Systematic Review of Level 1 and Level 2 Screening Tools for Autism Spectrum Disorders in Toddlers

The present study provides a systematic review of level 1 and level 2 screening tools for the early detection of autism under 24 months of age and an evaluation of the psychometric and measurement properties of their studies. Methods: Seven databases (e.g., Scopus, EBSCOhost Research Database) were screened and experts in the autism spectrum disorders (ASD) field were questioned; Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines and Consensus-based Standard for the selection of health Measurement INstruments (COSMIN) checklist were applied. Results: the study included 52 papers and 16 measures; most of them were questionnaires, and the Modified-CHecklist for Autism in Toddler (M-CHAT) was the most extensively tested. The measures' strengths (analytical evaluation of methodological quality according to COSMIN) and limitations (in term of Negative Predictive Value, Positive Predictive Value, sensitivity, and specificity) were described; the quality of the studies, assessed with the application of the COSMIN checklist, highlighted the necessity of further validation studies for all the measures. According to COSMIN results, the M-CHAT, First Years Inventory (FYI), and Quantitative-CHecklist for Autism in Toddler (Q-CHAT) seem to be promising measures that may be applied systematically by health professionals in the future.

Multiplex temporal measures reflecting neural underpinnings of brain functional connectivity under cognitive load in Autism Spectrum Disorder

Methods: Thirty individuals with ASD (11-18years) and thirty Typically Developing (TD) individuals (11-16years) were recruited to perform the mental task. The participants were instructed to flip the shown geometric images mentally and mark their response on a scale. The task-related multivariate EEG activations were analyzed using multiplex temporal Visibility Graphs (VGs) to compute local and global brain network functional connectivity dynamics.Results: With cognitive load (0-back to the 2-back task), the behavioral performance (d' index and Reaction Time) has reduced in ASD. The brain network has become more segregated and less integrated, reflecting more involvement of intra-regions over inter-regions in ASD. The frequent rerouting in hubs measured by Eigenvector Centrality (EC) indicated the progression of brain trajectory towards ASD. Overall, the neural mechanisms involving hyperactive response in frontal regions, frequent rewiring, and strengthened brain connectivity as a result of learning-induced performance reflected the adaptation to cognitive demands in ASD.Discussion: The correlation between complex graph measures and behavioral domain further reflected that neural metrics could predict the behavioral performance of the individuals in the task. In the future, modeling functional connectivity-based markers have the potential to reflect the brain trajectory alterations, which can detect ASD even before the behavioral manifestations become apparent.

Sex and gender impacts on the behavioural presentation and recognition of autism

PURPOSE OF REVIEW

With increasing awareness of potential differences of autism presentation in nonmale versus male individuals, this review summarizes the rapidly evolving literature on sex and gender impacts on autism across nosology, behavioural presentation, developmental change and contextual recognition biases.

RECENT FINDINGS

Most studies have not differentiated sex versus gender impacts. Regarding behavioural presentation, measurement invariance across sex/gender was found in several standard measures. On this basis, diagnosed females overall showed lower restricted/repetitive behaviour/interests/activities (RRBI) than males, with small and variable effects depending on age, developmental level and kinds of RRBI. Differences insufficiently captured by standard measures may include autistic females displaying female-gender-typical narrow interests, higher social attention, linguistic abilities, motivation for friendship and more camouflaging than autistic males. Regarding developmental change, diagnosed young girls were more likely to have better cognitive development, less intense autistic symptoms and reduction of symptoms over time. Difficulties in adaptive functioning and social challenges, however, may emerge more for females in adolescence. Regarding diagnosis, general expectancy biases and gender-stereotypes may impede timely recognition of autism in females.

SUMMARY

Appreciating the multilevel sex and gender impacts on presentation, development, and diagnosis is key to sex-equitable and gender-equitable care for autistic individuals. A holistic approach to understanding the person in the contexts of sex and gender is essential for timely and accurate diagnosis and support.

The role of technology-mediated music-making in enhancing engagement and social communication in children with autism and intellectual disabilities

Very little research has explored the impact of interventions combining music and technology on children with a dual diagnosis of autism and intellectual disabilities (ID) incorporating the active involvement of school staff. Video recordings and group interviews were used to collect data in this study. Video recordings of five children with autism and ID were conducted as they engaged with a technology-mediated music-making intervention over a period of 5 weeks. Additionally, five group interviews with classroom staff were carried out. This study is the first to explore the impact of a technology-mediated music-making intervention on the engagement levels and social communication skills of children with autism and ID at school. Some positive outcomes, especially regarding social communication skills, are reported, which are of significant value to educational researchers and school staff.

Caregivers’ perspectives on health-care transition in autism

Purpose

Adults with autism spectrum disorder (ASD) experience significant health-care disparities across physical and mental health domains resulting in poorer health and quality of life. Poor transitions to adult care negatively impact the health of adults with ASD. Current research focuses on personal factors in research samples that lack diversity. The purpose of this study is to examine the lived health-care experiences of geographically and ethnically diverse young adults with ASD in adult care settings in the USA to understand provider and system-level factors affecting their health.

Design/methodology/approach

Nine caregivers of young adults with ASD participated in key informant interviews describing their experiences in navigating the health-care system. Data were analyzed using a grounded theory approach.

Findings

The data indicated that limited quantity of services, poor quality of services, and high cost of services had a negative effect on the health of adults with ASD. Issues cascaded to become more complex.

Practical implications

Practical implications for payors, providers, persons with ASD and their families are discussed in this paper.

Originality/value

To the best of the authors’ knowledge, this study answers the call to better understand system-level factors affecting the health of geographically and ethnically diverse people with ASD.

Predictors of unmet needs and family debt among children and adolescents with an autism spectrum disorder: Evidence from Ireland

Autism Spectrum Disorders (ASDs) are a life-long neurodevelopmental condition where individuals affected and their families require varying intensities of services and supports. A growing body of evidence provides consensus that early intervention may improve long-term outcomes. The purpose of the paper is to identify the factors that explain variations between families raising a child/children with an ASD in their experience of specific unmet needs and/or experience of debt. Analysis was based on data collected as part of a larger study that examined the economics of autism spectrum disorder in Ireland among 195 families with 222 children aged between 2-18 years of age in 2014/2015. The findings from parental reported responses show over 74 % of children did not receive one or more services in the previous 12 months. Average debt per year per family was €3259. Regression analyses showed that families that had two or more children with an ASD were more likely to experience unmet needs and incur debt specifically because of the child's condition than families with one child with an ASD. The study shows there is a significant level of unmet need and economic hardship, as evident in the level of ASD related debt which may make current met needs unsustainable in the future. Issues of capacity and geographic inequity that warrant a policy response were also evident.

The Female Autism Phenotype and Camouflaging: a Narrative Review

Autism is more commonly diagnosed in males than females. One explanation is the ‘female protective effect’: there is something inherent in being female which reduces the likelihood of developing autism. However, evidence suggests that the condition is underdiagnosed in females, perhaps because females express their autism in ways which do not meet current diagnostic criteria. This review explores evidence for a female-typical autism presentation, the Female Autism Phenotype (FAP) and the component of camouflaging (compensating for and masking autistic characteristics) in particular. The evidence so far supports the existence of a female-typical autism presentation, although further examination of the characteristics and their impact across all genders and ages is needed.

Factually based autism awareness campaigns may not always be effective in changing attitudes towards autism: Evidence from British and South Korean nursing students

This study explored the relationship between autism knowledge, autistic traits, frequency of contact with autistic people and attitudes towards these individuals in British and South Korean student nurses and whether these relationships were affected by the presence of autistic traits. In total, 331 participants (156 South Korean and 175 British) completed self-report measures of autism knowledge, attitudes towards autistic people, frequency of contact with these individuals and autistic traits. Although British participants demonstrated greater knowledge and more favourable attitudes, significant knowledge deficiencies were noted in both groups. Among British participants, knowledge was found to be a significant, but a very marginal, predictor of attitudes, whereas neither knowledge nor frequency of contact were predictive of attitudes among South Korean participants. Contrary to previous research findings, cultural differences in the presence of autistic traits were not noted, nor were these traits found to correlate with attitudes towards autistic people. The findings suggest that awareness initiatives which aim to address attitudes towards autism need more than simply increasing factual knowledge. More importantly, the results suggest that Western-developed autism awareness initiatives may be ineffectual if cultural idiosyncrasies are not considered.

Lay abstract

This study explored the relationship between autism knowledge, autistic traits, frequency of contact with autistic people and attitudes towards these individuals in British and South Korean student nurses and whether these relationships were affected by the presence of autistic traits. In total, 331 participants (156 South Korean and 175 British) completed self-report measures of autism knowledge, attitudes towards autistic people, frequency of contact with these individuals and autistic traits. Although British participants demonstrated greater knowledge and more favourable attitudes, significant knowledge gaps were noted in both groups. Among British participants, knowledge was found to be only a marginal predictor of attitudes, whereas neither knowledge nor frequency of contact were predictive of attitudes among South Korean participants. Contrary to previous research findings, cultural differences in the presence of autistic traits were not noted, nor were these traits found to be related to attitudes towards autistic people. The findings suggest that awareness initiatives which aim to address attitudes towards autism need more than simply increasing factual knowledge. More importantly, the results suggest that Western-developed autism awareness initiatives may be ineffectual if cultural differences are not considered.

Health determinants of adolescent criminalisation

Several conditions related to health and development in adolescence can increase the risk that a young person will be exposed to the criminal justice system. Such determinants include neurodevelopmental disability, poor mental health, trauma, and experiences of maltreatment. Furthermore, the risk of exposure to the criminal justice system seems to be amplified by social marginalisation and inequality, such that young people are made susceptible to criminal behaviour and criminalisation by a combination of health difficulties and social disadvantages. This Review presents evidence on the health determinants of criminalisation among adolescents, providing a persuasive case for policy and practice reform, including for investment in approaches to prevent criminalisation on the basis of health and developmental difficulties, and to better address related needs once within a criminal justice system.

The health of adolescents in detention: a global scoping review

Adolescents detained within the criminal justice system are affected by complex health problems, health-risk behaviours, and high rates of premature death. We did a global synthesis of the evidence regarding the health of this population. We searched Embase, PsycINFO, Education Resources Information Center, PubMed, Web of Science, CINCH, Global Health, the Cochrane Database of Systematic Reviews, the Campbell Library, the National Criminal Justice Reference System Abstract Database, and Google Scholar for peer-reviewed journal articles, including reviews, that reported the prevalence of at least one health outcome (physical, mental, sexual, infectious, and neurocognitive) in adolescents (aged <20 years) in detention, and were published between Jan 1, 1980, and June 30, 2018. The reference lists of published review articles were scrutinised for additional relevant publications. Two reviewers independently screened titles and abstracts, and three reviewed full texts of relevant articles. The protocol for this Review was registered with PROSPERO (CRD42016041392). 245 articles (204 primary research articles and 41 reviews) were included, with most primary research (183 [90%]) done in high-income countries. A high lifetime prevalence of health problems, risks, and conditions was reported in detained adolescents, including mental disorders (0–95%), substance use disorders (22–96%), self-harm (12–65%), neurodevelopmental disabilities (2–47%), infectious diseases (0–34%), and sexual and reproductive conditions (pregnant by age 19 years 20–37%; abnormal cervical screening test result 16%). Various physical and mental health problems and health-risk behaviours are more common among adolescents in detention than among their peers who have not been detained. As the social and structural drivers of poor health overlap somewhat with factors associated with exposure to the criminal justice system, strategies to address these factors could help to reduce both rates of adolescent detention and adolescent health inequalities. Improving the detection of mental and physical disorders, providing appropriate interventions during detention, and optimising transitional health care after release from detention could improve the health outcomes of these vulnerable young people.

Preliminary Evidence That Resting State Heart Rate Variability Predicts Reactivity to Tactile Stimuli in Rett Syndrome

Patients with Rett syndrome may manifest altered pain perception/experience and are vulnerable to conditions associated with chronic pain. Pain response is difficult to measure, however, because of severe communicative impairment. There is also documented autonomic dysfunction, including decreased heart rate variability. Given the relation between pain and the autonomic nervous system, we tested the feasibility of using resting heart rate variability to predict nonverbal pain/discomfort behavior during a standardized modified quantitative sensory test in Rett syndrome. All stimulus applications resulted in increased behavioral reactivity compared to baseline, with repeated von Frey significantly greater than all other stimuli. Resting heart rate variability predicted behavioral reactivity to repeated von Frey. These preliminary findings provide feasibility evidence for an integrated autonomic-sensory measurement approach and are consistent at a construct level with preclinical evidence in Rett syndrome. Further work is needed to determine how heart rate variability changes during stimulus application.

Services for Adults With Autism Spectrum Disorder: a Systems Perspective

PURPOSE OF REVIEW

We review original research about services for adults on the autism spectrum published from January 2013 through December 2018. The main aim is to characterize the topical and methodological aspects of research about services. We review research on services related to employment, living in the community, and social participation. We compare our results with those from a similar review published in 2012 to assess progress and identify where new directions in research about services for adults with autism are needed.

RECENT FINDINGS

We found the evidence base about services for adults on the autism spectrum remains very small and highly variable in aims and methods. There is wide variability in methods used to define sampling frames and recruit participants. Most studies focus on employment. Almost no studies examine the overall ecosystem of services serving autistic adults. Few studies use a conceptual framework for understanding access to, or improvement of, services. The small size of the extant research coupled with inconsistent quality prevents the accumulation of new knowledge in ways that would significantly inform the improvement of systems of care for the growing population of adults on the autism spectrum.

How to Optimise Cognitive Behaviour Therapy (CBT) for People with Autism Spectrum Disorders (ASD): A Delphi Study

Children and adults with autism spectrum disorders (ASD) can benefit from cognitive behaviour therapy (CBT), yet the prevailing opinion is that this requires adaptations to accommodate commonly experienced socio-communication and neuropsychological impairments. There are, however, no empirically-derived guidelines about how best to adapt standard practice. In a three round Delphi survey, we asked expert clinicians and clinical-researchers, based in England, about how to optimise the design, delivery and evaluation of CBT for people with ASD. Of 50 people approached, 18 consented to take part in Round 1, nine in Round 2 and eight in Round 3. Using a five-point scale, participants rated the degree to which 221 statements—pertaining to the referral process, assessment, engagement, formulation, goal setting, therapy structure, interventions and techniques, homework, outcome measurement, managing endings and therapist attributes—were integral to CBT. The consensus was that 155 statements represented essential or important components of CBT. Adaptations to the structure and process of therapy were consistently endorsed, and an individualised formulation-derived approach was favoured when deciding upon which interventions and techniques to offer. Further studies are needed to clarify if adapted CBT is associated with improved treatment outcomes and acceptability.

Keys to engagement: A case study exploring the participation of autistic pupils in educational decision-making at school

BACKGROUND

The UNCRC (1989) established the importance of listening to children's views globally. In England, seeking the views of pupils with special educational needs and disability about their education, and involving them in decision-making, has been mandatory since 2015. Autistic children's views and experiences are particularly underrepresented in this context.

AIMS

To provide a detailed exploratory analysis of practices that enable autistic pupils to participate in educational decision-making, and to generate new knowledge about pupil participation in a school context, using the Framework for Participation (Black-Hawkins, 2010) as an analytical frame.

SAMPLE

Four male pupils aged 11-15, with autism spectrum diagnoses, and 11 staff members from a specialist, independent school took part in this case study.

METHODS

Observations were made of pupils in lessons, and pupils completed a photo-voice activity focusing on where they felt 'most listened to' in the school. Staff members participated in semi-structured interviews.

RESULTS

A range of practices supported pupils' participation in everyday decision-making, underpinned by a respectful and positive culture led by the senior management team. The focus was on what learners can do and how they make decisions to facilitate achievement. Pupils and staff developed mutually respectful relationships, within which boundaries were negotiated and compromises offered. Flexibility through decision-making was provided within the timetabling and content of the curriculum. Pupils' special interests and expertise were valued as 'keys' to supporting their engagement.

CONCLUSIONS

These insights provide a tool for reflection by educators and educational psychologists for considering how they might promote the participation of autistic pupils in different educational contexts.

Process Evaluation of Animal-Assisted Therapy: Feasibility and Relevance of a Dog-Assisted Therapy Program in Adults with Autism Spectrum Disorder

Simple Summary

An explorative study on the effects of animal-assisted therapy showed reduced stress and improved social communication in adults with autism spectrum disorder (ASD). To examine whether this intervention is suitable for a broader scope of application in clinical practice, we conducted a process evaluation alongside the effect study. The aim of this process evaluation was to gain insight into the quality of the study, the relevance and feasibility of the intervention, and the barriers and facilitators to the implementation of the intervention. Questionnaires, semi-structured interviews, and treatment reports were used to analyze process data in 27 participants who were randomized into the intervention condition and in three therapists. Both the participants and therapists evaluated the animal-assisted therapy program as satisfying, feasible, and relevant for adults with ASD. They reported the following arguments for their positive appraisal of the therapy: the therapy helped improve self-insight, joy, relaxation, and physical contact. The participants’ attitudes, personal skills for generalization, and severity of contextual problems were named as potential barriers to the feasibility of the therapy program. Females and dog owners were over-represented in this study, and therefore, generalization of the previously established effects should be made with caution. However, given the intervention’s effects and the positive evaluation of the program by the participants and therapists alike, animal-assisted therapy can be considered a valuable addition to treatment possibilities for reducing stress and improving social communication in adults with autism spectrum disorder.

Abstract

(1) Background: Randomized controlled trials (RCTs) are considered the gold standard for evaluating a treatment. However, the results of an RCT may remain meaningless for clinical practice in cases of poor intervention feasibility or fidelity (the extent to which the protocol was executed), or when health care professionals or patients experience the intervention as irrelevant or unpleasant. Feasibility and relevance of psychosocial interventions are highly understudied in adults with autism spectrum disorder (ASD). In order to put the effects revealed in an RCT on an animal-assisted therapy (AAT) program in adults with autism spectrum disorder (ASD) into the context of clinical practice and to formulate guidelines for potential improvements and further implementation of the therapy, the aim of this process evaluation was to gain insight into the relevance and feasibility of the intervention and barriers and facilitators to its implementation. (2) Methods: Data were collected from 27 participants with ASD and three therapists using questionnaires, semi-structured interviews, and treatment reports. Reach, adherence, program fidelity, and program appraisal were evaluated, and barriers and facilitators to recruitment and implementation of the AAT program were explored. (3) Results: The participants were satisfied with the program and evaluated it as feasible and relevant for adults with ASD. The participants documented improving self-insight, joy, relaxation, and physical contact with a therapy dog as the reason of their positive appraisal of the therapy. Documented aspects that may influence feasibility and appraised relevance were the participants’ therapy attitude, skills for generalization, and severity of contextual problems (e.g., problems at work, relationship problems). Regarding the sample quality, females and dog owners were slightly over-represented in the RCT. (4) Discussion: Considering the positive evaluation of the intervention and its positive effects revealed in the RCT, the AAT program can be added to the treatment repertoire to reduce stress and improve social communication in adults with ASD. More research in larger samples is needed for better understanding the generalization of the intervention effects, especially in male patients and those who do not have a dog at home.

Is There a Relationship Between Cyber-Dependent Crime, Autistic-Like Traits and Autism?

International law enforcement agencies have reported an apparent preponderance of autistic individuals amongst perpetrators of cyber-dependent crimes, such as hacking or spreading malware (Ledingham and Mills in Adv Autism 1:1–10, 2015). However, no empirical evidence exists to support such a relationship. This is the first study to empirically explore potential relationships between cyber-dependent crime and autism, autistic-like traits, explicit social cognition and perceived interpersonal support. Participants were 290 internet users, 23 of whom self-reported being autistic, who completed an anonymous online survey. Increased risk of committing cyber-dependent crime was associated with higher autistic-like traits. A diagnosis of autism was associated with a decreased risk of committing cyber-dependent crime. Around 40% of the association between autistic-like traits and cyber-dependent crime was mediated by advanced digital skills.

Aging and Autism: Understanding, Intervention and Proposals to Improve Quality of Life

BACKGROUND

The population with autism spectrum disorder (ASD) has been increasing and is currently estimated to be 1 in 58 births. The increased prevalence of ASD together with the lack of knowledge on the processes of aging in this population, the support needed at this stage of life, and the associated risk factors, have led to an urgent need for further research.

METHODS

This study provides a review of the literature on social- and health-related conditions that may appear when persons with ASD grow old.

RESULTS

In addition to the autism-related conditions, different neurological, genetic, and environmental factors may be involved in the process of aging. In this complex setting, this study provides proposals that may guide the development of support services that may improve the quality of life for aging people with ASD.

CONCLUSION

Aging in ASD is emerging as a growing problem, which requires immediate planning and targetted treatment development.

Social and Object Attention Is Influenced by Biological Sex and Toy Gender-Congruence in Children With and Without Autism

Emerging research suggests social attention in autism spectrum disorder (ASD) girls is enhanced relative to ASD boys but may also be affected by the type of social and nonsocial content presented. This study examined how biological sex and gender norms interact to influence visual attention in 79 school-aged children observing scenes that included gender-associated toys and actors of both sexes. Attention to social (faces) and object activity (hands with toys) stimuli was measured. Previously described distinctions between social attention in ASD boys and girls were replicated, with ASD girls looking more at faces than ASD boys. Irrespective of diagnosis, males and females attended more to actors that shared their same sex, and attended more to toys with gender-associations that were consistent with their own sex, suggesting that social and object salience increases for children under sex-consistent conditions. Importantly, ASD and typically developing (TD) children increased their gaze to faces when male actors were shown playing with female-associated toys, suggesting that both groups of children are sensitive to societal messages about the acceptability of males playing with female-associated toys. Our findings provide further evidence of heightened attention to faces in ASD girls relative to ASD boys, and indicate that social attention in ASD and TD children is influenced by who (male or female actor) and what (male- or female-associated toy) is being observed. Collectively, these results present a nuanced profile of attention in ASD that adds to a growing body of research indicating subtle phenotypic differences in ASD girls that may impact identification, assessment, and intervention. Autism Res 2020, 13: 763-776.. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Sex differences observed in typical development may also be present in individuals with autism. In this study, we developed an eye-tracking paradigm featuring videos of boys and girls playing with toys that varied in their gender associations. Attention to faces differed between autistic and non-autistic children but was also influenced by the sex of the actor and gender-association of toys. Autistic females demonstrated subtle attention differences that distinguished them from autistic males and may influence referral, diagnosis, and intervention.

The Medical Care of People With Intellectual Disability

BACKGROUND

An estimated 1.5 million persons in Germany are intellectually disabled. Persons with intellectual disability (ID) are especially vulnerable to somatic and mental illnesses.

METHODS

This review is based on pertinent literature retrieved by selective searches in PubMed and the Cochrane Library.

RESULTS

Genetic abnormalities are a frequent cause of diseases that affect multiple organs and need interdisciplinary treatment. A number of somatic diseases are more common in persons with ID than in the general population, including epilepsy (30-50% in persons with severe or very severe ID, vs. 0.5% in the general popu- lation) and dementia (five times more common than in the general population). Patients with Down syndrome are 20 times more likely than the general population to develop acute lymphoblastic leukemia. Some mental illnesses, too, are more common in persons with ID, e.g., autism spectrum disorders (7.5-15% vs. 1% in the general population). The history and the findings of the physical and psychiatric examination are assessed in accordance with the biopsychosocial model of disease, and in the light of the patient's mental developmental age. Structured instruments for behavioral evaluation and diagnosis are an important additional component of the diagnostic assessment. A holistic approach is required that takes multiple life areas into account and involves the patient's familial and social environment, while obeying the rules of simple language. Psychotherapeutic and psychosocial measures must be adapted to the patient's cognitive abilities and mental developmental age.

CONCLUSION

Intellectually disabled persons can be treated in a multimodal, multiprofessional approach. As of early 2019, there were 38 medical centers for adults with intellectual disability or severe multiple disabilities in Germany (Medizinische Behandlungszentren für Erwachsene mit geistiger Behinderung oder schweren Mehrfachbehinderungen, MZEB), where they can be cared for with due attention to their special needs.

ASD symptoms in toddlers and preschoolers: An examination of sex differences

Although considerable work has documented higher prevalence rates of autism spectrum disorder (ASD) in boys, fewer studies have focused on sex differences within samples of young children at-risk for ASD. This study examined sex differences in ASD symptom domains and ASD screening outcomes among toddlers (18-35 months) and preschoolers (36-72 months) with ASD-related concerns. Participants included 480 children between 18 and 72 months evaluated by university-based ASD specialty clinics. Results revealed significant sex differences in severity of social communication (SC) deficits across age groups. Within the toddler group, girls diagnosed with ASD displayed greater SC deficits according to standardized observation and clinician severity ratings. Within the preschool group, girls diagnosed with ASD were rated by parents as having more severe SC deficits, but these differences were not corroborated by standardized observations or clinician ratings. No sex differences emerged for severity of restricted repetitive behaviors (RRBs) for either age group. Across the entire referred sample, boys and girls did not differ in terms of scores on commonly used screening instruments. Importantly, results suggest that two of the most commonly used ASD screeners (i.e., Modified-Checklist for Autism in Toddlers-Revised with Follow-up and Social Communication Questionnaire ) may underidentify RRBs in toddler and preschool-aged girls as screening scores were only influenced by severity of SC deficits. Greater SC deficits in young girls with ASD along with its impact on screening status suggests greater attention be placed on the under-identification of ASD in girls as well as current screening measures' ability to tap into the topography of ASD symptoms across genders. Autism Res 2020, 13: 157-166. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: In this study, we found that young girls diagnosed with autism spectrum disorder tend to have greater social communication deficits than young boys and that these differences vary by age. Specifically, toddler-aged girls receive higher clinician ratings of social communication deficits when compared to boys, while preschool-aged girls receive higher parent ratings of social communication deficits. For girls, current screening tools seem to be more highly influenced by severity of social communication deficits than by restricted repetitive behaviors.

Why caregivers discontinue applied behavior analysis (ABA) and choose communication-based autism interventions

Purpose

The purpose of this paper is to explore why autistic people and their caregivers choose interventions other than applied behavior analysis (ABA), and how their decision impacts them over their lifespan. The focus group was divided into those who pursued augmentative and alternative communication (AAC)-based supports, received ABA, selected other interventions or received no intervention at all. The reported posttraumatic stress symptoms (PTSS) of ABA recipients were compared to non-ABA recipients in order to evaluate the long-term impacts of all intervention types. Using a mixed-method thematic analysis, optional comments submitted alongside a quantitative online survey were reviewed for emergent themes. These comments augmented the survey Likert scores with a qualitative impression of the diverse intervention-related attitudes among participants. Investigating the lived experiences of autism intervention recipients illuminated the scope of the long-term impacts of each intervention that was chosen. Overall, autistics who received no intervention fared best, based on the lowest reported PTSS. These findings may inform the potential redesign of autism interventions based on the firsthand reported experiences and opinions of autistics.

Design/methodology/approach

The aim of this study was to conduct research that is both question-driven and data-driven to aid in the analysis of existing data (Van Helden, 2013). In the research question-driven approach, the independent variables were the intervention type and duration of exposure relative to lifespan; the dependent variables were the PTSS severity score and binary indicator of meeting PTSS criteria. The analyses that were conducted included linear regression analyses of severity score on intervention type and duration, and χ2 tests for independence of the probabilities of PTSS criterion satisfaction and intervention type. This experiment was designed to test the data-driven hypothesis that the prevalence and severity of PTSS are dependent on the type of autism intervention and duration of exposure. After reviewing the primary data set, the data-driven inquiry determined that the sample for secondary analysis should be categorized by communication-based vs non-communication-based intervention type in order to best complement the limitations and strengths of the published findings from the primary analysis.

Findings

Autistics who received no intervention had a 59 percent lower likelihood of meeting the PTSS criteria when compared to their ABA peers, and they remained 99.6 percent stable in their reported symptoms throughout their lifespan (R2=0.004). ABA recipients were 1.74 times more likely to meet the PTSS criteria when compared to their AAC peers. Within the 23 percent who selected an intervention other than ABA, consisting of psychotherapy, mental health, son-rise and other varying interventions, 63 percent were asymptomatic. This suggests that the combined benefits of communication-based interventions over behaviorism-influenced ABA practices may contribute to enhanced quality of life. Although not generalizable beyond the scope of this study, it is indicated from the data that autistics who received no intervention at all fared best over their lifetimes.

Research limitations/implications

The obvious advantage of a secondary analysis is to uncover key findings that may have been overlooked in the preliminary study. Omitted variables in the preliminary data leave the researcher naive to crucially significant findings, which may be mitigated by subsequent testing in follow-up studies (Cheng and Phillips, 2014, p. 374). Frequency tables and cross-tabulations of all variables included in the primary analysis were reproduced. The secondary analysis of existing data was conducted from the design variables used in the original study and applied in the secondary analyses to generate less biased estimates (Lohr, 2010; Graubard and Korn, 1996). Inclusion criteria for each intervention group, PTSS scores and exposure duration, were inherited from the primary analysis, to allow for strategic judgment about the coding of the core variables pertaining to AAC and PTSS. The data sample from 460 respondents was reduced to a non-ABA group of n=330. An external statistician scored each respondent, and interrater reliability was assessed using Cohen’s κ coefficient (κ=1).

Practical implications

Including the autistic voice in the long-term planning of childhood interventions is essential to those attempting to meet the needs of the individuals, their families and communities. Both parents and autistic participant quotes were obtained directly from the optional comments to reveal why parents quit or persisted with an autism intervention.

Social implications

Practitioners and intervention service providers must consider this feedback from those who are directly impacted by the intervention style, frequency or intensity. The need for such work is confirmed in the recent literature as well, such as community-based participatory research (Raymaker, 2016). Autistics should be recognized as experts in their own experience (Milton, 2014). Community–academic partnerships are necessary to investigate the needs of the autistic population (Meza et al., 2016).

Originality/value

Most autistic people do not consider autism to be a mental illness nor a behavior disorder. It is imperative to recognize that when injurious behavior persists, and disturbance in mood, cognition, sleep pattern and focus are exacerbated, the symptoms are unrelated to autism and closely align to the diagnostic criteria for posttraumatic stress disorder (PTSD). When PTSD is underdiagnosed and untreated, the autistic individual may experience hyperarousal and become triggered by otherwise agreeable stimuli. Since autism interventions are typically structured around high contact, prolonged hours and 1:1 engagement, the nature of the intervention must be re-evaluated as a potentially traumatic event for an autistic person in the hyperarousal state. Any interventions which trigger more than it helps should be avoided and discontinued when PTSS emerge.

Undergraduate Disabled Students as Knowledge Producers including Researchers: A Missed Topic in Academic Literature

Research experience is beneficial for undergraduate students for many reasons. For example, it is argued in academic literature and in reports produced by various organizations that engage with science, technology, engineering and math (STEM) education and science education that undergraduate research experience increases the graduation rate in STEM disciplines as well as the amount of students thinking about STEM careers. As such, being researchers should also be of benefit to undergraduate disabled students in all disciplines including STEM education. However, given that undergraduate disabled students encounter many problems within post-secondary education, including STEM education, undergraduate disabled students might encounter problems in becoming researchers. Policies are to be guided by knowledge and evidence. However, knowledge and evidence deficits exist in relation to the lived experience of disabled people. Undergraduate disabled students could decrease the knowledge deficit as researchers and knowledge producers. The numbers of disabled academic faculty are judged as being too low and efforts are under way to increase the number of disabled academics. Increasing the number of undergraduate disabled researchers might increase the available pool of disabled students that pursue an academic career. Given the important role research performed by undergraduate disabled students can play and given that many studies highlight problems for disabled students in post-secondary education in general, we used a scoping review approach to investigate the coverage of undergraduate disabled students as knowledge producers, including as researchers, in the academic literature. Using various search strategies, we obtained 1299 initial hits. However, only 15 had relevant content. No study investigated how undergraduate disabled students select their research topics or how they are enticed to pursue research projects outside of a course-based framework. No study looked at the linkage between being an undergraduate disabled researcher and career choices or using the obtained research skills on the undergraduate level in one’s role as a community member after graduation. Our findings suggest an opportunity for many fields, ranging from disability studies to STEM education, to generate more empirical data and conceptual work on the role of undergraduate disabled students as knowledge producers including as researchers. Such studies could help to increase the numbers of undergraduate disabled students as knowledge producers, including researchers, which in turn could help to increase (a) the number of disabled academics, (b) the number of disabled students who perform research in the community after graduation, (c) the degree success of disabled students and (d) the knowledge available on the social situation of disabled people.

Improving Equity of Access Through Electronic Consultation: A Case Study of an eConsult Service

Background: Patients with complex circumstances pertaining to geography, socioeconomic status, or functional health often face inequities in accessing care. Electronic consultation (eConsult) is a secure online application that allows primary care providers (PCPs) and specialists to communicate regarding a patient's care. eConsult has demonstrated an ability to improve access to specialist care, and may be of particular use in cases of inequitable access. Methods: We examined how eConsult is used to improve equity of access for patients in complex circumstances by conducting a multiple case study of eConsults from seven patient groups: addiction, frail elderly, homeless, long-term care, rural, special needs, and transgender. Cases from these groups were selected from all eConsult cases completed between January 1 and December 31, 2017 using a data collection strategy tailored to each group. An access framework by Levesque et al. was applied to the data to examine five dimensions of access, arranged in chronological order, that reflect the process of a patient seeking care: approachability, acceptability; availability, affordability, and appropriateness. Two reviewers analyzed the cases using an iterative approach, regularly presenting findings to the research team for discussion and interpretation. Results: Eight hundred and twenty-five cases emerged across the seven target groups. The selected cases highlighted a number of key factors, including the value of the patient-PCP relationship, the importance of considering patient perspectives when providing care, and efforts to accommodate patients facing particular challenges to accessing care. Examples emerged among all five dimensions of the Levesque et al. access framework, with the final dimension, appropriateness, emerging across all cases. Conclusions: By leveraging the eConsult platform, PCPs can help improve equitable access to specialist care. More research is needed to understand why patients with complex circumstances face a longer wait time compared to the general population, and the impact that eConsults can have in improving health outcomes and wait times for this population.

Empowering autistic adults through their involvement in the development of a virtual world

Purpose

People with cognitive disabilities have a right to an inclusive society, and to have access to services and products that meet their specific needs. Participatory design (PD) represents a potentially effective way to ensure these rights, because users become influencers of the technological development and design process, are actively involved in the customization of that technology and develop a relationship with the designers/developers. Literature suggests that user involvement in technology development produces better products and has shown that this process offers users a voice and the process is also conducive to mutual learning between researchers and participants. This paper aims to discuss these issues.

Design/methodology/approach

Here the authors will present the development of a virtual world (VW) platform, having as a starting point a minimally viable initial version. This was followed by the creation of a networking framework to test each feature of the VW, which allowed connected users, most of whom on the autistic spectrum, to interact with each other in real time in the VW, and to see each other’s effects. Stress testing sessions were initiated with a mixed group of 15 users, 8 of whom with autism (7 male and 1 female). Ten of the participants were male and five were female (Figure 1).

Findings

Even though the platform is feature-complete, its code is still in development; features can be improved/expanded upon, which necessitates further testing. The most commonly flagged issues from the stress testing were requests for videos/text manuals, the camera controls and chat message errors. These were implemented/fixed or added to the feature roadmap. “Heavy avatar customization” was also suggested, which has conceptual merit, but is not a priority.

Practical implications

PD is an inclusive approach that addresses personal needs and preferences, matching up the person with the tools and environments to ensure equity and inclusion. The VW whose development is described in this paper has been used for communication skills training with autistic young adults. It could be used for other social, life, academic and vocational skills training. This type of training through VR/VW may help enhance the employment-related skills of neurodiverse populations (and thus empower independent living) and has the potential for broader implementation and wider access in terms of distance learning.

Originality/value

This paper adds to the rather limited literature on applying PD approaches in the development of products for people with neurodevelopmental disabilities. The authors will present such a process for the development of a VW with people with autism. Although literature suggests that user involvement produces better outcomes, adopting this approach is not straightforward. The paper will describe in detail not only the contribution the participants made in every phase but also the limitations of applying a PD approach with a neurodiverse population, in order for them to be equal partners in the process and be involved in a meaningful way.

Early Autism Screening: A Comprehensive Review

Autistic spectrum disorder (ASD) refers to a neurodevelopmental condition associated with verbal and nonverbal communication, social interactions, and behavioural complications that is becoming increasingly common in many parts of the globe. Identifying individuals on the spectrum has remained a lengthy process for the past few decades due to the fact that some individuals diagnosed with ASD exhibit exceptional skills in areas such as mathematics, arts, and music among others. To improve the accuracy and reliability of autism diagnoses, many scholars have developed pre-diagnosis screening methods to help identify autistic behaviours at an early stage, speed up the clinical diagnosis referral process, and improve the understanding of ASD for the different stakeholders involved, such as parents, caregivers, teachers, and family members. However, the functionality and reliability of those screening tools vary according to different research studies and some have remained questionable. This study evaluates and critically analyses 37 different ASD screening tools in order to identify possible areas that need to be addressed through further development and innovation. More importantly, different criteria associated with existing screening tools, such as accessibility, the fulfilment of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) specifications, comprehensibility among the target audience, performance (specifically sensitivity, specificity, and accuracy), web and mobile availability, and popularity have been investigated.

Evaluation of autism awareness training provided to staff working in a high secure psychiatric care hospital

Purpose

The purpose of this paper is to evaluate autism awareness training provided to staff working in a high secure psychiatric care (HSPC) hospital.

Design/methodology/approach

An online survey of staff views who had completed an autism awareness training day.

Findings

All staff who completed the evaluation questionnaire reported that an autism awareness training day had been useful and had increased their knowledge of how to work with individuals who have autism. However, most staff also reported that one day was not long enough and that more case discussion would have been helpful. Although most staff also reported that autism awareness training should be mandatory, motivation to attend such training was considered important. In terms of the number of staff who had completed the training, whilst a wide range of staff groups had attended training, only a minority had done so, with the number of staff completing the training each year remaining relatively constant over a five-year period.

Research limitations/implications

Within the context of promoting Enabling Environments in forensic settings and the recent government consultation paper exploring whether autism awareness training should be mandatory for all those working in health care, further investigation is required into how to increase staff motivation to attend autism awareness training and to explore how it is used during everyday work with patients.

Originality/value

As an initial evaluation of optional autism awareness training delivered in HSPC, the project offers some valuable information in terms of the number of staff who attend such training, what they find useful and how it might be improved for this setting.

[ADI-R and ADOS and the differential diagnosis of autism spectrum disorders: Interests, limits and openings]

INTRODUCTION

Current developments in international public health are leading qualified authorities to release clinical practice guidelines for Autism Spectrum Disorders (ASD) assessment and diagnosis. Such documents incorporate procedures that rely on the Autism Diagnostic Interview-Revised (ADI-R) and the Autism Diagnostic Observation Schedule (ADOS) which are considered to be the "gold standard" assessment measures in the evaluation of ASD. Although these tools do prove their effectiveness in the evaluation of autistic symptomatology, they nevertheless stumble whenever the situation becomes more complex and reveal differential diagnostic issues in infantile and adult autism cases. This differential diagnostic issue remains significant in the clinical practice of daily life and has strong implications for the course of therapeutic treatment.

OBJECTIVES

Our objective is to underline and nuance the metrological qualities of the ADI-R and the ADOS in the differential diagnosis of autistic disorders by presenting a synthesis of recent studies, thus supporting the interest of maintaining an open debate on diagnostic practices.

METHODS

Our selective review of the recent literature focuses on studies that confront the ADI-R and the ADOS - used either independently or in a combination - with various differential issues in adulthood and childhood autism in order to highlight their qualities and limits.

RESULTS

The ADI-R is a semi-structured interview applied by trained examiners and applied to relatives and/or caregivers who collect developmental information about the patient's first years of life on a variety of behaviors and skills. It is therefore relatively dependent on the availability and personal bias of the interviewed third parties. Metric features highlighted by the reviewed studies straightforwardly reveal a certain effectiveness of the tool and a good discrimination of childhood disorders. At the same time, the tool's discriminatory capacity seems insufficient when applied to toddlers, very young children, and adults alike. The latter seems particularly true when it comes to differentiating between autistic and schizophrenic spectrum disorders. The ADOS is a semi-structured standardized observation assessment tool that has experienced several successive developments, such as optimizations concerning the sensitivity of its cutoffs. Many works have contributed to building such a tool with reliable and solid metric qualities which nevertheless retain important biases such as the subjectivity of the caregiver or the evaluator during the scoring process. For assessments of autistic children the tool still has a good diagnostic validity but seems to retain cases of incorrect diagnosis of ASD (false positives). In other words, disorders or developmental disabilities of some children and adolescents could not be distinguished from ASD when relying on this test alone. The ADOS Module 4, designed for the diagnosis of adolescents and adults with fluent speech, has undergone less updating. This revisited algorithm has metrological qualities useful for clinicians and remains one of the few available tools for this population. Unfortunately, its diagnostic accuracy is lower when applied to women, the elderly, people with personality disorders or higher intellectual abilities, or for the discrimination between ASD and schizophrenia. Overall, scores from these two instruments bring strong evidence of their usefulness in the diagnostic process of ASD, provided that they are used with caution and a critical clinical perspective, and only as a secondary technical support. Their use in combination is effective since they are complementary and compensate for each other's limitations. However, their globalized hegemony as "gold-standard" tools constitutes a setback insofar as it constrains the diagnosis of ASD to a set of stereotyped items. The latter in turn sets a normative model of autism that excludes other phenotypic forms, especially in the case of women and the elderly. Finally, the discrimination between autism and psychosis for children seems to remain an insoluble task even for the ADI-R/ADOS combination.

CONCLUSIONS

The problematics of differential diagnosis remain critical for clinical approaches to autism. Therefore, formalizations of the diagnostic procedures must be able to remain open-minded and accompanied by a creative clinical approach, especially in the case of complex situations that are not soluble by means of conventional diagnostic tools. One possibility may lie in the deepening of the phenomenological approach to autism as an attempt to model the subjective phenomena of autistic subjects and thus operationalize elements that serve the diagnostic process. In the same way, a psychodynamic epistemology could help clinicians to go beyond the consideration of observable behaviors and scores, introducing a psychoanalytic point of view that interfaces objective behaviors with the individual's dynamic intrapsychic functioning. This project could be articulated with projective methodologies - notably the Rorschach test - which respects the needs for standardization and quantification of conventionally used diagnostic tools.

The Metacognitions Questionnaire and Its Derivatives in Children and Adolescents: A Systematic Review of Psychometric Properties

Background: The Metacognitions Questionnaire (MCQ) and its derivatives have been instrumental in research examining the Self-Regulatory Executive Function Model in adults. Studies testing whether findings are applicable to children and adolescents have been increasing and several different measures adapting the MCQ for younger populations have been developed. The current study aimed to systematically review the psychometric properties of MCQ measures or derivatives used in young people (aged 18 or less), to help assess current findings in this population and to guide future research in this growing area of investigation. Method: Systematic searches were carried out on PubMed and PsycINFO of studies published up to June 2018. Additional studies were identified through Google Scholar and article references. Validity, reliability, range and responsiveness of measures were examined as well as analyses of age and gender differences on scores. Results: Forty-five articles were identified. The total sample consisted of 7,803 children and adolescents (6,922 non-clinical, 881 clinical) aged 7-18. Studies used one of seven versions of the questionnaire, five adapted from the MCQ for younger populations: (1) The Metacognitions Questionnaire-Adolescent version; (2) The Metacognitions Questionnaire-Child version; (3) The Metacognitions Questionnaire-Child Version-Revised; (4) The Metacognitions Questionnaire-Child-30; and (5) The Metacognitions Questionnaire-65 Positive Beliefs Scale Revised; and two adult versions used without adaptation: (1) The Metacognitions Questionnaire-30 and (2) The Cognitive Self Consciousness Scale-Expanded. The validity and reliability of the Metacognitions Questionnaire-Adolescent version had the most extensive support. Other questionnaires had either mixed psychometrics or promising initial findings but more limited data. Conclusions: It is recommended that studies using adolescents (age 12-18) consider using the Metacognitions Questionnaire-Adolescent version. Based on initial data, it is suggested studies using younger populations should consider the Metacognitions Questionnaire-Child-30 but further psychometric research into this and other measures is needed.

Effects of Diagnostic Severity upon Sex Differences in Behavioural Profiles of Young Males and Females with Autism Spectrum Disorder

To determine if diagnostic severity of Autistic Spectrum Disorder (ASD) affected sex differences in the detailed ASD-related behavioural profiles of young males and female, two samples of males and females with a diagnosis of ASD, aged between 6 and 17 years, were compared across the 65 items of the Social Responsiveness Scale (2nd ed.). Results are reported for a sample of males and females matched on age and IQ (n = 51 pairs) and a smaller sample matched on age, IQ and ADOS-2 severity (n = 32 pairs). ASD-related behaviours from the SRS-2 that were significantly and meaningfully different across sexes were identified for both samples. ADOS-2 diagnostic severity was associated with different sets of sex-based differences in SRS-2 item scores.

A Systematic Review of What Barriers and Facilitators Prevent and Enable Physical Healthcare Services Access for Autistic Adults

Autistic people are more likely to: be diagnosed with a range of physical health conditions (i.e. cardio-vascular disease); experience premature mortality (for most disease categories); and experience barriers to effectively accessing healthcare. This systematic review sought to identify studies that report on barriers and facilitators to physical healthcare access for autistic people. A total of 3111 records were screened and six studies were included: two quantitative, two qualitative, and two mixed-methodology studies. Patient-provider communication, sensory sensitivities, and executive functioning/planning issues emerged as important barriers to healthcare. Recommendations for clinicians and those planning services are discussed.

Valproate Exposure in ovo Attenuates the Acquisition of Social Preferences of Young Post-hatch Domestic Chicks

Embryonic exposure to valproic acid (VPA) is known to produce sociability deficits, resembling human autistic phenotypes, in several vertebrate species. Animals living in groups prefer the proximity of peers and have the ability to perceive and to respond to social signals for modifying behavior. Chicks of Galliform birds, known to display early preference behaviors, have been used extensively for adaptive learning studies. Young precocial birds seem to be useful models also for studying the effect of embryonic VPA treatment. Here, domestic chicken eggs were injected with sodium valproate (200 μl of 35 μmol/L solution) or with vehicle (distilled water) on the 14th day of incubation. After hatching, the chicks were tested for one-trial passive avoidance learning at day 1, vocalization due to isolation as a measure of stress level (day 2), approach preference to large versus small groups of age-matched conspecifics (day 5), and to those with normal versus blurred head features (day 7). In addition, we tested the preference of birds to conspecifics reared in group versus those reared in isolation (day 9), as well as the preference of chicks to familiar versus non-familiar conspecifics (day 21). Our findings confirm previous reports concerning an adverse effect of VPA on embryonic development, including a tendency for aborted or delayed hatching and, occasionally, for locomotor disorders in a small percentage of birds (eliminated from later studies). Otherwise, VPA treatment did not impair motor activity or distress level. Memory formation for the aversive stimulus and discrimination of colors were not impaired by VPA treatment either. Innate social predispositions manifested in approach preferences for the larger target group or for the birds with natural facial features remained unaffected by VPA exposure. The most prominent finding was attenuation of social exploration in VPA-exposed birds (expressed as the frequency of positional switches between two stimulus chicks after the first choice), followed by a deficit in the recognition of familiar conspecifics, unfolding at the end of the third week. Social exploration and recognition of familiar individuals are the key elements impaired at this stage. The results underline the importance of early social exploration in ASD.

Diagnostic Assessment Techniques and Non-Invasive Biomarkers for Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a complex heterogeneous neurological disorder that has led to a spectrum of diagnosis techniques. The screening instruments, medical and technological tools initiate the diagnosis process. Clinicians and psychologists propose therapies depending on the examination done by these methodologies. The literature has accounted dozens of diagnostic methods and alternative and complementary therapies but still lack in highlighting the proper biomarker for early detection and intervention. The emerging multi-modal neuro-imaging techniques have correlated the brain's functional and structural measures and diagnosed ASD with more sensitivity than individual approaches. The purpose of this review article is: (i) to provide an overview of the emerging ASD diagnosis methods and different markers and; (ii) to present the idea of integrating all the individual methods in to a multi-modal diagnostic system to enhance detection sensitivity. This system possesses the potential to diagnose and predict ASD clinically, neurologically & objectively with high detection sensitivity.

Prevalence of intellectual and developmental disabilities among first generation adult newcomers, and the health and health service use of this group: A retrospective cohort study

BACKGROUND

Attention to research and planning are increasingly being devoted to newcomer health, but the needs of newcomers with disabilities remain largely unknown. This information is difficult to determine since population-level data are rarely available on newcomers or on people with intellectual and developmental disabilities (IDD), although in Ontario, Canada these databases are accessible. This study compared the prevalence of IDD among first generation adult newcomers to adult non-newcomers in Ontario, and assessed how having IDD affected the health profile and health service use of newcomers.

METHODS

This population-based retrospective cohort study of adults aged 19-65 in 2010 used linked health and social services administrative data. Prevalence of IDD among newcomers (n = 1,649,633) and non-newcomers (n = 6,880,196) was compared. Among newcomers, those with IDD (n = 2,830) and without IDD (n = 1,646,803) were compared in terms of health conditions, and community and hospital service use.

RESULTS

Prevalence of IDD was lower in newcomers than non-newcomers (171.6 versus 898.3 per 100,000 adults, p<0.0001). Among newcomers, those with IDD were more likely than those without IDD to have comorbid physical health disorders, non-psychotic, psychotic and substance use disorders. Newcomers with IDD were also more likely to have psychiatry visits, and frequent emergency department visits and hospitalizations.

CONCLUSION

First generation adult newcomers have lower rates of IDD than non-newcomers. How much of this difference is attributable to admission policies that exclude people expected to be high health service users versus how much is attributable to our methodological approach is unknown. Finding more medical and psychiatric comorbidity, and more health service use among newcomers with IDD compared to newcomers without IDD is consistent with patterns observed in adults with IDD more generally. To inform polices that support newcomers with IDD future research should investigate reasons for the prevalence finding, barriers and facilitators to timely health care access, and pathways to care.

Similarities and Differences in Theory of Mind Responses of Patients With Anorexia Nervosa With and Without Autistic Features

Theory of Mind (ToM) is the ability to understand and represent mental states of others, a skill that plays a key role in how we interact with people around us. Difficulties with ToM have been posited as an underlying mechanism for autism and implicated in difficulties faced by those with anorexia nervosa (AN). This study examined, both quantitatively and qualitatively, the responses of women between the ages of 14 and 25 years on the Frith-Happé Triangle Animations, a well-validated test of ToM. Participants were split into healthy controls (HCs), AN patients (AN), and AN patients with high levels of autistic features (AN+ASF). We found no significant quantitative differences between groups in performance on the task. Qualitatively, there were differences between groups such that AN patients, especially those in the AN+ASF group, were more focused on describing the videos than creating narratives, were more negative in their interpretations, and were much more anxious about their performance. These qualitative differences have clinical implications, including that not all AN patients with autistic features should be assumed to have difficulties with ToM.

LGBTQ + and autism spectrum disorder: Experiences and challenges

Background: Research focused on gender identity, autism spectrum disorder (ASD), and the experiences of those who identify as LGBTQ+, remains minimal. Initial findings have indicated that those on the autism spectrum may be more likely to identify as homosexual and experience more fluid gender identity. Insufficient consideration has been given to intersectionality around a disability status and gender identity, and few have focused this conversation specifically on the experiences of those with ASD. Aim: The aim of this study was to improve current understanding of the first-hand experiences of those on the autism spectrum who identify as LGBTQ+, particularly regarding challenges stemming from these dual identities. Method: A focus group was conducted with four participants with ASD who presented with a range of gender identities (as they defined them) including male, transgender; agender/nonbinary; agender; and queer. Results: Qualitative analysis of the focus group transcription identified key themes: (1) Effect of Dual Identities: experiencing dual identities, autism spectrum, and LGBTQ+; (2) Multiple Minority Stressors: challenges experienced by the participants, the impact of discrimination/misunderstanding, and holding minority statuses; (3) Isolation: barriers caused by lack of understanding; (4) Lack of Service Provision. Discussion: These preliminary findings underline the need for better support, understanding, and practices regarding sexuality and gender identity among those on the autism spectrum. The current study is important for giving voice to adults on the autism spectrum who identify as LGBTQ+, and has implications for the disability community more broadly.

Gender Differences and Similarities: Autism Symptomatology and Developmental Functioning in Young Children

A growing body of research suggests that symptoms of autism spectrum disorder (ASD) may present differently in males and females. This study examined gender differences in ASD symptoms and developmental functioning, using the Baby and Infant Screen for Children with aUtism Traits, Part 1 (BISCUIT-Part 1) and the Battelle Developmental Inventory, 2nd Edition (BDI-2), amongst children aged 17-37 months meeting ASD diagnostic criteria (n = 1317). No gender differences were found in regards to overall symptom severity or symptom domains on the BISCUIT-Part 1 when gender groups were matched by cognitive ability. Females with ASD had greater motor deficits and less communication impairment compared to their male counterparts as measured by the BDI-2. Secondary analyses examining item endorsement patterns were also conducted. Implications of the findings are discussed.

Diagnosing Autism in Adults with Intellectual Disability: Validation of the DiBAS-R in an Independent Sample

The study assessed the diagnostic validity of the diagnostic behavioral assessment for autism spectrum disorders-revised (DiBAS-R; 19-item screening scale based on ratings by caregivers) in a clinical sample of 381 adults with ID. Analysis revealed a sensitivity of 0.82 and a specificity of 0.67 in the overall sample (70.3% agreement). Sensitivity (0.79) and specificity (0.84) were balanced in individuals with mild to moderate ID (83.3% agreement), while specificity was lower in individuals with severe to profound ID (sensitivity: 0.83, specificity: 0.34, 51% agreement). The level of ID as well as its interaction with ASD explained a significant proportion of the variance in the DiBAS-R scores. The DiBAS-R is an adequate screening tool, especially in individuals with mild to moderate ID.

Understanding and recognising the female phenotype of autism spectrum disorder and the “camouflage” hypothesis: a systematic PRISMA review

Purpose

Females with autism spectrum disorder (ASD) may display superficial social skills which may mask their ASD symptomology impacting on the identification of the disorder – known as the “camouflage” hypothesis. Compared to males with ASD, it is increasingly recognised that females with ASD have a stronger ability to imitate behaviour which is socially acceptable, particularly those females who have higher cognitive abilities (i.e. intelligence considered to be within the normal range) (Ehlers and Gillberg, 1993). The paper aims to discuss this issue.

Design/methodology/approach

This paper will explore the literature on camouflaging or masking behaviour in females with ASD. A systematic PRISMA review was conducted.

Findings

The capacity to “camouflage” social difficulties in social situations is considered to be one of the main features of the female phenotype of ASD (e.g. Kenyon, 2014). Social imitation or camouflaging enables some level of success and coping, which results in some females never receiving a diagnosis of ASD. They typically may not exhibit any observable functional impairments. However, under the surface of the camouflage, females may experience high levels of subjective stress, anxiety and exhaustion and a need to re-charge or recuperate by withdrawing from any social interaction.

Research limitations/implications

There is relatively little understanding and knowledge of the female phenotype of ASD. This lack of understanding and knowledge impacts significantly on the ability to identify females with ASD (Laiet al., 2015; Bargielaet al., 2016), which can have a number of negative consequence (Adamouet al., 2018; National Collaborating Centre for Mental Health (UK), 2012).

Practical implications

There is a need for the development of a camouflaging measure.

Originality/value

There is a real need for further research exploring the positive and negative impact of the phenomenon of “camouflaging”, or “pretending to be normal” in females with ASD.

Commentary on “diagnosis and treatment of ASD in women in secure and forensic hospital”

Purpose

The purpose of this paper is to provide a commentary on “diagnosis and treatment of asd in women in secure and forensic hospital”.

Design/methodology/approach

The approach is a commentary on a personal experience of services.

Findings

Women with ASD are often not diagnosed until adult years which may impact on their long-term outcomes. Secure services may not always have care teams who are appropriately trained to support a woman with ASD.

Originality/value

A commentary on an original viewpoint piece published in this special edition on women with autism spectrum disorder.

Diagnosis and treatment of ASD in women in secure and forensic hospitals

Purpose

The purpose of this paper is to explore the experience and possibilities for misdiagnosis of women with ASD in secure and forensic hospitals, via the medium of a lived experience case study. To consider the clinical value of the patient perspective of and insight into their disorder. The case study is supplemented by relevant associations to the MHA Code of Practice, the CQC report, Monitoring the Mental Health Act (MHA) 2016–2017, published on 27 February 2018 and current research findings in the fields of service provision, quality of care and treatment of female patients with a diagnosis of ASD.

Design/methodology/approach

A review and commentary of the author’s lived experience of a formal diagnostic assessment for ASD as a female patient in a secure and forensic hospital. In reviewing aspects of the author’s clinical assessment, the author has made contextual reference to the MHA Code of Practice, the CQC report, Monitoring the MHA 2016–2017, published on 27 February 2018, and current research findings. The account focuses on aspects of the author’s recent experience assessment and treatment for ASD which the author believes may be of use in informing clinical practice.

Findings

Open-ended exploration of a lived experience account/case study of a diagnostic assessment of an adult female patient for ASD, demonstrating the possible ambiguity of responses to questionnaire-based assessment tools and other deficiencies inherent to the assessment process and care and treatment of adult female ASD sufferers in secure and forensic hospitals.

Research limitations/implications

The author uses the lived experience as a patient to review and provide commentary on the clinical assessment for ASD. This review is, therefore, informed by an authentic patient perspective and not clinical perspectives. This paper highlights the need for further research into the diagnostic assessment of females for ASD in a secure and forensic hospitals.

Practical implications

First, to encourage practitioners to extend their range of thinking to be more inclusive of the patient perspective when performing a diagnostic assessment. Second, to increase practitioner awareness of the deficiencies in the current service provision for adult female patients diagnosed with ASD in secure and forensic hospitals.

Social implications

To improve patient experience of diagnostic assessment for ASD and the quality of the assessment and patient outcomes in secure and forensic hospitals.

Originality/value

The paper is original in concept in that it considers the inclusion of patient experience/views in assessment and formulation and links them to wider social policy and practice guidance. The case study is an authentic patient account informed by the author’s experience of secure and forensic psychiatric hospitals. The value of the paper may be determined by the extent to which the paper encourages practitioners to consider the patient perspective and experience of the diagnostic assessment and how this and subsequent care and treatment may affect the adult female patient in secure and forensic hospitals.

Mock Juror Perceptions of Credibility and Culpability in an Autistic Defendant

One-hundred-and-sixty jury-eligible participants read a vignette describing a male who was brought to the attention of police for suspicious and aggressive behaviours and displayed atypical behaviours in court. Half of participants were informed that he had autism spectrum disorder (ASD) and were given background information about ASD; the other half received no diagnostic label or information. The provision of a label and information led to higher ratings of the defendant's honesty and likeability, reduced blameworthiness, and resulted in fewer guilty verdicts, and more lenient sentencing. Thematic analysis revealed that participants in the label condition were more empathetic and attributed his behaviours to his ASD and mitigating factors, while participants in the No label condition perceived the defendant as deceitful, unremorseful, rude and aggressive.