behavior Checklist—Dysregulation Profile; Emotion Dysregulation Inventory; Emotion Dysregulation Inventory—Dysphoria Scale; Temperament and Atypical Behavior Scale—Dysregulated; Wender-Reimherr Adult ADHD Scale), and (3) emotional control (Behavior Rating Inventory of Executive Function).

Data analysis

The Comprehensive Meta Analysis Version 3 (CMA-3; Borenstein et al., 2009) software was utilized to conduct the analyses.

Effect size

To establish the direction and magnitude of quantitative findings, effect sizes were calculated, and a Hedges’ g was utilized for small-sample correction. Unless otherwise specified, random-effects models were conducted for all computations (Schmidt et al., 2009). Random-effects models allow that the true effect size might differ from study to study and estimate the mean of a distribution of effects, compared to a fixed-effect model wherein it is assumed that the true effect size for all studies is identical. To increase generalization of the findings to other autistic populations, that is, those not studied in this set of studies, random-effects models were used as there is generally no reason to assume that the studies are “identical” in the sense that the true effect size is exactly the same in all studies (Borenstein et al., 2009). Cohen’s suggested effect size references were utilized to determine the magnitude of effect, where a small effect was 0.2 and below, a medium effect was 0.5, and a large effect was above 0.8, respectively (Cohen, 1992). In addition, sensitivity analyses were conducted, which removed each individual study systematically, to ensure that no individual study was inflating or minimizing the reported effect size.

Moderator analyses

Moderator analyses were conducted when variation was detected (Q; I²). Heterogeneity was examined through the Q-test by summing the squared deviation from each study’s effect size from the overall effect size and weighing each study by variance (Higgins & Green, 2011; Huedo-Medina et al., 2006). I² measure also examined heterogeneity and percentage of total variability among effect sizes accounted for by study variation rather than sampling error (Huedo-Medina et al., 2006).

Specifically, moderator analyses were conducted if: (a) significant Q statistics were established, or (b) according to the I² statistic, ⩾20% heterogeneity was established (e.g. a nontrivial amount; Borenstein et al., 2009; Huedo-Medina et al., 2006). Mixed-effects analyses were used for categorical moderator analyses, where a random-effects model was used to combine studies within subgroups, and a fixed-effect model was used to yield overall effect.

Publication bias

Funnel plots, Egger’s regression tests, and Duval and Tweedie trim-and-fill methods were used to detect publication bias (Duval & Tweedie, 2000; Egger & Smith, 1998). Taken together, publication bias was considered probable when all three methods suggested bias, possible when only one of two methods indicated bias, and not likely if no methods suggested bias (Sterne et al., 2011).

Results

Overview of identified studies

The first search yielded 10,729 articles, of which 211 were included for full-text review. The second search yielded a total of 476 articles, of which 67 were included for full-text review. Across both searches, 35 articles met criteria for inclusion (Supplemental Appendix 1). The selection process was reported in the PRISMA flow diagram (Figure 1). Articles (n = 11) from the same research group that were determined to be a part of an overlapping sample were excluded, with the article with the largest sample size or available data retained. Sixteen articles were excluded due to a lack of response from corresponding authors when they were contacted to provide data for the analyses, of which many, unfortunately, were conducted in adults.

Results of the quality assessment indicated that, of the final set of included articles, 94% met all the established criteria related to methodological rigor and internal validity, with the remainder of articles meeting seven out of eight criteria. The majority of research maintained a high standard of reporting, with minor flaws in reporting detailed information about their included sample. There were no substantial discrepancies in quality between included studies.

Articles included a total of 11,201 participants, where 5316 had an autism diagnosis, 2216 had another clinical disorder (e.g. ADHD, genetic disorder (GD), anxiety, anorexia, and Down syndrome (DS)), and 3669 were NT. Several articles included multiple autistic and OC groups; therefore, 41 distinct comparisons were made. All identified articles included well-established standardized measures of either self-regulation or emotional regulation (20 studies; Barnard-Brak et al., 2014; Ben Hassen et al., 2023; Bieberich & Morgan, 2004; Cai et al., 2018, 2021; Chen et al., 2022; Dağdelen, 2021; DeLucia et al., 2022; Di Renzo et al., 2020; Golshan et al., 2019; Jahromi et al., 2012; Murray et al., 2022; Ni et al., 2020; Özyurt et al., 2018; Pickard et al., 2020; Reyes et al., 2020; Samson et al., 2016; Sesso et al., 2020; Silva & Schalock, 2012; Zdankiewicz-Scigała et al., 2021), emotional control (five studies; Fong & Iarocci, 2020; Hovik et al., 2017; Semrud-Clikeman et al., 2010; Timko et al., 2021; Vasa et al., 2018) and/or the presence of ED (14 studies; risk of ED in autistic populations (Mazefsky, 2015; Mazefsky & White, 2014). One study included multiple methods of assessment (e.g. behavioral and parent-report measures; Costa et al., 2017), and eight included both NT and OC groups as comparison groups (Cai et al., 2021; Dağdelen, 2021; Edmunds et al., 2023; Helfer et al., 2021; Hovik et al., 2017; Özyurt et al., 2018; Semrud-Clikeman et al., 2010; Silva & Schalock, 2012). Articles included parent-reported (27), self-reported (8), and/or behavioral (2) measures of ED. Twenty-one identified studies included well-characterized autistic samples, utilizing either the Autism Diagnostic Observation Schedule, second edition (ADOS-2; Cai, Richdale, Dissanayake, & Uljarević, 2019; Chen et al., 2022; Chiu et al., 2023; Conner et al., 2021; Costa et al., 2017; Davico et al., 2022; Day et al., 2022; DeLucia et al., 2022; Di Renzo et al., 2020; Edmunds et al., 2023; Fong & Iarocci, 2020; Helfer et al., 2021; Lord, Gotham, et al., 2012; Mazefsky et al., 2020; Reyes et al., 2020; Samson et al., 2016, 2014; Semrud-Clikeman et al., 2010; Timko et al., 2021; Vasa et al., 2018, 2022; Ventura et al., 2022) and/or the Autism Diagnostic Interview-Revised (ADI-R; Rutter et al., 2003). Twenty-five articles utilized a clinician or school-based diagnosis to characterize their autistic participants, while the remaining articles relied on parents’ qualitative report of a prior diagnosis by a clinician, sometimes supplemented by parent-report dimensional measures. Chronological and developmental ages varied across the lifespan, with articles including mostly children and adolescents. Specifically, all participants fell between 1 and 63 years of age (M = 12.8; SD = 7.01; two studies did not report mean age), of which most participants were male (67%) and had an IQ greater than 80. Due to the lack of reporting in many included articles, data on socioeconomic status and race could not be examined.

Effect size analysis

For the 35 studies included in the overall analysis of ED comparing the autistic group with any comparison groups (NT and/or OC), the magnitude of the effect sizes ranged from g = −1.89 to 2.47 (Figure 2), with positive effects indicating more severe ED in autistic populations than in the comparison groups. Overall, relative to the comparison groups, the autistic group had significantly higher ED (g = 0.68, k = 41, 95% confidence interval (CI) [0.41–0.95], Z = 4.95, p < 0.001), suggesting a medium-large effect. Sensitivity analyses revealed that the overall effect remained significant after individually removing each study (all ps < 0.001).

Figure 2.

Overall effect sizes for ED autism groups to any comparison (NT and/or OC) groups.

The magnitude of effect sizes when examining ED severity in the autistic group compared to that in the NT group ranged from g = −1.27 to 2.58 (Figure 3). Overall, a random-effects model suggests that the autism group had significantly higher ED severity than the NT comparison groups (g = 1.07, k = 29, 95% CI (0.72–1.41), Z = 6.06, p < 0.001), with results suggesting a large effect.

Figure 3.

Overall effect sizes for ED when comparing autism and NT groups.

Finally, when examining the differences between the autistic and OC groups, effect sizes ranged from g = −2.52 to 1.12 (Figure 4). A random-effects model suggested that the autistic group had higher ED than the OC group (g = 0.27, k = 21, 95% CI [0.02–0.53], Z = 2.13, p = 0.03), with results suggesting a small effect.

Figure 4.

Overall effect sizes for ED when comparing autism to OC groups.

When studies with a specific OC group were examined in isolation, significant differences were revealed between the autistic group and the ADHD group, such that the autistic group demonstrated higher levels of ED (g = .36, k = 6, 95% CI [0.16–0.57], Z = 3.44, p = 0.001), suggesting a small-medium effect. Significant differences in ED were not observed between the autistic group and the developmental disability/intellectual disability (DD/ID) group (g = 0.33, k = 3, 95% CI [−0.6 to 1.25], Z = 0.68, p = 0.49). Likewise, significant differences were observed between the autistic group and a group with unspecified OC conditions such that the autistic group demonstrated higher ED (g = 0.74, k = 3, 95% CI [0.34−1.13], Z = 3.71, p < 0.001), suggesting a medium effect. Further no significant differences in ED were observed between the autistic group and a language disorder group (g = −1.56, k = 2, 95% CI [−3.78 to 1.46], Z = −0.87, p = 0.39). However, only two studies were included, both in young children with medium sample sizes (N = 87; N = 128; Di Renzo et al., 2020; Özyurt et al., 2018). Due to the reduced number of studies with this particular comparison group, the results should be interpreted with caution. Similarly, the difference in ED between the autistic group and DS group approached significance (g = 0.71, k = 1, 95% CI [−0.02, 1.44], Z = 1.90, p = 0.06), suggesting a large effect with greater ED severity in autistic children than in those with DS. Only one study with a small sample (N = 36) of children from a mixed clinical-community sample has examined differences in ED across autism and DS. These results should be interpreted with caution due to the small sample size from a single study (Bieberich & Morgan, 2004), thus limiting generalizability of the findings. Finally, no significant differences in ED were observed between the autistic group and eating disorder (ETD) group (Timko et al., 2021; g = 0.03, k = 1, 95% CI [−0.50 to 0.56], Z = 0.11, p = 0.91) or the autistic group and GD group (Glaser & Shaw, 2011; g = 0.54, k = 1, 95% CI [−0.10 to 1.19], Z = 1.66, p = 0.10). Both these studies were conducted with small samples of children and adolescents (N = 51 and 37, respectively). Notably, since each of the aforementioned groups (i.e. ETD and GD) only included one study, these results should be interpreted with caution, as generalizability to other sample types and adult populations is greatly reduced. Furthermore, sensitivity analysis suggested some samples may be driving the effect (p = 0.03).

Moderator analysis

Heterogeneity was significant, warranting further moderator analyses in the full sample of participants (i.e. when both comparison groups were accounted for; Q = 1393.04, p < 0.001, I² = 97.13). In the full sample of participants, age (p = 0.13), sex composition (p = 0.23), autistic traits (p = 0.49), informant (e.g. behavioral, parent report; p = 0.29), measured construct (ED, emotional control, ER; p = 0.74), and cognitive ability (p = 0.29) were not significant moderators. Due to the limited number of studies including measures of autistic traits, moderator analyses examining the moderation effects of autistic traits could not be fulfilled.

Additional moderator analyses were conducted after examining heterogeneity in autistic groups in contrast to NT (Q = 908.60, p < 0.001, I² = 96.92) and OC (Q = 249.57, p < 0.001, I² = 91.99), respectively. When comparing autistic to NT groups only, sex composition (B = −0.04; p = 0.07) and age (B = 0.04; p = 0.10) emerged as marginally significant predictors, which suggests the magnitude of effect of ED severity was greater in samples with more females and older participants. However, when comparing autistic and NT groups, cognitive ability was not a significant moderator (B = −0.01; p = 0.66). In congruence with the full sample, sex composition, cognitive ability, or age did not emerge as a significant moderator (ps > 0.18) when comparing autistic to OC groups only.

Publication bias

According to the criteria described earlier, publication bias appears possible for the overall analysis (autistic versus any comparison group). While the Egger’s regression method was not significant (p = 0.84), suggesting that publication bias is unlikely, inspection of the funnel plots suggested visually apparent bias, as the funnel plot is skewed to the right of the mean. Furthermore, the random-effects trim-and-fill method suggested possible publication bias as nine studies are likely to be missing to the left of the mean.

Publication bias appeared unlikely when comparing the NT and autistic groups based on all three methods of visual and statistical assessment. Visual examination of funnel plots showed the funnel of included studies was mean centered. Egger’s regression models were not significant (p = 0.66), and the random-effects trim-and-fill method did not suggest bias as no studies were likely to be missing to the right or left of the mean.

Publication bias appears possible when comparing autistic and OC groups. The Egger’s regression model was not significant (p = 0.19), and the funnel plots do not reflect visually apparent bias. However, the random-effects trim-and-fill method suggested possible bias as eight studies are likely to be missing to the left of the mean.

Discussion

This meta-analysis is the first to examine the magnitude of difference in ED severity between autistic versus non-autistic individuals. A medium-large effect was noted with higher ED severity in ASD relative to non-autistic individuals, such that autistic individuals may experience significantly more pronounced ED than those without ASD overall. Significant heterogeneity was found across study samples, which warranted moderator analyses. Of the moderators proposed, in the full sample (i.e. when accounting for both comparison groups, NT and OC), none of the moderators (i.e. age, cognitive ability, ASD symptom severity, sex composition, informant, measured construct) accounted for the variance in effect sizes. Furthermore, there were also significant, large differences in ED severity between autistic and NT individuals, such that autistic individuals displayed more severe ED. When comparing ASD to NT-only comparison group, moderator analyses suggested marginal significance levels; as such sex composition and age may account for the variance in effect sizes, such that the magnitude of the difference in ED severity between autistic and non-autistic groups was greater in samples with a higher percentage of females and older participants. Moderator analyses examining cognitive ability and ASD severity were not significant. For the OC-only comparison group, the differences between ASD and OC individuals evinced a small effect, such that more severe ED was present in the autistic individuals. This further effect was not moderated by the mean age of the sample, sex composition, ASD severity, or cognitive ability.

In terms of ED severity, the magnitude of effect was greater in the ASD group relative to the overall comparison group; findings may be explained by underlying mechanistic deficits in emotional processing and inhibitory control (Cai, Richdale, Dissanayake, Trollor, & Uljarević, 2019; Mazefsky, 2015). Specifically, it is well-established that autistic individuals experience impaired emotion recognition, perspective-taking, and regulatory control, which can result in inappropriate responses or lack of deployment of effective regulatory strategies (Cai et al., 2018; Keluskar et al., 2021). It is plausible that these underlying deficits, paired with limits in cognitive flexibility, may lead to maladaptive responses and dysregulated emotions and behaviors (Cai et al., 2018). Furthermore, as many autistic individuals experience differential sensory sensitivities (Grzadzinski et al., 2013; Maenner et al., 2023), environmental stimuli may become more triggering. As ED is often triggered by environmental stimuli (e.g. stimuli conditioned as aversive), the inability to understand and respond to the situation appropriately may heighten the risk of ED in autistic populations (Mazefsky, 2015; Mazefsky & White, 2014).

The same pattern of effects was observed in comparison with the NT group only, where the magnitude of differences in the severity of ED was larger. The aforementioned deficits in underlying sensory and regulatory mechanisms may be more pronounced than it does with NT individuals, and thereby may have contributed to the larger differences in effect sizes. On the other hand, a trend was observed for small effects of differences between ASD and OC individuals. These results are congruent with previous findings suggesting that autistic populations may have higher or comparable levels of ED severity in contrast to OC groups (Joshi et al., 2018; Vasa et al., 2018), who reportedly experience more ED than NT individuals (Joshi et al., 2018). Differences in the effects of ED severity could be related to the specific clinical population to which autistic individuals are being compared. For example, ED has been established to be significantly higher in anxiety and ADHD populations than in NT or OC groups, such as those with DS or learning disabilities (Bieberich & Morgan, 2004; Joshi et al., 2018; Vasa et al., 2018). Given the variability within OC populations, pooling OC populations with more-severe ED (i.e. ADHD) with those who experience less-severe ED (i.e. DS; Bieberich & Morgan, 2004) may obscure the magnitude of difference between OC and autistic groups.

Furthermore, the magnitude of the difference varied when autistic populations were compared to specific clinical populations individually (e.g. ADHD only). Specifically, the autistic group had higher ED than the ADHD group, which aligns with previous research (Joshi et al., 2018). However, no significant differences were observed between the autistic group and the DD/ID group or language disorder group, respectively. Notably, these findings are based on a small sample of articles (n_DD/ID = 2; n_LD = 2), which may have limited detection of extant differences in ED between these groups and the autistic group. Furthermore, the high degree of heterogeneity present in DD/ID samples (e.g. language ability, cognitive ability, adaptive functioning) may have further obscured relationships of interest with regard to ED (Bieberich & Morgan, 2004; Di Renzo et al., 2020; Özyurt et al., 2018). However, of the specific OC comparisons, several comparison groups had representation from only one study. In addition, no differences were found in ED severity when comparing autistic children to those with ETD (Timko et al., 2021) and genetic conditions (Glaser & Shaw, 2011), of which one study each was included. Timko et al. (2021) reported that autistic children had higher percentages of emotional control difficulties than those with ETDs. Similarly, Glaser and Shaw (2011) reported that autistic children presented with higher levels of ED than children with 22q13 Deletion Syndrome. However, due to the limited sample sizes and the reduced number of studies included, these findings should be interpreted with extreme caution until replication can take place in larger samples across multiple studies.

While the overall effect size was large, there was significant heterogeneity present across samples. As autistic traits (e.g. sensory sensitivities or sensory-seeking behaviors, emotion recognition abilities) manifest differently across individuals (Grzadzinski et al., 2013), the variability in these deficits or differential responding in scenarios is expected, which may contribute to the variability in reported levels of ED across studies. Findings from moderator analyses suggest a trend toward greater magnitude of effect size differences when compared to NT samples with a higher portion of females, which is in opposition with previous research in the NT literature. Previous findings suggest males may not deploy regulation strategies as quickly and flexibly as their female counterparts and may have fewer coping strategies to aid in reactivity (Conner, Golt, et al., 2020; Eschenbeck et al., 2007; Goubet & Chrysikou, 2019). However, the current findings suggest the contrary, that samples with a higher composition of female participants may experience more severe ED. This seemingly contradictory finding could have arisen from inclusion criteria specifying that participants must meet DSM-IV or DSM-V diagnostic criteria for ASD. Research suggests that higher prevalence in males being diagnosed with ASD may partly be due to biased diagnostic tools, meaning that females must often display more autistic traits to receive a formal diagnosis (Lai et al., 2015; Loomes et al., 2017). Given these trends, it is possible that the female participants included in the final set of studies demonstrated not only more autistic traits but also more ED, resulting in this surprising finding regarding sex differences in ED. One note of caution surrounding this finding relates to the use of the percentage of male participants included in the sample (e.g. sample composition), which does not provide a direct comparison of severity of ED in males and females to better understand sex differences in ED presentation. To better understand this relationship, direct comparisons between males and females should be made as these findings could add valuable information regarding differential presentations of dysregulated behaviors and cognitions.

Additional moderator analyses suggested another trend that mean age of the NT sample may impact the magnitude of difference in ED severity, such that autistic individuals compared to NT peers had higher ED severity in older samples. Developmental delays are commonly observed in autistic people, and it is plausible that development in specific regions of the brain in older autistic populations are delayed compared to other NT peers (Lord, Luyster, et al., 2012). Specifically, developmental deficits in executive functioning and emotional control in autism may relate to more pronounced ED during later developmental periods than that in NT populations. However, as autistic individuals age, delays often become more apparent, which may enhance the gap in differences between autistic and NT people in older samples (Lord, Luyster, et al., 2012). In addition, these differences may evolve if ED-related psychiatric symptoms emerge later in development. Therefore, when comparing these populations to autism, differences in developmental periods may become more important in explaining heterogeneity between autistic and NT populations. However, it is important to note that the distribution of ages in the current literature is skewed toward adolescents; samples of young children and adults were small, with few studies including these age ranges. Therefore, moderation analyses should be replicated when sample sizes increase.

In addition, moderator analyses examining differences across informants (i.e. parent, self, and behavioral tasks) indicated that effects do not differ significantly between informant types. Furthermore, results remained stable when examining studies using parent report only in this analysis. These findings provide some support for the viability of findings, suggesting that insight from different informants may still reflect differences in ED severity. However, only three studies utilized behavioral tasks, which limits the generalizability of these findings around less subjective assessment of ED. Similarly, moderator analyses suggest that there were no differences across measured constructs, specifically comparing ER, presence of ED, and emotional control. Therefore, despite constructional and content differences among measures examining these constructs, they may provide insights into the presence of dysregulated emotional profiles. In addition, these findings may suggest that autistic people may present with more maladaptive responses to triggering stimuli, as well as fewer regulatory strategies (Mazefsky & White, 2014). This may suggest that treatments targeting ED may benefit from targeting both areas by providing alternative responses, as well as distress tolerance skills.

According to our analyses, publication biases may be possibly present in the current results. Multiple methods used to examine publication bias denoted the possible presence of some bias in the published studies when examining both the full sample and NT-only comparisons. The funnel plots and Egger’s regression methods suggest that the included studies may reflect publication bias toward larger-than-average effects. As with any topic, it is important that future researchers seek to publish and report on null findings as well as those that are significant to ensure a balanced representation of the study population in the literature.

In sum, these findings suggest that, overall, autistic individuals may be at heightened risk of experiencing difficulties with ED and should be monitored throughout development to mitigate long-term impacts. Findings also offer insights into the comparative ED severity between autistic populations when specifically considering NT and OC groups, as well as the role of sex composition and mean age of participants in impacting the magnitude of these differences. In culmination, these findings provide several avenues for future research seeking to understand the effects and variability of ED in autistic individuals.

Limitations and future directions

Several limitations are present in the current project. First, this study was not pre-registered, rendering several relevant pieces of information (review protocol, conflict of interest) unavailable to the general public. In addition, several samples could not be included as authors did not respond to our requests for providing relevant statistics in their articles. Therefore, results are missing some relevant publications on ED. In addition, few studies included in the meta-analysis incorporated multi-informant measures of ED, reducing the ability to gather multiple perspectives and examine potential biases from informants. Due to the challenging nature of ED, it is likely many parents may over-report frequency or duration of ED behaviors because of caregiver fatigue or skewed perspectives. Prior research on the implications of informant discrepancy between parent and child report suggests that this may be a hindrance in identifying target treatment goals, which may lead to poor collaboration among the treatment team while monitoring behaviors (De Los Reyes & Kazdin, 2005; De Los Reyes & Ohannessian, 2016). Moreover, informant discrepancy on behavior rating scales between teachers and parents may highlight environmental variables that maintain externalizing or internalizing behaviors; therefore, this discrepancy may inform treatment recommendations (De Los Reyes et al., 2015). Crucially, future research should seek to gather multi-informant data to examine differences in reporting and to ensure effects are not a result of subjective biases. Specifically, including self-report measures will provide integral information about internalized experiences of ED (Kenworthy et al., 2022; Shea et al., 2021). Behavioral and neuroscientific methods should also be employed to better understand behavioral presentations and underlying neurological deficits that relate to expressions and experiences of ED.

Another limitation is the lack of diversity in sex and age in the samples. Many samples had a very limited number of female participants. However, as sex composition emerged as a moderator, it is important to continue to examine the differences in ED presentations between sexes. Future research should seek to recruit more balanced numbers of male and female participants to better evaluate sex differences in experiences and presentations of ED. Relatedly, this study could not parse sex assigned at birth from gender identity, but future work should strive to consider these factors separately in order to determine whether biological sex or gender effects have unique or interacting effects on ED in the autistic population. Furthermore, four studies conducted in adult populations identified from the search were not included in this review due to missing adequate statistical information. While three included studies report adult samples (Ben Hassen et al., 2023; Murray et al., 2022; Zdankiewicz-Scigała et al., 2021), the scope of this article is nonetheless limited to mainly children and adolescents. More studies are needed with adult samples in order to provide a better understanding of long-term trajectories of ED in autistic populations. Moreover, examining individual-level variables averaged across participants (e.g. mean age) may obscure how individual differences in age may relate to ED, which must be examined in subsequent empirical studies.

Another area of concern is the lack of information regarding the race and ethnicity of participants. Many articles did not report statistics relating to race and ethnicity or reported having majority White male samples. This reduces the generalizability of findings significantly for autistic youth identifying as a racial or ethnic minority and limits the ability to examine cultural differences in ED presentations. Finally, many studies reported limited information on the cognitive abilities of their participants, with most studies only including participants with IQ above 80. This limits the generalizability of findings to individuals with co-occurring ID, who are often underrepresented in empirical studies despite the notable proportion of autistic individuals with ID (Bryson et al., 2008; Stedman et al., 2019). Future research should seek to recruit more diverse samples so that heterogeneity in ED can be more closely examined.

Finally, future research should further delineate what factors result in the maintenance and development of ED. Specifically, it would help to further clarify predictive utility in experiences of ED and the development of internalizing and externalizing disorders. In addition, given the focus of much of the literature on ED in autistic people has been on examining its relationship to co-occurring anxiety disorders (e.g. Cai et al., 2018; Conner, White, et al., 2020), it is important to continue to expand the literature to include other significant associations that have been established in TD literature, including depression and ADHD (Bodalski et al., 2019; Uhl et al., 2019; Visted et al., 2018). Further clarifying these among other relationships with this construct can provide integral information for treatment planning and development targeting these co-occurring symptoms for autistic individuals.

Clinical implications

These findings have significant clinical implications for autistic individuals who may be experiencing more severe ED than their peers. In addition, this article provides a quantitative synthesis of ED and its level of severity in autistic people. In line with the National Institute of Mental Health goals for research and clinical practice (Insel et al., 2010), these findings provide strong support for ED as a transdiagnostic treatment target. These findings highlight the need for vigilance regarding dysregulated presentations by clinicians during the initial assessment process for autism. Furthermore, findings imply that ED may be more pronounced in younger autistic people in comparison to younger OC populations, making early identification and early intervention targets particularly important for some young children, as ED may exacerbate autistic traits and relate to worsening outcomes. As early intervention is a common treatment approach in autism, regulatory skills could be integrated into existing treatment methods in early development. This may help mitigate early signs of ED and long-term effects on mental health, prior to the onset of adolescence where academic, social, and regulatory demands increase (Bodalski et al., 2019; Cole et al., 1994; Keluskar et al., 2021). Future work could conduct a synthesis of the literature on the relationship of ED with internalizing and externalizing disorders to better understand the role of ED in these conditions. That being said, it is important to note several studies that excluded participants with clinical levels of internalizing and external conditions or examined participants during early development and still found higher levels of ED in autistic people. These findings provide some support for the ED as an underlying mechanism, and thus a strong preventive treatment target. Nevertheless, findings highlight the need for developing effective treatments that target ED-related difficulties across the lifespan. Recent research noted the effectiveness of ED treatments for autistic children and adults, where participants noted improvements in anxiety, regulation strategies, maladaptive behaviors, depression, and coping skills after treatment (Beck et al., 2020; Factor et al., 2019; Scarpa & Reyes, 2011; White et al., 2020). However, autistic youth experiencing ED are less likely to receive therapeutic intervention but more likely to be prescribed psychiatric medication (Vasa et al., 2022). These findings highlight the disparity in psychosocial treatment usage in autistic youth, despite its clear effectiveness in improving outcomes. Future research should seek to build on current treatment methods as well as continue to develop accessible community-based protocols to fill the gap in available and effective psychosocial treatment for autistic individuals. Relatedly, it is important to provide adequate training on the intersection of underlying transdiagnostic constructs (such as ED) to clinical practitioners as this will help to further expand the number of skilled providers who can deliver treatment to this growing population.

Conclusion

In this first quantitative synthesis of ED research in autistic people, a total of 11,201 individuals across 35 studies were examined to quantify the magnitude of difference in the presence of ED in autistic individuals compared to other samples. In sum, these findings provide important information about the experiences of ED in autistic populations. Specifically, the results displayed small to large effects seen when examining the severity of ED in autistic individuals compared to other clinical conditions or NT populations, respectively. These findings provide critical information that can be used in future treatment planning for autistic people. In addition, significant heterogeneity was seen across samples but was not explained by proposed moderators except at the trend level. These findings suggest that further research into severity, presentation, and treatment of ED is warranted in autistic populations. Future research should seek to examine ED in more diverse samples that include multimodal and multi-informant assessment to further expand upon the current literature.

Supplemental Material

sj-docx-1-aut-10.1177_13623613241257605 – Supplemental material for Emotion dysregulation in autism: A meta-analysis

Supplemental material, sj-docx-1-aut-10.1177_13623613241257605 for Emotion dysregulation in autism: A meta-analysis by Rachel G. McDonald, Mary Isaac Cargill, Sadaf Khawar and Erin Kang in Autism

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Rachel G. McDonald

Erin Kang

Supplemental material

Supplemental material for this article is available online.

Notes

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