Thermoregulation and Air Conditioning

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The research and literature reviews collated by our TAB Research Team are not to be shared external to the Branch. These are for internal TAB use only and are intended to assist our advisors with their reasonable and necessary decision-making. Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on access or planning matters, they are to call the TAPS line for advice.

The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters

Research question:

• What medical conditions or disabilities involve an impairment in thermoregulation?
• What cooling systems are available for use in Australia?
• Is air conditioning effective in managing symptoms of thermoregulatory impairment compared to other cooling systems?

Date: 8/2/2024 Requestor: redacted s47F - personal privacy Endorsed by: Melinda s47F - personal privacy Researcher: Aaron s47F - personal privacy Cleared by: Stephanie s47F - personal privacy

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Contents

Thermoregulation and air conditioning - [Page: {number}]

Summary - [{page_number}]

Human Thermoregulation - [{page_number}]

Thermoeffectors - [{page_number}]

Conditions resulting in thermoregulation impairment - [{page_number}]

Spinal cord injury - [{page_number}]

####### Acquired brain injury - [{page_number}] ######## Parkinson’s Disease - [{page_number}] ######### Multiple Sclerosis - [{page_number}] ############ Peripheral neuropathy - [{page_number}] ############# Psychosocial conditions - [{page_number}] ################ Epilepsy and seizure disorders - [{page_number}] ################# Autism - [{page_number}] ######################## Motor neurone disease / Amyotrophic lateral sclerosis - [{page_number}] ############################ Huntington’s disease - [{page_number}] ################################ Severe burns - [{page_number}]

Management of thermoregulation impairment - [{page_number}]

Air conditioning compared to other cooling strategies - [{page_number}]

Air conditioning and other cooling systems - [{page_number}]

Cooling garments - [{page_number}]

Fans - [{page_number}]

Evaporative cooling - [{page_number}]

Air conditioning (refrigerated cooling) - [{page_number}]

Air conditioning use in Australia - [Page: {number}]

References

2. Summary

A Note: This paper is a substantial revision of a research paper originally completed in October 2019 and reviewed in February 2024.

Themeroregulation impairment can result from a wide range of health conditions and disabilities. The human thermoregulatory system involves perceptual, physiological and behavioural components. A condition may result in a thermoregulatory impairment if it affects the peripheral or central nervous systems, or if the condition impacts strength, mobility, motor control, cognition or emotional regulation.

The main types of cooling systems found in Australian homes are fans, evaporative and refrigerative air conditioners. Refrigerative air conditions, including reverse cycle air conditioners, are the most common type of air conditioner used in Australia. The cost-effectiveness of cooling systems depends on several factors including climate, location, energy prices, architectural features of the home, device running time, temperature set-point and other lifestyle factors.

There is evidence for the benefits of air conditioner use in the general population to manage the effects of heat, especially in very hot and dry climates. However, there is very little evidence comparing air conditioning with other cooling devices or strategies and very little experimental evidence showing the circumstances in which air conditioning might contribute to managing the symptoms of thermoregulation impairment.

Despite this, public health messaging and recommendations from researchers and clinicians are consistent. They suggest that simple behavioral strategies and easily accessible cooling devices have a role in managing the symptoms of themperaturegualtion impairmenet. Behavioral strategies include:

• understanding personal heat tolerance and preferences
• staying inside during the hotter times of day
• planning outdoor or strenuous activities for cooler times of day
• wearing loose or light clothing
• wearing wet clothes or wraps
• taking regular breaks from activity
• consuming cold foods and drinks
• taking cold baths or showers.

Recommended equipment or devices include:

• space coolers (including evaporative coolers and air conditioning)
• electric fans
• cooling garments.

3. Human thermoregulation

Humans are homeothermic animals, which means that human body temperature is maintained at a nearly constant level largely, but not entirely, independent of the environment. Core human body temperature is maintained at around 37°C (+/- 0.5°C), while peripheral body temperature may vary more widely (Romanovsky, 2018; Cheshire, 2016).

When the core body temperature is too low, this is called hypothermia. When the core body temperature is too high, this is called hyperthermia. Some sources refer to hypo and hyperthermia as any variation outside the normal range of core body temperature. (Romanovsky, 2018). Other sources define states more specifically as below 35°C for hypothermia and above 40°C for hyperthermia (Cheshire, 2016).

Slight changes outside the accepted range can be controlled with physiological or behavioural responses. Extreme changes to core body temperature may lead to significant injury or death (Osila et al., 2023; Cheshire, 2016). Age can affect the ability to regulate body temperature due to both physiological changes (such as changes in metabolism or the cardiovascular system) and behavioral changes (spending more time at home, reduced activity), which is why older people are more susceptible to complications from environmental extremes (Osila et al., 2023; Bennetts et al., 2020).

Themergulation is the process of maintaining body temperature by balancing heat generation and heat loss. Temperature variations are picked up by thermoreceptors on the skin or inside the body. These receptors alert the thermoregulatory centre located in the hypothalamus to enact thermoeffectors, physiological or behavioral responses that regulate body temperature.

3.1 Thermoeffectors

Physiological thermoeffectors are involuntary body processes that help to control heat loss or heat generation. They include:

• skin vasodilation or vasoconstriction
• sweating
• shivering
• piloerection
• panting.

Behavioral thermoeffectors are voluntary or instinctual complex behaviors. They include behaviours such as changing posture, drinking water, adding or removing clothing, turning on a fan or air conditioning etc (Osila et al., 2023; Romanovsky, 2018). Thermoeffectors aid in heat loss, conservation or generation by affecting one or more of the four processes of heat exchange: conduction, convection, radiation, and evaporation (Osila et al., 2023; Romanovsky, 2018; Cheshire, 2016).

Conduction

Conduction occurs when heat is transferred from one object to another object in direct contact. Materials with high conductivity are more able to draw heat away from the body. For example, water has a high conductivity and so submersion in water is a good way to draw heat from thebody (Osila et al, 2023; Romanovsky, 2018).

Convection

Convection occurs when a body is submerged in a gas or liquid. Movement of the fluid replaces layers of fluid closer to the body with fluid further from the body. The layers of fluid closer to the body have a temperature closer to the temperature of the skin, while the more distant fluid has a temperature closer to the ambient temperature. Convection therefore intensifies conduction. If the environment is hotter, the body is exposed to hotter material and so heats up faster. If the environment is colder, the body is exposed to cooler material and so cools down faster. For example, a ceiling fan cools by convection by increasing movement of air on the skin, removing warmer air closer to the body and replacing it with cooler air further from body (Osila et al, 2023; Romanovsky, 2018).

Radiation

All materials emit and absorb heat via radiation in the form of electromagnetic waves. The human body loses approximately 60% of its heat via radiation. Unlike conduction or convection, radiation does not require contact with a medium. For example, solar radiation can warm the earth despite passing through colder layers of earth’s atmosphere (Osila et al, 2023; Connor, 2022; Romanovsky, 2018; Cheshire, 2016).

Evaporation

Liquid requires energy in the form of heat to evaporate. The heat required is drawn from the environment or from the liquid itself and transferred from the liquid to the gas. For example, animals make use of evaporative cooling in the form of sweating and panting (Osila et al, 2023; Romanovsky, 2018; Lohner, 2017). Evaporation accounts for about 22-30% of heat lost from the body (Osila et al, 2023; Cheshire, 2016). Evaporation is the most efficient form of heat loss in the human body, though it can be less effective in more humid environments and does consume large amounts of water. Evaporation is the only form of heat transfer that also works when the ambient temperature is higher than the temperature of the skin (Romanovsky, 2018).

Conditions resulting in thermoregulation impairment

Some conditions can impair our thermoregulatory processes and therefore increase the risk oftemperature related health problems. The sections below describe some, though not all, conditions for which there is evidence of thermoregulatory impairment. For most conditions, whether thermoregulation impairment occurs, or whether the impairment is substantial andresults in activity limitations or participation restrictions, will vary for individuals.

Conditions that Affect Thermoregulation

The following conditions can affect thermoregulatory function:

A range of factors may impair physiological and behavioural thermoeffectors (ηosila et al., 2023; Cheshire, 2016). Even when physiological thermoregulation processes are unaffected, some conditions can impact behaviourally-mediated thermo effectors, interrupting a person’s capacity to voluntarily regulate their body temperature. For example, any condition that affects mobility may also reduce capacity for heat generation due to reduced or infrequent muscle contractions. Any condition that impairs judgement may also reduce a person’s capability to respond appropriately to changes in temperature (Cheshire, 2016). Refer to Table 1 for an incomplete list of conditions that may lead to or increase the risk of temperature related illness.

Conditions that result in dysregulation impairment can significantly impact functional capacity and quality of life, though this is not always the case. These conditions may or may not result in activity limitations or participation restrictions in activities of daily living, social or economic participation. For example, there is evidence that most people with peripheral neuropathy experience anhydrosis or some level of impairment in their ability to sweat. However, only a quarter of those with this impairement will experience higher corebody temperatures compared to the general population (Fealey, 2018) Therefore, the impairment to a thermoregulatory process (reduced ability to sweat); may not ultimately increase the risk of heat related illnesses or reduce the person’s capacity to participate in any activity.

Table 1 Conditions That May Contribute To Thermoregulation Impairment

(Source: Cheshire, 2016)

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Sjögren syndrome, multiple system atrophy, Fabry’s disease, bilateral cervical sympathectomy

Conditions that may increase thermogenesis Status epilepticus, neuroleptic malignant syndrome, malignant hyperthermia

Other conditions that may lead to thermoregulatory impairment Hypoglycemia, Diabetic ketoacidosis, Hypothyroidism, Adrenal failure, Hypopituitarism, Renal failure, Shock, Sepsis, Anorexia nervosa, Thyrotoxicosis, Pheochromocytoma

4.1 Spinal cord injury

There is evidence of impaired thermoregulation in people with spinal cord injury, mostly likely due to a combination of reduced activity of thermoreceptors to detect changes in temperature, reduced muscle mass and impairment in thermoeffectors such as sweating, vasoconstriction and vasodilation (Osila et al., 2023; Grossman et al., 2021; Zhang, 2019; Price & Trbovich, 2018; Cheshire, 2016; Girard, 2015). People with higher level of lesion show greater thermoregulatory impairment (Osila et al, 2023; Grossman et al. , 2021). There is evidence that people with spinal cord injury below the level of T6 can regulate body temperature as effectively as people without spinal cord injury (Grossman et al., 2021; Price & Trbovich, 2018).

There is some evidence that thermoregulation impairment in people with spinal cord injuries above T6 may also lead to activity limitations. For example, high or low temperatures may prevent people with tetraplegia from participating in activities outside the home (Price & Trbovich, 2018).

4.2 Acquired brain injury

Thermoregulatory impairment after brain injury (traumatic brain injury or stroke) may involve injury to the hypothalamus, changes in blood flow, vascular control and metabolism, and difficulties with mobility or judgement (Gowda et al., 2018; Cheshire, 2016; Thompson et al., 2003). There is evidence that around 70% of people experience hyperthermia during the acute phase after traumatic brain injury. This may be due to the nature of the injury, post-traumatic inflammation or post-injury infection (Thompson et al., 2003). Hyperthermia is a risk factor for secondary injury. This includes rebound hyperthermia, which is a possible consequence of rewarming after induced hypothermia (Gowda et al. , 2018; Childs & Lunn, 2013). Clinicians regularly induce hypothermia soon after the initial brain injury to prevent secondary brain injury and improve other outcomes. Thermoregulatory impairment may be more common in some people with brain injury, though affected sub-groups have not been identified (Gowda et al. , 2018).

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4.3 Parkinson’s Disease

The thermoregulation difficulties are common in people with Parkinson’s disease and may lead to difficulties with sweating, sleep, and altered perception of heat and cold (Pfeiffer, 2020; Coon & Low, 2018; Zhong et al, 2013). The presence of peripheral neuropathy in people with Parkinson’s disease can result in impairments to thermoeffectors such as vasoconstriction/dilation, sweating, and piloerection (Coon & Law, 2018). Around 30–70% of people with Parkinson’s experience problems with sweating, including hyperhidrosis (increased sweating) and hypohidrosis (reduced sweating). This may be related to neurological changes or medications used to treat core symptoms of Parkinson’s disease. Hypohidrosis can increase risk of overheating while hyperhidrosis can be uncomfortable and lead to sleep difficulties (Pfeiffer, 2020; Jost, 2017). Thermoregulatory impairment can affect well-being and quality of life for people with Parkinson’s disease:

Patients are often bothered by heat intolerance which may influence activity levels and social endeavors. Needing to frequently change clothing or bedding due to excessive sweating episodes is also problematic for patients and their caregivers, particularly when motor function is compromised. Temperature intolerance or night sweats may impair a patient’s sleep, which is often affected due to motor dysfunction or concomitant sleep disorders. Social function is also affected by sweating episodes leaving some patients to feel embarrassed contributing to social isolation (Coon & Low, 2018, p.271).

4.4 Multiple Sclerosis

The thermoregulation impairment is more researched in multiple sclerosis than any other condition. Around 60–80% of people with multiple sclerosis experience temperature sensitivity. Thermoregulatory difficulties in people with multiple sclerosis especially susceptibility to hyperthermia, may be due impaired sweating function decreased sensitivity thermoceptors hypothalamic dysfunction. Hypertheria is significant as it exacerbates symptoms including muscle weakness spasticity fatigue blurred vision pain while worsening existing difficulties balance processing speed concentration attention (Osila et al, 2023; Christogianni et al, 2022; Razi et al, 2022; Davis et al, 2018; Christogianni et al, 2018; Allen et al, 2017). Hyperthermia can induced environmental increases temperature hot baths exercise (Razi et al, 2022; Christogianni et al, 2022; Davis et al, 2018; Christogianni et al, 2018). However there evidence that regular exercise for people with multiple sclerosis improves symptoms quality life. Heat management strategies should placed when clinicians recommend an exercise program for people with multiple sclerosis (Huang et al, 2015). Cold temperatures also lead a worsening of symptoms though less common and studied (Christogianni et al, 2018).

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4.5 Peripheral neuropathy

Peripheral neuropathy is a general term for conditions that cause damage to the nerves of the peripheral nervous system. Damage can occur to large-diametre or small-diammetre nerve fibres. Large fibres mediate motor and sensory functions, while small fibres mediate autonomicfunctions, pain and temperature (Novello & Pobre, 2023; Castelli et al, 2020).

The conditions that can result in peripheral neuropathy include Guillaine-Barre syndrome, diabetes mellitus, Fabry disease, Parkinson’s disease, Ehlers Danlos syndrome, postural orthostatic tachycardia syndrome (POTS) and Sjögren syndrome. Diabetes related peripheral neuropathy is the most prevalent form of the peripheral neuropathy in developed countries (Osila et al, 2023; Fealey, 2018; Cheshire, 2016).

Pere There is evidence that most people with some form of peripheral neuropathy experience abnormalities in core body temperature. Common thermoregulatory concerns for people with peripheral neuropathy include impairments to physiological thermoeffectors such as vasoconstriction/dilation, sweating, piloerection and shivering (Fealey, 2018; Cheshire, 2016). As peripheral neuropathy is associated with reduced sensitivity of thermoreceptors, there is also reason to believe the condition may lead to disruption of behavioural thermoeffectors (Fealey, 2018).

Heat intolerance is a possible symptom of POTS. High ambient temperatures may also exacerbate core symptoms of orthostatic intolerance (Fedorowski, 2018; Landero, 2014; Goodkin & Bellew, 2014). These symptoms may be associated with the presence of small fibre neuropathy. In a study of 276 participants with POTS, Angeli et al (2024) found 35% showed altered sweat patterns, which characterised the neuropathic phenotype. A small study of 30 people with POTS found significant differences in thermal perception and pain threshold (Billig et al, 2020). POTS is also a common co-occurring condition in Ehlers Danlos syndrome, which itself can present with thermoregulatory difficulties (Colman et al, 2023; Thwaites et al, 2022; Hakim et al, 2017).

4.6 Psychosocial conditions

While there is preliminary evidence that some people with anxiety disorders show abnormalities in physiological thermoeffectors such as vasodilation and sweating (Fischer et al, 2021), psychosocial conditions may coincide with thermoregulatory impairments in the form of altered sensation or disrupted behavioural thermoeffectors (due to altered cognition, judgement or executive control). RES 319 Weather and Bipolar Disorder contains some discussion of the effects of temperature on outcomes for people with bipolar and other psychosocial conditions.

4.7 Epilepsy and Seizure Disorders

Temperature may affect epilepsy and seizure activity differently, depending on the individual, the type of epilepsy or type of seizure. Hyperthermia is both a possible trigger and a possible consequence of seizure. It may be a consequence of seizure due to excessive muscle activity or activation of the autonomic system (Pollandt & Bleck, 2018; Cheshire, 2016). Hyperthermia can also cause seizures, as in the case of febrile seizures experienced mainly by children during episodes of fever. In Dravet syndrome, seizures can follow even small temperature increases caused by higher ambient emperatures, fever, cold-warm shifts, warm baths or exercise (Gulcebi et al., 2021; Pollandt & Bleck, 2018).

Higher temperatures may also increase risk of seizure in epilepsy. Hospital admission studies in Taiwan, Germany and Korea found that seizure risk increases in colder emperatures (Chang et al, 2019; Kim et al, 2017; Rakers et al, 2017). However, these studies take place in climates that tend to have mild summers and may not generalise to Australia. For example, Rakers et al (2017) found that ambient temperatures higher than 20°C decrease therisk of seizure, though the highest recorded temperature in the study was 28°C.

Epilepsy Action Australia (n.d.) states:

Whilst research related to weather and seizures has been limited, and based in the
northern hemisphere, there is no scientific evidence that hot weather itself causes
seizures to occur in people with epilepsy. In Australia it appears most people report that
the heat, or becoming overheated, tends to increase the likelihood of seizures.

Becoming severely overheated can cause seizures, but an average hot day is not in itself the culprit.

Obviously, heat can be a major contributor to dehydration. If someone is exposed to heat for a long period of time and does not drink enough fluid, this can cause dehydration which can increase the risk of a seizure in someone with epilepsy, sometimes later in the day. When fluid loss from the body (mostly perspiration) is greater than fluid intake, it causes a change in electrolytes – a drop in sodium (salt) and glucose (sugar) levels in the body. Ultimately, this can lead to low blood sugar levels (hypoglycemia) which can also trigger seizures for some people.

4.8 Autism

People with autism may experience sensory differences such as hypo- or hypersensitivity to heat or cold (Raising Children Network, 2024; Zaniboni et al., 2023; Hidaka et al., 2023). Based on their review, Zaniboni et al suggest the following sensory differences with respect to perception of heat and cold:

• Different tactile sensitivity as well as higher variability in warm and cold detection:
• paradoxical heat sensation
• hyper-sensitivity) lower thresholds in heat and cold detection(hypo-sensitive). • Thermal processing might be related environment adoption or self-injury. • Difficulties interoception heart-rate body temperature perception) regulation identification emotions, differences hypothalamus development homeostatic regulation including metabolic rate tempera emotion This can also lead depression anxiety sleep disorders obesity(2023,p.10). 49 Motor neurone disease Amyotrophic lateral sclerosis There is lack evi regarding thermod impairments motor neuron diseases such amyotrophic lateralsclerosis ALS It likely that behavioural thermoeffector impaired considering symptoms mobility cognitive functions minimal evide people experience altered heat sensatio hypothes volume may reduced Physiological thermoeffectors shivering affected progressive imp skeletal muscles(Dupuis et al., Much evid involvment thermoregulatory systems comes studies animal models(Rodriguez Sanchez Braun etc In their review Dupuis et al state:In our clinical experi observed ALS patients often complain feeling hot conversely unable to warm up some develop low body tempere Also, some report worsening of symptons cold weather However these symp generally not considered part core clini picture mostly because attributed muscle atrophy nerve degeneration Therefore potential thermoreg defects best knowledge have never been systematically studiedALS patients (Dupuis et al 2018 p750).Since then one study shown high rate hypothermia in people with ALS who had tracheostomy or invasive ventilation longer than five years(Nakayama et al, Huntington’s diseasThermoregulation problems sometimes reported by Huntington’s disease: some clinicians occasionally report anecdotally seem indifference cold they will dress too lightly for the weather while others profusely sweat resort cooling vests(Weydt et al. ,p. The first case study person presenting hypothermiawassubmitted year(Altiner et al., Most evide thermod impairment

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Huntington’s disease comes from animal models. These studies have shown evidence of hypothermia, weight loss, involuntary movements, as well as differences in circadian rhythms, brown adipose tissue, skeletal muscle and the hypothalamus. This suggests a possible effect of Huntington’s disease on heat retention, shivering and non-shivering thermogenesis. Development of psychiatric conditions and problems with mobility and cognitive function may also contribute to disruption of behavioural thermoeffectors. There are few studies directly investigating thermoregulation associated with Huntington’s disease in humans (Altiner et al, 2020; Weydt et al, 2018).

4.11 Severe burns

The skin plays an important role in thermoregulatory processes including heat retention, sensation, sweating, piloerection, vasodilation and vasoconstriction. When large parts of the iskin are lost or damaged, this enables increased heat loss and contributes to difficulties senying changes in temperature, thereby increasing the risk of hypothermia. People with severe burns are also at risk of hypermetabolism, which can lead to hyperthermia, excessive sweating, weight loss, muscle wasting and other symptoms (Radzikowska-Büchner et al, 2023; Mertin et al, 2022). In cases of severe burn injury, metabolic changes can last up to three years after the initial injury and function of damaged skin may not return (Radzkowskabuchner et al, 2023; Jeshke et al, 2011).

5. Management of Thermoregulation Impairment

Researchers and clinicians have recommended behavioural strategies to manage thermoregulation impairment in people with multiple sclerosis (Christogianni et al, 2022; Davis et al, 2018), autism (Zaniboni et al, 2023), and spinal cord injury (Girard, 2015). Behavioural strategies can include moving to a cooler area, planning activities for cooler times of the day, taking regular breaks from strenuous activity, choosing weather appropriate clothing or gradual acclimatisation in warmer or colder temperatures (Healthdirect, 2024; Zaniboni et al, 2023; Grossman et al, 2021; Davis et al, 2018; Girard, 2015; Australian Red Cross, n.d.). Standard first line treatment for hyperthermia includes cooling strategies that are usually lowcost or readily accessible: air conditioning, misting fans, cold bath or shower, drinking cold water and applying cold packs or ice packs (Healthdirect, 2024; Grossman et al, 2021; Christogianni et al, 2022; Davis et al, 2018; Gowda et al, 2018; Hopkins et al, 2018; Zawardska et al, 2017; Cheshire, 2016; Australian Red Cross, n.d.). These non-invasive methods are less easy to control than invasive cooling strategies such as intravenous injection of cooling substances. Where non-invasive strategies succeed in lowering body temperature they are not easily able to maintain a stable target temperature and therefore require monitoring and adjustment (Gowda et al, 2018). There is evidence of effectiveness of non-invasive cooling strategies to improve exercise performance and lower the risk of heat related effects of exercise in the general population (Heydenreich et al, 2023; Douzi et al, 2019). There is mixed evidence for the effectiveness of

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The document was released under the Freedom of Information Act 1982 by the National Disability Insurance Agency.

non-invasive strategies in people with thermoregulatory impairment. The inconsistency in the evidence may be due to the frequency of small, low powered studies and the heterogeneity of climatic conditions and outcome measures (Grossman et al, 2021).

A review of cooling strategies for people with spinal cord injury, Grossman et al (2021) found inconsistent evidence for the temperature reducing effects of cooling garments, cold drinks and misting fans. Some studies show cooling garments reduce skin temperature but not core body temperature, whereas a consistent effect across several studies showed pre-cooling using cooling garments or other methods could improve endurance during exercise and lower rate of increase of body temperature (Grossman et al, 2021; Davis et al, 2018).

A 2023 systematic review into the use of cooling garments for people with Multiple Sclerosis found that cooling garments are effective in reducing body temperature and improving walking capacity and functional mobility (Stevens et al, 2023). The authors found no significant differences between types of cooling garment. Active treatment groups were compared with either other cooling garments, sham active controls or passive controls. No study was reviewed that compared cooling garments with other cooling strategies such as air conditioning.

5.1 Air Conditioning Compared To Other Cooling Strategies

Researchers and clinicians have recommended reducing the ambient temperature of the environment with space cooling strategies/devices as a way of managing thermoregulation impairment in people with multiple sclerosis (Christogianni et al, 2022; Davis et al, 2018), autism (Zaniboni et al, 2023), spinal cord injury (Price & Trbovich, 2018), epilepsy (Epilepsy Action Australia, n.d.), and severe burns (Radzikowska-Büchner et al, 2023).

Existing evidence indicates that air conditioning has a role in managing thermoregulatory impairment. Hospital studies show air conditioning can improve or maintain patients’ thermal comfort, recovery rates and well-being, and reduce infections and length of hospital stays. However, more research is required to determine the optimum ambient temperature to maximise patient outcomes (Lenzer et al, 2020; Shajahan et al., 2019). In the case of severe burns, raising the ambient temperature of the room to 24°C – 38°C may prevent or reduce the risk of a hypermetabolic reaction (Radzikowska-Büchner et al, 2023).

There are very few studies in which air conditioning is assessed as an intervention aimed to manage thermoregulation impairment. In a survey study of 438 heat-sensitive people with multiple sclerosis, Christogianni et al (2022) found that around three quarters used air conditioning to manage risks of overheating. However, in a review of cooling therapies/interventions for people with multiple sclerosis, Bilgin et al (2022) did not find any studies that used any conditioning as an intervention.

No studies were found comparing the use of air conditioning with other cooling methods in illness management or treatment. One study compared the use of air conditioning with electric fans in the general population (Morris et al, 2021). The authors found that electric fans are an

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FOI 25/26-1818 appropriate way to manage risk of heat stress for adults in Australia when the ambient temperature is under 38°C. However, the authors also examined older people taking redacted medication that may impair sweating function. They found impaired sweating function lowers the effectiveness of electric fans. This is because fans cool by both convection and evaporation (refer to 6.2 Fans for more detail). Therefore, the authors recommend supplementing electric fan use with air conditioning systems for people with impaired sweating function. Most recommendations cited above are based on clinical opinion. Furthermore, the ecommendations focus on achieving or maintaining cool indoor air temperatures, and rarely mention the means to achieve those temperatures. They do not differentiate between air cconditioning and other space cooling strategies (evaporative cooling, ceiling fans, passive cooling).

6. Air Conditioning and Other Cooling Systems

Common home cooling systems include fans, evaporative cooling or refrigerated cooling. sometimes the term air conditioning is used to refer to all these systems. Most often it is used to refer only to refrigerated cooling systems. Not all systems will be appropriate in all circumstances. The most appropriate air conditioning system for a person will depend on factors including: • environment – regional climate, average temperature, humidity • building – size, layout, solar power, air flow and other passive cooling features • occupancy – whole house or single room, rent or own, number of residents • lifestyle – budget, habits, cooling needs, sustainability preferences (Wrigsley, 2023; Barnes, 2023; Lockyer, 2023; Milne et al., 2020; Gilmour & Steen, n.d.).

6.1 Cooling Garments

The National Disability Insurance Agency released under the Freedom Information Act 1982 Cooling garments can include jackets, vests, hats, hoods, gloves, wrist bands and thigh straps (Stevens et al. 2023; Laique & Hussain, 2018). Ren et al (2022) identify six types of cooling mechanism used in garments:
• ice cooling – garment contains insulated pockets to hold ice • phase change materials cooling – made from a designed material that uses the latent heat from the body to lower the temperature of the microclimate between the body and the garment • radiative cooling – made from a designed material that aims to maximise heat loss allowing more infrared radiation to escape the body • thermo-electric cooling – garment contains conductors which can be used to directly draw heat energy from the body as an electric current is passed through the conductor • liquid cooling – garment contains pipes carrying cold liquid and a pump to ensure liquid is spread over the garment.

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• air-cooling – garment that maximises ventilation through the use of design and small electric fans.

6.2 Fans

Fans work by moving air around a room more quickly. They do not cool the air, but rather aid the body’s thermoregulatory processes. Faster moving air helps sweat evaporate more quickly (evaporation) and blows cooler air at the skin (convection). Fans are less effective in higher temperatures, though the exact threshold is still being debated in the literature (Morris et al, 2021; Milne et al, 2020; Iorio, 2019). Fans can be effective for healthy adults in temperatures up to 38°C (Morris et al, 2021) and may help to a lesser extent up to 42°C (Iorio, 2019). The Australian government’s Your Home site states:

Fans should be the first appliance of choice for cooling. They are cheap to run and generally use less energy than evaporative coolers or air-conditioners. Typically, the airflow created by a fan provides a similar improvement to comfort as reducing the temperature by around 3°C. With good design and insulation, fans can often supply adequate cooling for acclimatised residents in all Australian climates (Department of Climate Change, Energy, the Environment and Water; n.d.).

Fans are most effective when aimed directly toward the body, in humid climates or when used in combination with water spray, wet clothing or wraps (Morris et al, 2021; Milne et al, 2020; Iorio, 2019; Department of Climate Change, Energy, the Environment and Water; n.d.).

6.3 Evaporative Cooling

An evaporative cooler blows cool, humid air into a space by drawing outside air through a wet filter which is then expelled by a fan. An evaporative cooler may be less expensive to purchase and run than an air conditioning system, but this depends on the model. Evaporative coolers are less effective in humid environments and require large amount of water to operate (Milne et al, 2020; Department of Climate Change, Energy, the Environment and Water; n.d.).

6.4 Air Conditioning (Refrigerated Cooling)

Air conditioning systems that operates by refrigerated cooling draws warm air from inside the space and cools it via contact with a refrigerant gas. The cool air is blown back into the space and the extracted heat is expelled outside (Barnes, 2023; Milne et al, 2020; Barnes, 2019;Department of Climate Change, Energy, the Environment and Water; n.d.). Air conditioning systems can vary by cost, size, energy efficiency and type of refrigerant used. \ Air conditioners can be: • fixed or portable • single unit, split system, or multi-split system • ducted or non-ducted

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• reverse cycle or cooling only (Wrigsley, 2023; Barnes, 2023; Department of Climate Change, Energy, the Environment and Water, n.d.; Milne et al, 2020).

For comparison of purchase and running costs of different air conditioning systems in Australia, refer to 7. Air conditioning in Australia.

Reverse Cycle Air Conditioning

A reverse cycle air conditioner operates in a similar way to a cooling-only system. However, a reverse cycle system is also able to reverse the refrigeration process, sending cold air outside and warm air inside. Reverse cycle air conditioners are often considered the most efficient systems because they can provide both heating and cooling. However, energy efficiency ultimately depends on a range of factors (Department of Climate Change, Energy, the Environment and Water, n.d.; Milne et al, 2020; Barnes, 2019).

Single Unit, Split System, or Multi-Split System Air Conditioning

Split system air conditioners have an outside unit and an inside unit. They are the most common fixed air conditioning systems and are usually more energy efficient than single unit systems. Split systems can be ducted or non-ducted. Multi-split systems have an outside unit and multiple indoor units, which can be placed in different rooms. They are an alternative to ducted systems (Barnes, 2023; Department of Climate Change, Energy, the Environment and Water, n.d.; Milne et al, 2020; Barnes, 2019). Single unit systems are generally suited to smaller areas. They are generally less energy efficient than split systems. They can be fixed or portable. Portable systems are generally less expensive to purchase than fixed systems. They may be appropriate for smaller areas or when the system needs to be moved to different areas. They may also be appropriate when installing a fixed unit is not feasible, such as in rental properties (Lockyer, 2023; Milne et al, 2020; Barnes, 2019).

Ducted Air Conditioning

A ducted system is a central heating or cooling system, which means it is designed to warm or cool a whole house or building rather than a single room. Ducted systems can be evaporative coolers, reverse cycle split systems or cooling only split systems. There is usually an outdoor unit on the roof and an indoor unit under the floor or in the ceiling. Ducts extend from the indoor unit and into multiple rooms or multiple areas of a bigger space (Department of Climate Change, Energy, the Environment and Water, n.d.; Milne et al, 2020; Barnes, 2019). In terms of cost, ducted systems are generally more expensive to purchase, install and run, and therefore are generally less cost effective than non-ducted systems (refer to Table 2). Installation is a significant upfront cost for ducted systems as work is required to install the roof unit as well as ducts throughout the home. Furthermore, ducted systems are not possible in some houses due to lack of space or other architectural features (King, 2023; Mullane, 2023).

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Running costs are generally higher for ducted systems. Ducted systems may cool a large area faster than non-ducted single split units because the ductwork distributes the warm/cool air from a central unit. However, they are usually less energy efficient as they require a larger fan and some energy is lost as the warm/cool air travels through the ducts. As a central heating system, ducted air conditioning may waste energy if its cooling or heating rooms that are not in use. Running costs may be partially addressed with well insulated ducting that limits energy loss. Running rings may also be reduced by using a zoned system that allows the user to switch on off different sections of the home (Milne et al., 2020).

While ducted systems are generally less cost-effective than non-ducted systems, upfront running costs vary widely depending on several factors: climate, temperature setting, maintenance schedule, system quality and features etc.. There may be circumstances in which ducted systems ultimately more cost-effective. For example, if the user needs to cool a large house with multiple rooms or with very large rooms, a ducted system may end up less costly than installing multiple indoor units of a non-duplicated split system. In one study based in Texas, a ducted system was compared to a non-ducted multiplit split system. The authors found the ducted system was better at maintaining a constant temperature; better at humidity control and used almost 30% less energy (Bandari & Fumo, 2022). However, this study was conducted in a single house with only one model of each air conditioning system. It therefore cannot account for variables such as room size, insulation, climate etc.

Table 2 Cost comparison of ducted and non-dueted air conditionning systems

Air Conditioning use in Australia

Air conditioners are increasing in popularity usage wise within Australian dwellings ; it is now at approximately 30% in 2021 up from 22 % way back in 2003. (Australian Government , 2019). Coastal areas have a higher rate with Western Australia having the highest rates of AC penetration : 35 %(Commonwealth Scientific Industrial Research Organisation [CSIRO], 2021). The most common types of air conditioning systems used include split system units and ducted Systems . Split System accounts for around 55-60% of all sales whereas Ducted account for about 20–25%(Queensland Competition Authority, 2021), while window unit’s accounted for only 5%

Table 3 – Percentage of households with heating or cooling systems

(Source: Energy Consumers Australia, 2023)

Table – Comparison of average annual air conditioner (split system, reverse-cycle) running cost for ducted and non-ducted small, medium and large rooms in Australian capital cities

(Source: Wrigsley, 2023)

References

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Multiple sclerosis

Multiple sclerosis is a chronic autoimmune disease that affects myelin sheaths surrounding nerve fibers.

Temperature Sensitivity In Multiple Sclerosis: An Overview Of Its Impact On Sensory And Cognitive Symptoms

Christogianni et al.(2018) discuss temperature sensitivity’s impact on sensory symptoms such as pain perception changes or cognitive functions like memory impairment among people with multiple sclerosis.

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Autistic burnout

The content of this document is OFFICIAL.

Please note:

The research and literature reviews collated by our TAB Research Team are not to be shared external to the Branch. These are for internal TAB use only and are intended to assist our advisors with their reasonable and necessary decision-making.

Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on access or planning matters, they are to call the TAPS line for advice.

The Research Team unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters

Research questions:

What are the symptoms of autistic burnout? How long do symptoms typically last and how are symptoms managed? What does recovery look like after autistic burnout?

What are the usual causes or triggers of autistic burnout?

How does autistic burnout differ from occupational burnout, stress, depression or anxiety in autistic or non-autistic people?

date: 12/3/2024 Requester: redacted Endorsed by: Nicole redacted Researcher: Aaron redacted Cleared by: Stephanie redacted

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Research paper

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1. Contents

The National Disability Insurance Agency. This document was released under the Freedom of Information Act 1982.

• Autistic burnout ……………………………. 1
  • Contents ………………………….. 2
  • Summary …………………………. 2
  • Current state of research ………….. 3
  • What is autistic burnout? ……………… 3
    • Definition …………………… 3
    • Symptoms ………………….. 5
    • Triggers …………………. 6
    • Autistic burnout and other conditions … 6
  • Management ……………………… 8
  • References ………………………. 9

2. Summary

Autistic burnout is the experience of exhaustion brought on participating in activities or being in environments that are not accessible for autistic people. It has long been recognised by the autistic community as a feature of autistic people’s experience. However, the earliest formal study sourced that focusses on autistic burnout was published in 2020.

Since then, a handful of preliminary studies have focussed mainly on defining the concept, differentiating it from similar constructs, understanding how autistic burnout is experienced by persons with autism and establishing reliable outcome measures.

The symptoms described in the literature include fatigue, cognitive difficulties, loss of skills and sensory intolerance. The triggers described in the literature include the effort of suppressing or covering up autistic traits or behaviours, adopting neurotypical traits or behaviors, frequent social interaction and sensory overstimulation. The duration of autistic burnout is unclear. Episodes reported in the literature may be as short as a few hours or as long as a few years.

The relations between autistic burnout and other constructs are unclear. Autistic burnout shares similarities with depression, anxiety, chronic stress and occupational burnout. Researchers have observed that autistic burnout is described by those who experience it as having features uniquely related to their autism which often differentiates autistic burnout from other more general conditions. More research is required to clarify differences betweenthese concepts.

The only published study focused on treatment or management approach is a single case report describing successful use of stimulant medication to resolve symptoms of burnout in a young adult with autism. Some management strategies are reported by people with lived experiences.

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The experience of autistic burnout. These include withdrawing from social activities or inaccessible environments, focussing on special interests and requesting reasonable accommodations to make environments more accessible.

Current state of research

The earliest formal study sourced that focusses on autistic burnout was published in 2020 (Raymaker et al, 2020). Most research to date is qualitative, focusing on the burnout experiences of autistic people or attempting to understand or define the concept of autistic burnout. Current research examines symptoms, triggers and management strategies mostly through survey or interview-based studies (Arnold et al, 2023a-b; Øverland et al, 2022; Mantzalas et al, 2022a-b; Higgins et al, 2021; Raymaker et al, 2020). One quantitative observational study examines the relationship between autistic burnout and escapist behaviour (Pyszkowska et al, 2023).

at present, there are no validated measures of autistic burnout (Arnold et al, 2023b). Some research exists describing occupational or professional burnout experiences for people with autism, though this is intended to be a construct distinct from autistic burnout (Watanabe & Akechi, 2023; Tomczak & Kulikowski, 2023; Cage & McManemy, 2022).

Only one study was found that proposes an underlying mechanism responsible for autistic burnout (Mahony & Ryan, 2022). In this review paper, the authors suggest susceptibility to autistic burnout may be a result of early life stress or chronic adolescent stress.

More research exists focusing on phenomena overlapping or contributing to autistic burnout, such as depression, fatigue, masking, accessibility of social and occupational spaces. For example, Zhuang et al (2023) review 58 studies linking camouflaging or masking by autistic people with stress, depression, anxiety, and burnout. The literature on autistic burnout takes masking or camouflaging as central to the definition of autistic burnout (Arnold et al 2023a; Higgins et al, 2021; Raymaker et al, 2020).

What is autistic burnout?

The idea of autistic burnout originated from within the autistic community. It describes a complex experience of exhaustion brought on by the effort of suppressing or covering up autistic traits or behaviours, adopting neurotypical traits or behaviors, or frequenting inaccessible places or places not designed for autistic people (Deweert, 2020). The concept is intended to be distinct from, but analogous to, occupational burnout (Tomczak & Kulikowski, 2023; Cage & McManemy, 2022; for more on the relationship with occupational burnout, refer to section 4.4 Autistic burnout and other conditions).

Definition

There are two definitions of autistic burnout that are used in the research literature:

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Raymaker et al: Autistic burnout is a syndrome conceptualized as resulting from chronic life stress and a mismatch of expectations and abilities without adequate supports. It is characterized by pervasive long-term typically >3+< month exhaustion loss function reduced tolerance stimulus [2020](p. p.133).

**Higgins et al:*Autistic Burnout severely debilitating condition onset preceded fatigue camouflaging masking traits interpersonal interactions overload cognitive input, sensory environment unaccommodating autistic sensitivities other additional stressors changes Onset episodes may interact co occurring physical mental health conditions following criteria must be met:

• Significant mental physiological exhaustion.
• Interpersonal withdrawal With one or more significant reduction social occupational educational academic behavioural important areas functioning confusion difficulties executive function**, dissociative states Increased intensity autistic traits capacity camouflage mask e.g increased sensory sensitivity repetitive stimming behaviour difficulty engaging communication others.” The not better explained psychiatric illness such depression psychosis personality disorder trauma related disorders Extended chronically episodic autism burnout may precede brief intermittent episode[2021] (pp.p .26). Raymaker et al(2020) based definition on interviews people experienced burnt out thematic analysis online sources including blogs Higgins et al 2021 base their Delphi consensus process participants lived expertise autistic burnout There overlap between these definitions compatible with each Raymaker et al refer chronic life stress mismatch expectations abilities whereas Higgins expand specifying stressor inaccessible situations(masking, social situation,sensory cognitve load The most difference in timeframe Raymaker reserve diagnosis symptoms lasting longer than three months In contrast Higgins found reported widely varied duration hours days to month years Arnold argue currently insufficient information determine typical duration of autistic burnout

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Aailable research has not formed a consensus on the best definition. Mantzalas et al (2022b) orse the definition from Raymaker et al, though without considering the definition from This Higgins et al. An Australian study of 141 people who had experienced autistic burnout found dat most participants strongly endorsed the definition from Higgins et al (Arnold et al, 2023a). of note, the studies reported in Higgins et al (2021) and Arnold et al (2023a) were conducted documentby the same team of researchers.

4.2 Symptoms

Studies agree on some core symptoms of autistic burnout including exhaustion, reduced cognitive function, social withdrawal, and increase in autistic traits (Arnold et al, 2023b; Mantzalas et al, 2022b; Higgins et al, 2021; Raymaker et al, 2020). Symptoms identified as features of autistic burnout also include:

• Physical symptoms: fatigue, exhaustion, sleep problems (Arnold et al, 2023a; mantzalas et al, 2022a; Higgins et al, 2021; Raymaker et al, 2020; Deweert, 2020)

• Cognitive symptoms: confusion, dissociation, loss of executive function (Mantzalas et al, 2022a; Higgins et al, 2021; Raymarker et al, 2020)

• Emotional symptoms: difficulties with emotional regulation, short temper, depression, anxiety, emotional numbness, suspicion or loss of trust in others (Mantzalas et al, 2022a; Higgins et al, 2021; Raymaker et al, 2020)

• Other psychological symptoms: dissociation, suicidality, lower tolerance for sensory stimulus (Mantzalas et al, 2022a; Higgins et al, 2021; Raymaker et al, 2020)

• Behavioural symptoms: increased intensity or frequency of self-stimulating behaviour, increased repetitive behaviours, avoiding social situations, escapist behaviour (Pyszkowska et al, 2023; Mantzalas et al, 2022a; Higgins et al, 2021; Raymaker et al, 2020; Deweert, 2020)

• Functional symptoms: loss of social skills, reduced capacity or desire for social interaction, inability or reduced ability to speak or communicate, loss of daily living orself-care skills, increased difficulty of work or school; reduced quality of life (Vinayagam et al, 2023; Arnold et al, 2023a; Manatzlas et al, 2022a; Øverland et al, 2022; Higgins et al, 2021; Raymarker et al, 2020)

There is some disagreement about whether certain symptoms are features of autistic burnoutor of co-occurring depression. For example, Raymaker et al (2020) note that sleep problems and emotional numbness or inability to feel pleasure are features of depression that are outliers in autistic burnout. In contrast, Higgins et al (2021) cites sleep problems and emotional numbness as characteristic features of autistic burnout.

There is also some ambiguity around the behavioural symptoms associated with autistic burnout. What are described as symptoms may also be coping mechanisms or managementstrategies. Pyszkowska et al (2023) find that autistic burnout is associated with self-

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suppressing escapist behaviour in the form of time spent playing videogames. However, the authors note that this observation is in line with some autistic people’s preferences for time outside of social situations, special interests or hyperfocus. Researchers also note that increase in self-stimulating behaviour and social withdrawal may be appropriate management strategies to address the symptoms of autistic burnout Mantzalas et al, 2022b; Higgins et al, 2021; Raymaker et al, 2020.

4.3 Triggers

Researchers suggest that autistic burnout is a result of the accumulation of life stressors and exacerbated by a lack of supports or reasonable accommodations. The stressors identified in the literature generally relate to the added effort of actively engaging in inaccessible environments. This is characterised as a lack of fit between the needs and preferences of an autistic person and the environments that form the backdrop of everyday social and occupational activities [Arnold et al., 2023a–b; Mantzalas et al. , 2022a–b; Øverland et al, 2022; Higgins et al, 2021; Raymaker et al, 2020; Deweert, 2020]. Stressors that may precipitate an episode of autistic burnout include:

• Masking: suppressing autistic behaviours in order to function more easily in non-autistic environments.
• Sensory overload: acting in environments that are not aligned to the autistic person’s sensory needs.
• Interpersonal engagement: participating in activities that demand a high level of social interaction.
• Task design: performing tasks at school, work or in social activities that are inaccessible or not aligned with the autistic person’s cognitive or physical needs or preferences.

4.4 Autistic Burnout and Other Conditions

Researchers observe that characteristics of autistic burnout overlap with occupational burnout, stress and depression. However, most researchers argue that autistic burnout is a distinct construct with core features that differentiate it from these other conditions [Tomczak & Kulikowski, 2023; Mantzalas et al., 2022a–b; Cage & McManemy, 2022; Mahony & Ryan, 2022; Higgins et al., 2021; Raymaker et al. , 2020]. Autistic burnout has also been compared to other experiences described by autistic people including autistic inertia, meltdowns and shutdowns.

Burnout, inertia, meldown, shutdown Phung et al (2021) proposes a distinction between four autistic experiences:

• Burnout (feeling exhausted): extreme exhaustion after masking in inaccessible environments.
• Inertia (feeling stuck): inability to initiate tasks, even personally desirable tasks.

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Meltdown (feeling out of control): significant overwhelm accompanied by externalising behaviours. Shutdown (feeling frozen): significant overwhelm accompanied by internalising behaviours. Phung et al found substantial overlap between inertia, meltdown and shutdown and Raymaker et al’s definition of autistic burnout. The authors note that these experiences can occur consecutively, with meltdowns preceding burnouts or happening at the start of burnouts. Higgins et al (2021) suggest that meltdown can be distinguished from burnout as the latter is more likely to involve emotional numbness, whereas the former is more likely to involve inability to control emotions. As noted above (Definition), the presence of emotional numbness in autistic burnout is a point of disagreement between Higgins et al and Raymaker et al. More empirical work is required to differentiate between these categories (Arnold et al, 2023a; Phung et al, 2021). Arnold et al (2023b) suggest a possible autistic exhaustion syndrome that could encompass burnout, inertia and shutdown, though more research would be required to substantiate this posit.

Occupational Burnout

Occupational burnout is a response to chronic work stress that involves physical or emotional exhaustion, cynicism or indifference to people associated with the job or to work related tasks and reduced personal achievement at work (Edú-Valsania et al, 2022). The concept of burnout was originally applied to care workers, then generalised for other workplace and professional contexts. It has been expanded to include responses to non-professional contexts such as education, and to systemic problems such as racism and sexism (Wolbring & Lillywhite, 2023; Watanabe & Akechi, 2023). Burnout is not included in the DSM-5 and is counted in the ICD-11 as an occupational phenomenon, but not a distinct health condition (Higgins et al, 2021). There is a lack of consensus in the literature on burnout regarding its definition, subtypes, causes, symptoms, prevalence, and appropriate measurement tools (Tomczak & Kulikowski, 2023; Wolbring & Lillywhite, 2023; Edú- Valsania et al, 2022; Higgins et al, 2021). Some studies suggest that the difference between occupational burnout and depression is artificial (Higgins et al, 2021). Autistic burnout was named by analogy with occupational burnout, though the constructs are intended to be different (Tomczak & Kulikowski, 2023; Higgins et al, 2021; Raymaker et al, 2020). While acknowledging the similarities, Higgins et al (2021) differentiate autistic and non-autistic burnout according to differences in triggers and symptoms. They note non-autistic burnout is almost always employment related, whereas autistic burnout is generally precipitated by masking, social interaction and inaccessible environments. Whereas non-autistic burnout is characterised by cynicism towards the workplace or task, autistic burnout may be characterized by indifference or antipathy to non-autistic people, social groups or

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environments. Autistic burnout may include more severe cognitive symptoms and skills loss compared with non-autistic burnout.

Considering the lack of consensus in burnout research, it is not clear if the differences described in Higgins et al are sufficient to differentiate two conditions, rather than broaden the existing category of burnout. Cage & McManemy (2022) note that autistic traits, even in non- autistic people, are correlated with increased risk of occupational burnout. They suggest that autistic and occupational burnout may be two manifestations of a more general construct.

Stress

Stress is a core feature of all conceptions of autistic burnout. Researchers argue that autistic burnout is a response to chronic stress, with unique triggers and symptoms. Mahony & Ryan (2022) note the similarities between descriptions of autistic burnout and early life stress (ELS) or chronic adolescent stress (CAS). Based on these similarities, they suggest that autistic burnout is a specific type of CAS. However, further work is required to substantiate these ideas.

Depression

There are apparent similarities between depression and autistic burnout, such as fatigue, lack of emotional control, and social withdrawal. Risk of depression is increased for autistic people even in the absence of burnout. Depression is also a commonly reported feature of autistic burnout (Higgins et al, 2021; Raymaker et al, 2020).

According to Mahony & Ryan (2022, p.4):

Both [Major Depressive Disorder (MDD)] and autistic burnout are associated with chronic fatigue, cognitive incapacitation, and suicidal ideation; however, the anhedonia and existential hopelessness that characterizes MDD is not always a defining feature of autistic burnout. While depression is described as a lack of motivation to participate in life, autistic burnout is experienced as a lack of capacity to do so. Nevertheless, autistic burnout can lead to the subsequent development of MDD and vice versa.

A further reason for differentiation relates to appropriate treatment methods. What works for depression may not work for autistic burnout. For example, whereas physical activity and community or social participation are appropriate management strategies for depression, they may exacerbate the underlying problems that lead to autistic burnout. In contrast, social withdrawal and focus on individual special interests is a commonly recommended management strategy.

5. Management

One treatment study was found, a conference abstract included in a supplement to the journalNeurology, that investigates the management of autistic burnout (Hale & Sanders, 2023). The authors present the case of a 24-year-old redacted autistic student who presented with symptoms of autistic burnout. They were prescribed dextroamphetamine, associated with treatment ofattention-deficit hyperactivity disorder, and reported positive outcomes.

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Several qualitative studies note strategies that those who experience autistic burnout have used to recover. Examples include:

• Social support from the right people (which could include other autistic people)
• ‘Unmasking’, reducing masking behaviours or avoiding situations where they are necessary
• Taking time to understand one’s own needs and preferences
• Taking time to focus on a special interest
• Request reasonable accommodations and appropriate supports from work or school
• Reduced activity, rest, regular breaks Gabrielsen et al, 2023; Mantzalas et al., 2022a; Higgins et al, 2021 ; Raymaker et al ,* 2020).

References

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