1. Alcañiz M, Chicchi-Giglioli IA, Carrasco-Ribelles LA, Marín-Morales J, Minissi ME, Teruel-García G, Sirera M, Abad L. Eye gaze as a biomarker in the recognition of autism spectrum disorder using virtual reality and machine learning: A proof of concept for diagnosis. Autism research : official journal of the International Society for Autism Research. 2022; 15(1): 131-45.

The core symptoms of autism spectrum disorder (ASD) mainly relate to social communication and interactions. ASD assessment involves expert observations in neutral settings, which introduces limitations and biases related to lack of objectivity and does not capture performance in real-world settings. To overcome these limitations, advances in technologies (e.g., virtual reality) and sensors (e.g., eye-tracking tools) have been used to create realistic simulated environments and track eye movements, enriching assessments with more objective data than can be obtained via traditional measures. This study aimed to distinguish between autistic and typically developing children using visual attention behaviors through an eye-tracking paradigm in a virtual environment as a measure of attunement to and extraction of socially relevant information. The 55 children participated. Autistic children presented a higher number of frames, both overall and per scenario, and showed higher visual preferences for adults over children, as well as specific preferences for adults’ rather than children’s faces on which looked more at bodies. A set of multivariate supervised machine learning models were developed using recursive feature selection to recognize ASD based on extracted eye gaze features. The models achieved up to 86% accuracy (sensitivity = 91%) in recognizing autistic children. Our results should be taken as preliminary due to the relatively small sample size and the lack of an external replication dataset. However, to our knowledge, this constitutes a first proof of concept in the combined use of virtual reality, eye-tracking tools, and machine learning for ASD recognition. LAY SUMMARY: Core symptoms in children with ASD involve social communication and interaction. ASD assessment includes expert observations in neutral settings, which show limitations and biases related to lack of objectivity and do not capture performance in real settings. To overcome these limitations, this work aimed to distinguish between autistic and typically developing children in visual attention behaviors through an eye-tracking paradigm in a virtual environment as a measure of attunement to, and extraction of, socially relevant information.

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2. Chinawa JM, Chinawa AT, Ossai EN, Duru CO. Predictors of pulmonary hypertension among children with atrial septal defects (ASD). The Libyan journal of medicine. 2022; 17(1): 2007603.

INTRODUCTION: Atrial septal defect (ASD) is a common congenital heart disease in children that uncommonly presents with pulmonary hypertension. Much is not known about the exact predictor of PAH in children with ASD. OBJECTIVES: This study aimed to determine the predictors of pulmonary hypertension in children with ASD. PATIENTS AND METHODS: This was a descriptive analysis of children with ASD carried out in three different institutions over a five-year period. Data entry and analysis were done using IBM Statistical Package for Social Sciences (SPSS) statistical software, version 25. RESULTS: The majority of the participants, 52.2%, had pulmonary hypertension and 62.5% of them occurred as mild pulmonary hypertension. There was a very weak positive correlation between pulmonary hypertension and the size of atrial septal defect, increases in size of atrial septal defect correlate with increases in pulmonary hypertension and this was found not to be statistically significant (n = 67, r = 0.193, p = 0.118). There was a positive correlation between the size of atrial septal defect and the age of participants in months, increases in age correlate with increases in size of atrial septal defect and this was found to be statistically significant (n = 67, r = 0.357, p = 0.003).The highest proportion of respondents who had pulmonary hypertension, 64.7%, was seen among children less than 1 year old while the least proportion, 27.3%, was within 1-5 years, and the difference in proportions was found to be statistically significant (χ(2) = 8.187, p = 0.017). CONCLUSION: Pulmonary hypertension in children with ASD occur usually in the mild form. Age is the only strong predictor of PAH in children with isolated ASD.

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3. Ellis K, Moss J, Stefanidou C, Oliver C, Apperly I. The development of early social cognitive skills in neurogenetic syndromes associated with autism: Cornelia de Lange, fragile X and Rubinstein-Taybi syndromes. Orphanet journal of rare diseases. 2021; 16(1): 488.

BACKGROUND: Cornelia de Lange (CdLS), Fragile X (FXS) and Rubinstein-Taybi syndromes (RTS) evidence unique profiles of autistic characteristics. To delineate these profiles further, the development of early social cognitive abilities in children with CdLS, FXS and RTS was compared to that observed in typically developing (TD) and autistic (AUT) children. METHODS: Children with CdLS (N = 22), FXS (N = 19) and RTS (N = 18), completed the Early Social Cognition Scale (ESCogS). Extant data from AUT (N = 19) and TD (N = 86) children were used for comparison. RESULTS: Similar to AUT children, children with CdLS, FXS and RTS showed an overall delay in passing ESCogS tasks. Children with CdLS showed a similar degree of delay to AUT children and greater delay than children with FXS and RTS. The CdLS, FXS and RTS groups did not pass tasks in the same sequence observed in TD and AUT children. Children with CdLS (p = 0.04), FXS (p = 0.02) and RTS (p = 0.04) performed better on tasks requiring understanding simple intentions in others significantly more than tasks requiring joint attention skills. CONCLUSIONS: An underlying mechanism other than general cognitive delay may be disrupting early social cognitive development in children with CdLS, FXS and RTS. Factors that may disrupt early social cognitive development within these syndromes are discussed.

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4. Fumagalli L, Nicoli M, Villa L, Riva V, Vicovaro M, Casartelli L. The (a)typical burden of COVID-19 pandemic scenario in Autism Spectrum Disorder. Scientific reports. 2021; 11(1): 22655.

Psychological and mental health consequences of large-scale anti-contagion policies are assuming strong relevance in the COVID-19 pandemic. We proposed a specific focus on a large sample of children with Autism Spectrum Disorder (ASD), developing an ad hoc instrument to investigate changes occurred in specific (sub-)domains during a period of national lockdown (Italy). Our questionnaire, named AutiStress, is both context-specific (being set in the COVID-19 pandemic scenario) and condition-specific (being structured taking into account the autistic functioning peculiarities in the paediatric age). An age- and gender-matched group of neurotypical (TD) controls was also provided. As expected, the severe lockdown policies had a general negative impact both on ASD and TD children, reflecting the obvious burden of the pandemic situation. However, our findings also indicate that children with ASD experienced more positive changes than TD ones. Noteworthy, we report a thought-provoking double dissociation in the context-specific predictor (i.e., accessibility to private outdoor spaces), indicating that it impacts differently on the two groups. Focusing on the ASD group, results suggest a condition-specific impact of the COVID-19 pandemic on core autistic (sub-)domains. Taken together, our data call for a multi-layered, context- and condition-specific analysis of the pandemic burden beyond any oversimplification.

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5. Gentles S, Duku E, Kerns C, McVey AJ, Hunsche MC, Ng Cordell EC, Bednar ED, Banfield L, Szatmari P, Georgiades S. Trajectory research in children on the autism spectrum: a scoping review protocol. BMJ open. 2021; 11(11): e053443.

INTRODUCTION: Longitudinal trajectory methods, featuring outcome assessments at three or more time points, are increasingly being used as appropriate approaches to understand developmental pathways of people on the autism spectrum across the lifespan. Understanding the scope of this rapidly expanding body of research can help inform future trajectory studies and identify areas for potential meta-analysis as well as key evidence gaps. We present the protocol for a scoping review whose objective is to identify and summarise the scope of research that uses a longitudinal trajectory study design to examine development in children diagnosed with autism. Specifically, we will identify outcome domains and age intervals that have been well characterised, areas where further research is needed and the historical use of various longitudinal trajectory analytical approaches. METHODS AND ANALYSIS: We outline the methods for the proposed scoping review according to the framework outlined by Arksey and O’Malley, with subsequent clarifications and enhancements by other authors. Using a search strategy developed by a medical librarian, we will search six databases for relevant publications. Titles and abstracts will be screened in duplicate, followed by full-text screening. Data extraction fields developed predominantly a priori from a set of guiding subquestions will be used to chart relevant data. The findings will include quantitative aggregate summaries, narrative summaries, and appraisal of trajectory studies according to our methodological subquestions. We will consult autistic self-advocate and parent-caregiver stakeholders to facilitate interpretation of the findings. ETHICS AND DISSEMINATION: Research ethics approval is not required for this scoping review. The results will be presented to researcher, care professional, policy-maker and stakeholder audiences at local and international conferences, other dissemination activities and published in a peer-reviewed journal.

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6. Hálfdánarson Ó, Cohen JM, Karlstad Ø, Cesta CE, Bjørk MH, Håberg SE, Einarsdóttir K, Furu K, Gissler M, Hjellvik V, Kieler H, Leinonen MK, Nørgaard M, Öztürk Essen B, Ulrichsen SP, Reutfors J, Zoega H. Antipsychotic use in pregnancy and risk of attention/deficit-hyperactivity disorder and autism spectrum disorder: a Nordic cohort study. Evidence-based mental health. 2022; 25(2): 54-62.

BACKGROUND: Antipsychotics are increasingly used among women of childbearing age and during pregnancy. OBJECTIVE: To determine whether children exposed to antipsychotics in utero are at increased risk of attention-deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD), accounting for maternal diagnoses of bipolar, psychotic and other psychiatric disorders. Design Population-based cohort study, including a sibling analysis. Setting Nationwide data on all pregnant women and their live-born singletons in Denmark (1997-2017), Finland (1996-2016), Iceland (2004-2017), Norway (2004-2017), and Sweden (2006-2016). Participants 4 324 086 children were eligible for inclusion to the study cohort. Intervention Antipsychotic exposure in utero, assessed by pregnancy trimester, type of antipsychotic, and varying patterns of use. Main outcome measures Non-mutually exclusive diagnoses of ADHD and ASD. We used Cox proportional hazard models to calculate hazard ratios (HRs) controlling for maternal psychiatric disorders and other potential confounding factors. FINDINGS: Among 4 324 086 singleton births, 15 466 (0.4%) were exposed to antipsychotics in utero. During a median follow-up of 10 years, we identified 72 257 children with ADHD and 38 674 children with ASD. Unadjusted HRs were raised for both outcomes but shifted substantially towards the null after adjustment; 1.10 (95%CI 1.00 to 1.27) for ADHD and 1.12 (0.97 to 1.29) for ASD. Adjusted HRs remained consistent by trimester of exposure and type of antipsychotic. Comparing in utero exposure with pre-pregnancy use yielded HRs of 0.74 (0.62 to 0.87) for ADHD and 0.88 (0.70 to 1.10) for ASD. Sibling analyses yielded HRs of 1.14 (0.79 to 1.64) for ADHD and 1.34 (0.75 to 2.39) for ASD. DISCUSSION: Our findings suggest little or no increased risk of child ADHD or ASD after in utero exposure to antipsychotics. CLINICAL IMPLICATIONS: Results regarding child neurodevelopment are reassuring for women who need antipsychotics during pregnancy.

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7. Martin LJ, Poulson SJ, Mannan E, Sivaselvachandran S, Cho M, Setak F, Chan C. Altered nociceptive behavior and emotional contagion of pain in mouse models of autism. Genes, brain, and behavior. 2022; 21(1): e12778.

Individuals with autism spectrum disorder (ASD) have altered sensory processing but may ineffectively communicate their experiences. Here, we used a battery of nociceptive behavioral tests to assess sensory alterations in two commonly used mouse models of ASD, BTBR T(+) Itpr3(tf) /J (BTBR), and fragile-X mental retardation-1 knockout (Fmr1-KO) mice. We also asked whether emotional contagion, a primitive form of empathy, was altered in BTBR and Fmr1 KO mice when experiencing pain with a social partner. BTBR mice demonstrated mixed nociceptive responses with hyporesponsivity to mechanical/thermal stimuli and intraplantar injections of formalin and capsaicin while displaying hypersensitivity on the acetic acid test. Fmr1-KO mice were hyposensitive to mechanical stimuli and intraplantar injections of capsaicin and formalin. BTBR and Fmr1-KO mice developed significantly less mechanical allodynia following intraplantar injections of complete Freund’s adjuvant, while BTBR mice developed slightly more thermal hyperalgesia. Finally, as measured by the formalin and acetic acid writhing tests, BTBR and Fmr1-KO mice did not show emotional contagion of pain. In sum, our findings indicate that depending on the sensation, pain responses may be mixed, which reflects findings in ASD individuals.

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8. Pietropaolo S, Marsicano G. The role of the endocannabinoid system as a therapeutic target for autism spectrum disorder: Lessons from behavioral studies on mouse models. Neuroscience and biobehavioral reviews. 2022; 132: 664-78.

Recent years have seen an impressive amount of research devoted to understanding the etiopathology of Autism Spectrum Disorder (ASD) and developing therapies for this syndrome. Because of the lack of biomarkers of ASD, this work has been largely based on the behavioral characterization of rodent models, based on a multitude of genetic and environmental manipulations. Here we highlight how the endocannabinoid system (ECS) has recently emerged within this context of mouse behavioral studies as an etiopathological factor in ASD and a valid potential therapeutic target. We summarize the most recent results showing alterations of the ECS in rodent models of ASD, and demonstrating ASD-like behaviors in mice with altered ECS, induced either by genetic or pharmacological manipulations. We also give a critical overview of the most relevant advances in designing treatments and novel mouse models for ASD targeting the ECS, highlighting the relevance of thorough and innovative behavioral approaches to investigate the mechanisms acting underneath the complex features of ASD.

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9. Préfontaine I, Morizot J, Lanovaz MJ, Rivard M. Changes in Autistic Symptoms and Adaptive Functioning of Children Receiving Early Behavioral Intervention in a Community Setting: A Latent Growth Curve Analysis. Journal of autism and developmental disorders. 2021.

Despite showing effects in well-controlled studies, the extent to which early intensive behavioral intervention (EBI) produces positive changes in community-based settings remains uncertain. Thus, our study examined changes in autistic symptoms and adaptive functioning in 233 children with autism receiving EBI in a community setting. The results revealed nonlinear changes in adaptive functioning characterized by significant improvements during the intervention and a small linear decrease in autistic symptoms from baseline to follow-up. The intensity of intervention, initial age, IQ and autistic symptoms were associated either with progress during the intervention or maintenance during the follow-up. The next step to extend this line of research involves collecting detailed data about intervention strategies and implementation fidelity to produce concrete recommendations for practitioners.

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10. Qian Y, Zhou Y, Wu B, Chen H, Xu S, Wang Y, Zhang P, Li G, Xu Q, Zhou W, Xu X, Wang H. Novel Variants of the SMARCA4 Gene Associated with Autistic Features Rather Than Typical Coffin-Siris Syndrome in Eight Chinese Pediatric Patients. Journal of autism and developmental disorders. 2021.

Autism spectrum disorders (ASDs) are a group of neurodevelopmental-related disorders with a high genetic risk. Recently, chromatin remodeling factors have been found to be related to ASDs. SMARCA4 is such a catalytic subunit of the chromatin-remodeling complex. In this report, we identified seven novel missense variants in the SMARCA4 gene from eight pediatric patients. All eight patients had moderate to severe intellectual disability, and seven showed autistic/likely autistic features. Compared with the patients reported in the literature, our patients were less likely to show craniofacial or finger/toe anomalies. Our findings further supported that SMARCA4 is associated with ASDs. We suggest that individuals with the abovementioned phenotypes should consider genetic testing.

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11. Ratto AB, Reimann G, Nadwodny N. Dual Language Learning Predicts Improved Executive Functioning in Youth with Autism. Journal of autism and developmental disorders. 2021.

Previous findings show executive functioning advantages associated with dual language learning (DLL) among neurotypical individuals, yet few studies have investigated these effects in youth with autism spectrum disorder (ASD). The present study investigated effects of DLL and socioeconomic status (SES) on parent-reported executive functioning, verbal ability, and social-emotional functioning using a sample of DLL (n = 53) and monolingual (n = 106) youth with ASD without intellectual disability, matched on gender and full-scale IQ scores. After controlling for the effects of SES, results showed that monolingual youth had better outcomes on verbal ability, while DLL youth had fewer parent-reported problems with executive functioning and unusual behaviors. These findings indicate that bilingualism may mitigate executive functioning deficits in youth with ASD.

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12. Rios K, Aleman-Tovar J, Burke M. Exploring Patterns of Advocacy and Well-Being of Parents of Children With Intellectual and Developmental Disabilities. Intellectual and developmental disabilities. 2021; 59(6): 459-71.

Advocacy is often an expectation for parents of children with intellectual and developmental disabilities (IDD). However, little is known about how advocacy may impact parent well-being, including stress, family dynamics, and marital relationships. By exploring the effects of advocacy on well-being, interventions can be implemented to support both the advocacy and well-being of parents of children with IDD. To this end, the purpose of the study was to explore the pattern between positive and negative advocacy experiences of parents of children with IDD and the well-being of parents, families, and marriages. Semi-structured interviews were conducted with 38 parents of children with IDD. Regardless of the nature (i.e., positive, or negative) of the advocacy experience, participants reported that advocacy increased their stress. When the advocacy experience was positive, some participants reported improved family quality of life. Also, regardless of the nature of the advocacy experience, some participants reported feeling frustration within their marital relationships. Implications for future research and practice are discussed.

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13. Rothman EF, Heller S, Graham Holmes L. Sexual, physical, and emotional aggression, experienced by autistic vs. non-autistic U.S. college students. Journal of American college health : J of ACH. 2021: 1-9.

ObjectiveTo compare rates of aggression victimization for autistic vs. non-autistic U.S. college students. Participants: n = 1,411 autistic and n = 218,430 non-autistic students from 78 colleges. Methods: We used a three-way interaction term to examine moderation of the relationship between autism and sexual, physical and emotional aggression victimization by depression and sense of belonging. Results: Autistic students were nearly twice as likely as non-autistic students to report past-year emotional victimization (44% vs. 26%, p < 0.001), and more likely to report physical victimization (8.4% vs. 5.7%, p < 0.001). Autistic students who experienced sexual assault were 2.23 times more likely than non-autistic students to report it affected academic performance (80.4% vs. 36.0%, p < 0.001). At both low and high levels of depression, sense of belonging was protective against physical and sexual victimization for autistic students more than for non-autistic students. Conclusions: Institutions of higher education should prioritize preventing and responding to interpersonal aggression against autistic students.

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14. Sari NP, Luijk M, Prinzie P, van IMH, Jansen PW. Children’s autistic traits and peer relationships: do non-verbal IQ and externalizing problems play a role?. Child and adolescent psychiatry and mental health. 2021; 15(1): 67.

BACKGROUND: Children with autism have difficulties in understanding relationships, yet little is known about the levels of autistic traits with regard to peer relationships. This study examined the association between autistic traits and peer relationships. Additionally, we examined whether the expected negative association is more pronounced in children with a lower non-verbal IQ and in those who exhibit more externalizing problems. METHOD: Data were collected in a large prospective birth cohort of the Generation R Study (Rotterdam, the Netherlands) for which nearly 10,000 pregnant mothers were recruited between 2002 and 2006. Follow up data collection is still currently ongoing. Information on peer relationships was collected with PEERS application, an interactive computerized task (M = 7.8 years). Autistic traits were assessed among general primary school children by using the Social Responsiveness Scale (M = 6.1 years). Information was available for 1580 children. RESULT: Higher levels of autistic traits predicted lower peer acceptance and higher peer rejection. The interaction of autistic traits with externalizing problems (but not with non-verbal IQ or sex) was significant: only among children with low externalizing problems, a higher level of autistic traits predicted less peer acceptance and more peer rejection. Among children exhibiting high externalizing problems, a poor peer acceptance and high level of rejection is seen independently of the level of autistic traits. CONCLUSION: We conclude that autistic traits-including traits that do not classify as severe enough for a clinical diagnosis-as well as externalizing problems negatively impact young children’s peer relationships. This suggests that children with these traits may benefit from careful monitoring and interventions focused at improving peer relationships.

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15. Smith SE, McCann HP, Urbano RC, Dykens EM, Hodapp RM. Training Healthcare Professionals to Work With People With Intellectual and Developmental Disabilities. Intellectual and developmental disabilities. 2021; 59(6): 446-58.

This study assessed 155 healthcare providers, from nine disciplines, who work professionally with people with intellectual and developmental disabilities (IDD). Using a national, web-based survey, respondents rated their experience, comfort, and competence in treating individuals with different disability types and preferred methods of continuing education; respondents also provided suggestions for attracting others to work with the IDD population. Findings revealed that experiences, comfort, and competence were all higher concerning persons with autism spectrum disorder (ASD) and intellectual disability (ID), lower for those with deaf-blindness. Overall, levels of experience exceeded levels of comfort, which in turn exceeded levels of competence. The most helpful venues for continued training involved day-to-day contact with persons with IDD, which also characterized open-ended responses. Research and practical implications are discussed.

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16. Spruit S, Carter EW. Friendships Through Inclusive Postsecondary Education Programs: Perspectives of Current and Former Students With Intellectual and Developmental Disabilities. Intellectual and developmental disabilities. 2021; 59(6): 487-501.

The formation of friendships is central to the college experience. Yet little is known about the relationships young adults with intellectual and developmental disabilities form through their inclusive postsecondary education programs or maintain after graduation. We interviewed 12 current students and alumni about their social networks and their views regarding friendships. Participants shared their perspectives on the multiple meaning of friendship, the size and composition of their social networks, and the areas in which college has positively impacted their social lives. We offer recommendations for research and practice aimed at understanding and enhancing friendship formation within the inclusive higher education movement.

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17. Turriziani L, Ricciardello A, Cucinotta F, Bellomo F, Turturo G, Boncoddo M, Mirabelli S, Scattoni ML, Rossi M, Persico AM. Gut mobilization improves behavioral symptoms and modulates urinary p-cresol in chronically constipated autistic children: A prospective study. Autism research : official journal of the International Society for Autism Research. 2022; 15(1): 56-69.

Chronic constipation is common among children with ASD and is associated with more severe hyperactivity, anxiety, irritability, and repetitive behaviors. Young autistic children with chronic constipation display higher urinary, and foecal concentrations of p-cresol, an aromatic compound produced by gut bacteria, known to negatively affect brain function. Acute p-cresol administration to BTBR mice enhances anxiety, hyperactivity and stereotypic behaviors, while blunting social interaction. This study was undertaken to prospectively assess the behavioral effects of gut mobilization in young autistic children with chronic constipation, and to verify their possible correlation with urinary p-cresol. To this aim, 21 chronically constipated autistic children 2-8 years old were evaluated before (T0), 1 month (T1), and 6 months (T2) after intestinal mobilization, recording Bristol stool scale scores, urinary p-cresol concentrations, and behavioral scores for social interaction deficits, stereotypic behaviors, anxiety, and hyperactivity. Gut mobilization yielded a progressive and highly significant decrease in all behavioral symptoms over the 6-month study period. Urinary p-cresol levels displayed variable trends not significantly correlated with changes in behavioral parameters, mainly increasing at T1 and decreasing at T2. These results support gut mobilization as a simple strategy to ameliorate ASD symptoms, as well as comorbid anxiety and hyperactivity, in chronically constipated children. Variation in p-cresol absorption seemingly provides limited contributions, if any, to these behavioral changes. Further research will be needed to address the relative role of reduced abdominal discomfort following mobilization, as compared to specific modifications in microbiome composition and in gut bacteria-derived neuroactive compounds.

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18. Wasson Simpson KS, Gallagher A, Ronis ST, Miller DAA, Tilleczek KC. Youths’ Perceived Impact of Invalidation and Validation on Their Mental Health Treatment Journeys. Administration and policy in mental health. 2022; 49(3): 476-89.

Youths’ experiences in seeking and accessing help for mental health problems can have pervasive and lasting effects on personal and interpersonal functioning. In particular, youth who experience validating experiences presumably persevere in seeking help and generally have positive treatment outcomes, whereas youth who experience invalidation are also likely to experience, at least in the short term, ruptures in therapeutic relationships, shame, and reluctance to seek services. The goal of the current study was to expand on previous research assessing youths’ interactions with mental health providers, allied professionals, family members, and peers, with a focus on subjective experiences of validation and invalidation. The current study investigated both validating and invalidating experiences in seeking, accessing, and maintaining professional services among 31 Canadian youth (n = 20 girls, n = 11 boys; 12 to 21 years old [M = 16.97, SD = 2.01]) who were diagnosed or self-identified with at least one of five conditions: depression (n = 26), anxiety (n = 22), eating disorders (n = 9), autism spectrum disorder (n = 2), or conduct disorder or oppositional defiant disorder (n = 2). Youth were recruited using convenience (e.g., posted advertisements in mental health clinics) and snowball sampling methods. Journey mapping methodology (i.e., participants created visual representations of milestones of their mental health journeys) was employed accompanied by semi-structured interviews to prompt youth to expand on their experiences (e.g., « Could you describe what was happening in your life when you first felt you would need support for your mental health? »). Four themes emerged using inductive thematic analysis, marked by the presence (validation) or lack (invalidation) of: feeling heard, feeling seen, feeling understood, and receiving helpful actions. Participants also reported key consequences of validation and invalidation. Findings broaden a conceptualization of validation across supportive relationships and an understanding of factors that enhance or impede the formation or maintenance of therapeutic relationships with youth. Clinical implications and limitations are discussed.

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