Examining the relationship between cognitive inflexibility and internalizing and externalizing symptoms in autistic children and adolescents: A systematic review and meta-analysis.

Most studies used parent-report for both CI and symptoms, which the authors flag as a source of shared method variance that can inflate the apparent link. Samples were heavily male (82 to 84% across studies), so the findings may not generalize to autistic girls and women. Most studies excluded or did not report on participants with intellectual disability, limiting applicability to that group. Only three of the 24 studies were longitudinal, so the direction of causation between CI and symptoms is not established. The authors state it is ambiguous. Co-occurring conditions (especially ADHD) were not consistently assessed or reported across the included studies, making it hard to separate the effect of ASD from that of comorbidity.

Dr. Charman has served as a paid consultant to F. Hoffmann-La Roche Ltd. and Servier, and has received royalties from Sage Publications and Guildford Publications. Dr. Russell has received royalties from Jessica Kingsley (Hachette) Publications. The remaining authors declared no conflicts.

Do not read this as evidence that cognitive inflexibility causes anxiety or behavioral problems in autistic children. The studies are mostly cross-sectional correlations, and the authors state the direction of causation is ambiguous. Also, most studies used the same parent-report method for both CI and symptoms, which can inflate the apparent link.