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Background: High unemployment rates are found among autistic adults. Difficulties with social functioning in non-autistic workplaces can be significant barriers to employment success. Autistic social functioning challenges in non-autistic spaces have traditionally been attributed to assumed impairments in Theory of Mind (ToM). Alternatively, the Double Empathy Problem (DEP) posits that autistic social challenges arise not from assumed impairments within the autistic person but instead from mutual misunderstandings in the autistic/non-autistic social interaction. The purpose of this study was to compare the ToM impairments explanation of autistic social functioning with the DEP, within the context of autistic employee social functioning in a non-autistic workplace. Methods: This study compared autistic and non-autistic participants' ability to accurately interpret the behaviors of an autistic employee at work. A sample of 254 participants (173 non-autistic and 81 autistic) read a vignette about a hypothetical autistic employee having difficulty coping in the workplace. Participants answered open-ended questions regarding their interpretation of the employee's behavior and emotional state. Results: A significantly greater proportion of autistic participants (50.7%) accurately interpreted the behavior of the employee compared with non-autistic participants (31.2%) (χ 2 = 8.65, p = 0.003). Autistic participants with the highest behavior interpretation scores had significantly higher mean self-reported autism traits scores (M = 26.8) compared with autistic participants who scored lowest on behavior interpretation (M = 19.3, p < 0.001). The opposite relationship was found for non-autistic participants. Conclusions: Results from this study contribute to evidence supporting the DEP, shifting the paradigm of autistic social functioning away from a deficit model and toward addressing mutual misunderstandings in the autistic/non-autistic social interaction. The pattern of findings between neurotype groups by behavior interpretation abilities on an autism traits measure points to mutual misunderstandings as a clash of neurologically different social cultures. Addressing the DEP in the workplace would contribute to removing barriers to successful employment for autistic adults.

Why is this an important issue? Autistic adults have difficulty finding work and staying employed. One reason for this is problems they report having with social interactions in non-autistic workplaces. Traditionally, autistic people are assumed to have trouble with social skills because they lack the ability to read what is going on in the minds of other people, something non-autistic people are assumed to be able to do. However, there is another theory that says the problem is not that there is something wrong with autistic people, but rather that autistic and non-autistic people do not understand each other due to being socially and neurologically different. Therefore, the problem lies not within the autistic person but in the autistic/non-autistic social interaction. What was the purpose of this study? This study examined the two competing ways of explaining autistic social difficulties in workplaces that are primarily non-autistic: (1) autistic people having trouble with reading the minds of other people versus (2) autistic and non-autistic people being socially different and mutually misunderstanding each other. What did the researchers do? With help from autistic people, we wrote a story about an autistic employee having a difficult day in a non-autistic workplace, which results in negative social interactions and an emotional reaction. We had 81 autistic and 173 non-autistic people read the story and tell us what they think is going on with the person in the story and the reason for the person's behavior. What were the results of the study? Autistic people who read the story were more likely to accurately understand the autistic employee in the story (50.7% accurate), compared with non-autistic people (31.2% accurate). Autistic study participants who were the best at understanding the autistic person in the story on average also reported having more characteristics of autism. What do these findings add to what was already known? This study adds to a growing group of studies that demonstrate that autistic people have strong social rapport and communicate well with each other and also demonstrate that non-autistic people have trouble in understanding autistic people. This study applied these previous findings to autistic social challenges in non-autistic workplaces. It contributes evidence that autistic people are not impaired socially, but rather that their social difficulties in non-autistic workplaces are due to problems within the autistic/non-autistic social interaction. What are potential weaknesses in the study? Because it was an online survey, people in the study could not ask questions about the story. The researchers also could not confirm participant autism diagnosis. The sample did not have enough people of different races and possibly not enough participants who routinely use the internet or social media and therefore may have been excluded from the study. How will these findings help autistic adults now or in the future? This work is important because it contributes to changing the way we think about why autistic people struggle to function socially in a world where the majority of people are non-autistic, including in the workplace. Rather than placing sole responsibility on autistic employees for mutual misunderstandings between autistic and non-autistic persons in the workplace, findings of this study point to shifting workplace environment and culture that understands and values autistic social differences.

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African American youth living in low-resourced communities are at high risk for bullying victimization which is positively associated with suicidal ideation. This study explored whether positive future orientation mediated the relationship between bullying victimization and suicidal ideation. This study engaged 627 African American adolescents and measured bullying victimization, internalizing problems, suicidal ideation, future orientation, and several covariates. Major findings indicated that controlling for gender, socioeconomic status, school motivation, and perceived teacher support, internalizing problems mediated the relationship between bullying victimization and suicidal ideation. Furthermore, both the effect of bullying victimization on suicidal ideation and the mediating effect of internalizing problems were moderated by future orientation. The effects were weakened when the level of future orientation increased. The implications for future research and supporting resiliency are discussed based on these findings.

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The current study explores variations among racially/ethnically diverse adolescents regarding parents' role in mitigating internalizing problems. Adolescents with a higher level of parental awareness, ease of talking to parents, and parental support were less likely to show internalizing problems. Parental awareness was negatively associated with internalizing problems among Whites and Hispanics. The ease of talking to parents was significant for all groups except for American Indians/Alaska Natives. These findings can inform culturally relevant treatments.

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PURPOSE: A few studies have found that children whose families are economically disadvantaged and financially struggling are at an elevated risk of victimization by their peers. However, extant research is largely descriptive. To address this gap, this study empirically tested the proposed pathways from family financial struggle to children's bullying victimization, including the role of barriers to healthcare access in this association using a nationally representative sample. DESIGN AND METHODS: The study utilizes the 2016 National Survey of Children's Health, a survey of a cross-sectional, weighted probability sample of US children (ages 0-17 years) living in 50 states and the District of Columbia, and their caregivers. The sample used for the current study included 14,374 racially and ethnically diverse caregivers of children, aged 6-11 years. RESULTS: Positive significant associations between family financial struggle and children's bullying victimization, and between financial struggle and barriers to healthcare access were found. Barriers to healthcare access mediated the association between family financial struggle and bullying victimization. PRACTICE IMPLICATIONS: Given the documented effects of bullying victimization on children, findings point to the importance of developing psychotherapeutic practices that are appropriate for children who are flagged as "high-risk."

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Technological innovations in cognitive-behavioral therapy (CBT) provide excellent opportunities for mental health clinicians to expand access to mental health treatment among culturally diverse and marginalized populations. This brief report highlights challenges that mental health clinicians encounter as they integrate technological innovations in CBT into their work with diverse clients and provides recommendations for addressing them. The authors identify five key challenges of using technology-driven CBT: development of the therapeutic alliance; potential fit for clients from culturally diverse backgrounds and marginalized groups; geographic and economic access; ethical and legal concerns; and competency in CBT practice, training, and supervision. Technological advances in CBT allow clinicians to treat more individuals from underserved communities. Existing challenges compel clinicians across disciplines to ensure that their practice is congruent with CBT practice values and ethics, policy, and research and that the best available CBT intervention can be integrated into all aspects of mental health practice.

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Purpose: This pilot study assesses the association of Raising Our Spirits Together (ROST), a technology-assisted, group-based cognitive behavioral therapy for depression, with rural adults' depressive symptoms and anxiety. Method: Nine adults from rural Michigan participated in an open pilot of ROST. Clergy facilitated pilot groups. The pilot began in February 2020 in-person. Due to COVID-19, the pilot was completed virtually. Results: Mean depressive symptom scores, based on the PHQ-9, significantly decreased from pre-treatment (M = 14.4) to post-treatment (M = 6.33; t (8) = 6.79; P < .001). Symptom reduction was maintained at 3-month follow-up (M = 8.00), with a significant pattern of difference in depressive symptoms over time (F(2) = 17.7; P < .001; eta-squared = .689). Similar patterns occurred for anxiety based on the GAD-7. Participants attended an average of 7.33 of 8 sessions. Fidelity ratings were excellent. Discussion: ROST is a potentially feasible intervention for rural adults' depressive symptoms. ROST offers a promising model for increasing treatment access and building capacity in rural areas.

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Impairments in family functioning are associated with more severe depressive and manic symptoms, earlier recurrences, and more suicidal behaviors in early-onset bipolar disorder. This study examined whether family-focused treatment for adolescents (FFT-A) with BD I or II disorder led to greater increases in family cohesion and adaptability and decreases in conflict over 2 years compared to a briefer psychoeducational treatment (enhanced care, EC). Participants were 144 adolescents (mean age: 15.6 ± 1.4 years) with BD I or II with a mood episode in the previous 3 months. Adolescents and parents were randomized to either FFT-A (21 sessions) or EC (three sessions). Patients received guideline-based pharmacotherapy throughout the 2-year study. Trajectories of adolescent- and parent-rated family cohesion, adaptability, and conflict were analyzed over 2 years. FFT-A had greater effects on adolescent-rated family cohesion compared to EC over 2 years. Participants in FFT-A and EC reported similar improvements in family conflict across the 2 years. In the FFT-A group, low-conflict families had greater adolescent-rated family cohesion throughout the study compared to high-conflict families. High-conflict families in both treatment groups tended to show larger reductions in conflict over 2 years than low-conflict families. Family psychoeducation and skills training may improve family cohesion in the early stages of BD. Measuring levels of family conflict at the start of treatment may inform treatment responsiveness among those receiving FFT-A.

Los problemas en el funcionamiento familiar están asociados con síntomas depresivos y maníacos más graves, recidivas en periodos más breves y más conductas suicidas en el trastorno bipolar de inicio precoz. Este estudio analizó si el "Tratamiento centrado en la familia para adolescentes" (Family-Focused Treatment for Adolescents, FFT-A) con trastorno bipolar tipo I y tipo II condujo a mayores aumentos en la cohesión familiar y en la adaptabilidad y a disminuciones en el conflicto durante dos años en comparación con un tratamiento psicoeducativo más breve (atención optimizada; Enhanced Care: EC). Los participantes fueron 144 adolescentes (edad promedio: 15.6±1.4 años) con trastorno bipolar tipo I o tipo II con un episodio de alteración del humor en los tres meses previos. Los adolescentes y los padres fueron asignados aleatoriamente al FFT-A (21 sesiones) o a la EC (3 sesiones). Los pacientes recibieron farmacoterapia pautada durante todo el estudio de dos años. Las trayectorias de la cohesión familiar evaluada por los adolescentes y los padres, la adaptabilidad y el conflicto se analizaron durante dos años. El FFT-A tuvo mayores efectos en la cohesión familiar evaluada por los adolescentes en comparación con la EC durante dos años. Los participantes del FFT-A y de la EC informaron mejoras similares en el conflicto familiar durante los dos años. Las familias con un alto nivel de conflicto en el FFT-A tuvieron una menor cohesión evaluada por los adolescentes y una menor adaptabilidad durante dos años en comparación con las familias con un bajo nivel de conflicto en el FFT-A. Las familias con un alto nivel de conflicto en ambos grupos de tratamiento tendieron a mostrar reducciones más grandes en el conflicto durante dos años que las familias con un bajo nivel de conflicto. La psicoeducación familiar y la capacitación en habilidades pueden mejorar la cohesión familiar en las etapas iniciales del trastorno bipolar. La medición de los niveles de conflicto familiar al comienzo del tratamiento puede respaldar la capacidad de respuesta al tratamiento entre aquellos que reciben el FFT-A.

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OBJECTIVE: Individuals with active major depressive disorder (MDD) have shown affective biases in cognitive flexibility and memory, particularly for negatively valenced stimuli. We evaluated whether impairments in affective flexibility would remain even during remission (rMDD), potentially representing trait- or scar-like effects of illness. METHOD: Participants completed the Emotion Card Sort Test (ECST), a measure of cognitive flexibility containing emotionally valenced stimuli, and the Emotion Word Stimulus Test (EWST), a measure of affective biases in delayed recall and recognition memory, and several self-report measures. RESULTS: Healthy controls (HCs; n = 35) and individuals with rMDD (n = 93) did not differ on performance for any of the three word types on the ECST or EWT. However, individuals with rMDD demonstrated greater negative bias on EWT recognition trials relative to HCs (d = .36). On self-report measures, individuals with rMDD exhibited greater levels of neuroticism, problems with attentional control, pessimistic attributional style, and negative automatic thoughts compared to HCs. CONCLUSIONS: These results provide initial evidence that some performance, but not self-reported, indices of affective bias may improve during remission from MDD. Results of this study could suggest that some components of affective bias may represent state feature of illness and others trait-like risk or scar features. PRACTITIONER POINTS: This study suggests that self-reported affective biases may persist in remission of major depressive disorder (rMDD). Affective attentional biases and affective memory biases were not demonstrated in individuals with rMDD, with the exception of a bias for recognizing negatively versus neutrally valenced stimuli. CAUTIONS OR LIMITATIONS: A limitation of this study was its cross-sectional design. Under ideal conditions, the same individuals would be studied in both the active and remitted phases of illness. Another limitation of this study was the smaller number of healthy controls relative to individuals with rMDD.

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BACKGROUND: Traditional assessment and treatment of bipolar disorder (BD) often overlooks an important feature of the illness, mood instability (MI). MI - the presence of intense, rapidly shifting emotional states - is associated with a number of poor prognostic outcomes. This study examined whether MI among adolescents with BD was cross-sectionally related to bipolar subtype (I vs. II) and prognostically associated with symptoms and functioning over 3 months. METHODS: Participants included 145 adolescents (mean age: 15.6 years ±â€¯1.4) with BD I or II with a mood episode in the previous 3 months. Depression and (hypo)mania instability were computed using the root mean square successive difference (rMSSD) score, reflecting both the size and temporal order of changes in weekly depression and (hypo)mania scores (over 12 weeks) from the Adolescent Longitudinal Interval Follow-Up Evaluation. RESULTS: Greater depression instability was associated with BD II, whereas greater (hypo)mania instability was associated with BD I. Baseline MI, particularly depression, predicted more instability, a higher percentage of weeks in a clinical mood state, and poorer global functioning over 3 months, even when covarying concurrent mood severity scores. LIMITATIONS: The clinical measure of symptoms used retrospective reports of clinically significant symptoms only. We were unable to standardize medication use or adherence. CONCLUSIONS: MI differs by diagnostic subtype, is relatively stable over time, and predicts clinical and functional outcomes. Targeting MI should be considered a clinical focus to augment traditional methods of assessing and treating BD during adolescence to enhance clinical and functional outcomes.

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Habit Reversal Therapy (HRT) is helpful for many persons suffering from trichotillomania. However successful habit reversal therapy requires awareness of hair pulling behaviors. Available methods to monitor hair pulling behaviors are less than ideal, particularly when sufferers are unaware of their pulling-related behaviors. This open feasibility trial included 20 persons with trichotillomania who were treated with nine weeks of HRT with experienced clinicians following a well-established HRT protocol. HRT was augmented with an electronic Awareness Enhancing and Monitoring Device (AEMD) designed to alert users of hand to head contact and to monitor the frequency of pulling-related behaviors. The AEMD included a neck unit and two wrist units, each equipped with vibrating alert functions. The results of the open trial revealed significant improvements in trichotillomania symptoms as measured by clinician and self-report rating scales. Most participants met study criteria for HRT completion and treatment effects were large. Participants reported that the AEMD, when operational, was effective in alerting participants to TTM-related behaviors. The monitoring function of the AEMD did not operate as designed. Subjective feedback focused on the AEMD concept was positive but AEMD reliability problems and complaints about the wearability the units were common. Recommendations for AEMD design modifications were included.

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BACKGROUND: Adolescents with bipolar disorder (BD) report lower quality of life (QoL) than adolescents with other psychiatric disorders. This study compared the efficacy of family-focused therapy for adolescents (FFT-A) plus pharmacotherapy to brief psychoeducation (enhanced care, or EC) plus pharmacotherapy on self-rated QoL in adolescents with BD over 2 years. METHODS: Participants were 141 adolescents (mean age: 15.6±1.4yr) with BD I or II who had a mood episode in the previous 3 months. Adolescents and parents were randomly assigned to (1) FFT-A, given in 21 sessions in 9 months of psychoeducation, communication enhancement training, and problem-solving skills training, or (2) EC, given in 3 family psychoeducation sessions. Study psychiatrists provided patient participants with protocol-based pharmacotherapy for the duration of the study. QoL was assessed with The KINDLRQuestionnaire (Ravens-Sieberer and Bullinger, 1998) during active treatment (baseline to 9 months) and during a post-treatment follow-up (9-24 months). RESULTS: The two treatment groups did not differ in overall QoL scores over 24 months. However, adolescents in FFT-A had greater improvements in quality of family relationships and physical well-being than participants in EC. For quality of friendships, the trajectory during active treatment favored EC, whereas the trajectory during post-treatment favored FFT-A. LIMITATIONS: We were unable to standardize medication use or adherence over time. Quality of life was based on self-report rather than on observable functioning. CONCLUSIONS: A short course of family psychoeducation and skills training may enhance relational functioning and health in adolescents with BD. The effects of different psychosocial interventions on peer relationships deserves further study.

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INTRODUCTION: Deficits in cognitive flexibility, a difficulty altering thoughts and behavioral responses in a changing environment, are found in individuals with bipolar disorder (BD) and are associated with poor social and work functioning. However, the current literature is inconsistent in clarifying the long-term nature of these deficits for those with BD. We administered a common task of cognitive flexibility, the Wisconsin Card Sorting Task (WCST) and accounted for demographics, clinical, and cognitive features of BD, to determine the state versus trait characteristics of these deficits. METHOD: The Wisconsin Card Sorting Test (WCST) was administered to 154 adults with BD and 95 healthy controls twice, one year apart. RESULTS: The main findings show that cognitive inflexibility is a trait feature of BD, independent of clinical features, that may modestly worsen over time due to the presence of certain demographic, cognitive, and functional features of the disorder. In addition, improvements in WCST performance over an extended period of time in both those with and those without already existing cognitive flexibility deficits indicate potential practice effects. CONCLUSIONS: These findings suggest that the implementation of early interventions before the illness progresses could potentially prevent further cognitive impairment, mitigate functional outcomes, and improve the quality of life of the individual with BD.

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BACKGROUND: Bipolar Disorder (BD) is characterized by impairments in psychosocial functioning with occupational disability being one of the most significant. Depression and neurocognitive deficits are features of BD most commonly associated with poor occupational functioning (OF). Few studies have examined these features over an extended period of time focusing on distinct aspects of work functioning. METHODS: This longitudinal study included 273 adults with bipolar I disorder (N=173), bipolar II disorder (N=69), and bipolar not otherwise specified (N=31). The participants underwent an annual clinical assessment, neuropsychological testing, and work functioning measures over 5 years. We employed multilevel modeling (MLM) to determine which demographic, clinical, and neurocognitive characteristics influence 4 aspects of work functioning (work attendance, conflict, enjoyment, performance) over this 5-year period. LIMITATIONS: Work functioning was measured using a self-report measure, which may be confounded by responder bias and is not tailored for distinct occupations. Due to insufficient power, medication use was not accounted for and our sample may not generalize to the broader BD population. RESULTS: Using MLM, those with higher levels of depression and greater cognitive flexibility deficits were more likely to experience poorer work attendance (p<0.01), lower quality of work (p<0.01), and reduced satisfaction from work (p<0.001). These occupational hardships persisted over the 5-year period. CONCLUSIONS: This study emphasizes the need for interventions that specifically focus on the treatment of depressive symptoms and neurocognitive deficits within the context of work functioning, particularly attendance at work, to enable BD patients to live more productive, financially secure, and satisfying lives.

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We designed and pilot-tested a group-based, work-related cognitive-behavioral therapy (WCBT) for unemployed individuals with social anxiety disorder (SAD). WCBT, delivered in a vocational service setting by vocational service professionals, aims to reduce social anxiety and enable individuals to seek, obtain, and retain employment. We compared WCBT to a vocational services as usual control condition (VSAU). Participants were unemployed, homeless, largely African American, vocational service-seeking adults with SAD (N = 58), randomized to receive either eight sessions of WCBT plus VSAU or VSAU alone and followed three months post-treatment. Multilevel modeling revealed significantly greater reductions in social anxiety, general anxiety, depression, and functional impairment for WCBT compared to VSAU. Coefficients for job search activity and self-efficacy indicated greater increases for WCBT. Hours worked per week in the follow-up period did not differ between the groups, but small sample size and challenges associated with measuring work hours may have contributed to this finding. Overall, the results of this study suggest that unemployed persons with SAD can be effectively treated with specialized work-related CBT administered by vocational service professionals. Future testing of WCBT with a larger sample, a longer follow-up period, and adequate power to assess employment outcomes is warranted.

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