Anxiety Levels in Children with Autism Spectrum Disorder: A Meta-Analysis

Is cognitive inflexibility a missing link? The role of cognitive inflexibility, alexithymia and intolerance of uncertainty in externalising and internalising behaviours in young people with autism spectrum disorder

BACKGROUND

Internalising (anxiety and low mood) and externalising (aggressive or outburst behaviours, and irritability) difficulties are very common in autism spectrum disorder (ASD) across the life span, relatively stable over time and often associated with poorer quality of life. Understanding the cognitive mechanisms underlying internalising and externalising difficulties in ASD is essential for developing targeted supports and interventions. In the present study, we investigated established and less-researched cognitive factors hypothesised to contribute to internalising and/or externalising difficulties in ASD, namely cognitive inflexibility (CI), intolerance of uncertainty (IU) and alexithymia. Based on previous models and clinical experience, we hypothesised that IU would lead to internalising symptoms, with alexithymia contributing to this pathway, and that CI would have a direct effect on externalising behaviours and may indirectly contribute to internalising symptoms via increasing IU.

METHODS

Our sample consisted of 95 5- to 18-year-olds presenting to a specialist neurodevelopmental clinic and receiving a diagnosis of ASD. Parents/caregivers completed questionnaires assessing ASD symptomatology, internalising and externalising difficulties, CI, IU and alexithymia. Structural equation modelling was used to examine the hypothesised pathways and relationships between the main variables of interest.

RESULTS

Cognitive Inflexibility played a significant direct role in the pathway from ASD symptoms to externalising symptoms in ASD, and indirect role via IU in the pathway to internalising problems. Relationships between alexithymia and both internalising and externalising symptoms were weaker, with alexithymia predicting internalising difficulties via IU only.

CONCLUSIONS

The finding of a direct pathway from CI to externalising behaviours is novel, as is the indirect role of CI in internalising symptomatology. Of the three cognitive mechanisms examined, only CI significantly predicted externalising symptoms. Possible implications for interventions and supports targeting these cognitive processes in ASD are discussed.

Estudiantes universitarios con trastornos del espectro del autismo: revisión de sus necesidades y notas para su atención

En los últimos 10 años hemos visto incrementar el número de publicaciones relacionadas con la inclusión en las aulas universitarias de estudiantes con Trastornos del Espectro del Autismo, síndrome de Asperger o Autismo de alto funcionamiento. En este artículo, se resume la literatura sobre la presencia de estudiantes con Trastornos del Espectro del Autismo en la Universidad y se reflexiona sobre la necesidad de desarrollar programas específicos para su atención en el marco de los servicios de apoyo a los estudiantes con discapacidad u otras estructuras de servicios similares. Entre las medidas específicas, hemos encontrado experiencias sobre programas de sensibilización a profesores y estudiantes con la finalidad de generar una cultura sobre “el autismo”, programas para tratar la ansiedad, programas de prevención de salud mental, etc. En definitiva, medidas que, aunque están dirigidas a un colectivo en particular, pueden beneficiar a toda la comunidad universitaria.

Is Bullying Associated with Emerging School Refusal in Autistic Boys?

The experience of being bullied is widespread among autistic youth. Relatively little empirical work has been done on the relationship between the bullying of these youth and school refusal (SR). This study of 67 school-age autistic boys (M = 11.7 years, SD = 2.3 years) examined several factors that may contribute to SR. Data regarding boys' age, generalised anxiety disorder (GAD), major depressive disorder (MDD), key ASD diagnostic criteria, and frequency of being bullied were collected. Results indicated that, while boys displaying emerging SR also had significantly higher GAD and MDD than boys without emerging SR, only the frequency of being bullied made a significant contribution to emerging SR. Implications for prevention and treatment of SR among autistic youth are discussed.

How is COVID-19 Affecting the Mental Health of Children with Special Educational Needs and Disabilities and Their Families?

Parents of children with Special Educational Needs and Disabilities in the UK (n = 241) were asked to describe the impact of COVID-19 on their own mental health and that of their child. An inductive content analysis of the data was undertaken. Both parents and children appear to be experiencing loss, worry and changes in mood and behaviour as a result of the rapid social changes that have occurred. Some parents reported feeling overwhelmed and described the impact of child understanding and awareness. Finally, a minority of parents reported that COVID-19 has had little impact on mental health in their family, or has even led to improvements. Implications for how to support these families in the immediate future are discussed.

Exploratory Study of Cat Adoption in Families of Children with Autism: Impact on Children's Social Skills and Anxiety

PURPOSE

The diagnosis of Autism Spectrum Disorder (ASD) occurs in one in 54 children and companion animals (CA) are common in families of children with ASD. Despite evidence of CA ownership benefits for children with ASD, little is known about cats. The purpose was to explore the impact of shelter cat adoption by families of children with ASD.

DESIGN AND METHODS

This was the first randomized controlled trial of adoption of a temperament screened cat by families of children with ASD. Families assigned to the treatment group adopted a cat and were followed for 18 weeks. Families assigned to the control group were followed for 18 weeks without intervention, then converted to treatment, by adopting a cat and were followed another 18 weeks. Adopted cats were screened using the Feline Temperament Profile to identify a calm temperament. Surveys measured children's social skills and anxiety and parent/child cat bonding.

RESULTS

Our study (N = 11) found cat adoption was associated with greater Empathy and less Separation Anxiety for children with ASD, along with fewer problem behaviors including Externalizing, Bullying and Hyperactivity/Inattention. Parents and children reported strong bonds to the cats.

CONCLUSION

This exploratory study found introduction of a cat into the home may have a positive impact on children with ASD and their parents. Based on this intial finding, future studies with larger sample sizes are recommended.

PRACTICE IMPLICATIONS

If parents of children with ASD are considering cat adoption, health care providers might consider recommending adoption of a cat screened for calm temperament.

COVID-19 pandemic effects in people with Autism Spectrum Disorder and their caregivers: Evaluation of social distancing and lockdown impact on mental health and general status

Among the difficulties associated with Autism Spectrum Disorder (ASD) are those related to adaptation to changes and new situations, as well as anxious-depressive symptoms frequently related to excessive environmental requirements. The main objective of this research is to study the psychological impact of the lockdown due to the social emergency situation (COVID-19) in children/adolescents and adults diagnosed with ASD. Participants were 37 caregivers of children/adolescents with ASD, also 35 ASD adults and 32 informants. Evaluation was conducted through a web survey system and included standardized clinical questionnaires (CBCL and SCL-90-R), which were compared with results before lockdown start, and a brief self-reported survey addressing the subjective perception of changes in daily functioning areas. The results revealed a reduction of psychopathological symptoms in both age groups, but only reaching statistical significance in the adult group, except for Somatization, Anxiety, and Obsessive-Compulsive domains. ASD severity Level 2 showed greater improvement after lockdown onset in the children/adolescent group when compared to ASD Level 1 participants. Younger adults (18-25 yoa) reported greater improvement than older adults (=>25 yoa). Survey results indicate an improvement of feeding quality and a reduction in the number of social initiations during the lockdown. Adult ASD participants perceived a decrease in stress levels after the lockdown onset, whereas caregivers reported higher stress levels at the same point in both age groups. Limitations included the small number of participants and a heterogeneous evaluation window between measures. Pyschopathological status after two months of social distancing and lockdown seems to improve in ASD young adult population.

Symptom profiles and correlates of anxiety and depression among parents of autistic girls and boys

BACKGROUND

Although it has been reported for some time that parenting an autistic child is associated with elevated anxiety and depression, no direct comparison has been published regarding the relative anxiety and depressive states of parents of an autistic son versus an autistic daughter.

AIMS

To investigate the presence of differences in anxiety and depression in parents of autistic girls and boys, and to identify if there were any meaningful child-based correlates of those states.

METHODS AND PROCEDURES

A sample of 51 parents of young autistic males (M age = 10.2 yr, SD = 2.8 yr, range to 6-17 yr) and 51 parents of autistic females (M age = 10.1 yr, SD = 2.7 yr, range to 6-17 yr) completed the GAD7 and PHQ9. Autistic children were assessed for IQ and autism severity.

OUTCOMES AND RESULTS

Although there were no significant differences between the two sets of parents' GAD7 or PHQ9 total scores, there were significant and meaningful differences at the individual GAD7 and PHQ9 item level. Moreover, when examined at the within-child-sex subgroup level, different aspects of the autistic sons' and daughters' age and IQ were correlated with specific items from the GAD7 and PHQ9.

CONCLUSIONS AND IMPLICATIONS

Because these items were somatic in nature, implications are discussed for possible treatment strategies with these parents.

State and Trait Anxiety of Adolescents with Autism Spectrum Disorders

OBJECTIVE

This study examined how state and trait anxiety of adolescents with autism spectrum disorders (ASD) are associated with their demographic characteristics, repetitive and restricted behaviors (RRBs), and internalizing and externalizing problem behaviors.

METHODS

A total of 96 participants with ASD (mean age=14.30 years; 91 males) completed a battery of tests including the State/Trait Anxiety Inventory (STAI), the Autism Diagnostic Interview-Revised, the Social Responsiveness Scale (SRS), and a cognitive test measuring intelligence quotient (IQ). Participants' parents completed the Child Behavior Checklist (CBCL). Pearson's correlations among age, IQ, two subscales of the STAI (i.e., STAIS and STAIT, measuring self-reported state and trait anxiety, respectively), and the Anxiety subscale of CBCL (i.e., CBCL-Anxiety, measuring parent-reported trait anxiety) were computed. Subsequently, Pearson's correlations were computed among the three anxiety measures, RRBs, and problem behaviors, while controlling for participants' age and IQ.

RESULTS

The STAIS and CBCL-Anxiety were both significantly correlated with higher age, sensory sensitivity, depressive symptoms, somatic complaints, and aggressive behaviors. All three anxiety variables were significantly and positively correlated with total SRS RRB scores. Additionally, the STAIS and STAIT were significantly associated with more severe Compulsion/Adherence behaviors, and the CBCL-Anxiety was also significantly associated with more severe Rule-breaking Behaviors.

CONCLUSION

Self-reported state anxiety showed association patterns similar to those of parent-reported trait anxiety. Future studies investigating the precise operationalization of different anxiety instruments are needed to accurately measure the anxiety of adolescents with ASD.

How have youth with Autism Spectrum Disorder managed quarantine derived from COVID-19 pandemic? An approach to families perspectives

Quarantine derived from COVID-19 pandemic has challenged children and adolescents with Autism Spectrum Disorder (ASD) and their families daily life and routines. Because of these children unique needs related to manage uncertainty and overcoming situations, an in-depth approach to how they navigated through quarantine urged to better comprehend their current support needs. Forty-seven families with a child with ASD ranging in age between 2 and 17 years old (M = 7.3, SD = 3.4) from the north of Spain responded to an online developed questionnaire on different aspects of their daily life management of quarantine. Most of the families stressed that their offspring better drove quarantine than expected. Some families reported that youth participated more often in families' routines and were more communicative with their parents. Families, beyond some difficulties aroused, had more time to qualitatively spend with their children to teach new skills as autonomy or house care related skills. Families also developed new strategies to manage quarantine, such as structuring their days, using visual supports or new technologies for learning or leisure, and found more useful in this effort their family cohesion, online contact with relatives, and having online psychological supports.

Differential roles of ARID1B in excitatory and inhibitory neural progenitors in the developing cortex

Genetic evidence indicates that haploinsufficiency of ARID1B causes intellectual disability (ID) and autism spectrum disorder (ASD), but the neural function of ARID1B is largely unknown. Using both conditional and global Arid1b knockout mouse strains, we examined the role of ARID1B in neural progenitors. We detected an overall decrease in the proliferation of cortical and ventral neural progenitors following homozygous deletion of Arid1b, as well as altered cell cycle regulation and increased cell death. Each of these phenotypes was more pronounced in ventral neural progenitors. Furthermore, we observed decreased nuclear localization of β-catenin in Arid1b-deficient neurons. Conditional homozygous deletion of Arid1b in ventral neural progenitors led to pronounced ID- and ASD-like behaviors in mice, whereas the deletion in cortical neural progenitors resulted in minor cognitive deficits. This study suggests an essential role for ARID1B in forebrain neurogenesis and clarifies its more pronounced role in inhibitory neural progenitors. Our findings also provide insights into the pathogenesis of ID and ASD.

Differential Item Functioning Based on Autism Features, IQ, and Age on the Screen for Child Anxiety Related Disorders (SCARED) Among Youth on the Autism Spectrum

Anxiety commonly occurs among youth on the autism spectrum, yet measurement of anxiety in this population is complicated by a number of factors, including potentially overlapping symptomatology, the child's intellectual functioning, and changes in anxiety across development. Moreover, few studies have examined the psychometric properties of anxiety measures in this population, and no study to date has tested whether there are systematic differences in the measurement of anxiety, or differential item functioning (DIF), across the high degree of heterogeneity and the developmental course of autism. To test this possibility, data were combined across multiple studies using the National Database for Autism Research, an NIH-funded data repository. Parent-report on the Screen for Child Anxiety Related Disorders (SCARED) and Social Communication Questionnaire (SCQ) were used as measures of anxiety and autism features, respectively. A confirmatory factor analysis indicated good fit of the literature standard five-factor structure. Moderated nonlinear factor analysis (MNLFA) revealed multiple items with intercept and loading DIF based on level of autism features, IQ, and age, especially for items related to social behavior. Therefore, although the measure's factor structure is consistent with that found in the general population, the SCARED may not capture differences in anxiety equivalently for all children on the spectrum and across their development. Clinicians and researchers need to be especially vigilant in measuring anxiety symptoms in children with autism by removing items flagged for DIF from the SCARED and/or by using multiple measures and informants. LAY ABSTRACT: Autistic youth often experience clinical levels of anxiety. Many tools used to measure anxiety were developed for the general population, but not for use with autistic youth. This study found that the Screen for Child Anxiety Related Disorders (SCARED) measures the same five dimensions of anxiety as in the general population. Parents, however, may respond differently to questions on the SCARED based on their child's autism features, intellectual functioning, and age, which impacts our ability to accurately measure anxiety among autistic youth.

Psychiatric Comorbidities in Children With ASD: Autism Centre Experience

Autism spectrum disorder (ASD) is a neurodevelopmental disorder with social communication deficits, restricted interests, and repetitive behaviours. In this lifelong condition the core features that cause impairment may also be expanded by behavioural and emotional problems. Individuals with ASD are likely to experience a higher prevalence of common mental disorders compared to the typically developed individuals. This high epidemiological burden of various psychiatric disorders among ASD population encourages further research and improvement in diagnostic practise in ASD and comorbid disorders. In this brief research report of a cross-sectional study, I aimed to estimate the psychiatric comorbidity prevalence and describe their general characteristics in children with ASD in the Autism Centre in Montenegro. The study population consisted of 152 patients who were diagnosed with ASD, 117 male and 35 female, and the mean age (SD) was 8.02 (4.26). In this brief research report prevalence of children with ASD with at least one psychiatric comorbidity was 36.84%. Only one psychiatric comorbidity disorder was reported in 17.16%, two in 9.87%, three in 8.55%, and in 0.66% patients four other psychiatric disorders. Psychiatric disorders present in this population sample were attention deficit hyperactivity disorder (17.76%), conduct disorder (13.10%), disruptive mood dysregulation disorder (9.87%), anxiety disorder and insomnia (7.89%), elimination disorder (3.29%), and depression (1.97%).

An Exploratory Analysis of Predictors of Youth Suicide-Related Behaviors in Autism Spectrum Disorder: Implications for Prevention Science

Although autism spectrum disorder (ASD) is associated with significant mental health concerns, little is known about suicidality, particularly among youth. To address this critical gap in the literature, the current study examined the predictive validity of (1) demographics, (2) core autism symptoms, (3) cognitive abilities and adaptive behavior, (4) comorbid psychopathology, and (5) medical problems, for suicide-related behaviors among autistic youth (N = 481; M_age = 11.56 years). As indices of suicide-related behaviors, parents reported on whether the child had ever (1) talked about killing themselves, and (2) engaged in deliberate self-harm or attempted suicide. These two suicide-related outcomes had distinct clinical correlates, including child age, parental education, restricted and repetitive behaviors, IQ and adaptive behavior, affective and conduct problems, and medical concerns.

Anxiety and intellectual functioning in autistic children: A systematic review and meta-analysis

Autistic children experience higher levels of anxiety than their peers. Making appropriate diagnoses of anxiety disorders and providing effective treatment for these children is particularly difficult. Inconsistent evidence suggests that levels of anxiety in autistic children are related to intellectual functioning. We provide the first meta-analysis of this evidence. A systematic search identified 49 papers for review. These papers included measures of anxiety and intelligence quotient in 18,430 autistic children. Studies employing correlations showed evidence of a significant relationship between intelligence quotient and anxiety in autistic children: children with higher intelligence quotient scored higher on measures of anxiety. Studies directly comparing groups of autistic children with and without intellectual disability also supported this conclusion. Most studies employing other designs also supported this finding. Employing a quality assessment framework identified common threats to validity. Many studies used measures of anxiety that were not validated across the samples they measure. This was most notable for those autistic children with an intellectual disability. It is vital that future research determines whether the identified relationship between intelligence quotient and anxiety reflects something important in the mechanism for anxiety in autistic children, or quantifies the lack of sensitivity of our measures of anxiety across different groups.

Caregiver- and Child-Reported Anxiety Using an Autism-Specific Measure: Measurement Properties and Correlates of the Anxiety Scale for Children with Autism Spectrum Disorder (ASC-ASD) in Verbal Young People with ASD

Identifying and measuring anxiety in young people on the autism spectrum can be challenging. The present study investigated the use of the Anxiety Scale for Children with Autism Spectrum Disorder (ASC-ASD), a self- and caregiver-rated screening tool in a Singaporean sample of ninety-one verbal autistic youths and their caregivers. Internal consistency ranged from satisfactory to desirable (α = .74-.92). Convergent validity with medium-large effect size was established using a structured diagnostic interview, the Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID). ASC-ASD scores were positively associated with autistic symptoms and response patterns indicated strong endorsement of autism-specific items. The findings are discussed in relation to existing literature on assessment of anxiety in ASD and in light of the study's strengths and limitations.

Reliability and validity of the Pediatric Anxiety Rating Scale modified for autism spectrum disorder

LAY ABSTRACT

Many youth with autism spectrum disorder have anxiety, but it can be difficult to assess anxiety with existing measures. We modified the Pediatric Anxiety Rating Scale for youth with autism spectrum disorder and tested the new measure in a group of 116 youth (age: 5-17 years) with autism spectrum disorder. The Pediatric Anxiety Rating Scale for youth with autism spectrum disorder is an interview that a clinician usually completes with the child and parent together. We modified the interview questions and scoring instructions based on feedback from parents of children with autism spectrum disorder and from a panel of experts in autism spectrum disorder and anxiety. Unlike many other anxiety measures, the Pediatric Anxiety Rating Scale for youth with autism spectrum disorder relies less on a child's verbal expression of anxiety and more on signs that a parent can easily observe. Training clinicians to administer and score the Pediatric Anxiety Rating Scale for youth with autism spectrum disorder was uncomplicated, and raters showed excellent agreement on video-recorded interviews. Youth who were not currently in treatment for anxiety had stable Pediatric Anxiety Rating Scale for youth with autism spectrum disorder scores with repeat measurement over a 1-month period. The Pediatric Anxiety Rating Scale for youth with autism spectrum disorder is a useful clinician-rated measure of anxiety in youth with autism spectrum disorder and fills a gap for assessing anxiety in this population.

The effect of background strain on the behavioral phenotypes of the MDGA2+/- mouse model of autism spectrum disorder

The membrane-associated mucin (MAM) domain containing glycosylphosphatidylinositol anchor 2 protein single knock-out mice (MDGA2^+/- ) are models of ASD. We examined the behavioral phenotypes of male and female MDGA2^+/- and wildtype mice on C57BL6/NJ and C57BL6/N backgrounds at 2 months of age and measured MDGA2, neuroligin 1 and neuroligin 2 levels at 7 months. Mice on the C57BL6/NJ background performed better than those on the C57BL6/N background in visual ability and in learning and memory performance in the Morris water maze and differed in measures of motor behavior and anxiety. Mice with the MDGA2^+/- genotype differed from WT mice in motor, social and repetitive behavior and anxiety, but most of these effects involved interactions between MDGA2^+/- genotype and background strain. The background strain also influenced MDGA2 levels and NLGN2 association in MDGA2^+/- mice. Our findings emphasize the importance of the background strain used in studies of genetically modified mice.

The relationship between intolerance of uncertainty and anxiety in autism: A systematic literature review and meta-analysis

LAY ABSTRACT

People who find it especially hard to cope with the unexpected or unknown are said to have an intolerance of uncertainty. Autistic individuals often report a preference for certainty and experience levels of anxiety that can interfere with their daily life. Understanding more about the link between the intolerance of uncertainty and anxiety in autistic people might lead to better treatments for anxiety being developed. Therefore, this work aimed to review previous research in order to explore this link. Twelve studies were found and their results were compared and contrasted. The autistic people who participated in the studies completed questionnaires that suggested a large number of them experienced very high levels of anxiety and intolerance of uncertainty. Of 10 studies that used relevant statistics, nine found a statistically significant link between anxiety and the intolerance of uncertainty. In general, the strength of the link was about the same as previous research found in people who did not have a diagnosis of autism. This might mean that interventions that aim to help people who are intolerant of uncertainty could be effective for autistic individuals.

Self- vs Parent Reports of Generalised Anxiety Disorder Symptomatology in Mildly Impaired Girls with an Autism Spectrum Disorder

Previous data have suggested that parents of boys with autism spectrum disorder (ASD) may rate their sons' generalised anxiety disorder (GAD) more severely than the boys do themselves. However, no reports have been published to date which examine this issue in a girls-only sample. This study investigated the extent and nature of mother-daughter agreement on ratings of GAD in a sample of 53 girls with an ASD with mild impairment, aged 6 to 17 years. Mothers rated their daughters' GAD more severely than the girls did themselves, despite confounding effects from the girls' medication and menarche status. Suggestions are made for the valid assessment of GAD in girls with an ASD.

Examining the Treatment Efficacy of PEERS in Japan: Improving Social Skills Among Adolescents with Autism Spectrum Disorder

This study examines the efficacy of the Japanese version of the Program for the Education and Enrichment of Relational Skills (PEERS), which focuses on improving social functioning through making friends and maintaining good relationships for adolescents with autism spectrum disorder (ASD) without intellectual disabilities. Originally developed in the United States, PEERS is one of the few evidence-based social skills training programs for youth with ASD. The present study shows that with linguistic and cultural modifications, PEERS is effective in improving social functioning for adolescents with ASD in Japan. Positive results were found specifically in the areas of socialization, communication, knowledge of social skills, autistic mannerisms, and behavioral and emotional problems. In addition, most treatment gains were maintained at a 3-month follow-up assessment. These findings suggest that the Japanese version of PEERS is beneficial across multiple socio-emotional and behavioral domains for adolescents with ASD.

Prevalence of comorbid psychiatric disorders among people with autism spectrum disorder: An umbrella review of systematic reviews and meta-analyses

With ever-increasing prevalence of various mental disorders worldwide, a comprehensive evaluation of the prevalence of co-occurring psychiatric disorders among individuals with autism spectrum disorder (ASD) is needed to strengthen the knowledge base. This umbrella review aims to summarize the current evidence on the prevalence of comorbid psychiatric disorders among people with ASD. A systematic search of 12 major databases and additional sources was conducted. Any systematically conducted narrative, qualitative, or meta-analytic review reporting the prevalence of psychiatric disorders among people with ASD with no age or geographical restriction were included. From a total of 2755 records, 26 articles representing 14 systematic reviews and 12 meta-analyses met the criteria of this review. The synthesized findings reveal a high burden of comorbid psychiatric disorders among people with ASD, including anxiety disorders, depressive disorders, bipolar and mood disorders, schizophrenia spectrum, suicidal behavior disorders, attention-deficit/hyperactivity disorder, disruptive, impulse-control and conduct disorders amongst diverse age groups, with a majority in younger participants. Most studies were conducted in developed nations, with limited evidence from low and middle-income countries. These synthesized findings provide high-quality evidence for clinical and policy-level decision-making from a global overview of the status of comorbid psychiatric disorders among people with ASD.

The role of emotion regulation and core autism symptoms in the experience of anxiety in autism

LAY ABSTRACT

Many children with autism spectrum disorder have problems with managing their emotions (emotion regulation) and anxiety. In this study, over 1000 parents completed an online survey which showed that emotion regulation and anxiety are closely linked. Although emotion regulation and anxiety are inter-connected, the results also show that autism symptoms play an important role in anxiety in autism spectrum disorder. Emotion regulation problems may be an important target for the treatment of anxiety in autism.

Anxiety in young people with autism spectrum disorder: Common and autism-related anxiety experiences and their associations with individual characteristics

Anxiety is common in autism spectrum disorder. Many anxiety symptoms in autism spectrum disorder are consistent with Diagnostic and Statistical Manual of Mental Disorders (5th ed.) anxiety disorders (termed "common" anxieties), but others may be qualitatively different, likely relating to autism spectrum disorder traits (herein termed "autism-related" anxieties). To date, few studies have examined both "common" and "autism-related" anxiety experiences in autism spectrum disorder. We explored caregiver-reported Spence Children's Anxiety Scale-Parent version data from a multi-site (United Kingdom, Singapore, and United States) pooled database of 870 6- to 18-year-old participants with autism spectrum disorder, of whom 287 provided at least one written response to the optional open-ended Spence Children's Anxiety Scale-Parent item 39 ("Is there anything else your child is afraid of?"). Responses were thematically coded to explore (a) common and autism-related anxiety presentations and (b) their relationship with young people's characteristics. Nearly half of the responses were autism-related anxieties (mostly sensory, uncommon, or idiosyncratic specific phobias and worries about change and unpredictability). The other half described additional common anxieties not covered in the original measure (mostly social, weather and environmental disasters, and animals). Caregivers of participants who were more severely affected by autism spectrum disorder symptoms reported more autism-related, as compared to common, additional anxieties. Implications for the assessment and understanding of anxiety in autism are discussed.

Exploring the profiles of children with autism spectrum disorder: association with family factors

This study aimed to identify different profiles of children with autism spectrum disorder (ASD) without intellectual disability (ID) and maternal factors characteristic of these profiles. Participants were 89 children between 7 and 11 years old and their mothers, distributed in two groups, 52 children with ASD and 37 with typical development (TD). Based on the children's adaptive, behavioral, and pragmatic manifestations, three clusters were obtained in the ASD group. Children with the most serious difficulties in all the domains assessed were assigned to Cluster 1, whereas the children in Cluster 3 were characterized by relatively minor problems. Cluster 2 comprised children with moderate difficulties in the different domains. Compared to the TD group, group 1, with 'Serious Difficulties', and group 2, with 'Moderate Difficulties', showed significant differences on all the variables evaluated. Group 3, 'Slight Difficulties', was only significantly differentiated from the group with TD on ASD and attention deficit hyperactivity disorder (ADHD) symptoms, pragmatic competence, and applied theory of mind. Therefore, it was outlined as the purest group and basically manifested core ASD symptoms. In addition, mothers of children in the 'Serious Difficulties' group showed higher stress levels and less use of emotional and instrumental support and acceptance strategies, as well as more mental health problems, than mothers of children in the 'Slight Difficulties' group. The results support the need to assess the presentation of other possible problems in ASD children without ID, and design interventions for parents who may be at risk of experiencing higher levels of stress and have fewer coping strategies.

Development of the Parent-Rated Anxiety Scale for Youth With Autism Spectrum Disorder

OBJECTIVE

Anxiety is common in youth with autism spectrum disorder (ASD). There is no accepted outcome measure for anxiety in this population.

METHOD

Following a series of focus groups with parents of youth with ASD, we generated 72 items (scored 0-3). Parents of 990 youth with ASD (aged 5-17 years; 80.8% male) completed an online survey. Factor analysis and item response theory analyses reduced the content to a single factor with 25 items. Youth with at least mild anxiety (n = 116; aged 5-17 years; 79.3% male) participated in a comprehensive clinical assessment to evaluate the validity and reliability of the 25-item Parent-Rated Anxiety Scale for ASD (PRAS-ASD).

RESULTS

In the online sample, the mean PRAS-ASD score was 29.04 ± 14.9 (range, 0-75). The coefficient α was 0.93. The item response theory results indicated excellent reliability across a wide range of scores with low standard errors. In the clinical sample (n = 116), the PRAS-ASD mean was 31.0 ± 15.6 (range, 1-65). Pearson correlations with parent ratings of ASD symptom severity, repetitive behavior, and disruptive behavior ranged 0.33 to 0.66, supporting divergent validity of the PRAS-ASD. Pearson correlation with a parent-rated measure of anxiety used in the general pediatric population of 0.83 supported convergent validity. A total of 40 participants (32 boys, 8 girls; mean age, 11.9 ± 3.4 years) returned at time 2 (mean, 12.2 days) and time 3 (mean, 24.2 days). Intraclass correlation showed test-retest reliabilities of 0.88 and 0.86 at time 2 and time 3, respectively.

CONCLUSION

The 25-item PRAS-ASD is a reliable and valid scale for measuring anxiety in youth with ASD.

Anxiety in 3- to 7-year-old children with autism spectrum disorder seeking treatment for disruptive behavior

Anxiety is a common and impairing problem in children with autism spectrum disorder, but little is known about it in preschool children with autism spectrum disorder. This article reports on the characteristics of anxiety symptoms in young children with autism spectrum disorder using a parent-completed rating scale. One hundred and eighty children (age 3-7 years) participated in a clinical trial of parent training for disruptive behaviors. Anxiety was measured as part of pre-treatment subject characterization with 16 items from the Early Childhood Inventory, a parent-completed scale on child psychiatric symptoms. Parents also completed other measures of behavioral problems. Sixty-seven percent of children were rated by their parents as having two or more clinically significant symptoms of anxiety. There were no differences in the Early Childhood Inventory anxiety severity scores of children with IQ < 70 and those with ⩾70. Higher levels of anxiety were associated with severity of oppositional defiant behavior and social disability. Anxiety symptoms are common in preschoolers with autism spectrum disorder. These findings are consistent with earlier work in school-age children with autism spectrum disorder. There were no differences in anxiety between children with IQ below 70 and those with IQ of 70 and above. Social withdrawal and oppositional behavior were associated with anxiety in young children with autism spectrum disorder.

Cortisol awakening response in children and adolescents with autism spectrum disorder: a systematic review and meta-analysis

BACKGROUND

The cortisol awakening response (CAR) is characterised by an increase in cortisol in the 30 to 60 min after waking. Research has found significant associations between an atypical CAR and symptoms of stress and anxiety in typically developing (TD) children and adolescents. A number of studies have explored the CAR in autism spectrum disorder (ASD), but no evidence synthesis is available to date.

OBJECTIVE AND METHODS

Based on a preregistered protocol (PROSPERO: CRD42017051187), we carried out a systematic review (SR) and meta-analysis (MA) of CAR studies to explore potential significant differences between children and adolescents with ASD and TD controls. Web of Science, PubMed and PsychInfo were searched until January 2019. A random-effects model was used to pool studies and we used the Newcastle-Ottawa scale (NOS) to assess study quality and risk of bias.

FINDINGS

The SR retrieved a total of nine studies, with mixed findings on the comparison of the CAR between children and adolescents with ASD and TD controls. The MA, based on four studies (ASD; n=117 and TD n=118), suggested no differences between the CAR in ASD and TD populations (SMD: -0.21, 95% CI -0.49 to 0.08). In terms of NOS items, no study specified Representativeness of the cases and Non-response rate. DISCUSSION AND CLINICAL IMPLICATIONS: Given the relatively few studies and lack of appropriately matched TD controls, additional research is needed to further understand and recommend the utility of the CAR as a reliable marker to differentiate ASD and TD.

A Psychometric Analysis of the Social Anxiety Scale for Adolescents Among Youth With Autism Spectrum Disorder: Caregiver-Adolescent Agreement, Factor Structure, and Validity

Social anxiety is common among adolescents with autism spectrum disorder (ASD). An ongoing challenge for both research and clinical practice in ASD is the assessment of anxious symptomatology. Despite its widespread use in samples of youth with ASD, the Social Anxiety Scale for Adolescents (SAS-A) has not received psychometric evaluation within this population; thus, the validity of its use in research and clinical practice for ASD remains unclear. The present study conducted a psychometric analysis of caregiver and adolescent SAS-A forms in a sample of adolescents with ASD (N = 197). Results revealed (1) poor caregiver-adolescent item-level agreement, (2) a two-factor structure, (3) lack of measurement invariance between reporters, and (4) modest evidence for convergent and discriminant validity. Overall, findings suggest that this measure demonstrates reasonable psychometric properties in an ASD sample. Lack of measurement invariance, however, calls for careful interpretation of research involving the SAS-A in ASD samples, particularly when the primary goal is to compare adolescent and caregiver reports. The implications of these findings for future research and clinical practice are discussed.

Strain differences in the susceptibility to the gut-brain axis and neurobehavioural alterations induced by maternal immune activation in mice

There is a growing realization that the severity of the core symptoms of autism spectrum disorders and schizophrenia is associated with gastrointestinal dysfunction. Nonetheless, the mechanisms underlying such comorbidities remain unknown. Several genetic and environmental factors have been linked to a higher susceptibility to neurodevelopmental abnormalities. The maternal immune activation (MIA) rodent model is a valuable tool for elucidating the basis of this interaction. We induced MIA with polyinosinic-polycytidylic acid (poly I:C) at gestational day 12.5 and assessed behavioural, physiological and molecular aspects relevant to the gut-brain axis in the offspring of an outbred (NIH Swiss) and an inbred (C57BL6/J) mouse strain. Our results showed that the specific MIA protocol employed induces social deficits in both strains. However, alterations in anxiety and depression-like behaviours were more pronounced in NIH Swiss mice. These strain-specific behavioural effects in the NIH Swiss mice were associated with marked changes in important components of gut-brain axis communication: the endocrine response to stress and gut permeability. In addition, MIA-induced changes in vasopressin receptor 1a mRNA expression in the hypothalamus were observed in NIH Swiss mice only. Taken together, these data suggest that genetic background is a critical factor in susceptibility to the gut-brain axis effects induced by MIA.

Linking social motivation with social skill: The role of emotion dysregulation in autism spectrum disorder

Autism spectrum disorder (ASD) is associated with pervasive social deficits as well as marked emotion dysregulation across the life span. Decreased social motivation accounts in part for social difficulties, but factors moderating its influence are not fully understood. In this paper, we (a) characterize social and emotional functioning among children and adolescents with ASD, (b) explore contributions of social motivation and emotion dysregulation to social skill, and (c) consider biological sex and intellectual functioning as moderators of these associations. In a sample of 2,079 children and adolescents with ASD from the Simons Simplex Collection, we document direct effects of social motivation, internalizing symptoms, aggression, attention problems, irritability, and self-injurious behavior on children's social skills. Furthermore, dysregulation in several domains moderated the association between social motivation and social skill, suggesting a blunting effect on social motivation in the context of emotional difficulties. Moreover, when considering only individuals with intellectual skills in the average range or higher, biological sex further moderated these associations. Findings add to our understanding of social-emotional processes in ASD, suggest emotion dysregulation as a target of intervention in the service of social skill improvements, and build on efforts to understand sources of individual difference that contribute to heterogeneity among individuals with ASD.

Journey to diagnosis for women with autism

Purpose

The purpose of this paper is to review the barriers that girls and women face in receiving an accurate and timely autism diagnosis. The journey to late-in-life diagnosis will be explored with a focus on mental health and well-being. The aim is to improve the awareness of the female autism phenotype to provide access to early identification and appropriate supports and services.

Design/methodology/approach

The author’s clinical experience as an individual, couple and family therapist specializing in girls and women with autism informs the paper. Research on co-occurring mental health experience and diagnoses are reviewed and combined with case examples to outline the themes leading to and obscuring autism diagnosis.

Findings

Females with autism are less likely to be diagnosed or are identified much later than their male counterparts. Living with unidentified autism places significant mental strain on adults, particularly females. Achieving a late-in-life diagnosis is very valuable for adults and can improve self-awareness and access to limited support.

Practical implications

Mental health professionals will develop a better understanding of the overlap between autism and psychiatric conditions and should consider autism in females who are seeking intervention.

Originality/value

This paper provides a clinical approach to working with autistic girls and women. This knowledge can complement the existing research literature and help build the foundation for a greater understanding of the female autism phenotype.

Anxiety and depression in adults with autism spectrum disorder: a systematic review and meta-analysis

Adults with autism spectrum disorder (ASD) are thought to be at disproportionate risk of developing mental health comorbidities, with anxiety and depression being considered most prominent amongst these. Yet, no systematic review has been carried out to date to examine rates of both anxiety and depression focusing specifically on adults with ASD. This systematic review and meta-analysis examined the rates of anxiety and depression in adults with ASD and the impact of factors such as assessment methods and presence of comorbid intellectual disability (ID) diagnosis on estimated prevalence rates. Electronic database searches for studies published between January 2000 and September 2017 identified a total of 35 studies, including 30 studies measuring anxiety (n = 26 070; mean age = 30.9, s.d. = 6.2 years) and 29 studies measuring depression (n = 26 117; mean age = 31.1, s.d. = 6.8 years). The pooled estimation of current and lifetime prevalence for adults with ASD were 27% and 42% for any anxiety disorder, and 23% and 37% for depressive disorder. Further analyses revealed that the use of questionnaire measures and the presence of ID may significantly influence estimates of prevalence. The current literature suffers from a high degree of heterogeneity in study method and an overreliance on clinical samples. These results highlight the importance of community-based studies and the identification and inclusion of well-characterized samples to reduce heterogeneity and bias in estimates of prevalence for comorbidity in adults with ASD and other populations with complex psychiatric presentations.

Teacher responses to anxiety-related behaviours in students on the autism spectrum

BACKGROUND

At least 50% of students on the autism spectrum experience clinical or subclinical levels of anxiety but there is scant research on how teachers respond to anxiety in children on the spectrum.

AIMS

To compare teacher responses to anxiety-related behaviour in students who do and do not have a diagnosis on the spectrum using the Teacher Responses to Anxiety in Children (TRAC).

METHODS AND PROCEDURES

Teachers (N = 64), predominantly from mainstream primary schools, completed an online survey comprised of a demographic questionnaire and two versions of the TRAC, one for students without autism and one for students with autism.

OUTCOMES AND RESULTS

Teachers report differences in the way they would likely respond to anxiety-related behaviours observed in students with and without autism. Teachers reported being more likely to use anxiety-promoting responses for students with autism who are showing behaviours indicative of general and separation anxiety, but not when they are showing behaviours indicative of social anxiety. Whilst there was no significant difference in the overall likelihood of use of autonomy-promoting responses between groups, there were differences in the likelihood of using specific autonomy-promoting responses dependent upon diagnosis and type of anxiety.

CONCLUSIONS AND IMPLICATIONS

Teachers report they are likely to respond differently to anxiety-related behaviours of students on the autism spectrum but the impact of this on the behaviour of these students is yet to be determined. Professional development is a priority to increase teacher knowledge about anxiety-related behaviours in students with autism and the ways in which teachers' responses may promote or reduce anxiety and autonomy.

Trends in Prevalence and Management of Childhood Anxiety by Australian Pediatricians

OBJECTIVE

Rising anxiety rates and equity of care are ongoing concerns. Through 2 pediatric practice audits conducted 5 years apart, we aimed to determine the change in 1) anxiety diagnoses; 2) associated comorbid diagnoses; 3) variance in management by location; and 4) child, family, and pediatrician predictors of management.

METHODS

Members of the Australian Paediatric Research Network (APRN) were invited to participate in patient-level prospective national pediatric practice audits in 2008 and 2013. Pediatricians were asked to complete standardized forms for 100 consecutive patients or all patients seen over 2 weeks, whichever was completed first. Demographic data, diagnoses, medications, and referrals were collected. Logistic regressions were conducted, clustered at the pediatrician level.

RESULTS

Of eligible APRN pediatricians in 2013 and 2008, 48% and 66% participated and contributed 7102 and 8345 consultations, respectively. Anxiety diagnoses increased over the 5-year period (4.4% vs 7.6%; P < .001), as did proportions with comorbid autism spectrum disorder (18.4% vs 29.5%; P < .001) and sleep problems (5.1% vs 9.5%; P = .02). There was an increase in the prescription of core anxiety medications, with prescription of selective serotonin reuptake inhibitors increasing from 2.0% to 27.7% (P = .01). Children were more likely to be referred to a psychologist if they were seen in metropolitan practices (odds ratio = 2.0; 95% confidence interval, 1.1-3.9; P = .03) or had learning difficulties (odds ratio = 2.1; 95% confidence interval, 1.1-3.9; P = .03).

CONCLUSIONS

Prevalence of anxiety among children and adolescents attending pediatricians nearly doubled over the 5-year period. Children in regional and remote locations are less likely to be referred to psychological services, prompting concerns about inequity in access to care.

Depression, Anxiety, and Hyperactivity in Youth with HFASD: A Replication and Extension of Symptom Level Differences in Self-Report Versus Parent Report

The present study compared parent ratings to self-report ratings of depression, anxiety, hyperactivity, attention problems, and atypical behaviors in youth with high-functioning autism spectrum disorder (HFASD) and typically developing (TD) controls. Measures included parent and self-report forms from the Behavioral Assessment System for Children-Second Edition (BASC-2), and self-report forms from the Children's Depression Inventory (CDI) and the Multidimensional Anxiety Scale for Children (MASC). Results across all five BASC-2 scales indicated parent ratings for the HFASD condition were significantly higher than HFASD self-ratings, and were significantly higher than parent and self-ratings from the TD condition. In addition, average self-report scores did not differ significantly between HFASD and TD conditions on any of the BASC-2 scales, the CDI, or the MASC.

Gastrointestinal and Psychiatric Symptoms Among Children and Adolescents With Autism Spectrum Disorder

Individuals with autism spectrum disorder (ASD) are at heightened risk of psychiatric comorbidities across the lifespan, including elevated rates of internalizing, externalizing, and self-injurious behaviors. Identification of medical comorbidities that contribute to these concerns may elucidate mechanisms through which psychiatric concerns arise, as well as offer additional avenues for intervention. Gastrointestinal (GI) conditions are of particular interest, as they are prevalent among those with ASD, may share genetic or neurobiological etiologies with the core features of ASD, and are linked with psychiatric difficulties in the general population. In this paper, we draw on data from nearly 2,800 children and adolescents with ASD within the Simons Simplex Collection to characterize the unique contributions of (1) autism symptoms, (2) psychosocial factors (child's age, sex, verbal and nonverbal IQ, adaptive behavior, race, and household income), and (3) GI concerns with respect to multiple psychiatric outcomes. Multiple regression models revealed unique contributions of ASD symptoms and multiple psychosocial factors such as verbal IQ, adaptive behavior, and family income to internalizing, externalizing, and self-injurious behavior. In general, higher levels of psychiatric symptoms were associated with more ASD symptoms, higher verbal IQ, lower adaptive behavior skills, and lower family income. Furthermore, levels of GI symptoms accounted for unique variance in psychiatric outcomes over and above these other factors, linking increased GI problems with increased psychiatric symptoms in children with ASD. Taken together, results indicate that the presence and quantity of GI symptoms should be considered when evaluating psychiatric and behavioral concerns among children with ASD, and that treatment of GI conditions may be an important component in alleviating a broad array of mental health concerns in this group.

Preparing for Autistic Patients in Orthopaedic Surgery: Tips for a Successful Health-Care Interaction

The prevalence of autism in the United States has been climbing for the last 3 decades, and this comes at a time when the medical community is poorly equipped to address the various needs of individuals with autism spectrum disorder (ASD). Because busy orthopaedic surgery practices will invariably encounter more patients with ASD, they may want to develop pragmatic strategies and protocols that will promote a successful health-care interaction with these patients.

Views of Teachers on Anxiety Symptoms in Students with Autism Spectrum Disorder

People with autism spectrum disorder (ASD) exhibit comorbidity with anxiety. The aim of this study was the investigation of the perception of teachers on anxiety in school children with ASD. The Scale Teacher Response (SAS-TR) questionnaire was completed by 291 special education and 118 general education teachers, providing data on students in their classes with ASD and of typical development (TD), respectively. According to the total scores on SAS-TR, 46.8% of the children with ASD presented levels of anxiety within the clinical spectrum compared with 15.3% of the children of TD. Gender and age were not associated with the anxiety scores, but in the children with ASD, higher intelligence quotient (IQ) was weakly, and better verbal skills more strongly correlated with a higher anxiety level. Teachers' awareness of anxiety symptoms in children with ASD may contribute to their social inclusion.