Anxiety is an area of documented challenge for people with Autism Spectrum Disorder (ASD). Despite this, some studies state that those with ASD and language deficits have lower reported anxiety than those without language deficits. This effect may be due to the complicated task of appropriately evaluating anxiety in those with compromised language. Using biomarkers of anxiety, such as reduced Heart Rate Variability (HRV) and increased Heart Rate (HR), may improve anxiety assessment but more research is necessary. Specifically, it would be helpful to understand if the relationship between HRV/HR and anxiety is moderated by language abilities in children with ASD, and whether HRV/HR can discriminate between anxiety and other emotions, like anger, in children with ASD. This study examined the relationship between baseline HRV/HR, language ability, and different emotional states (i.e., anxiety and anger) in a sample of 23 children with ASD. It was hypothesized that receptive language would moderate the relationship between decreased HRV/increased HR and increased anxiety but not the relationship between decreased HRV/increased HR and increased anger. Multiple regression analyses indicated that HRV and HR were not significant predictors of anxiety or anger, and language was not a significant moderator. Future studies may wish to take new approaches to determining the role of language in the relationship between HRV/HR and anxiety. / Master of Science / Anxiety is an area of documented challenge for people with Autism Spectrum Disorder (ASD). Despite this, some studies state that those with ASD and language deficits have lower reported anxiety than those without language deficits. This effect may be due to the complicated task of appropriately evaluating anxiety in those with compromised language. Using biomarkers of anxiety, such as reduced Heart Rate Variability (HRV) and increased Heart Rate (HR), may improve anxiety assessment but more research is necessary. Specifically, it would be helpful to understand if the relationship between HRV/HR and anxiety is moderated by language abilities in children with ASD, and whether HRV/HR can discriminate between anxiety and other emotions, like anger, in children with ASD. This study examined the relationship between baseline HRV/HR, language ability, and different emotional states (i.e., anxiety and anger) in a sample of 23 children with ASD. It was hypothesized that receptive language would moderate the relationship between decreased HRV/increased HR and increased anxiety but not the relationship between decreased HRV/increased HR and increased anger. Multiple regression analyses indicated that HRV and HR were not significant predictors of anxiety or anger, and language was not a significant moderator. Future studies may wish to take new approaches to determining the role of language in the relationship between HRV/HR and anxiety.

Emerging research suggests that many adults with Autism Spectrum Disorder (ASD) experience impairing Social Anxiety Disorder (SAD) or social anxiety symptoms (e.g., Joshi et al., 2013; Kleinhans et al., 2010), yet there is little guidance or agreement about how to best assess social anxiety in this population. Direct examination of overt eye gaze patterns may help determine if the attentional biases often reported in people with SAD also operate in those with ASD and co-occurring social anxiety. This study sought to assess the influence of social anxiety on gaze patterns in adults with ASD. An exploratory aim was to better understand the phenomenology of SAD within ASD. Three groups of participants were included: adults with ASD (n = 25), adults with SAD (n = 25), and adults without ASD or SAD (n = 25). As hypothesized, a large subset (n = 11; 44%) of the participants with ASD met diagnostic criteria for SAD. Contrary to study hypotheses related to gaze patterns, however, there was no evidence for gaze vigilance followed by avoidance for socially threatening stimuli in either the ASD or SAD groups, and there was no relationship between fear of negative evaluation and gaze duration toward socially threatening stimuli within the ASD group. Possible reasons for these null findings are considered. Clinical implications and suggestions for future research are also discussed. / Ph. D.

Although clinically significant symptoms of anxiety or depression are present in nearly one in two people with autism spectrum disorder (ASD), little is known about how these symptoms may relate to social motivation, a key construct in the etiology of ASD. The aim of the current study was to examine patterns of anxiety, depression, ASD symptomatology, and social motivation in youth with ASD. Using a large public dataset of well-characterized youth with ASD (N = 195), we examined varying patterns of these symptoms via latent profile analysis (LPA). Three distinct classes emerged: one with moderate ASD severity and low levels of comorbid psychopathology, a second with more severe ASD symptoms and similarly low anxiety and depression, and a third with significantly elevated anxiety and depression. Neither sex nor age differed significantly among these classes, and indices of social interest early in development did not predict class membership. Implications of these symptom patterns for assessment and treatment of comorbidity in ASD are discussed. / Doctor of Philosophy / A large proportion of individuals with autism spectrum disorder (ASD) experience symptoms of anxiety and depression. Anxiety and depression might be related to social motivation, which is a key concept associated with the development of ASD. The current study examined variation in anxiety, depression, social motivation, and ASD symptom severity in a large sample of youth with ASD. Individuals in the sample were classified in groups by a statistical model. Models produced three separate groups: one group with moderate symptoms of ASD and relatively low levels of anxiety and depression, a second with more severe ASD symptoms and similarly low anxiety and depression, and a final group with moderate ASD symptoms and high anxiety and depression. Social motivation was strongest in the first and second groups, and low social motivation was strongly associated with anxiety and depression symptoms. Age and sex did not predict group membership, nor did items measuring social motivation early in development. Implications of these symptom patterns for the assessment and treatment of anxiety and depression in ASD are discussed.

Prior studies have identified diminished attending to faces, and in particular the eye region, in individuals with Autism Spectrum Disorder (ASD), which may contribute to the impairments they experience with emotion recognition and expression. The current study evaluated the acceptability, feasibility, and preliminary effectiveness of an attention modification intervention designed to attenuate deficits in facial emotion recognition and expression in children with ASD. During the 10-session experimental treatment, children watched videos of people expressing different emotions with the facial features highlighted to guide children's attention. Eight children with ASD completed the treatment, of nine who began. On average, the children and their parents rated the treatment to be acceptable and helpful. Although treatment efficacy, in terms of improved facial emotion recognition (FER), was not apparent on task-based measures, children and their parents reported slight improvements and most parents indicated decreased socioemotional problems following treatment. Results of this preliminary trial suggest that further clinical research on visual attention retraining for ASD, within an experimental therapeutic program, may be promising. / PHD / Previous studies have shown that individuals with Autism Spectrum Disorder (ASD) show lower looking at faces, especially the eyes, which may lead to the difficulties they show with ability to recognize other’s emotions and express their own emotions. This study looked at a new treatment designed to decrease the difficulties in emotion recognition and expression in children with ASD. The study looked at whether the treatment is possible, acceptable to children and their parents, and successful in decreasing the difficulty with emotion recognition. During the 10-session treatment, children watched videos of people making different expressions. The faces of the actors in the videos were highlighted to show the children the important area to look at. Eight children with ASD completed the treatment, of nine who started the treatment. On average, the children and their parents said that the treatment is acceptable and helpful. While the treatment was not successful in improving ability to recognize emotions on other’s faces on several tasks, children and their parents reported slight improvements. In addition, most parents reported less problems with social skills and emotion recognition and expression after the treatment. These results suggest that more clinical research may be needed to evaluate usefulness of such attention retraining for children with ASD.

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder that presents many challenges for parents and service providers. Unfortunately, there are limited examples of parent-mediated interventions for parents of children with ASD that can help manage behavioral problems, especially those that can be implemented in both urban and rural communities. COMPASS for Hope (C-HOPE) is an 8-week parent-mediated intervention that enhances parent knowledge, behavior management skills, and supportive strategies. Telehealth-based interventions can be especially effective for rural communities due to its ability to address common barriers of geographic location and lack of resources. When implementing this intervention, the ability to decrease child problem behaviors as well as increase parental activation, self-management, perceived competence, and knowledge are essential to determine the efficacy of this treatment. The purpose of the current study is to evaluate these outcomes in the implementation of C-HOPE via telehealth in rural versus urban communities. 20 parents with children from 3-12 years of age with a diagnosis of ASD were sampled from two rural sites and two urban sites in Kentucky. Few differences were noted between the participants in the rural versus urban group at pre-treatment. Following C-HOPE, in the urban area, there were significant treatment effects in parent knowledge outcomes. In the rural areas, a significant effect was found in change of parent self-management skills of toileting issues. Future directions for telehealth treatments for this population are discussed. / M.S. / ASD is a developmental disorder that presents many challenges for parents and providers. Unfortunately, there are limited behavioral treatment options for parents of children with ASD, especially those that can be utilized in both urban and rural communities. COMPASS for Hope (C-HOPE) is a parent intervention that improves parent knowledge, management, and supportive strategies. Technology-based interventions can be especially effective for rural communities due to its ability to address barriers of geographic location and lack of resources. In this intervention, the ability to decrease child problem behaviors as well as increase parental activation, self-management, competence, and knowledge are essential for this treatment to be effective. The current study evaluates these outcomes in C-HOPE using technology in rural versus urban communities. 20 parents with children with ASD, ranging from 3-12 years of age, were sampled from rural and urban areas in Kentucky. Few differences were noted between the participants in the rural versus urban group before treatment. After treatment, in the urban area, there were significant effects in parent knowledge outcomes. In the rural areas, a significant effect was found in change of parent self-management skills. Future directions for technology treatments for this population are discussed.

Self-injurious behavior (SIB) is one of the most dangerous behavioral responses among individuals with autism spectrum disorder (ASD), often leading to injury and hospitalization. There is an ongoing need to measure the triggers of SIB to inform management and prevention. These triggers are determined traditionally through clinical observations of the child with SIB, often involving a functional assessment (FA), which is methodologically documenting responses to stimuli (e.g., environmental or social) and recording episodes of SIB. While FA has been a "gold standard" for many years, it is costly, tedious, and often artificial (e.g., in controlled environments). If performed in a naturalistic environment, such as the school or home, caregivers are responsible for tracking behaviors. FA in naturalistic environments relies on caregiver and patient compliance, such as responding to prompts or recalling past events. Recent technological developments paired with classification methods may help decrease the required tracking efforts and support management plans. However, the needs of caregivers and individuals with ASD and SIB should be considered before integrating technology into daily routines, particularly to encourage technology acceptance and adoption. To address this, the perspectives of SIB management and technology were first collected to support future technology design considerations (Chapter 2). Accelerometers were then selected as a specific technology, based on caregiver preferences and reported preferences of individuals with ASD, and were used to collect movement data for classification (Chapter 3). Machine learning algorithms with featureless data were explored, resulting in individual-level models that demonstrated high accuracy (up to 99%) in detecting and classifying SIB. Group-level classifiers could provide more generalizable models for efficient SIB monitoring, though the highly variable nature of both ASD and SIB can preclude accurate detection. A multi-level regression model (MLR) was implemented to consider such individual variability (Chapter 4). Both linear and nonlinear measures of motor variability were assessed as potential predictors in the model. Diverse classification methods were used (as in Chapter 3), and MLR outperformed other group level classifiers (accuracy ~75%). Findings from this research provide groundwork for a future smart SIB monitoring system. There are clear implications for such monitoring methods in prevention and treatment, though additional research is required to expand the developed models. Such models can contribute to the goal of alerting caregivers and children before SIB occurs, and teaching children to perform another behavior when alerted. / Doctor of Philosophy / Autism spectrum disorder (ASD) is a prevalent developmental disorder that adversely affects communication, social skills, and behavioral responses. Roughly half of individuals diagnosed with ASD show self-injurious behavior (SIB), including self-hitting or head banging), which can lead to injury and hospitalization. Clinicians or trained caregivers traditionally observe and record events before/after SIB to determine possible causes (“triggers”) of this behavior. Clinicians can then develop management plans to redirect, replace, or extinguish SIB at the first sign of a known trigger. Tracking SIB in this way, though, requires substantial experience, time, and effort from caregivers. Observations may suffer from subjectivity and inconsistency if tracked across caregivers, or may not generalize to different contexts if SIB is only tracked in the home or school. Recent technological innovations, though, could objectively and continuously monitor SIB to address the described limitations of traditional tracking methods. Yet, “smart” SIB tracking will not be adopted into management plans unless first accepted by potential users. Before a monitoring system is developed, caregiver needs related to SIB, management, and technology should be evaluated. Thus, as an initial step towards developing an accepted SIB monitoring system, caregiver perspectives of SIB management and technology were collected here to support future technology design considerations (Chapter 2). Sensors capable of collecting the acceleration of movement (accelerometers) were then selected as a specific technology, based on the reported preferences of caregivers and individuals with ASD, and were used to capture SIB movements from individuals with ASD (Chapter 3). These movements were automatically classified as “SIB” or “non-SIB” events using machine learning algorithms. When separately applying these methods to each individual, up to 99% accuracy in detecting and classifying SIB was achieved. Classifiers that predict SIB for diverse individuals could provide more generalizable and efficient methods for SIB monitoring. ASD and SIB presentations, however, range across individuals, which impose challenges for SIB detection. A multi-level regression model (MLR) was implemented to consider individual differences, such as those that may occur from diagnosis or behavior (Chapter 4). Model inputs included measures capturing changes of movement over time, and these were found to enhance SIB identification. Diverse classification models were also developed (as in Chapter 3), though MLR outperformed these (yielding accuracy of ~75%). Findings from this research provide groundwork for a smart SIB monitoring system. There are clear implications for monitoring methods in prevention, though additional research is required to expand the developed models. Such models can contribute to the goal of alerting caregivers and children before SIB occurs, and teaching children to perform another behavior when alerted.

Since the start of the COVID-19 pandemic, tele-based methods of autism assessment have been relied upon to a previously unparalleled degree; however, the need for such advancements is not new. Observation-based measures are a crucial component of face-to-face autism diagnostic evaluations, but few validated observation tools exist for remotely assessing autism across childhood, particularly for older children and adolescents, providing minimal guidance in this arena. Sanchez and Constantino (2020) previously validated a brief, face-to-face, clinician-facilitated observation coded according to the Childhood Autism Rating Scale, Second Edition (CARS-2). During the pandemic, this measure was adapted as a remote observation (rCARS2 Observation), but has yet to be validated in this format. The current study validated the rCARS2 Observation against the "gold-standard," in-person Autism Diagnostic Observation Schedule, Second Edition (ADOS-2). In this sample of 30 children ages 1.97 to 16.66 years (M = 7.35, SD = 4.00), ADOS-2 and rCARS2 Observation total scores were highly correlated (ρ = .644, p < .001). Receiver operating characteristic (ROC) curves optimized rCARS2 Observation cutoff scores to maximize sensitivity and specificity in predicting possible diagnostic classification (88.9% sensitivity, 80% specificity) and ADOS-2 classification (83.3% sensitivity, 70.6%, specificity). At optimal cutoffs, the rCARS2 Observation predicted the correct diagnosis in 82.8% of cases and the same classification as the ADOS-2 in 75.9% of cases. Validation of this instrument provides support for an accessible and efficient remote autism observation. This is crucial in ensuring uniform training and clinical procedures for tele-assessment of autism, to help mitigate long-standing barriers to service access (e.g., geography, cost, availability). / Doctor of Philosophy / During the COVID-19 pandemic, many in-person services, including assessments for an autism diagnosis, were forced to shift to telehealth. When an autism assessment is completed in-person, it requires an "observation-based" measure, meaning that a clinician directly observes a child's behavior, in addition to an interview with a parent or caregiver. Families have faced barriers to accessing in-person autism assessments even prior to the pandemic, including geography, transportation difficulties, shortage of autism-specific providers, and high cost of services. As such, tele-assessment of autism is an important tool to consider in helping families to access these services. However, observation-based autism assessment measures that can be completed through telehealth from families' homes are few and not well-understood. The current study explores a brief telehealth observation tool (the rCARS2 Observation) and compares it to the "gold-standard" autism observation-based tool (the ADOS-2) that is typically used during in-person assessments of autism. This study found that scores on this remote measure and the in-person measure were strongly related and the remote observation measure showed great promise for predicting a diagnosis of autism in this study. This is the first study to explore the rCARS2 Observation to understand how well it can evaluate children's autism characteristics from home as compared with an in-person assessment tool. The success of this remote observation measure in the current study is promising and suggests that this may be one remote tool that clinicians can use in combination with a parent- or caregiver-interview to evaluate a child for an autism diagnosis as a shorter and more accessible tool to overcome many barriers to accessing services.

Learning to drive represents a rite of passage for many adolescents and young adults, which increases their access to vocational, education, and social opportunities (Almberg et al., 2015; Cox et al., 2012; Lindsay, 2016). When examining licensure rates for individuals with developmental disabilities and/or Autism Spectrum Disorder, research demonstrates lower licensure rates and more difficulties obtaining licensure (Almberg et al., 2015; Cox et al., 2012). Most research focusses on teaching on the road or simulation based driving skills to increase licensure rates, however little research addresses the barriers these individuals face obtaining their drivers permit (Huang et al., 2012; Pandolfe, 2015; Smigiel, 2020; Vindin et al., 2021); . The current research study sought to fill in gaps in the literature by investigating the effects of a traditional academic intervention, Incremental Rehearsal’s, effects on increasing participants knowledge of the drivers manual used for the driver’s permit exam. Results demonstrated positive increases in correct responding for one participant, however inconsistent results for the other two participants. Varying results may be partially due to differing participant characteristics, which could be important for future research considerations.

The ‘Structured Days Hypothesis’ suggests during less-structured periods, such as summer months or weekend days, children’s physical activity (PA) is lower and thus, may be detrimental to health. Exploring this hypothesis in children with autism spectrum disorder (ASD) is important, given they are less active and tend to prefer structure and routine compared to neurotypical peers. Weekend days are similar to summer days since both have reduced structure in comparison to the consistent weekday routine. The purpose of this review was to examine differences in PA levels of children with ASD during weekend days versus weekdays. Three databases (PubMed, APA PsycInfo, and ERIC) found 604 studies for screening. Seven studies met inclusion criteria (e.g., children 5-13 years, ASD diagnosis, weekend day and weekday PA outcomes). Three of the seven studies reported PA was greater on weekdays, two reported that PA was greater on weekend days, and two reported no differences. Findings provide researchers with insight into potential differences in PA of children with ASD during weekdays versus weekend days. Further studies are needed that purposefully measure PA during different environments to help inform PA interventions targeting children with ASD.

Title: Specifics of motor development in children with autism spectrum disorder Objectives: The aim of this thesis is to summarize the accessible literary sources about possibilities of early diagnostic of autism spectrum disorders, characteristic features of motor development and presence of movement and other abnormalities during early development in children who were later diagnosed with some disorder of autism spectrum. Methods: The study is divided into two main parts. In the first part, general information about autism spectrum disorders is presented. The ethiopatogenesis, characteristic features and different types of autism spectrum disorders are described. The second, descriptively analitical part, contains a brief description and resume of many studies, which deal with early identification of autism spectrum disorder, with examination of features of autism spectrum disorder in early development and motor abnormalities in individuals with autism spectrum disorder or high risk infants. Results: The results of this study indicate, that there are differences in social behaviour, motor development and specific autistic features already in the early development of children later diagnosed with autism spectrum disorder. Among motor abnormalities in early development in this children there are...