Abstract
Purpose
Many individuals with autism spectrum disorder (ASD) experience challenges with facial emotion recognition (FER), which may exacerbate social difficulties in ASD. Few studies have examined whether FER can be experimentally manipulated and improved for autistic people. This study utilized a randomized controlled trial design to examine acceptability and preliminary clinical impact of a novel mixed reality-based neurofeedback program, FER Assistant, using EEG brain computer interface (BCI)-assisted technology to improve FER for autistic adolescents and adults.
Methods
Twenty-seven autistic male participants (M age: 21.12 years; M IQ: 105.78; 85% white) were randomized to the active condition to receive FER Assistant (n = 17) or waitlist control (n = 10). FER Assistant participants received ten sessions utilizing BCI-assisted neurofeedback training in FER. All participants, regardless of randomization, completed a computerized FER task at baseline and endpoint.
Results
Results partially indicated that FER Assistant was acceptable to participants. Regression analyses demonstrated that participation in FER Assistant led to group differences in FER at endpoint, compared to a waitlist control. However, analyses examining reliable change in FER indicated no reliable improvement or decline for FER Assistant participants, whereas two waitlist participants demonstrated reliable decline.
Conclusion
Given the preliminary nature of this work, results collectively suggest that FER Assistant may be an acceptable intervention. Results also suggest that FER may be a potential mechanism that is amenable to intervention for autistic individuals, although additional trials using larger sample sizes are warranted.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Adolphs, R. (2002). Neural systems for recognizing emotion. Current Opinion in Neurobiology, 12(2), 169–177. https://doi.org/10.1016/S0959-4388(02)00301-X.
Amaral, C. P., Simões, M. A., Mouga, S., Andrade, J., & Castelo-Branco, M. (2017). A novel brain computer interface for classification of social joint attention in autism and comparison of 3 experimental setups: A feasibility study. Journal of Neuroscience Methods, 290, 105–115. https://doi.org/10.1016/j.jneumeth.2017.07.029.
Amaral, C., Mouga, S., Simões, M., Pereira, H. C., Bernardino, I., Quental, H., & Castelo-Branco, M. (2018). A feasibility clinical trial to improve social attention in autistic spectrum disorder using a brain computer interface. Frontiers in Neuroscience, 12, 1–13.
Anagnostou, E., Soorya, L., Chaplin, W., Bartz, J., Halpern, D., Wasserman, S., & Hollander, E. (2012). Intranasal oxytocin versus placebo in the treatment of adults with autism spectrum disorders: A randomized controlled trial. Molecular Autism, 3(1), 16. https://doi.org/10.1186/2040-2392-3-16.
Antezana, L., Factor, R. S., Condy, E. E., Strege, M. V., Scarpa, A., & Richey, J. A. (2019). Gender differences in restricted and repetitive behaviors and interests in youth with autism. Autism Research, 12(2), 274–283. https://doi.org/10.1002/aur.2049.
Baron-Cohen, S., Leslie, A. M., & Frith, U. (1985). Does the autistic child have a theory of mind? Cognition, 21(1), 37–46. https://doi.org/10.1016/0010-0277(85)90022-8.
Baron-Cohen, S., Wheelwright, S., Hill, J., Raste, Y., & Plumb, I. (2001). The reading the mind in the eyes test revised version: A study with normal adults, and adults with Asperger syndrome or high-functioning autism. The Journal of Child Psychology and Psychiatry and Allied Disciplines, 42(2), 241–251. https://doi.org/10.1017/S0021963001006643.
Berggren, S., Fletcher-Watson, S., Milenkovic, N., Marschik, P. B., Bölte, S., & Jonsson, U. (2018). Emotion recognition training in autism spectrum disorder: A systematic review of challenges related to generalizability. Developmental Neurorehabilitation, 21(3), 141–154. https://doi.org/10.1080/17518423.2017.1305004
Brain Research Through Advancing Innovative Neurotechnologies (BRAIN) Working Group. (2014). BRAIN Working Group Report to the Advisory Committee to the Director. NIH.
Charman, T., & Gotham, K. (2013). Measurement issues: Screening and diagnostic instruments for autism spectrum disorders–lessons from research and practise. Child and Adolescent Mental Health, 18(1), 52–63. https://doi.org/10.1111/j.1475-3588.2012.00664.x.
Chevallier, C., Kohls, G., Troiani, V., Brodkin, E. S., & Schultz, R. T. (2012). The social motivation theory of autism. Trends in Cognitive Sciences, 16(4), 231–239. https://doi.org/10.1016/j.tics.2012.02.007.
Ciccarelli, G., Federico, G., Mele, G., Di Cecca, A., Migliaccio, M., Ilardi, C. R., & Cavaliere, C. (2023). Simultaneous real-time EEG-fMRI neurofeedback: A systematic review. Frontiers in Human Neuroscience, 17, 1–15.
Constantino, J., & Gruber, C. (2012). Social responsiveness scale: SRS-2. Western Psychological Services.
Corbett, B. A., Schwartzman, J. M., Libsack, E. J., Muscatello, R. A., Lerner, M. D., Simmons, G. L., & White, S. W. (2021). Camouflaging in Autism: Examining sex-based and Compensatory Models in Social Cognition and Communication. Autism Research, 14(1), 127–142. https://doi.org/10.1002/aur.2440.
Ekman, P. (1992). Facial expressions of emotion: An old controversy and new findings. Philosophical Transactions of the Royal Society of London Series B: Biological Sciences, 335(1273), 63–69. https://doi.org/10.1098/rstb.1992.0008.
Eldeeb, S., Susam, B. T., Akcakaya, M., Conner, C. M., White, S. W., & Mazefsky, C. A. (2021). Trial by trial EEG based BCI for distress versus non distress classification in individuals with ASD. Scientific Reports, 11(1), 1–13. https://doi.org/10.1038/s41598-021-85362-8.
Evers, K., Steyaert, J., Noens, I., & Wagemans, J. (2015). Reduced recognition of dynamic facial emotional expressions and emotion-specific response bias in children with an autism spectrum disorder. Journal of Autism and Developmental Disorders, 45(6), 1774–1784. https://doi.org/10.1007/s10803-014-2337-x.
Fernández-Abascal, E. G., Cabello, R., Fernández-Berrocal, P., & Baron-Cohen, S. (2013). Test-retest reliability of the ‘Reading the mind in the eyes’ test: A one-year follow-up study. Molecular Autism, 4(1), 1–6. https://doi.org/10.1186/2040-2392-4-33.
Friedrich, E. V., Suttie, N., Sivanathan, A., Lim, T., Louchart, S., & Pineda, J. A. (2014). Brain–computer interface game applications for combined neurofeedback and biofeedback treatment for children on the autism spectrum. Frontiers in Neuroengineering, 7, 21. https://doi.org/10.3389/fneng.2014.00021.
Friedrich, E. V., Sivanathan, A., Lim, T., Suttie, N., Louchart, S., Pillen, S., & Pineda, J. A. (2015). An effective neurofeedback intervention to improve social interactions in children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 45(12), 4084–4100. https://doi.org/10.1007/s10803-015-2523-5.
Frith, C. (2003). What do imaging studies tell us about the neural basis of autism. Autism: Neural Basis and Treatment Possibilities, 149–176. https://doi.org/10.1002/0470869380.ch10.
Golan, O., & Baron-Cohen, S. (2006). Systemizing empathy: Teaching adults with Asperger syndrome or high-functioning autism to recognize complex emotions using interactive multimedia. Development and Psychopathology, 18(2), 591–617. https://doi.org/10.1017/S0954579406060305.
Guastella, A. J., Einfeld, S. L., Gray, K. M., Rinehart, N. J., Tonge, B. J., Lambert, T. J., & Hickie, I. B. (2010). Intranasal oxytocin improves emotion recognition for youth with autism spectrum disorders. Biological Psychiatry, 67(7), 692–694. https://doi.org/10.1016/j.biopsych.2009.09.020.
Guastella, A. J., Gray, K. M., Rinehart, N. J., Alvares, G. A., Tonge, B. J., Hickie, I. B., & Einfeld, S. L. (2015). The effects of a course of intranasal oxytocin on social behaviors in youth diagnosed with autism spectrum disorders: A randomized controlled trial. Journal of Child Psychology and Psychiatry, 56(4), 444–452. https://doi.org/10.1111/jcpp.12305.
Harrop, C., Jones, D., Zheng, S., Nowell, S. W., Boyd, B. A., & Sasson, N. (2018). Sex differences in social attention in autism spectrum disorder. Autism Research, 11(9), 1264–1275. https://doi.org/10.1002/aur.1997.
Hayes, A., & Johnson, K. (2019). Cultural embodiment in virtual reality education and training: A reflection on representation of diversity. Foundations and trends in smart learning (pp. 93–96). Springer. https://doi.org/10.1007/978-981-13-6908-7_13.
Herba, C., & Phillips, M. (2004). Annotation: Development of facial expression recognition from childhood to adolescence: Behavioural and neurological perspectives. Journal of Child Psychology and Psychiatry, 45(7), 1185–1198. https://doi.org/10.1111/j.1469-7610.2004.00316.x.
Humphreys, K., Minshew, N., Leonard, G. L., & Behrmann, M. (2007). A fine-grained analysis of facial expression processing in high-functioning adults with autism. Neuropsychologia, 45(4), 685–695. https://doi.org/10.1016/j.neuropsychologia.2006.08.003.
IBM Corp (2021). IBM SPSS Statistics for Windows: Version 28.0.
Izard, C., Fine, S., Schultz, D., Mostow, A., Ackerman, B., & Youngstrom, E. (2001). Emotion knowledge as a predictor of social behavior and academic competence in children at risk. Psychological Science, 12(1), 18–23. https://doi.org/10.1111/1467-9280.00304.
Jaswal, V. K., & Akhtar, N. (2019). Being versus appearing socially uninterested: Challenging assumptions about social motivation in autism. Behavioral and Brain Sciences, 42. https://doi.org/10.1017/S0140525X18001826.
Jones, C. R., Pickles, A., Falcaro, M., Marsden, A. J., Happé, F., Scott, S. K., & Charman, T. (2011). A multimodal approach to emotion recognition ability in autism spectrum disorders. Journal of Child Psychology and Psychiatry, 52(3), 275–285. https://doi.org/10.1111/j.1469-7610.2010.02328.x.
Kaiser, T., Volkmann, C., Volkmann, A., Karyotaki, E., Cuijpers, P., & Brakemeier, E. L. (2022). Heterogeneity of treatment effects in trials on psychotherapy of depression. Clinical Psychology: Science and Practice. https://doi.org/10.1037/cps0000079.
Kennedy, D. P., & Adolphs, R. (2012). The social brain in psychiatric and neurological disorders. Trends in Cognitive Sciences, 16(11), 559–572. https://doi.org/10.1016/j.tics.2012.09.006.
Kittel, A. F. D., Olderbak, S., & Wilhelm, O. (2022). Sty in the mind’s Eye: A Meta-Analytic Investigation of the Nomological Network and Internal consistency of the reading the mind in the eyes test. Assessment, 29(5), 872–895. https://doi.org/10.1177/1073191121996469.
Ko, J. A., Miller, A. R., & Vernon, T. W. (2019). Social conversation skill improvements associated with the Social Tools and rules for teens program for adolescents with autism spectrum disorder: Results of a randomized controlled trial. Autism, 23(5), 1224–1235. https://doi.org/10.1177/1362361318808781.
Kothari, R., Skuse, D., Wakefield, J., & Micali, N. (2013). Gender differences in the relationship between social communication and emotion recognition. Journal of the American Academy of Child & Adolescent Psychiatry, 52(11), 1148–1157. https://doi.org/10.1016/j.jaac.2013.08.006.
Lee, C. S., Lam, S. H., Tsang, S. T., Yuen, C. M., & Ng, C. K. (2018). The effectiveness of technology-based intervention in improving emotion recognition through facial expression in people with autism spectrum disorder: A systematic review. Review Journal of Autism and Developmental Disorders, 5(2), 91–104. https://doi.org/10.1007/s40489-017-0125-1.
Lee, M. J. W., Georgieva, M., Alexander, B., Craig, E., & Richter, J. (2021). The state of XR and immersive learning: Outlook report 2021. https://immersivelrn.org/the-state-of-xr-and-immersive-learning/, 2021. [Last accessed 5 Feb. 2022].
Leung, F. Y. N., Sin, J., Dawson, C., Ong, J. H., Zhao, C., Veić, A., & Liu, F. (2022). Emotion recognition across visual and auditory modalities in autism spectrum disorder: A systematic review and meta-analysis. Developmental Review, 63. https://doi.org/10.1016/j.dr.2021.101000.
Livingston, L. A., Shah, P., & Happé, F. (2019). Compensation in autism is not consistent with social motivation theory. Behavioral and Brain Sciences, 42, e99. https://doi.org/10.1017/S0140525X18002388.
Lord, C., Rutter, M., DiLavore, P., Risi, S., Gotham, K., Bishop, S. L., & Guthrie, W. (2012). Autism Diagnostic Observation schedule, Second Edition (ADOS-2). Western Psychological Services.
Lozier, L. M., Vanmeter, J. W., & Marsh, A. A. (2014). Impairments in facial affect recognition associated with autism spectrum disorders: A meta-analysis. Development and Psychopathology, 26(4pt1), 933–945. https://doi.org/10.1017/S0954579414000479.
McMahon, R. J., & Forehand, R. L. (1983). Consumer satisfaction in behavioral treatment of children: Types, issues, and recommendations. Behavior Therapy, 14(2), 209–225. https://doi.org/10.1016/S0005-7894(83)80111-7.
Mulder, R., Boden, J., Carter, J., Luty, S., & Joyce, P. (2017). Ten month outcome of cognitive behavioural therapy v. interpersonal psychotherapy in patients with major depression: A randomised trial of acute and maintenance psychotherapy. Psychological Medicine, 47(14), 2540–2547.
Nielsen, L., Riddle, M., King, J. W., Aklin, W. M., Chen, W., Clark, D., & Weber, W. (2018). The NIH Science of Behavior Change Program: Transforming the science through a focus on mechanisms of change. Behaviour Research and Therapy, 101, 3–11. https://doi.org/10.1016/j.brat.2017.07.002.
Nye, A., Delgadillo, J., & Barkham, M. (2023). Efficacy of personalized psychological interventions: A systematic review and meta-analysis. Journal of Consulting and Clinical Psychology.
Peñuelas-Calvo, I., Sareen, A., Sevilla-Llewellyn-Jones, J., & Fernández-Berrocal, P. (2019). The reading the mind in the eyes test in autism-spectrum disorders comparison with healthy controls: A systematic review and meta-analysis. Journal of Autism and Developmental Disorders, 49(3), 1048–1061.
Peterson, V., Galván, C., Hernández, H., & Spies, R. (2020). A feasibility study of a complete low-cost consumer-grade brain-computer interface system. Heliyon, 6(3), e03425. https://doi.org/10.1016/j.heliyon.2020.e03425.
Petroni, A., Canales-Johnson, A., Urquina, H., Guex, R., Hurtado, E., Blenkmann, A., & Ibanez, A. (2011). The cortical processing of facial emotional expression is associated with social cognition skills and executive functioning: A preliminary study. Neuroscience Letters, 505(1), 41–46. https://doi.org/10.1016/j.neulet.2011.09.062.
Quintana, D. S., Westlye, L. T., Hope, S., Nærland, T., Elvsåshagen, T., Dørum, E., & Stensønes, E. (2017). Dose-dependent social-cognitive effects of intranasal oxytocin delivered with novel Breath powered device in adults with autism spectrum disorder: A randomized placebo-controlled double-blind crossover trial. Translational Psychiatry, 7(5), 1–9. https://doi.org/10.1038/tp.2017.103.
Ratto, A. B., Kenworthy, L., Yerys, B. E., Bascom, J., Wieckowski, A. T., White, S. W., & Anthony, L. G. (2018). What about the girls? Sex-based differences in autistic traits and adaptive skills. Journal of Autism and Developmental Disorders, 48(5), 1698–1711. https://doi.org/10.1007/s10803-017-3413-9.
Richey, J. A., Gracanin, D., LaConte, S., Lisinski, J., Kim, I., Coffman, M., & White, S. W. (2022). Neural mechanisms of facial emotion recognition in Autism: Distinct roles for anterior cingulate and dlPFC. Journal of Clinical Child & Adolescent Psychology, 1–21. https://doi.org/10.1080/15374416.2022.2051528.
Riddle, M., & Ferrer, R. (2015). The science of behavior change. APS Observer, 28(9).
Rigby, S. N., Stoesz, B. M., & Jakobson, L. S. (2018). Empathy and face processing in adults with and without autism spectrum disorder. Autism Research, 11(6), 942–955. https://doi.org/10.1002/aur.1948.
Sato, W., Uono, S., Kochiyama, T., Yoshimura, S., Sawada, R., Kubota, Y., & Toichi, M. (2017). Structural correlates of reading the mind in the eyes in autism spectrum disorder. Frontiers in Human Neuroscience, 11, 361. https://doi.org/10.3389/fnhum.2017.00361.
Schmidt, M., Newbutt, N., Schmidt, C., & Glaser, N. (2021). A process-model for minimizing adverse effects when using head mounted display-based virtual reality for individuals with autism. Frontiers in Virtual Reality, 2, 13. https://doi.org/10.3389/frvir.2021.611740.
Shanok, N. A., Jones, N. A., & Lucas, N. N. (2019). The nature of facial emotion recognition impairments in children on the autism spectrum. Child Psychiatry & Human Development, 50(4), 661–667. https://doi.org/10.1007/s10578-019-00870-z.
Strickland, D., Marcus, L. M., Mesibov, G. B., & Hogan, K. (1996). Brief report: Two case studies using virtual reality as a learning tool for autistic children. Journal of Autism and Developmental Disorders, 26(6), 651–659. https://doi.org/10.1007/BF02172354.
Sucksmith, E., Allison, C., Baron-Cohen, S., Chakrabarti, B., & Hoekstra, R. A. (2013). Empathy and emotion recognition in people with autism, first-degree relatives, and controls. Neuropsychologia, 51(1), 98–105. https://doi.org/10.1016/j.neuropsychologia.2012.11.013.
Taylor, V. J., Valladares, J. J., Siepser, C., & Yantis, C. (2020). Interracial contact in virtual reality: Best practices. Policy Insights from the Behavioral and Brain Sciences, 7(2), 132–140. https://doi.org/10.1177/2372732220943638.
Torres, J. M. M., Clarkson, T., Hauschild, K. M., Luhmann, C. C., Lerner, M. D., & Riccardi, G. (2022). Facial emotions are accurately encoded in the neural signal of those with autism spectrum disorder: A deep learning approach. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 7(7), 688–695. https://doi.org/10.1016/j.bpsc.2021.03.015.
Trevisan, D. A., & Birmingham, E. (2016). Are emotion recognition abilities related to everyday social functioning in ASD? A meta-analysis. Research in Autism Spectrum Disorders, 32, 24–42. https://doi.org/10.1016/j.rasd.2016.08.004.
Uljarevic, M., & Hamilton, A. (2013). Recognition of emotions in autism: A formal meta-analysis. Journal of Autism and Developmental Disorders, 43(7), 1517–1526. https://doi.org/10.1007/s10803-012-1695-5.
Velikonja, T., Fett, A. K., & Velthorst, E. (2019). Patterns of nonsocial and social cognitive functioning in adults with autism spectrum disorder: A systematic review and meta-analysis. JAMA Psychiatry, 76(2), 135–151. https://doi.org/10.1001/jamapsychiatry.2018.3645.
Wallace, G. L., Case, L. K., Harms, M. B., Silvers, J. A., Kenworthy, L., & Martin, A. (2011). Diminished sensitivity to sad facial expressions in high functioning autism spectrum disorders is associated with symptomatology and adaptive functioning. Journal of Autism and Developmental Disorders, 41(11), 1475–1486. https://doi.org/10.1007/s10803-010-1170-0.
Wang, A. T., Dapretto, M., Hariri, A. R., Sigman, M., & Bookheimer, S. Y. (2004). Neural correlates of facial affect processing in children and adolescents with autism spectrum disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 43(4), 481–490. https://doi.org/10.1097/00004583-200404000-00015.
Wechsler, D. (2011). WASI-II: Wechsler Abbreviated Scale of Intelligence (2nd ed.). NCS Pearson.
White, S. W. (2022). Introduction to the special issue: Experimental therapeutics in clinical child and adolescent psychology: Identifying mechanisms and moving the needle. Journal of Clinical Child & Adolescent Psychology, 51(3), 261–263. https://doi.org/10.1080/15374416.2022.2051521.
White, S. W., Richey, J. A., Gracanin, D., Bell, M. A., LaConte, S., Coffman, M., & Kim, I. (2015). The promise of neurotechnology in clinical translational science. Clinical Psychological Science, 3(5), 797–815. https://doi.org/10.1177/2167702614549801.
White, S. W., Richey, J. A., Gracanin, D., Coffman, M., Elias, R., LaConte, S., & Ollendick, T. H. (2016). Psychosocial and computer-assisted intervention for college students with autism spectrum disorder: Preliminary support for feasibility. Education and Training in Autism and Developmental Disabilities, 51(3), 307.
Widen, S. C., & Russell, J. A. (2003). A closer look at preschoolers’ freely produced labels for facial expressions. Developmental Psychology, 39(1), 114–128. https://doi.org/10.1037/0012-1649.39.1.114.
Wieckowski, A. T., & White, S. W. (2017). Application of technology to social communication impairment in childhood and adolescence. Neuroscience & Biobehavioral Reviews, 74, 98–114. https://doi.org/10.1016/j.neubiorev.2016.12.030.
Wieckowski, A. T., Flynn, L. T., Richey, J. A., Gracanin, D., & White, S. W. (2020). Measuring change in facial emotion recognition in individuals with autism spectrum disorder: A systematic review. Autism, 24(7), 1607–1628. https://doi.org/10.1177/1362361320925334.
Williams, B. T., & Gray, K. M. (2013). The relationship between emotion recognition ability and social skills in young children with autism. Autism, 17(6), 762–768. https://doi.org/10.1177/1362361312465355.
Yeung, M. K. (2022). A systematic review and meta-analysis of facial emotion recognition in autism spectrum disorder: The specificity of deficits and the role of task characteristics. Neuroscience & Biobehavioral Reviews, 133. https://doi.org/10.1016/j.neubiorev.2021.104518.
Zhang, Q., Wu, R., Zhu, S., Le, J., Chen, Y., Lan, C., & Kendrick, K. M. (2021). Facial emotion training as an intervention in autism spectrum disorder: A meta-analysis of randomized controlled trials. Autism Research, 14(10), 2169–2182. https://doi.org/10.1002/aur.2565.
Funding
This work was supported by the National Institute of Mental Health, R33MH100268-03 [PI: Richey; White]. Author L. Antezana was also funded by the National Institute of Mental Health, T32MH018951, at the time of submission.
Author information
Authors and Affiliations
Contributions
Conceptualization: S. White, J. Richey, and D. Gracanin; Methodology: J. Richey, I. Kim, and D. Gracanin; Funding Acquisition: S. White and J. Richey; Formal Analysis: A. Brewe; Investigation: L. Antezana, C. Carlton, J. Richey, D. Gracanin, and S. White; Writing – Original Draft Preparation: A. Brewe, L. Antezana, J. Richey, D. Gracanin, and S. White; Writing – Review & Editing: A. Brewe, L. Antezana, C. Carlton, J. Richey, D. Gracanin, I. Kim, and S. White.
Corresponding author
Ethics declarations
Conflict of Interest
The authors declare that there were no conflicts of interest with respect to the authorship or the publication of this article.
Clinical Trial Registration Information
This clinical trial was registered with clinicaltrials.gov (registration number: NCT03376373).
Human and Animal Rights and Informed Consent
All study procedures were approved by the institutional review board for human subject research. All participants provided informed consent.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Brewe, A.M., Antezana, L., Carlton, C.N. et al. A Randomized Trial Utilizing EEG Brain Computer Interface to Improve Facial Emotion Recognition in Autistic Adults. J Autism Dev Disord (2024). https://doi.org/10.1007/s10803-024-06436-w
Accepted:
Published:
DOI: https://doi.org/10.1007/s10803-024-06436-w