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The Role of Intellectual Disability and Emotional Regulation in the Autism-Depression Relationship

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Title: The Role of Intellectual Disability and Emotional Regulation in the Autism-Depression Relationship
Language: English
Authors: Sáez-Suanes, Gema P. (ORCID 0000-0003-3154-1101), García-Villamisar, Domingo, Del Pozo Armentia, Araceli
Source: Autism: The International Journal of Research and Practice. Oct 2023 27(7):1960-1967.
Availability: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
Peer Reviewed: Y
Page Count: 8
Publication Date: 2023
Document Type: Journal Articles
Reports - Research
Descriptors: Emotional Response, Self Control, Autism Spectrum Disorders, Depression (Psychology), Adults, Comorbidity, Anxiety, Foreign Countries, Intellectual Disability
Geographic Terms: Spain (Madrid), Spain
Assessment and Survey Identifiers: Leiter International Performance Scale
DOI: 10.1177/13623613231161881
ISSN: 1362-3613
1461-7005
Abstract: Research shows significant rates of depressive symptoms in people with autistic spectrum disorder and intellectual disabilities. Finding factors related to the development of depression in autism spectrum disorder and intellectual disability is necessary. Emotion regulation is associated with depression in autism spectrum disorder and intellectual disability. The role of the intellectual disability in this relationship is not clear, so it is necessary to clarify it. One hundred twenty-one adults (M = 35.46 years, SD = 9.46) with autism spectrum disorder and intellectual disabilities were evaluated to verify moderating role of intellectual disability and mediating role of emotion regulation. A moderated mediation analysis supported the moderated role of mild intellectual disability in the relationship mediated by emotional dysregulation between autism spectrum disorder and depression symptoms. These findings suggest that interventions designed to prevent or reduce depressive symptoms in people with autism spectrum disorder and mild intellectual disability should include among their goals emotional regulation.
Abstractor: As Provided
Entry Date: 2023
Accession Number: EJ1392838
Database: ERIC
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  Value: <anid>AN0171988786;f9d01oct.23;2023Sep20.03:57;v2.2.500</anid> <title id="AN0171988786-1">The role of intellectual disability and emotional regulation in the autism–depression relationship </title> <p>Research shows significant rates of depressive symptoms in people with autistic spectrum disorder and intellectual disabilities. Finding factors related to the development of depression in autism spectrum disorder and intellectual disability is necessary. Emotion regulation is associated with depression in autism spectrum disorder and intellectual disability. The role of the intellectual disability in this relationship is not clear, so it is necessary to clarify it. One hundred twenty-one adults (M = 35.46 years, SD = 9.46) with autism spectrum disorder and intellectual disabilities were evaluated to verify moderating role of intellectual disability and mediating role of emotion regulation. A moderated mediation analysis supported the moderated role of mild intellectual disability in the relationship mediated by emotional dysregulation between autism spectrum disorder and depression symptoms. These findings suggest that interventions designed to prevent or reduce depressive symptoms in people with autism spectrum disorder and mild intellectual disability should include among their goals emotional regulation. Many people with autism and intellectual disability have significant levels of depressive symptoms. However, this relationship is not clear. For this reason, knowing the factors that are associated with having depression in autism and intellectual disability is important. Emotion regulation is associated with depression in autism spectrum disorder and intellectual disability. After evaluating a group of people with autism and intellectual disability, we found that people with mild intellectual disability have problems regulating their emotions which lead them to develop depressive symptoms. These findings suggest that interventions designed to prevent or reduce depressive symptoms in people with autism spectrum disorder and mild intellectual disability should include among their goals emotional regulation.</p> <p>Keywords: anxiety; autism spectrum disorders; depression; emotional dysregulation; gender; intellectual disability; transdiagnostic model</p> <hd id="AN0171988786-2">Introduction</hd> <p>Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by social-communication difficulties and restricted and repetitive behaviors, interests, and sensory differences (<emph>Diagnostic and Statistical Manual of Mental Disorders</emph> (5th ed.; DSM-5; [<reflink idref="bib3" id="ref1">3</reflink>])). ASD is an increasingly prevalent disorder that affects the life cycle of the individual ([<reflink idref="bib24" id="ref2">24</reflink>]). In the last few years, the diagnosis of ASD has been associated with significant internalized symptoms across the life span ([<reflink idref="bib12" id="ref3">12</reflink>]). Research shows that depressive symptomatology is one of the most common psychopathologies in this population ([<reflink idref="bib5" id="ref4">5</reflink>]; [<reflink idref="bib8" id="ref5">8</reflink>]; [<reflink idref="bib10" id="ref6">10</reflink>]).</p> <p>Likewise, internalized symptoms such as depressive disorders appear more frequently in people with intellectual disability (ID) ([<reflink idref="bib33" id="ref7">33</reflink>]). Depression symptoms are more common in people with developmental disorders than in the general population ([<reflink idref="bib10" id="ref8">10</reflink>]). A significant number of people with ASD also have ID ([<reflink idref="bib11" id="ref9">11</reflink>]; [<reflink idref="bib38" id="ref10">38</reflink>]), leaving this group doubly vulnerable. Despite this, most of the research on comorbidity has been conducted on people with ASD without ID ([<reflink idref="bib38" id="ref11">38</reflink>]).</p> <p>This may be because the study and diagnosis of depressive symptoms in people with ID, with severe cognitive and communicative impairments, can be complex ([<reflink idref="bib21" id="ref12">21</reflink>]; [<reflink idref="bib50" id="ref13">50</reflink>]). Given this difficulty, the role of ID in internalizing symptoms is unclear in the literature. On one hand, we found a group of researchers who propose that people who experience higher levels of depressive symptomatology have mild ID ([<reflink idref="bib22" id="ref14">22</reflink>]). On the other hand, another group of authors think that people with severe ID are more prone to the development of depressive symptoms ([<reflink idref="bib32" id="ref15">32</reflink>]). Also, we found authors who believe that people with mild ID have symptoms more similar to those presented by the general population, while people with severe ID show less cognitive and more behavioral symptoms ([<reflink idref="bib21" id="ref16">21</reflink>]; [<reflink idref="bib44" id="ref17">44</reflink>]; [<reflink idref="bib50" id="ref18">50</reflink>]).</p> <p>Despite the controversy, some factors associated with depressive symptoms in ASD and ID have been identified. Among them are difficulties in emotional regulation (ER). ER is an ability to adjust the experience and expression of emotions in a way that is socially acceptable and in line with individual goals ([<reflink idref="bib23" id="ref19">23</reflink>]). The literature supports that both people with ID and people with ASD make greater use of maladaptive ER strategies ([<reflink idref="bib34" id="ref20">34</reflink>]). We found more use of avoidance and less use of strategies such as cognitive reappraisal in the ID population ([<reflink idref="bib31" id="ref21">31</reflink>]). In addition, emotion dysregulation is significantly elevated in autism ([<reflink idref="bib12" id="ref22">12</reflink>]). The most common ER strategies used by people with ASD are avoidance, victimization ([<reflink idref="bib9" id="ref23">9</reflink>]; [<reflink idref="bib42" id="ref24">42</reflink>]), and rumination ([<reflink idref="bib43" id="ref25">43</reflink>]). Several studies have proposed that depression is the result of problems people have with regulating emotions (e.g. [<reflink idref="bib2" id="ref26">2</reflink>]; [<reflink idref="bib7" id="ref27">7</reflink>]). People with ASD and ID have, therefore, serious problems in regulating their emotions and this may lead to a greater presence of internalized symptoms. The role that ID may play in emotion regulation is interesting, given that research proposes that those with more intellectual deficits have more trouble using ER strategies given their cognitive complexity ([<reflink idref="bib31" id="ref28">31</reflink>]; [<reflink idref="bib35" id="ref29">35</reflink>]).</p> <p>Considering this evidence suggests that there is value in examining the association of emotion regulation for adults with ASD and ID, a group who have been the focus of limited research to date. It is also useful to know the role of ID in the relationship between autism and depressive symptoms, especially in those with ID, as ER strategies are often primarily cognitive. Therefore, it would be interesting to know the role of intellectual capacity in ER and its effect on the development of internalized symptoms.</p> <p>It is still necessary to carry out research that goes beyond the work already done, mainly focused on infantile-juvenile populations and people without ID. Its study is key to promoting prevention, diagnosis, and a better understanding of this group of symptoms in the adult population with autism and ID.</p> <p>Therefore, the general objective of this study is to know the role of ID in the relationship between ASD, internalized symptoms and emotional dysregulation. Specifically, the following hypotheses are addressed:</p> <p></p> <ulist> <item> <emph>Hypothesis 1.</emph> Emotional dysregulation is positively and significantly associated with depression symptoms in adults with ASD and ID.</item> <p></p> <item> <emph>Hypothesis 2.</emph> Emotional dysregulation plays a significant mediating role between ASD severity and depressive symptoms in adults with ASD and ID.</item> <p></p> <item> <emph>Hypothesis 3.</emph> ID plays a significant moderated role in the ASD–depression relationship mediated by emotional dysregulation for adults with ASD and ID.</item> </ulist> <hd id="AN0171988786-3">Method</hd> <p></p> <hd id="AN0171988786-4">Participants</hd> <p>One hundred twenty-one adults aged between 18 and 62 years of age (M = 35.46; SD = 9.46) with ASD and ID participated in this study (Table 1). Participants were recruited from healthcare facilities in the communities of Madrid and Galicia, Spain. Primary inclusion criteria for the participants were being over 18 years old and having a diagnosis of ASD and ID. The people included in this study had a diagnosis of ASD and ID. The diagnosis of ASD was confirmed with the Diagnostic Behavioral Assessment for Autism Spectrum Disorder–Revised (DiBAS-R; [<reflink idref="bib46" id="ref30">46</reflink>]). DiBAS-R is an ASD assessment measure based on the DSM-5. Likewise, the diagnosis of ID was confirmed by the [<reflink idref="bib30" id="ref31">30</reflink>]. Severity levels were defined according to those established in the DSM-5 for intellectual developmental disorder or ID. All participants exceeded the DiBAS-R cut-off point. Informed consent was provided by all participants' guardians.</p> <p>Graph</p> <p>Table 1. Demographic and clinical characteristics of the sample.</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left" rowspan="2">Variables</th><th align="left" colspan="3">SampleN = 121</th></tr><tr><th align="left">M</th><th align="left">SD</th><th align="left">n (%)</th></tr></thead><tbody><tr><td>Chronological age</td><td>35.460</td><td>9.467</td><td /></tr><tr><td colspan="4">Gender</td></tr><tr><td> Males</td><td /><td /><td>81 (66.9%)</td></tr><tr><td> Females</td><td /><td /><td>40 (33.1%)</td></tr><tr><td colspan="4">ID level</td></tr><tr><td> Mild ID</td><td /><td /><td>19 (15.70%)</td></tr><tr><td> Moderate ID</td><td /><td /><td>38 (31.4%)</td></tr><tr><td> Severe ID</td><td /><td /><td>29 (24%)</td></tr><tr><td> Profound ID</td><td /><td /><td>25 (20.7%)</td></tr><tr><td> ID not specified</td><td /><td /><td>10 (8.3%)</td></tr></tbody></table> </ephtml> </p> <p>1 ID: intellectual disability.</p> <p>According to Table 1, 15.70% (n = 19) of the sample had mild ID, 31.4% (n = 38) had moderate ID, 24% had severe ID (n = 29), 20.70% (n = 25) had profound ID, and the remaining 8.3% (n = 10) had unspecified ID.</p> <hd id="AN0171988786-5">Procedure</hd> <p>Participants were recruited from specialized residential healthcare facilities for people with ASD. The questionnaires of this research were completed by proxy therapists who were not included as researchers in the project. They are psychologists or educators and were not included as researchers in the project. For several years, these therapists have been working with the people being evaluated and are their tutors within the center. The project was approved by the ethics committee at the Unit of Psychopathology and Clinic Psychology.</p> <hd id="AN0171988786-6">Measures</hd> <p></p> <hd id="AN0171988786-7">DiBAS-R</hd> <p>The DiBAS-R is a 20-item other-report screening scale of ASD traits for adults with ID. Items are distributed in two subscales based on the two symptomatic ASD domains of DSM-5 ([<reflink idref="bib3" id="ref32">3</reflink>]; [<reflink idref="bib46" id="ref33">46</reflink>]). The <emph>Communication and Social Interaction</emph> scale has 12 items, and the <emph>Stereotypies, Rigidity, and Sensory Abnormalities</emph> scale comprises seven items ([<reflink idref="bib46" id="ref34">46</reflink>]). Internal consistency of the total scale is high (0.91). For the communication and interaction subscale, it is 0.91, and for the repetitive behavior scale, it is 0.84 ([<reflink idref="bib46" id="ref35">46</reflink>]).</p> <hd id="AN0171988786-8">Leiter International Performance Scale</hd> <p>The purpose of the Leiter intelligence scale is to assess the non-verbal intellectual level of the person being evaluated. Its application does not require the use of language ([<reflink idref="bib30" id="ref36">30</reflink>]; [<reflink idref="bib49" id="ref37">49</reflink>]).</p> <p>The test is composed of 54 subtests distributed in three blocks with four elements per level. These six types of cognitive functioning are evaluated: concrete thinking, quantitative and progressive discrimination, symbolic transformation, spatial ability, matching, and immediate memory ([<reflink idref="bib49" id="ref38">49</reflink>]). The test has been shown to have high psychometric properties with satisfactory internal consistency and a reliability of 0.91 ([<reflink idref="bib27" id="ref39">27</reflink>]).</p> <hd id="AN0171988786-9">Glasgow Depression Scale for people with a Learning Disability–carer supplement version</hd> <p>The caregiver version of the Glasgow Depression Scale for people with a Learning Disability (GDS-LD) has 16 items that a person who has a close relationship with the person completes ([<reflink idref="bib14" id="ref40">14</reflink>]). The GDS-LD is an instrument used for evaluating behaviors related to depression in people with ID; however, some studies (e.g. [<reflink idref="bib18" id="ref41">18</reflink>]) successfully used this measure to assess adults with ASD and ID. Test–retest reliability of the caregiver version is very high (r = 0.98) as well as the convergent validity between the self-report and other-report versions (0.93). Internal consistency is 0.88. The convergent validity of this scale was evaluated with the Beck Depression Inventory II, with a correlation of 0.88. The sensitivity and specificity values of the version used in this research reached 96% for sensitivity and 90% for specificity ([<reflink idref="bib14" id="ref42">14</reflink>]).</p> <hd id="AN0171988786-10">Emotional Regulation Checklist</hd> <p>The Emotional Regulation Checklist (ERC) is an other-report 24-item instrument used to assess ER ([<reflink idref="bib47" id="ref43">47</reflink>]). The items are rated on a 4-point Likert-type scale assessing frequency of behaviors. The scale is divided into two subscales: emotion regulation and lability/negativity. Emotion regulation (eight items) assesses the ability to modulate the emotional excitement that favors the person's adaptation to the environment, emotional self-awareness, demonstrations of affection, and other adaptive traits such as empathy. The lability/negativity (15 items) assesses mood instability, emotional inflexibility, emotional dysregulation, negative affection, emotional reactivity, and anger regulation. A high score on the first subscale assumes management of adaptive ER skills; high scores on the second subscale indicate the use of non-adaptive ER strategies ([<reflink idref="bib29" id="ref44">29</reflink>]). Internal consistency is good for the lability/negativity scale (α = 0.90) and somewhat lower for the ER scale (α = 0.79) ([<reflink idref="bib36" id="ref45">36</reflink>]).</p> <hd id="AN0171988786-11">Statistical analysis</hd> <p>All analyses were completed using SPSS, version 22 ([<reflink idref="bib28" id="ref46">28</reflink>]). Descriptive statistics of the demographic and psychological variables were indicated with mean, SD, number (N), and percentage (%) as appropriate. Pearson's correlation was used to examine correlations among ASD symptoms, depressive symptoms, and emotional dysregulation.</p> <p>Subsequently, this moderated mediation or conditional process analysis (Hayes' model 14) was performed with the PROCESS macro in SPSS (version 3. 2; [<reflink idref="bib25" id="ref47">25</reflink>]) to test the role of emotional dysregulation (M2) as a mediator and ID (W) as a moderator in the autistic symptomatology (X)—depressive symptomatology (Y) relationship. This analysis is based on regression and path analysis. Mediation calculates the indirect effect and bootstrapping confidence intervals. An indirect effect is considered significant when the confidence interval range does not include zero ([<reflink idref="bib17" id="ref48">17</reflink>]). The variables introduced as moderators are those demographic variables of a categorical nature, given the statistical needs of the analysis. In this case, the variable that meets these characteristics is the ID, divided into five levels of severity: mild, moderate, severe, profound, and not specified. This analysis was performed with 10,000 bootstrapping samples.</p> <hd id="AN0171988786-12">Results</hd> <p></p> <hd id="AN0171988786-13">Pearson correlations</hd> <p>Pearson's bivariate correlations are shown in Table 2. Results revealed that all variables were significantly correlated with each other and were in the expected direction. Specifically, we expected a positive and significant association between dysregulation emotion strategies and depressive symptoms (r = 0.430; p = 0.000).</p> <p>Graph</p> <p>Table 2. Pearson R correlations between autistic symptomatology, depressive symptoms, and emotional dysregulation.</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th /><th align="left">DiBAS-R</th><th align="left">ED</th><th align="left">M</th><th align="left">SD</th></tr></thead><tbody><tr><td>DEP</td><td>0.302<xref ref-type="table-fn" rid="tfn3">**</xref></td><td>0.430<xref ref-type="table-fn" rid="tfn3">**</xref></td><td>8.626</td><td>3.471</td></tr><tr><td>DiBAS-R</td><td /><td>0.336<xref ref-type="table-fn" rid="tfn3">**</xref></td><td>43.314</td><td>5.885</td></tr><tr><td>ED</td><td /><td /><td>38.264</td><td>8.496</td></tr></tbody></table> </ephtml> </p> <ulist> <item>2 DiBAS-R: Diagnostic Behavioral Assessment for Autism Spectrum Disorder–Revised ([<reflink idref="bib46" id="ref49">46</reflink>]); ED: Emotional Dysregulation subscale of the Emotional Regulation Checklist ([<reflink idref="bib47" id="ref50">47</reflink>]); DEP: Glasgow Depression Scale for people with a Learning Disability–carer supplement ([<reflink idref="bib14" id="ref51">14</reflink>]).</item> <item>3 <emph>p</emph> < 0.01.</item> </ulist> <hd id="AN0171988786-14">Moderate mediation analysis</hd> <p>Model 14 of the PROCESS macro was used to determine whether the moderate mediation effects of emotional dysregulation on ASD severity-depressive symptoms relationship were significant (Table 2).</p> <p>The direct effect of ASD symptomatology on depressive symptomatology was significant (c′ = 0.127, SE = 0.052; p = 0.016) in this model. The mediating role of emotional dysregulation between autism and depression was found to be significant (F(1119) = 15.174; p = 0.000). The direct effect of ID on the mediating variable emotional dysregulation was also significant (b2 = 2.029, SE = 1.056; p = 0.038). Similarly, the interaction effect of the moderating variable (ID) was significant (b3 = −0.057, SE = 0.027; p = 0.03). Consequently, the moderating mediation effect for the emotional dysregulation variable was significant (b1b3 = −0.025, SE = 0.0132; 0.000–0.005). Thus, hypotheses 2 and 3 regarding the relationship mediated and moderated between ASD and depressive symptoms were confirmed.</p> <p>The moderated mediation analysis is shown in Figure 1, and its results are in Table 3.</p> <p>Graph: Figure 1. Graphical representation of the conditional process model of emotion regulation and intellectual disability on autistic and depressive symptomatology.a1: direct effect of ASD symptomatology on ED; b1: direct effect of ED on depressive symptomatology; b3: interaction effect of the ID on the relationship ED and depressive symptomatology; c′: direct effect of ASD symptomatology on depressive symptomatology.* p < 0.050; ** p < 0.010; *** p < 0.001.</p> <p>Graph</p> <p>Table 3. Indirect conditional of ID between depressive symptoms and emotional dysregulation.</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /></colgroup><thead><tr><th align="left">Mild ID</th><th /></tr></thead><tbody><tr><td>Moderate ID</td><td>(0.001 to 0.052)</td></tr><tr><td>Sever ID</td><td>(0.004 to −0.008)</td></tr><tr><td>Profound ID</td><td>(−0.008 to 0.010)</td></tr><tr><td>Unspecified ID</td><td>(−0.103 to 0.230)</td></tr></tbody></table> </ephtml> </p> <p>4 ID: intellectual disability.</p> <p>The differences in each of the levels of the moderator variable in its indirect conditional effects show that this relationship was significant for people with mild ID (0.001–0.052). For the rest of the ID severity levels, the confidence interval was non-zero; therefore, it was not significant. These can be seen in Table 4.</p> <p>Graph</p> <p>Table 4. Conditional process model of emotional dysregulation and ID on autistic and depressive symptomatologies.</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left" rowspan="3">Antecedent</th><th align="left" colspan="8">Constant</th></tr><tr><th /><th align="left" colspan="3">M<sub>1</sub> (emotional dysregulation)</th><th /><th align="left" colspan="3">Y (depressive symptoms)</th></tr><tr><th /><th align="left">Coef.</th><th align="left">SE</th><th align="left">p</th><th /><th align="left">Coef.</th><th align="left">SE</th><th align="left">p</th></tr></thead><tbody><tr><td>X (ASD symptoms)</td><td>a<sub>1</sub></td><td>0.485</td><td>0.124</td><td><0.001</td><td>cʹ</td><td>0.127</td><td>0.052</td><td><0.050</td></tr><tr><td>M (emotional dysregulation)</td><td>—</td><td>—</td><td>—</td><td>—</td><td>b<sub>1</sub></td><td>0.246</td><td>0.080</td><td><0.010</td></tr><tr><td>W (ID)</td><td>—</td><td>—</td><td>—</td><td>—</td><td>b<sub>2</sub></td><td>2.029</td><td>1.056</td><td><0.050</td></tr><tr><td>M × W (Emotional Dysregulation × ID)</td><td>—</td><td>—</td><td>—</td><td>—</td><td>b<sub>3</sub></td><td>−0.057</td><td>0.027</td><td><0.050</td></tr><tr><td>Constant</td><td>i<sub>M1</sub></td><td>17.233</td><td>5.448</td><td><0.010</td><td>i<sub>y</sub></td><td>−6.908</td><td>3.615</td><td><0.050</td></tr><tr><td /><td /><td colspan="3">R2 = 0.116</td><td /><td colspan="3">R2 = 0.185</td></tr><tr><td /><td /><td colspan="3">F(1119) = 15.174, p < 0.001</td><td /><td colspan="3">F(4116) = 6.672, p < 0.000</td></tr></tbody></table> </ephtml> </p> <p>5 Note: iM and iY are intercepts of the regression. ID: intellectual disability; ASD: autism spectrum disorder.</p> <hd id="AN0171988786-15">Discussion and conclusions</hd> <p>The objective of this research was to study depressive symptoms in people with ASD and their relationship with emotion regulation and the role of ID. Our findings support that there is a relationship between the depression of adults with ASD and ID and emotion regulation. This association has been widely supported by research (e.g. [<reflink idref="bib7" id="ref52">7</reflink>]; [<reflink idref="bib10" id="ref53">10</reflink>]; [<reflink idref="bib19" id="ref54">19</reflink>]; [<reflink idref="bib45" id="ref55">45</reflink>]). Literature shows how people with ID and with ASD use more maladaptive ER strategies ([<reflink idref="bib34" id="ref56">34</reflink>]). Moreover, it is common to find work identifying the use of non-adaptive ER strategies as transdiagnostic factors in the development of internalizing-type disorders ([<reflink idref="bib7" id="ref57">7</reflink>]; Charlton et al., 2019). However, the moderating role of ID in the relationship between autism, depression, and emotion regulation had not been studied previously.</p> <p>In our research, emotional dysregulation played a mediating role between ASD and depressive symptoms. Based on these results, the association between both symptomatologies is best explained by the indirect effect exerted by ER strategies. As previously described, several works have pointed to these variables as vulnerability factors to the development and maintenance of depressive symptoms ([<reflink idref="bib20" id="ref58">20</reflink>]; [<reflink idref="bib41" id="ref59">41</reflink>]). Several authors demonstrated that maladaptive ER strategies were a transdiagnostic factor linked to internalized problems and ASD symptoms ([<reflink idref="bib4" id="ref60">4</reflink>]; [<reflink idref="bib39" id="ref61">39</reflink>]). Along these lines, some recent research reports positive results of transdiagnostic ER-based interventions for internalizing symptoms in the ASD population ([<reflink idref="bib13" id="ref62">13</reflink>]; [<reflink idref="bib15" id="ref63">15</reflink>]). These results are interesting, but it should be noted that they mostly come from work done with people with ASD and without ID.</p> <p>This research wanted to know the relationship of ID in emotion regulation and its link with depressive symptoms. Our results supported the moderating role of ID in the mediated relationship between ASD and depression by ER. Specifically, our analyses point to a significant relationship in people with mild ID. In this sense, and according to our results, autistic symptomatology is associated with depressive symptoms through ER problems. This linkage is significant in those individuals with mild ID. This significant relationship does not seem to hold at deeper ID levels. On one hand, we must consider that the disability levels of our participants were very high and many of them lacked language. Therefore, the evaluation of ER was complex ([<reflink idref="bib1" id="ref64">1</reflink>]), which could affect the analysis. It would be interesting to replicate this model in larger samples with the same number of subjects at each level of ID. On the other hand, ER is a process with high cognitive content, and people with profound ID may not have conscious emotion regulation. The expression of depressive symptoms and emotions in people with profound ID is more behavioral ([<reflink idref="bib21" id="ref65">21</reflink>]; [<reflink idref="bib44" id="ref66">44</reflink>]; [<reflink idref="bib50" id="ref67">50</reflink>]). These facts could be affecting the role of ER in the ASD–depression. In any case, these results suggest that it is valuable to develop preventive actions that directly address the regulation of emotions, especially for mild ID people on the spectrum.</p> <p>Studies such as [<reflink idref="bib37" id="ref68">37</reflink>] highlight the atypical expression and qualitative differences of depression in the autistic collective versus people with depression and without ASD. Therefore, they consider it important to study the variables associated with the presentation of depression on the spectrum versus the general population. These similarities or differences may have clinical implications for prevention and intervention. In this regard, in the literature, we found few studies of depressive symptomatology in people with ASD and severe ID. There is more research on ER and ID focused on people with mild deficits ([<reflink idref="bib16" id="ref69">16</reflink>]). Perhaps this is due to the difficulty in assessing this process in people with significant intellect. They report higher levels of depressive symptoms in the population with lower ID.</p> <p>This study expands previous research and provides a potential explanation of depression in the lives of people with ASD and ID; however, these results should be interpreted considering limitations. First, it is difficult to assess depressive symptomatology in ASD due to the lack of instruments, especially for people with ASD who also have ID. We must be careful in the interpretation of these results, especially concerning people with profound ID given the significant limitations in assessing their mental states in them. In addition, the assessment was observational, based on behavior, which could introduce response bias. One might wonder whether the findings would be different if the measures used were of a different type such as clinical observation. However, data resulting from the application of instruments of different nature to assess internalizing symptoms in ASD have reported moderate to strong correlations ([<reflink idref="bib26" id="ref70">26</reflink>]; [<reflink idref="bib48" id="ref71">48</reflink>]). Several studies do rely on observations made by people knowledgeable about those with ASD. Specifically, the studies propose caregivers or therapists for the completion of the questionnaires, because of the knowledge they have of the persons under evaluation ([<reflink idref="bib6" id="ref72">6</reflink>]; [<reflink idref="bib40" id="ref73">40</reflink>]).</p> <p>Second, although the size of the sample is quite large in comparison with other similar studies, the generalization of results should be taken with caution. In addition, the sample used in this study is very specific since they are people who have ASD and ID. Although this limits our ability to generalize findings to all people with ASD and complicates the interpretation of the directionality of identified relationships, studying such a sample is valuable since these individuals are members of an under-researched group. It would be interesting to have a control group of people with ASD and without ID. Thus, we could learn more about the role of intellectual abilities in the presentation of depressive symptoms.</p> <p>As future lines of research, the mediating role of other transdiagnostic variables that the literature has related to the development of depression such as executive dysfunction should be investigated.</p> <p>In conclusion, emotional dysregulation was an important variable for the development of depressive symptoms in people with ASD and mild ID. This suggests the need to work on emotion regulation in people with this profile to avoid the development of depressive symptoms. Therefore, emotional dysregulation should be a potential target of intervention programs in the population with ASD and mild ID.</p> <p>We would like to thank the therapists of the centers for people with autism for their voluntary participation in this research.</p> <ref id="AN0171988786-16"> <title> References </title> <blist> <bibl id="bib1" idref="ref64" type="bt">1</bibl> <bibtext> Adams D., Oliver C. (2011). The expression and assessment of emotions and internal states in individuals with severe or profound intellectual disabilities. Clinical Psychology Review, 31(3), 293–306. https://doi.org/10.1016/j.cpr.2011.01.003</bibtext> </blist> <blist> <bibl id="bib2" idref="ref26" type="bt">2</bibl> <bibtext> Aldao A., Nolen-Hoeksema S., Schweizer S. (2010). Emotion-regulation strategies across psychopathology: A meta-analytic review. 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A systematic review of the rates of depression in children and adults with high-functioning autism spectrum disorder. Journal of Mental Health Research in Intellectual Disabilities, 10(6), 1–21.</bibtext> </blist> </ref> <ref id="AN0171988786-17"> <title> Footnotes </title> <blist> <bibtext> The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.</bibtext> </blist> <blist> <bibtext> The ethics commission of the Psychopathology Teaching Unit of the Complutense University of Madrid, Spain, reviewed and approved this study.</bibtext> </blist> <blist> <bibtext> The author(s) received no financial support for the research, authorship, and/or publication of this article.</bibtext> </blist> <blist> <bibtext> Informed consent was provided by all guardians of the participants.</bibtext> </blist> <blist> <bibtext> Gema P Sáez-Suanes</bibtext> </blist> <blist> <bibtext>Graph https://orcid.org/0000-0003-3154-1101</bibtext> </blist> </ref> <aug> <p>By Gema P Sáez-Suanes; Domingo García-Villamisar and Araceli Del Pozo Armentia</p> <p>Reported by Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib24" firstref="ref2"></nolink> <nolink nlid="nl2" bibid="bib12" firstref="ref3"></nolink> <nolink nlid="nl3" bibid="bib10" firstref="ref6"></nolink> <nolink nlid="nl4" bibid="bib33" firstref="ref7"></nolink> <nolink nlid="nl5" bibid="bib11" firstref="ref9"></nolink> <nolink nlid="nl6" bibid="bib38" firstref="ref10"></nolink> <nolink nlid="nl7" bibid="bib21" firstref="ref12"></nolink> <nolink nlid="nl8" bibid="bib50" firstref="ref13"></nolink> <nolink nlid="nl9" bibid="bib22" firstref="ref14"></nolink> <nolink nlid="nl10" bibid="bib32" firstref="ref15"></nolink> <nolink nlid="nl11" bibid="bib44" firstref="ref17"></nolink> <nolink nlid="nl12" bibid="bib23" firstref="ref19"></nolink> <nolink nlid="nl13" bibid="bib34" firstref="ref20"></nolink> <nolink nlid="nl14" bibid="bib31" firstref="ref21"></nolink> <nolink nlid="nl15" bibid="bib42" firstref="ref24"></nolink> <nolink nlid="nl16" bibid="bib43" firstref="ref25"></nolink> <nolink nlid="nl17" bibid="bib35" firstref="ref29"></nolink> <nolink nlid="nl18" bibid="bib46" firstref="ref30"></nolink> <nolink nlid="nl19" bibid="bib30" firstref="ref31"></nolink> <nolink nlid="nl20" bibid="bib49" firstref="ref37"></nolink> <nolink nlid="nl21" bibid="bib27" firstref="ref39"></nolink> <nolink nlid="nl22" bibid="bib14" firstref="ref40"></nolink> <nolink nlid="nl23" bibid="bib18" firstref="ref41"></nolink> <nolink nlid="nl24" bibid="bib47" firstref="ref43"></nolink> <nolink nlid="nl25" bibid="bib29" firstref="ref44"></nolink> <nolink nlid="nl26" bibid="bib36" firstref="ref45"></nolink> <nolink nlid="nl27" bibid="bib28" firstref="ref46"></nolink> <nolink nlid="nl28" bibid="bib25" firstref="ref47"></nolink> <nolink nlid="nl29" bibid="bib17" firstref="ref48"></nolink> <nolink nlid="nl30" bibid="bib19" firstref="ref54"></nolink> <nolink nlid="nl31" bibid="bib45" firstref="ref55"></nolink> <nolink nlid="nl32" bibid="bib20" firstref="ref58"></nolink> <nolink nlid="nl33" bibid="bib41" firstref="ref59"></nolink> <nolink nlid="nl34" bibid="bib39" firstref="ref61"></nolink> <nolink nlid="nl35" bibid="bib13" firstref="ref62"></nolink> <nolink nlid="nl36" bibid="bib15" firstref="ref63"></nolink> <nolink nlid="nl37" bibid="bib37" firstref="ref68"></nolink> <nolink nlid="nl38" bibid="bib16" firstref="ref69"></nolink> <nolink nlid="nl39" bibid="bib26" firstref="ref70"></nolink> <nolink nlid="nl40" bibid="bib48" firstref="ref71"></nolink> <nolink nlid="nl41" bibid="bib40" firstref="ref73"></nolink>
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  Label: Abstract
  Group: Ab
  Data: Research shows significant rates of depressive symptoms in people with autistic spectrum disorder and intellectual disabilities. Finding factors related to the development of depression in autism spectrum disorder and intellectual disability is necessary. Emotion regulation is associated with depression in autism spectrum disorder and intellectual disability. The role of the intellectual disability in this relationship is not clear, so it is necessary to clarify it. One hundred twenty-one adults (M = 35.46 years, SD = 9.46) with autism spectrum disorder and intellectual disabilities were evaluated to verify moderating role of intellectual disability and mediating role of emotion regulation. A moderated mediation analysis supported the moderated role of mild intellectual disability in the relationship mediated by emotional dysregulation between autism spectrum disorder and depression symptoms. These findings suggest that interventions designed to prevent or reduce depressive symptoms in people with autism spectrum disorder and mild intellectual disability should include among their goals emotional regulation.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2023
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1392838
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1392838
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1177/13623613231161881
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 8
        StartPage: 1960
    Subjects:
      – SubjectFull: Emotional Response
        Type: general
      – SubjectFull: Self Control
        Type: general
      – SubjectFull: Autism Spectrum Disorders
        Type: general
      – SubjectFull: Depression (Psychology)
        Type: general
      – SubjectFull: Adults
        Type: general
      – SubjectFull: Comorbidity
        Type: general
      – SubjectFull: Anxiety
        Type: general
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Intellectual Disability
        Type: general
      – SubjectFull: Spain (Madrid)
        Type: general
      – SubjectFull: Spain
        Type: general
      – SubjectFull: Leiter International Performance Scale
        Type: general
    Titles:
      – TitleFull: The Role of Intellectual Disability and Emotional Regulation in the Autism-Depression Relationship
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Sáez-Suanes, Gema P.
      – PersonEntity:
          Name:
            NameFull: García-Villamisar, Domingo
      – PersonEntity:
          Name:
            NameFull: Del Pozo Armentia, Araceli
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 10
              Type: published
              Y: 2023
          Identifiers:
            – Type: issn-print
              Value: 1362-3613
            – Type: issn-electronic
              Value: 1461-7005
          Numbering:
            – Type: volume
              Value: 27
            – Type: issue
              Value: 7
          Titles:
            – TitleFull: Autism: The International Journal of Research and Practice
              Type: main
ResultId 1