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Research in Autism Spectrum Disorders

journal homepage: www.elsevier.com/locate/rasd

Self-reported emotion regulation in children with autism spectrum disorder, without intellectual disability

Talia Burtona,*, Belinda Ratcliffea,b, James Collisona, David Dossetorb, Michelle Wongb

a School of Social Sciences and Psychology, Western Sydney University, Bankstown Campus, Locked Bag 1797, Penrith, NSW 2751, Australia b Department of Psychological Medicine, The Children’s Hospital at Westmead, Locked Bag 4001, Westmead, Sydney, NSW 2145, Australia

A R T I C L E I N F O

Number of reviews completed is 2

Keywords: Autism spectrum disorder Emotion regulation Social skills Mental health Autism severity

A B S T R A C T

Background: Emotion regulation (ER) may be a critical underlying factor contributing to mental health disorders in children with Autism Spectrum Disorder (ASD). Scant literature has utilised self-reported ER in children with ASD and explored the association between mental health and social skills. This study explored the association between self-reported ER skills, and parent/ teacher proxy reports of ER, social skills, autism severity and mental health. Method: The pre-existing data set included a community sample of 217 students aged seven to 13-years (Mage = 9.51, SD = 1.26; 195 Male, 22 Female) with ASD. The study employed a correlational design, whereby existing variables were explored as they occurred naturally (Hills, 2011). Children self-rated ER, while parents and teachers rated ER, social skills, and mental health difficulties via standardised questionnaires. Results: Multiple regression analyses were conducted separately for parent and teacher reports. The linear combination of parent-reported emotion regulation, social skills, autism severity, and child-reported ER accounted for 46.5 % of the variance, compared to 58.7 % for the teacher- report analysis. Social skills appeared to be a stronger predictor of mental difficulties than emotional regulation irrespective of source. Conclusions: The current study suggests self-reported ER to be a significant contributor to mental health when in isolation. However, in the context of social skills and autism severity, ER is no longer a significant contributor in a child and adolescent community sample, in determining mental health. This suggests, that for children aged seven to 13-years with ASD, without ID, to reduce mental health difficulties, social skills may be the focus of intervention, with some focus on ER ability.

1. Introduction

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterised by difficulties in two core domains; social- communication and restricted/ repetitive patterns of behaviour, interests or activities (American Psychiatric Association, 2013). Compared to their typically developing (TD) peers, children with ASD have difficulties in social-emotional reciprocity, non-verbal social-communicative behaviours, and developing and maintaining relationships. They may also experience an inflexible adherence to routine, repetitive motor movements, and highly restricted/ fixated interests (American Psychiatric Association, 2013).

https://doi.org/10.1016/j.rasd.2020.101599 Received 7 January 2020; Received in revised form 8 May 2020; Accepted 3 June 2020

⁎ Corresponding author. E-mail address: [email protected] (T. Burton).

Research in Autism Spectrum Disorders 76 (2020) 101599

Available online 13 June 2020 1750-9467/ © 2020 Elsevier Ltd. All rights reserved.

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Approximately 1.4 % of Australian school children have a diagnosis of ASD (Aspect, 2018). Of those, some 72 % have at least one co-morbid mental health disorder (either internalizing or externalizing), compared to just 14 % of TD children (Gurney, McPheeters, & Davis, 2006; Leyfer et al., 2006; Simonoff et al., 2008). Poor social skills and autism severity may be significant contributing factors towards the very high level of mental health difficulties within the ASD population (Ratcliffe, Wong, Dossetor, & Hayes, 2015; Eussen et al., 2012; Greenlee, Mosley, Shui, Veenstra-VanderWeele, & Gotham, 2016; Mazzone et al., 2013; Ratcliffe, Wong, Dossetor, & Hayes, 2014; Van Steensel & Heeman, 2017). For example, social skills explain between 49.7%–54.7 % of the variance in mental health scores among school-aged children with ASD, based on parent- and teacher-reports (Ratcliffe et al., 2015). In addition, while some studies suggest greater autism severity indicates greater mental health difficulties (Ratcliffe et al., 2015), and others suggest reduced severity indicates greater mental health difficulties (Eussen et al., 2012; Mazurek & Kanne, 2010; Van Steensel & Heeman, 2017), it is largely agreed upon that autism severity (i.e., whether this be greater or lower) plays a significant role in mental health outcomes.

Emerging evidence suggests that emotion competence skills (e.g., emotion regulation) is also a critical capacity underlying and driving social communicative competence (Laurent & Rubin, 2004), which should also be considered as an underlying factor con- tributing to poor mental health in ASD (Rieffe et al., 2011). Emotion regulation (ER) is the ability to control or modify the intensity and duration of an emotional response to achieve goal-directed behaviour (MacDermott, Gullone, Allen, King, & Tonge, 2010; Mazefsky et al., 2013). Successful ER thus requires an individual to firstly recognise their emotional state (i.e., “emotional self- awareness”), access self-soothing strategies for strong levels of negative emotions or high arousal (i.e., “emotional control”), and simultaneously maintain progress in current activities while behaving in a socially or situationally appropriate manner (i.e., “si- tuational responsiveness”) (Berkovits, Eisenhower, & Blacher, 2016; MacDermott et al., 2010).

Children with ASD have significantly higher levels of emotion dysregulation compared to their TD peers (Ashburner, Ziviani, & Rodger, 2010; Jahromi, Bryce, & Swanson, 2013; Samson et al., 2014). Teacher-reports indicate children with ASD have higher levels of difficulties within behavioural, emotional, and academic skill domains compared to their TD peers (Ashburner et al., 2010). Emotional difficulties were notably expressed through frequent temper outbursts, a tendency to cry, rapid mood changes, and be- coming easily frustrated when demands were not immediately met. Parent-reports indicate a similar pattern, noting children with ASD have significantly lower ER than their TD peers (Jahromi et al., 2013; Samson et al., 2014; Shields & Cicchetti, 1997). Research also indicates individuals with ASD to more frequently utilise “maladaptive” (e.g., avoidance, negative rumination), and fewer “adaptive” (e.g., acceptance, cognitive reappraisal) ER strategies, compared to TD individuals (Mazefsky, Borue, Day, & Minshew, 2014; Rieffe et al., 2011; Rieffe, De Bruine, De Rooij, & Stockmann, 2014). Overall, with few exceptions (Pouw, Rieffe, Stockmann, & Gadow, 2013), research indicates ER difficulties to be a significant issue in children with ASD (Cai, Richdale, Uljarevic, Dissanayake, & Samson, 2018), across differing age-groups, with some with some even positioning poor ER as a core diagnostic feature of ASD (Ashburner et al., 2010; Samson et al., 2014).

In TD children, there is a strong link between poor ER skills and the development of internalising disorders, such as anxiety and depression (Rieffe et al., 2011). As previously outlined, there is a significantly high prevalence of internalising and externalising disorders in children with ASD, compared to TD children (Leyfer et al., 2006; Simonoff et al., 2008; Van Steensel & Heeman, 2017). As poor ER has been observed to be a significant factor in ASD (Ashburner et al., 2010; Samson et al., 2014), it could be that poor ER significantly contributes to the high prevalence of mental health difficulties in children with ASD. For example, Berkovits et al. (2016) found 5-to 7-year-old children with ASD and poor ER, indicated poorer social skills and increased internalising and externalising behaviours across a ten-month time span. In addition, Jahromi and colleagues (2013) found greater ER to be a significant and positive prediction of prosocial peer engagement, in 6- to 16-year-old children. ER may therefore sit alongside social skills and ASD symptom severity as significant factors in determining mental health (Laurent & Rubin, 2004). This recognition of ER playing an important role in mental health in ASD is reflected in the shift of focus from targeting social skills development to emotion-based social skills development in interventions for children with ASD (Ratcliffe et al., 2014; Samson et al., 2014).

1.1. Issues in the assessment of emotion regulation

The recommended “gold standard” approach to measuring ER in children in both research and clinical practice is a multi-method assessment (Mash & Hunsley, 2005; Mazefsky et al., 2013). Multiple methods may be utilised to investigate ER, such as direct, naturalistic observation of behaviour, informant report (i.e., parent- or teacher-report), self-report, physiological measures and open- ended/ qualitative measures (Mazefsky et al., 2013; Weiss, Thomson, & Chan, 2014).

Self-report in adults with ASD is supported for assessing alexithymia (i.e., difficulty identifying and expressing emotion; Berthoz & Hill, 2005), internalising symptoms (Williams, 2010), quality of life, and ASD traits (Baron-Cohen et al., 2011), assuming the in- dividual is of at least average intelligence (Hesselmark, Eriksson, Westerlund, & Bejerot, 2015). TD children between the ages of 10- and 12-years are increasingly able to reflect upon their own internal states and emotions (Harris, 1989; Rieffe et al., 2011). As a core difficulty in individuals with ASD is identifying and reflecting on one’s own emotions, it is unclear whether ER self-report measures for children with ASD are valid (Mazefsky & White, 2014; Rieffe et al., 2011). Nevertheless, self-reports are extremely important in both the assessment and treatment phases, as they provide data reflective of the individual’s own experience (Hesselmark et al., 2015).

Agreement between child- and parent/teacher-report has been found to be greatest during middle childhood (i.e., between 6–11- years) and significantly greater for externalising problems, when compared to internalising problems and social skills, for children with ASD and TD children (Renk & Phares, 2004; Stratis & Lecavalier, 2015). While some studies have reported inconsistency across self- and parent-reports regarding “negative emotions” (e.g., nervous and upset; Samson, Harden, Lee, Phillips, & Gross, 2015), other

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studies have indicated good correspondence between self- and parent-report (Khor, Melvin, Reid, & Gray, 2014), with Rieffe et al. (2011) emphasising the importance of recognising the child’s perspective of their emotional experience, regardless of discrepancies. To gain a comprehensive picture of the child, the use of multiple informants is critical, and considered a “gold standard” approach (Mash & Hunsley, 2005), as certain patterns of behaviour may be present or absent depending on contextual factors (Stratis & Lecavalier, 2015). A significant limitation of previous studies measuring ER has been a lack of employing the “gold standard” approach, with up to 75 % of studies including only one methodological approach to ER measurement (Mazefsky et al., 2014; Weiss et al., 2014). Other limitations include utilising small sample sizes (e.g., 31 participants; Jahromi et al., 2013; Khor et al., 2014), male-only samples (Cederlund, Hagber, & Gillberg, 2010; Pouw et al., 2013), or samples that do not differentiate between ASD with and without intellectual disability for statistical analyses (Berkovits et al., 2016). In addition, some studies that claim to measure ER fail to provide an adequate definition of the concept or simply measure constructs of ER, such as, “coping style” (Cai et al., 2018; Mazefsky et al., 2014; Pouw et al., 2013; Rieffe et al., 2014; Weiss et al., 2014).

1.2. The current study

Together, these studies reveal a notable gap in our understanding of ER and its assessment, particularly among children with ASD, and how poor ER may be a core factor in developing mental health difficulties. Further, scant literature has explored ER (self and teacher/ parent) alongside social skills in determining mental health difficulties. This study will therefore investigate the association between ER ability, social skills, autism severity, and mental health in a community sample of school-aged children. To improve on the limitations of existing studies, we will use a multi-informant method, clearly define our sample as children without co-occurring ID and utilise a large sample size (i.e., > 200 participants).

More specifically, the study will explore self-reported ER, and how this compares to parent/teacher-reported ER, social skills, autism severity and mental health. We hypothesise that self-reported ER will be of similar agreement to parent/teacher- reports of ER, as research indicates agreement to be greatest during middle childhood, and higher than TD peers (Stratis & Lecavalier, 2015). Secondly, it is anticipated that poorer self-reported ER ability will be associated with increased mental health difficulties, poorer social skills, and greater autism severity for both parent- and teacher-reports. Finally, we predict that self- and parent/teacher- reported ER would be significant contributors of mental health difficulties among children with ASD alongside social skills and autism severity.

2. Method

2.1. Design

This study employed a natural-groups correlational design (Hills, 2011). Dependent variables included ER measured via the Emotion Regulation Index for Children and Adolescents (ERICA; (MacDermott et al., 2010) and the Emotions Development Ques- tionnaire (EDQ; Wong, Heriot, & Lopes, 2009), social skills measured via the Social Skills Improvement System- Rating Scales (SSIS- RS; Gresham & Elliot, 2008), autism severity and social responsiveness measured via the Social Responsiveness Scale (SRS; Constantino, 2002), and mental health difficulties measured via the Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997a).

2.2. Participants

Participants included 217 students aged 7- to 13-years (Mage = 9.51, SD = 1.26; 195 Male, 22 Female) with ASD, drawn from the Emotion-Based Social Skills Training (EBSST) in Schools study databank, held and collected by the Children’s Hospital at Westmead, Australia. A range of demographic, social skills, and mental health data is held within the confidential, non-identifiable databank, based on parent- and teacher-report, for students with ASD with and without mild ID. All children in the databank attended NSW Department of Education and Communities Primary Schools, making the sample non-clinical and school-based.

As the EBSST trial pre-dated the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (i.e., DSM-5; APA, 2013), participants in the sample were included if they had a confirmed or suspected diagnosis of ASD based on diagnostic nosology from the text-revised fourth-edition (i.e., DSM-IV-TR; American Psychiatric Association, 2000). Hence, participation was limited to participants with a diagnosis of Autistic Disorder, Asperger’s Disorder, and Pervasive Developmental Disorder-Not Otherwise Specified (American Psychiatric Association, 2000), as assessed by a registered psychologist or specialist medical prac- titioner. Participants were classified as having no ID present, with an Intelligence Quota (IQ) of above 70 on a standardised measure of cognitive ability, with no concurrent deficits in adaptive behaviour (DSM-5; American Psychiatric Association, 2013). Parent- reported scores on the SRS (Constantino, 2002) were in the severe range for all participants, indicating a strong association with an ASD diagnosis (Murray, Mayes, & Smith, 2011; Wilkinson, 2010a, 2010b). Informed consent was obtained from all parents/guardians of children involved in the EBSST in Schools trial, as well as school principals, counsellors, and teachers.

2.3. Materials

2.3.1. Demographic information Brief background information, including age, gender and school grade was obtained via surveys from school counsellors, teachers,

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and parents.

2.3.2. Emotion regulation The ERICA (MacDermott et al., 2010) is a 16-item self-report questionnaire designed to assess ability to regulate emotions for

children and youth aged 9−16. It is a revised adaptation of the Emotion Regulation Checklist for Adolescents (ERCA; Biesecker & Easterbrooks, 2001) and employs a 5-point Likert scale (i.e., “Strongly Disagree” to “Strongly Agree”). The questionnaire yields an overall emotion regulation index score with higher scores indicating greater ability. Subscales of the ERICA are: Emotional Control (EC), Emotional Self-Awareness (SA), and Situational Responsiveness (SR). The ERICA has demonstrated good test-retest reliability, internal consistency and convergent and construct validity in a sample of youth aged 9–16. (MacDermott et al., 2010). Presently, Cronbach’s α = 0.80.

The EDQ (Wong et al., 2009) is a 29-item informant report, comprising of both parent (EDQ-P) and teacher (EDQ-T) forms to rate the child’s emotional competence. Items on the scale include questions such as, “How often can your child choose an appropriate strategy to manage their feelings?”. The teacher form includes the same 29-items utilised for the parent form, with the statement “your student” replacing “your child”. The EDQ employs a 5-point response scale (i.e., “Never” to “Always”) and includes a sixth option of “Don’t Know”. It has demonstrated excellent internal consistency for parents and teachers in a sample of children aged 7- to 13-years (Ratcliffe et al., 2014).

As a comprehensive measure of emotional competence, the EDQ also includes questions that relate to the abilities of the parent/ teacher (e.g., “Do you talk to your student about their good feelings?”). However, these items are irrelevant to the current application as a measure of emotional regulation and retaining them in the analyses may skew the result. As per Wong et al. (2009), those items relevant to the parent or teacher emotion coaching style (i.e., items 1–7) were excluded from the analysis to ensure the EDQ served as a measure of ER. Presently, parent-report indicates Cronbach’s α = 0.92 (29-items) and teacher-report indicates Cronbach’s α = 0.91 (30-items).

2.3.3. Social skills The SSIS-RS (Gresham & Elliot, 2008) is a standardised, norm-referenced assessment of social skills (children aged 3–18),

comprised of both parent (SSIS-P) and teacher (SSIS-T) forms. The rating scale yields an overall social skills score (i.e., higher scores indicating better skills), which includes the subscales of communication, cooperation, assertion, responsibility, empathy, engage- ment, and self-control. The SSIS-RS indicates good internal and test-retest reliability, and adequate criterion and convergent validity (Gresham & Elliot, 2008). Presently, parent-report indicates Cronbach’s α = 0.77, and teacher-report indicates Cronbach’s α = 0.82.

2.3.4. Autism severity and social responsiveness The SRS (Constantino, 2002) is a standardised, norm-referenced, 65-item informant report of reciprocal social interactions in

children aged 4–18, which are core difficulties in children with ASD. The scale is comprised of both parent (SRS-P) and teacher (SRS- T) forms and is highly correlated with the Autism Diagnostic Interview Revised (gold-standard diagnostic tool; Rutter, Le Couteur, & Lord, 2003). The scale has thus been utilised to capture the severity of autistic behaviours (e.g., Constantino et al., 2003), with domains assessed including social awareness, social information processing, reciprocal social communication, social anxiety/ avoidance, and stereotypic behaviours/ restricted interests. The scale has satisfactory psychometric properties, including: Cronbach’s alpha = 0.97; internal consistency; predictive validity; inter-rater reliability, parents and teachers r = 0.73 (Constantino, 2002). Presently, Cronbach’s α = 0.95 for both parent and teacher forms.

2.3.5. Mental health The SDQ (Goodman, 1997a) is a brief, standardised norm-referenced assessment of overall mental health, which is commonly

utilised in Australian clinical practice for children aged 5–16 (Hawes & Dadds, 2004). The single version 25-item questionnaire was completed by both parents (SDQ-P) and teachers (SDQ-T), which comprises five subscales: conduct problems, hyperactivity, emo- tional symptoms, peer problems, and prosocial behaviour. The ‘total difficulties score’ is determined by totalling the four deficit focused subscales (i.e., all except prosocial behaviour). Total difficulties scores above 16 and 15 on parent- and teacher- reports respectively, are indicated to sit within the “abnormal” range (Goodman, 1997b). Presently, parent-report indicates Cronbach’s α = 0.66, and teacher-report indicates Cronbach’s α = 0.75. Previous studies have indicated overall acceptable internal consistency, with Cronbach’s α = 0.73 (Goodman, 2001).

2.4. Procedure

The appropriate baseline measure outcome data for students without ID participating in the EBSST in Schools study was retrieved from the original database, and a new database was developed for analysis purposes for the present study. The data is based on a secondary, non-identifiable databank originally collected by the Children’s Hospital at Westmead. The Children’s Hospital at Westmead and the Western Sydney University Human Ethics Committee granted the use of such data, otherwise known as the EBSST in Schools databank.

2.5. Ethics

The current study is based on secondary data originally collected by The Children’s Hospital at Westmead. The previous research

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involving the existing database gained consent from school counsellors, school principals, parents and teachers for all children involved. The current study gained ethics approval from the Human Research Ethics Committee at The Children’s Hospital at Westmead, and endorsed by Western Sydney University Human Ethics Committee.

2.6. Data analysis

All analysis was done using IBM Statistical Package for Social Sciences (SPSS) (Version 24.0 2016), with alpha set at .05. Bonferroni adjustments were employed where to adjust for the increased rate of Type 1 error when making multiple comparisons (Hills, 2011). Data screening did not reveal missing data. Several measures allowed for a “don’t know” response, and thus number of participants vary slightly. Two univariate outliers were identified (i.e., z-score > +/− 3.29;) and adjusted to one unit smaller (or larger) than the next most extreme score, as per Tabachnick and Fidell (2013). Preliminary analyses were then conducted to evaluate required assumptions. Normality assumptions were satisfied for all measures (i.e., p < .05; Shapiro- Wilkes, as per Hills, 2011), with some measures (i.e., SRS-P, SSIS-P and ERICA factors SA and SR) showing a greater amount of non-significant negative skewing than others. Data transformations were unnecessary in the absence of significant departures from normality, as per Tabachnick and Fidell (2013). Test specific assumptions are addressed during the relevant analysis.

3. Results

3.1. Descriptive statistics

Means and standards deviations for all dependent variables are reported in Table 1 below. A gender difference ratio of ap- proximately 1:9 males was noted, which is consistent with previous studies utilising an ASD population (Khor et al., 2014; Rieffe et al., 2011), but inconsistent with reported gender prevalence rates more broadly (i.e., 1:4 males; Fombonne, 2009; Halladay et al., 2015; Werling & Geschwind, 2013). This difference was significant, indicating that ASD may be more prevalent in school-aged boys than girls than has been previously reported, X 2 (1, N = 217) = 137.92, p < .001. Cohen’s w was 0.80, which is consistent with a large effect size (Cohen, 1988).

3.2. Self-reported emotion regulation and parent/ teacher-reported emotion regulation, social skills, autism severity and mental health

Pearson correlations were calculated (Hills, 2011) to assess the strength of the relationship between self-reported ER and parent/ teacher-reported ER, social skills, autism severity, and mental health difficulties. Prior analyses ensured assumptions of linearity and homoscedasticity were not violated. As displayed in Table 2, there were no significant correlations found between self-reported ER and either parent-reported ER or teacher-reported ER. Greater self-reported ER was associated with greater social skills and lower mental health difficulties, for parent/ teacher-report measures. Correlations between the self-reported ER and parent/ teacher-re- ported mental health and social skills ranged from r = .19 (weak) to r = .30 (medium), and were significant at the 0.01 level. Self- reported ER however was not correlated with autism severity.

There were significant correlations between self-reported ER and all subscales of the parent-reported mental health questionnaire, except the emotion symptoms (r = .001) and hyperactivity subscales (r = −.14). Correlations ranged from r = −.17 for both peer problems, to r = −.23 for conduct problems subscale. There were significant correlations between self-reported ER and all subscales

Table 1 Descriptive Statistics for Demographic Data and Outcome Measures.

M Range SD n

Sample Age 9.51 7−13 1.26 217 Year at school 4.00 1−7 1.26 217

Measures ERICA

Total 52.8 30−74 9.01 199 EC 21.0 9−35 5.69 199 SA 16.3 7−25 3.33 199 SR 15.6 5−20 2.77 199 EDQ-P 81.9 35−142 19.0 203 EDQ-T 76.5 35- 127 16.3 215 SSIS-P 67.0 18−116 20.8 190 SSIS-T 68.1 22−127 19.5 197 SRS-P 96.6 23−174 33.4 171 SRS-T 89.2 16−159 30.7 203 SDQ-P 20.5 4−35 6.30 192 SDQ-T 17.0 1−37 7.03 207

ERICA: Emotion Regulation Index for Children and Adolescents; EDQ: Emotions Development Questionnaire; SSIS-RS: Social Skills Improvement System-Rating Scales; SRS: Social Responsiveness Scale.

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of the teacher-reported mental health questionnaire, except emotions symptoms (r = .03) and peer problems (r = −.14) subscales. Correlations ranged from r = −.19 for both the hyperactivity and total difficulties subscales, to r = −.24 for the conduct problems subscale.

3.3. Emotion regulation and mental health difficulties

Standard linear regression was employed to examine the contribution of ER to mental health difficulties in children with ASD (Hills, 2011). Two standard linear regression analyses were conducted first for parents and then secondly for teachers (i.e., four analyses in total). The ERICA and EDQ were entered as predictor variables, with SDQ scores as the criterion variable. Multiple regression analyses were then conducted to examine the contribution of self- and parent/teacher-reported ER on mental health, in the context of social skills and autism severity. Thus, in a separate analysis the SSIS, SRS, ERICA, and EDQ scores were entered as predictor variables, with SDQ scores remaining as the criterion variable. Pearson correlations ranged from r = .02 and r = .74, indicating singularity and multi-collinearity between dependent variables was not present (Tabachnick & Fidell, 2013).

Inspection of the normal probability plot of standardised residuals and the scatterplot of standardised residuals against stan- dardised predicted values indicated that the assumptions of normality, linearity, and homoscedasticity of residuals were met (Allen & Bennett, 2008). Two multivariate outliers were identified in the parent-report multiple regression (i.e., Mahalanobis distance > critical χ2 = 18.47, p < .001; Tabachnick & Fidell, 2013) and temporarily supressed for the parent-report multiple regression. Multivariate outliers were not present in the teacher-report analysis, nor was there evidence of multicollinearity in either analysis when assessed by the variance inflation factor (VIF; Tabachnick & Fidell, 2013).

3.3.1. Parent report Results of the first regression analysis indicated that ERICA scores explained 4% of the variance in overall mental health diffi-

culties, R2 = .04, F(1, 177) = 7.13, p = .008, whereas parent EDQ scores was a non-significant predictor of overall mental health difficulties (p = .112). The multiple regression involving the ERICA and EDQ-P, in addition to the SSIS-P and SRS-P, indicated the linear combination of predictors explained 46.5 % of the variance in overall mental health difficulties, R2 = .47, F(4, 154) = 33.41, p < .001. The EDQ-P was a significant predictor of overall mental health difficulties, while ERICA scores became non-significant. The SSIS-P and SRS-P contributed significantly, positively and negatively respectively, to overall mental health difficulties. Autism severity (SRS-P) recorded a higher standardised beta value than social skills (SSIS-P), indicating a stronger predictor of mental health difficulties. Thus, in the context of context of social skills (SSIS-P) and autism severity (SRS-P), while self-reported ER (ERICA) is a non-significant contributor of mental health difficulties in children with ASD, parent-reported ER (EDQ-P) is significant. Multiple regression analyses are summarised in Table 3.

3.3.2. Teacher report Results of the initial regression analysis indicated that ERICA scores explained 3.7 % of the variance in overall mental health

Table 2 Pearson Correlations Between the ERICA Total and Sub-Scales Scores with EDQ-No Emotion Coaching, SSIS-RS, SRS and SDQ subscales.

Parent- and Teacher-Report Self-reported ER measure

ERICA-Total EC SA SR

ER measure EDQ-P .095 .05 .13 .05 EDQ-T .116 .18* .03 −.02

Social skills measure SSIS-P .25*** .24*** .16* .13 SSIS-T .30*** .27*** .20** .18*

Autism severity measure SRS-P −.09 −.05 −.10 −.08 SRS-T −.12 −.07 −.10 −.14

Mental health measure SDQ-P Total difficulties score −.20** −.21** −.070 −.11 Emotional symptoms subscale .001 .04 −.06 −.01 Conduct problems subscale −.23** −.30*** −.02 −.10 Hyperactivity subscale −.14 −.21** .02 −.03 Peer problems subscale −.17* −.12 −.12 −.16*

SDQ-T Total difficulties score −.19** −.16* −.15* −.13 Emotional symptoms subscale .03 .12 −.08 −.07 Conduct problems subscale −.24*** −.23*** −.14 −.13 Hyperactivity subscale −.19** −.21** −.10 −.08 Peer problems subscale −.14 −.13 −.10 −.08

*p < .05. **p < .01. ***p < .001.

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difficulties, R2 = .04, F(1, 190) = 7.40, p = .007, whereas teacher EDQ scores was a non-significant predictor of overall mental health difficulties (p = .775). The multiple regression combining the ERICA, EDQ-T, SSIS-T and SRS-T indicated the four predictors explained 58.7 % of the variance in overall mental health difficulties, R2 = .59, F(4, 173) = 61.43, p < .001. However, only the SSIS-T and SRS-T contributed significantly, negatively and positively respectively, to overall mental health difficulties. This indicates that as autism severity (SRS-T) increases and social skills decrease (SSIS-T), total mental health difficulties increase. Similar to parent analysis, autism severity (SRS-T) recorded a higher standardised beta value than social skills (SSIS-T). Such findings indicate that within the context of social skills (SSIS) and autism severity (SRS), neither self-reported or teacher-reported ER are significant contributors to mental health difficulties in children with ASD. Multiple regression analyses are summarised in Table 3.

4. Discussion

The current study explored the association between self-reported ER skills, parent- and teacher-reported ER, social skills, autism severity, and mental health in a community sample of children with ASD. The hypothesis that self-reported ER would be consistent with parent- and teacher- reported ER was not supported. Results partially supported the hypothesis that poorer self-reported ER ability would be associated with increased mental health difficulties, poorer social skills, and greater autism severity for parent/ teacher-reports. Only social skills and mental health difficulties were associated with self-reported ER in children with ASD. Finally, the hypothesis that self- and parent/teacher-reported ER would be significant predictors of mental health difficulties alongside social skills and autism severity was not supported. Multiple regression analyses found parent-reported emotion regulation, social skills, autism severity, and child-reported ER accounted for 46.5 % of the variance, compared to 58.7 % for the teacher-report analysis. However, in the context of social skills and autism severity, self- and teacher-reported ER were not significant contributors to mental health.

The current study found that self-reported ER was not associated with parent- and teacher-reported ER. Such findings are somewhat inconsistent with previous research (Renk & Phares, 2004; Stratis & Lecavalier, 2015) as research exploring agreement between child- and parent/teacher-report varies. This inconsistency with previous research may be due to the current study utilising differing measures of ER for self-report, compared to parent/teacher-report. However, the overall variability in previous research regarding agreement between child and parent/teacher report may reflect a dearth of valid and reliable ER measures which include self-, parent- and teacher-report variations, and future studies could benefit from developing a measure with such variations (Weiss et al., 2014).

Results indicated that parent- and teacher-reported social skills and mental health are associated with self-reported ER in children with ASD. Consistent with previous research (Rieffe et al., 2011) in TD children, current findings indicate poorer ER skills (self- reported) are associated with poorer mental health in children with ASD. Upon further exploration of the mental health subscales (i.e., emotion symptoms, conduct problems, hyperactivity, peer problems), emotion symptoms (e.g., depression and anxiety) were not correlated with ER skills (self-reported). This finding contradicts previous research where emotional symptoms were associated with poorer ER in adolescents with ASD (e.g. Mazefsky et al., 2014). There are several explanations for this discrepancy. For example, the current sample used a younger age group (i.e., 7−13 years rather than 12–19 years), which may have influenced results. This suggests there may be differences in self-reported ER between primary school age children and adolescents. The current study also utilised the SDQ, whereas previous research has utilised the Child Behaviour Checklist (Achenbach, 1991; Mazefsky et al., 2014; CBCL). Research indicates SDQ as the preferred measure by parents in comparison to the CBCL, and both are roughly equivalent in detecting internalising and externalising problems (Goodman & Scott, 1999).

Autism severity was found to not be associated with self-reported ER. Previous research suggests an unclear relationship between autism severity and ER (Mazefsky et al., 2014; Samson et al., 2014) as well as with mental health (Eussen et al., 2012). Discrepancies in research may be due to many factors, such as the type of assessment tools utilised, whether these have been validated for the ASD population, and how a mental health disorder and emotion regulation have been defined (Eussen et al., 2012).

The current findings suggest that for a community, school-based sample, social skills may be a stronger predictor of mental health

Table 3 Standardised (β) Regression Coefficients, Standard Error (SE), Squared Semi-Partial Correlations (sr2), and p-values For Each Predictor in a Regression Model Predicting Overall Mental Health Difficulties for Parent- and Teacher-Report.

Variable β SE sr2 p

Parent-Report ERICA −.054 .043 .003 .378 EDQ-P .164 .020 .027 .006** SSIS-P −.255 .022 .043 .001** SRS-P .478 .013 .158 < .001**

Teacher-Report ERICA −.056 .040 .003 .281 EDQ-T .092 .022 .008 .067 SSIS-T −.264 .025 .035 < .001** SRS-T .564 .015 .171 < .001**

*p < .05. **p < .01.

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difficulties, compared to ER. In the context of social skills and autism severity, self- and teacher-reported ER were not significant contributors to mental health. Interestingly, parent-reported ER was not a significant contributor to parent-reported mental health when in isolation, however became significant when in the context of social skills and autism severity. The current findings also indicated self-reported ER to be a significant contributor to mental health when in isolation. However, when in the context of social skills and autism severity, ER is no longer a significant contributor in a child and adolescent community sample, in determining mental health. This finding may be due to the utilisation of a non-clinical, school-based sample, where findings may become sig- nificant in a clinical sample (i.e., participants with a co-occurring mental health disorder, diagnosed upon clinical examination). In addition, the instruments utilised to measure social skills, mental health difficulties and ER may not have been sensitive enough to exclusively distinguish between symptoms within each of these areas, and a degree of symptom overlap may have occurred.

4.1. Limitations

The current exploratory study aimed to investigate the association between ER, social skills, autism severity and mental health in a community-based sample of school-aged children with ASD, without ID. A limitation in the current study was the utilisation of differing instruments to measure self-reported ER and parent/ teacher-reported ER. Despite this limitation, the current study has the strength of implementing a gold standard approach to measuring ER (Mash & Hunsley, 2005), which highlights the importance of self-report within the assessment phase. Self-report has the strength of providing data reflective of the individual’s own views (Hesselmark et al., 2015). It is also consistent with inclusive research practice in ASD (Cooperative Research Centre for Living with Autism, 2016).

In addition, the study included no independent diagnostic validation of each participant’s diagnosis of ASD and cognitive ability, instead utilising the SRS to measure ASD severity. Mental health difficulties were measured via the SDQ and included no clinical examination for co-morbid mental health disorders. Although increased scores on the SDQ are associated with mental health dis- orders, it is unclear whether symptoms may have overlapped with ASD characteristics or with the ER measures. These are both significant limitations of the current study, and future studies could implement a rigorous, clinical assessment of ASD diagnosis, cognitive ability and mental health via measures with sensitivity and specificity for an ASD population, when available, to explore whether the current findings can be replicated. Future studies may also implement more objective measures of ER, in addition to informant report, to avoid overlap of measures. This might include naturalistic observation of behaviour (Jahromi, Bryce, & Swanson, 2012; Konstantareas & Stewart, 2006) and physiological measures such as electroencephalography (EEG) of brain activity, heart rate variability and skin conductance as indexes of ER (Bal et al., 2010; South, Newton, & Chmaberlain, 2012; Van Hecke et al., 2009).

4.2. Clinical implications and future directions

The findings indicate that for a community, school-based sample, social skills may be a stronger predictor of mental health difficulties, compared to ER skills. This suggests that for children aged 7−13 years with ASD without ID, to reduce mental health difficulties, social skills may be the focus of intervention with some focus on ER ability. Social skills techniques found to be effective for children with ASD include social stories (Ozdemir, 2008), video modelling (Lantz, 2005) and visual activity schedules (Betz, Higbee, & Reagon, 2008). The findings also support interventions which target both social skills and ER skills. For example, EBSST (Ratcliffe, 2011; Wong, Lopes, & Heriot, 2010) targets emotional competency skills, such as emotional problem solving, under- standing other’s emotions and emotion regulation, in the context of social situations.

In addition, this study applied the ERICA to measure self-reported emotion regulation in children, aged 7−13-years, with ASD. The psychometric evaluation of the ERICA (MacDermott et al., 2010) was based on TD children aged 9−16-years old. This is the first study to utilise this measure for an ASD population, and below the age of 9-years old. Future research into the ERICA (MacDermott et al., 2010) as a self-report measure of ER in children with ASD may be appropriate, whereby a comparative study of TD children and children with ASD is conducted. Future studies could also compare the current findings to other neurodevelopmental populations with difficulties in ER ability, such as Attention-Deficit/Hyperactivity Disorder (APA, 2013; Bunford, Evans, & Langberg, 2018). This may identify similarities and differences across neurodevelopmental disorders within the ER domain, and thus inform and direct treatment intervention.

4.3. Conclusion

The current study was an investigation into the association between self-reported ER and parent/teacher-reported ER, social skills, autism severity, and mental health in school-age children with ASD without ID. Poorer levels of self-reported ER were asso- ciated with decreased social skills and increased mental health difficulties, as rated by both parents and teachers across the sample. In the context of social skills and autism severity, self- and teacher-reported ER ability were non-significant factors in explaining the variance of mental health difficulties in children aged 7–13-years with ASD. This suggests that for a community, school-based sample, social skills may be a stronger predictor of mental health difficulties, compared to ER. This study provides a valuable basis for future research exploring ER in an ASD population.

CRediT authorship contribution statement

Talia Burton: Conceptualization, Methodology, Formal analysis, Writing - original draft, Writing - review & editing,

T. Burton, et al. Research in Autism Spectrum Disorders 76 (2020) 101599

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Visualization. Belinda Ratcliffe: Conceptualization, Methodology, Formal analysis, Writing - review & editing, Visualization, Supervision. James Collison: Methodology, Formal analysis, Writing - review & editing, Visualization, Supervision. David Dossetor: Investigation, Writing - review & editing, Supervision. Michelle Wong: Investigation, Writing - review & editing, Supervision.

Declaration of Competing Interest

No actual or potential conflicts of interest exist for this research study.

Acknowledgements

We would like to gratefully acknowledge and thank the Children’s Hospital at Westmead and Western Sydney University for their support of this project. We would also like to acknowledge and thank the NSW Department of Education and Communication for their partnership in this project and their support in organising the initial data collection and the time given by the school counsellors, teachers and parents.

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