Trajectory of development in adolescents and adults with autism

Parent Expectations and Preparatory Activities as Adolescents with ASD Transition to Adulthood

Community stakeholders, researchers, and providers are increasingly focused on individual, family, and systemic factors that contribute to positive outcomes for adults on the autism spectrum. Parent expectations for their youth's future are associated with adult outcomes (e.g., employment, school success, independence), yet the mechanism for this effect remains unclear. This study investigated how expectations were related to parent transition-related activities in a sample of 298 parents of adolescents on the autism spectrum (48% female adolescents), stratified by parent-reported IQ (average or above, borderline, or below 70). Parent expectations for the future predicted engagement in some activities intended to enhance adult outcomes when controlling for IQ, gender, age, and household income. The results have implications for how providers discuss expectations and support families in preparing for adulthood.

"Older Adults with ASD: The Consequences of Aging." Insights from a series of special interest group meetings held at the International Society for Autism Research 2016-2017

A special interest group (SIG) entitled "Older Adults with ASD: The Consequences of Aging" was held at the International Society for Autism Research (INSAR) annual meetings in 2016 and 2017. The SIG and subsequent meetings brought together, for the first time, international delegates who were members of the autistic community, researchers, practitioners and service providers. Based on aging autism research that is already underway in UK, Europe, Australia and North America, discussions focussed on conceptualising the parameters of aging when referring to autism, and the measures that are appropriate to use with older adults when considering diagnostic assessment, cognitive factors and quality of life in older age. Thus, the aim of this SIG was to progress the research agenda on current and future directions for autism research in the context of aging. A global issue on how to define 'aging' when referring to ASD was at the forefront of discussions. The 'aging' concept can in principle refer to all developmental transitions. However, in this paper we focus on the cognitive and physical changes that take place from mid-life onwards. Accordingly, it was agreed that aging and ASD research should focus on adults over the age of 50 years, given the high rates of co-occurring physical and mental health concerns and increased risk of premature death in some individuals. Moreover, very little is known about the cognitive change, care needs and outcomes of autistic adults beyond this age. Discussions on the topics of diagnostic and cognitive assessments, and of quality of life and well-being were explored through shared knowledge about which measures are currently being used and which background questions should be asked to obtain comprehensive and informative developmental and medical histories. Accordingly, a survey was completed by SIG delegates who were representatives of international research groups across four continents, and who are currently conducting studies with older autistic adults. Considerable overlap was identified across different research groups in measures of both autism and quality of life, which pointed to combining data and shared learnings as the logical next step. Regarding the background questions that were asked, the different research groups covered similar topics but the groups differed in the way these questions were formulated when working with autistic adults across a range of cognitive abilities. It became clear that continued input from individuals on the autism spectrum is important to ensure that questionnaires used in ongoing and future are accessible and understandable for people across the whole autistic spectrum, including those with limited verbal abilities.

Childhood autism in the UK and Greece: a cross-national study of progress in different intervention contexts

Aim: This is a cross-national study with the aim to explore the development of children with autism over time in the UK and Greece. The focus of the study was to investigate the differences in language and social skills between children with autism across the two countries who were receiving different types of treatment: speech and language therapy, psychoanalytic/psychodynamic psychotherapy, and occupational therapy. Study design: A cross-national longitudinal design with a mixed (between-subjects and within-subjects) design. Participants: A sample of 40 children in total. In the UK, 20 children with autism who had received psychotherapy (n = 10) and speech and language therapy (n = 10) were recruited and monitored post-therapy twice over a two-year period. In Greece, 20 children with autism who received occupational therapy (n = 10) and speech and language therapy (n = 10) were recruited and monitored post-therapy twice over a two-year period. Results: All children changed significantly over time on all aspects of measurement, demonstrating that children with autism are developing in a very similar way across the two countries. With respect to the effect of the therapy context on the development of children with autism, it was found that there were no differences across intervention contexts at the start of the study, and there were mainly nonsignificant interactions in the rate of change across the differing types of intervention. However, further analysis showed some important differences: speech and language therapy participants presented more widespread change on language scores across the measures; psychotherapy participants showed significant greater increase in imagination and decrease in stereotypical behavior; and occupational therapy participants presented significant reduction of stereotypical behavior. Conclusions: This study can help professionals who work with children with autism further their understanding of the disorder and how it manifests through time in order to provide appropriate services based on each child's needs. Keywords: Childhood autism, speech and language therapy, psychotherapy, occupational therapy, UK, Greece.

Interventions Targeting Expressive Communication in Adults With Autism Spectrum Disorders: A Systematic Review

Purpose The aims of this systematic review are to (a) synthesize the literature on interventions targeting expressive communication in adults with autism spectrum disorder and (b) evaluate the effectiveness of the interventions. Method The literature search resulted in 7,196 articles. The research team used 2 reviewers and consensus for title/abstract review, full-text review, and quality review. To be included, studies had to (a) include at least 1 adult (18 years of age and above) with an autism spectrum disorder; (b) examine an intervention, treatment, or model of care; (c) provide outcome data related to expressive communication modalities/domains; (d) be experimental or quasi-experimental; and (e) be published in English. Twenty-two studies (14 single-case design and 8 group design), with a total of 256 participants and varied interventions and outcome variables, met criteria for inclusion. Effect sizes are presented for group design studies, and visual analysis results are outlined for single-case design studies. Results Examination of treatment effects in the included studies showed positive effects, overall; however, there was great variability between studies. Single-case design studies showed evidence of functional relations in all but 1 study, with most showing medium to large effects, as well as maintenance and generalization of gains. Group design studies showed a wide range of effects from near-zero to large effects. Differences in intervention strategies and durations, as well as in participant characteristics and outcome measures, presented barriers to aggregation. Conclusions This review highlights the need for increased high-quality research examining interventions targeting expressive communication in adults with autism spectrum disorder and also pinpoints interventions with potential for future study and use in this population.

Dissecting the Heterogeneous Cortical Anatomy of Autism Spectrum Disorder Using Normative Models

BACKGROUND

The neuroanatomical basis of autism spectrum disorder (ASD) has remained elusive, mostly owing to high biological and clinical heterogeneity among diagnosed individuals. Despite considerable effort toward understanding ASD using neuroimaging biomarkers, heterogeneity remains a barrier, partly because studies mostly employ case-control approaches, which assume that the clinical group is homogeneous.

METHODS

Here, we used an innovative normative modeling approach to parse biological heterogeneity in ASD. We aimed to dissect the neuroanatomy of ASD by mapping the deviations from a typical pattern of neuroanatomical development at the level of the individual and to show the necessity to look beyond the case-control paradigm to understand the neurobiology of ASD. We first estimated a vertexwise normative model of cortical thickness development using Gaussian process regression, then mapped the deviation of each participant from the typical pattern. For this, we employed a heterogeneous cross-sectional sample of 206 typically developing individuals (127 males) and 321 individuals with ASD (232 males) (6-31 years of age).

RESULTS

We found few case-control differences, but the ASD cohort showed highly individualized patterns of deviations in cortical thickness that were widespread across the brain. These deviations correlated with severity of repetitive behaviors and social communicative symptoms, although only repetitive behaviors survived corrections for multiple testing.

CONCLUSIONS

Our results 1) reinforce the notion that individuals with ASD show distinct, highly individualized trajectories of brain development and 2) show that by focusing on common effects (i.e., the "average ASD participant"), the case-control approach disguises considerable interindividual variation crucial for precision medicine.

Facilitating the transition of young people with long-term conditions through health services from childhood to adulthood: the Transition research programme

Background

As young people with long-term conditions move from childhood to adulthood, their health may deteriorate and their social participation may reduce. ‘Transition’ is the ‘process’ that addresses the medical, psychosocial and educational needs of young people during this time. ‘Transfer’ is the ‘event’ when medical care moves from children’s to adults’ services. In a typical NHS Trust serving a population of 270,000, approximately 100 young people with long-term conditions requiring secondary care reach the age of 16 years each year. As transition extends over about 7 years, the number in transition at any time is approximately 700.

Objectives

Purpose – to promote the health and well-being of young people with long-term conditions by generating evidence to enable NHS commissioners and providers to facilitate successful health-care transition. Objectives – (1) to work with young people to determine what is important in their transitional health care, (2) to identify the effective and efficient features of transitional health care and (3) to determine how transitional health care should be commissioned and provided.

Design, settings and participants

Three work packages addressed each objective. Objective 1. (i) A young people’s advisory group met monthly throughout the programme. (ii) It explored the usefulness of patient-held health information. (iii) A ‘Q-sort’ study examined how young people approached transitional health care. Objective 2. (i) We followed, for 3 years, 374 young people with type 1 diabetes mellitus (150 from five sites in England), autism spectrum disorder (118 from four sites in England) or cerebral palsy (106 from 18 sites in England and Northern Ireland). We assessed whether or not nine proposed beneficial features (PBFs) of transitional health care predicted better outcomes. (ii) We interviewed a subset of 13 young people about their transition. (iii) We undertook a discrete choice experiment and examined the efficiency of illustrative models of transition. Objective 3. (i) We interviewed staff and observed meetings in three trusts to identify the facilitators of and barriers to introducing developmentally appropriate health care (DAH). We developed a toolkit to assist the introduction of DAH. (ii) We undertook a literature review, interviews and site visits to identify the facilitators of and barriers to commissioning transitional health care. (iii) We synthesised learning on ‘what’ and ‘how’ to commission, drawing on meetings with commissioners.

Main outcome measures

Participation in life situations, mental well-being, satisfaction with services and condition-specific outcomes.

Strengths

This was a longitudinal study with a large sample; the conditions chosen were representative; non-participation and attrition appeared unlikely to introduce bias; the research on commissioning was novel; and a young person’s group was involved.

Limitations

There is uncertainty about whether or not the regions and trusts in the longitudinal study were representative; however, we recruited from 27 trusts widely spread over England and Northern Ireland, which varied greatly in the number and variety of the PBFs they offered. The quality of delivery of each PBF was not assessed. Owing to the nature of the data, only exploratory rather than strict economic modelling was undertaken.

Results and conclusions

(1) Commissioners and providers regarded transition as the responsibility of children’s services. This is inappropriate, given that transition extends to approximately the age of 24 years. Our findings indicate an important role for commissioners of adults’ services to commission transitional health care, in addition to commissioners of children’s services with whom responsibility for transitional health care currently lies. (2) DAH is a crucial aspect of transitional health care. Our findings indicate the importance of health services being commissioned to ensure that providers deliver DAH across all health-care services, and that this will be facilitated by commitment from senior provider and commissioner leaders. (3) Good practice led by enthusiasts rarely generalised to other specialties or to adults’ services. This indicates the importance of NHS Trusts adopting a trust-wide approach to implementation of transitional health care. (4) Adults’ and children’s services were often not joined up. This indicates the importance of adults’ clinicians, children’s clinicians and general practitioners planning transition procedures together. (5) Young people adopted one of four broad interaction styles during transition: ‘laid back’, ‘anxious’, ‘wanting autonomy’ or ‘socially oriented’. Identifying a young person’s style would help personalise communication with them. (6) Three PBFs of transitional health care were significantly associated with better outcomes: ‘parental involvement, suiting parent and young person’, ‘promotion of a young person’s confidence in managing their health’ and ‘meeting the adult team before transfer’. (7) Maximal service uptake would be achieved by services encouraging appropriate parental involvement with young people to make decisions about their care. A service involving ‘appropriate parental involvement’ and ‘promotion of confidence in managing one’s health’ may offer good value for money.

Future work

How might the programme’s findings be implemented by commissioners and health-care providers? What are the most effective ways for primary health care to assist transition and support young people after transfer?

Study registration

This study is registered as UKCRN 12201, UKCRN 12980, UKCRN 12731 and UKCRN 15160.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Factors impacting employment for people with autism spectrum disorder: A scoping review

The aim of this study is to holistically synthesise the extent and range of literature relating to the employment of individuals with autism spectrum disorder. Database searches of Medline, CINAHL, PsychINFO, Scopus, ERIC, Web of Science and EMBASE were conducted. Studies describing adults with autism spectrum disorder employed in competitive, supported or sheltered employment were included. Content analysis was used to identify the strengths and abilities in the workplace of employees with autism spectrum disorder. Finally, meaningful concepts relating to employment interventions were extracted and linked to the International Classification of Functioning, Disability and Health Core Sets for autism spectrum disorder. The search identified 134 studies for inclusion with methodological quality ranging from limited to strong. Of these studies, only 36 evaluated employment interventions that were coded and linked to the International Classification of Functioning, Disability and Health, primarily focusing on modifying autism spectrum disorder characteristics for improved job performance, with little consideration of the impact of contextual factors on work participation. The International Classification of Functioning, Disability and Health Core Sets for autism spectrum disorder are a useful tool in holistically examining the employment literature for individuals with autism spectrum disorder. This review highlighted the key role that environmental factors play as barriers and facilitators in the employment of people with autism spectrum disorder and the critical need for interventions which target contextual factors if employment outcomes are to be improved.

Longitudinal stability of reading profiles in individuals with higher functioning autism

The reading difficulties of individuals with autism spectrum disorders have been established in the literature, with particular attention drawn toward reading comprehension difficulties. Recent papers have highlighted the heterogeneous nature of reading abilities in this population by utilizing statistical methods that allow for investigations of unique reading profiles. This article extends this literature by investigating reading profiles longitudinally, to investigate the stability of reader profiles across time. Latent profile and transition analyses were conducted to establish categorically distinct reading profiles at two time points, 30 months apart. This study also examined whether age and autism symptom severity were related to the profiles at each time point. Finally, transitions between profiles at each time point were identified. Age did not predict profile membership, but there were significant differences in symptom severity that were largely stable over time. Results indicate that heterogeneous reading profiles exist within the autism population, ranging from average reading ability to severe difficulties across different reading subskills. The data from this study demonstrate that reading profiles of children and adolescents with autism spectrum disorders shift when examined across time.

Transition-Age Medicaid Coverage for Adolescents With Autism and Adolescents With Intellectual Disability

Although the majority of adolescents with autism spectrum disorder (ASD) rely on healthcare coverage through Medicaid during their transition into adulthood, little is known about their continuing eligibility. This study used Medicaid Analytic Extract (MAX) data to examine Medicaid coverage in a national sample using a cohort of adolescents with ASD ( n = 4,179) and a like-aged cohort with intellectual disability (ID, n = 21,844) over 5 years using survival analysis and Cox regression models. More than 1 in 4 adolescents with ASD lost coverage and fewer than half subsequently regained it. They were more likely to disenroll than adolescents with ID. Similarities in overall patterns among the 2 groups suggest that the experience of adolescents with ASD was characteristic of more general aspects of behavioral health coverage and indicate the need for programmatic reforms.

Differences of Symptom Distribution Across Adult Age in High Functioning Individuals on the Autism Spectrum Using Subscales of the Autism Spectrum Quotient

Little is known about the distribution of symptoms of Autism Spectrum Disorder (ASD) across the lifespan. In this cross-sectional study, we examined differences between subscales of the Autism Spectrum Quotient (AQ) between different age groups. 654 Subjects referred to an outpatient University Clinic with specialized expertise in ASD were included. Data collection, including self-report and report by spouses, was performed from 2008 to 2014. Results show no significant differences between the different age groups. AQ scores based on self-report corresponded remarkably well with those from their spouses. In conclusion, the main traits of an ASD appear stable between the different age groups. Also, the results show that using the AQ, patients have largely the same appreciation of symptoms as their spouses.

Assessing subtypes of restricted and repetitive behaviour using the Adult Repetitive Behaviour Questionnaire-2 in autistic adults

Background

The majority of previous research into restricted and repetitive behaviours (RRBs) has focussed on children, partly due to a lack of suitable measures for RRBs in adults. This study aimed to explore the psychometric properties of the Adult Repetitive Behaviour Questionnaire-2 (RBQ-2A) in a large sample of autistic adults using a self-report questionnaire method.

Methods

The RBQ-2A and Autism-Spectrum Quotient (AQ) were administered online. Data from 275 autistic adults aged 18-66 (M = 36.56, SD = 12.24; 100 men and 171 women) were analysed using polychoric principal components analysis (PCA). Reliability and validity were assessed using Cronbach's alpha and correlation analyses.

Results

PCA resulted in two components of the RBQ-2A, interpretable as repetitive sensory and motor behaviours (RSMB) and insistence on sameness (IS). Both components showed acceptable internal consistency (α = .70 and .81 respectively) and were significantly moderately correlated with scores on the AQ (r _s  = .25 and .42). Participants' scores on IS were higher than their scores on RSMB. RSMB, but not IS, was negatively associated with age, particularly in older adults (≥ 50 years). There were no gender differences.

Conclusions

The RBQ-2A is a reliable and valid self-report measure of RRBs in the present sample of autistic adults. As one of the few measures of RRBs aimed at adults, it is suitable for adults with the ability to read and complete a self-report questionnaire. Results build on previous work with children using the Repetitive Behaviour Questionnaire-2 (RBQ-2).

Improving emotion regulation ability in autism: The Emotional Awareness and Skills Enhancement (EASE) program

Emotion regulation impairments are common among individuals with autism spectrum disorder and are believed to often underlie commonly seen problems with aggression, depression, and anxiety. The Emotional Awareness and Skills Enhancement program was developed to reduce emotion regulation impairment and thereby improve behavioral disturbance, via mindfulness. Emotional Awareness and Skills Enhancement consists of a 16-week individual therapy treatment targeting emotion regulation impairments among individuals with autism spectrum disorder. We describe the conceptual framework and development of the program and present data on feasibility and preliminary efficacy from a pilot trial. The Emotional Awareness and Skills Enhancement manual was developed using a participatory action framework, based on emotion regulation research specific to autism spectrum disorder and input from individuals with autism spectrum disorder, therapists, and parents of children with autism spectrum disorder. Emotional Awareness and Skills Enhancement was piloted in a two-site open trial with 20 participants with autism spectrum disorder (12-17 years old, confirmed autism spectrum disorder diagnosis, IQ > 80).Outcome data support program feasibility and acceptability to participants, as well as significant improvement in emotion regulation impairments and related concerns.Findings offer preliminary support for both the feasibility and clinical effectiveness of the Emotional Awareness and Skills Enhancement program.

Adaptive trajectories and early risk factors in the autism spectrum: A 15-year prospective study

Little is known about long-term outcomes. We investigate the adaptive trajectories and their risk factors in ASD. Data were obtained from 281 children prospectively followed untill adulthood. The final sample consisted of 106 individuals. Vineland scores were collected at baseline (T1), 3 (T2), 10 (T3), and 15 (T4) years later. A group-based method was used to identify homogeneous patterns of adaptive skills trajectories. Results show that among the children initially categorized as autistic, 82.6% remained over the ADOS diagnostic threshold, 11.9% converted to atypical autism, and 5.4% fell under the ADOS threshold. Most atypical autism diagnoses were unstable. Most (81.7%) autistic participants had an ID at inclusion. At T1, 59.3% were nonverbal, but only 39% at T4. Most changes occurred between 4 and 8 years of age. Approximately 25% of participants exhibited a "high" growth trajectory, in which progress continues throughout adolescence, and 75% a "low" growth trajectory, characterized by greater autistic symptoms, intellectual disability, and lower language abilities reflected by high CARS scores, low apparent DQ, and speech difficulties, which mostly, but not always, predicted low trajectories. Our findings suggest that the adaptive prognosis of autism is mostly poor in this cohort, biased toward intellectual disability. However, changes in diagnostic, speech, and adaptive status are not uncommon, even for indivduals with low measured intelligence or apparent intellectual disability, and are sometimes difficult to predict. Autism Research 2018, 11: 1455-1467. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Most autism diagnoses given before 5 years of age are stable to adulthood, but one-fifth of individuals are no longer considered to be autistic, even in a cohort biased toward apparent intellectual disability. Conversely, atypical autism diagnoses are mostly unstable. One-third of children who are nonverbal at 5 years are verbal within 15 years, mostly before 8 years of age. Concerning adaptive behavior outcomes, only one-fourth of children exhibit a high-growth trajectory through at least 15 years.

Deficits in mesolimbic reward pathway underlie social interaction impairments in children with autism

Lack of interest in social interaction is a hallmark of autism spectrum disorder. Animal studies have implicated the mesolimbic reward pathway in driving and reinforcing social behaviour, but little is known about the integrity of this pathway and its behavioural consequences in children with autism spectrum disorder. Here we test the hypothesis that the structural and functional integrity of the mesolimbic reward pathway is aberrant in children with autism spectrum disorder, and these aberrancies contribute to the social interaction impairments. We examine structural and functional connectivity of the mesolimbic reward pathway in two independent cohorts totalling 82 children aged 7-13 years with autism spectrum disorder and age-, gender-, and intelligence quotient-matched typically developing children (primary cohort: children with autism spectrum disorder n = 24, typically developing children n = 24; replication cohort: children with autism spectrum disorder n = 17, typically developing children n = 17), using high angular resolution diffusion-weighted imaging and functional MRI data. We reliably identify white matter tracts linking-the nucleus accumbens and the ventral tegmental area-key subcortical nodes of the mesolimbic reward pathway, and provide reproducible evidence for structural aberrations in these tracts in children with autism spectrum disorder. Further, we show that structural aberrations are accompanied by aberrant functional interactions between nucleus accumbens and ventral tegmental area in response to social stimuli. Crucially, we demonstrate that both structural and functional circuit aberrations in the mesolimbic reward pathway are related to parent-report measures of social interaction impairments in affected children. Our findings, replicated across two independent cohorts, reveal that deficits in the mesolimbic reward pathway contribute to impaired social skills in childhood autism, and provide fundamental insights into neurobiological mechanisms underlying reduced social interest in humans.

Examining the intertwined development of prosocial skills and ASD symptoms in adolescence

Autism spectrum disorder (ASD) and reduced prosocial behaviour are strongly intertwined. However, social interactions with peers may be increasingly practiced over the course of development and may instigate a reduction in ASD symptoms and vice versa. We, therefore, sought to determine if, during adolescence, possible improvements in prosocial behaviours and ASD symptoms may benefit one another over time. Participants were 2773 adolescents from the Tracking Adolescents' Individual Lives Survey (TRAILS) cohorts. Measurements took place over three waves (mean ages: 11.1, 13.4, and 16.2 years). Longitudinal associations between teacher-rated classroom prosocial skills and parent-rated ASD symptoms were examined using the random intercept cross-lagged panel model (RI-CLPM). In addition to estimating the stable, between-person associations, the dynamical effects between prosocial skills and ASD symptoms over time were estimated at the within-person level. At the between-person level, prosocial skills and ASD symptoms were substantially negatively correlated. At the within-person level, a small and unexpected positive cross-lagged effect from wave 1 ASD symptoms on wave 2 prosocial skills was observed. We added to the existing literature by showing that, in addition to replicating the already firmly established between-person association between low prosocial skills and ASD, within-person gains in prosocial skills do not lead to subsequent reduction of ASD symptoms, and reductions in ASD symptoms do not lead to subsequent enhancement of prosocial skills. We, therefore, conclude from our findings that the inverse association between autistic symptoms and prosocial skills in adolescence is highly stable.

Using machine learning to identify patterns of lifetime health problems in decedents with autism spectrum disorder

Very little is known about the health problems experienced by individuals with autism spectrum disorder (ASD) throughout their life course. We retrospectively analyzed diagnostic codes associated with de-identified electronic health records using a machine learning algorithm to characterize diagnostic patterns in decedents with ASD and matched decedent community controls. Participants were 91 decedents with ASD and 6,186 sex and birth year matched decedent community controls who had died since 1979, the majority of whom were middle aged or older adults at the time of their death. We analyzed all ICD-9 codes, V-codes, and E-codes available in the electronic health record and Elixhauser comorbidity categories associated with those codes. Diagnostic patterns distinguished decedents with ASD from decedent community controls with 75% sensitivity and 94% specificity solely based on their lifetime ICD-9 codes, V-codes, and E-codes. Decedents with ASD had higher rates of most conditions, including cardiovascular disease, motor problems, ear problems, urinary problems, digestive problems, side effects from long-term medication use, and nonspecific lab tests and encounters. In contrast, decedents with ASD had lower rates of cancer. Findings suggest distinctive lifetime diagnostic patterns among decedents with ASD and highlight the need for more research on health outcomes across the lifespan as the population of individuals with ASD ages. As a large wave of individuals with ASD diagnosed in the 1990s enters adulthood and middle age, knowledge about lifetime health problems will become increasingly important for care and prevention efforts. Autism Res 2018, 11: 1120-1128. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: This study looked at patterns of lifetime health problems to find differences between people with autism who had died and community controls who had died. People with autism had higher rates of most health problems, including cardiovascular, urinary, respiratory, digestive, and motor problems, in their electronic health records. They also had lower rates of cancer. More research is needed to understand these potential health risks as a large number of individuals with autism enter adulthood and middle age.

Dendritic spine actin cytoskeleton in autism spectrum disorder

Dendritic spines are small actin-rich protrusions from neuronal dendrites that form the postsynaptic part of most excitatory synapses. Changes in the shape and size of dendritic spines correlate with the functional changes in excitatory synapses and are heavily dependent on the remodeling of the underlying actin cytoskeleton. Recent evidence implicates synapses at dendritic spines as important substrates of pathogenesis in neuropsychiatric disorders, including autism spectrum disorder (ASD). Although synaptic perturbations are not the only alterations relevant for these diseases, understanding the molecular underpinnings of the spine and synapse pathology may provide insight into their etiologies and could reveal new drug targets. In this review, we will discuss recent findings of defective actin regulation in dendritic spines associated with ASD.

Screening of Autism Spectrum Disorders in Geriatric Psychiatry

Autism spectrum disorders (ASD) are difficult to detect in old age. This study examined if ASD symptoms in older adults (age > 60) can be detected with the Dutch informant personality questionnaire, (Hetero-Anamnestische Persoonlijkheidsvragenlijst, HAP) in a mental health setting. Patients with ASD (N = 40) were compared to patients with a different psychiatric diagnosis (N = 43; personality disorders excluded). The ASD group had significant higher scores on the scales 'Socially avoidant behavior', 'Rigid behavior' and 'Unpredictable and impulsive behavior'. These scales were able to discriminate between individuals with or without ASD. The HAP can thus be used as a screening instrument for ASD symptoms in elderly patients. Further research is needed to clarify what items have the best predictive validity for ASD symptoms.

Is Older Age Associated with Higher Self- and Other-Rated ASD Characteristics?

Autism spectrum disorder (ASD) characteristics seem to abate over time, but whether this protracts until late adulthood is largely unknown. We cross-sectionally investigated self- and other-reported ASD characteristics of adults with (ASD: Nmax-self = 237, Nmax-other = 130) and without ASD (COM: Nmax-self = 198, Nmax-other = 148) aged 19-79 years. Within the ASD group, self-reported ASD characteristics, and sensory sensitivities were highest in middle adulthood, while age was not associated to empathy. Sex differences were also found. However, age-and sex-related differences were not revealed by others and self- and other-report were poorly concordant. These results show that ASD characteristics in adulthood are differently perceived across age, sex, and informants and suggest that it is important to repeatedly assess self-reported ASD characteristics during adulthood.

Exploration and Comparison of Adolescents With Autism Spectrum Disorder and Their Caregiver's Perspectives on Transitioning to Adult Health Care and Adulthood

Background

Adolescents with autism spectrum disorder (ASD) experience challenges achieving independence. Few studies assess both adolescents and caregivers' needs as adolescents transition to adult health care.

Objective/Methods

This study explored and compared the health-related independence experiences of 27 adolescents with ASD and their caregivers. Caregivers participated in focus groups and adolescents participated in semi-structured interviews.

Results

Thematic analysis of dyads' responses highlighted three common themes: (a) efforts toward independence, (b) low self-efficacy for adolescents' independence, and (c) desire for independence. Nuances in responses indicated that although members of dyads shared many experiences, they were not communicating these experiences with each other.

Conclusions

Results suggest both groups understand the importance of health-related independence and are motivated to achieve independence but lack skills and supports. Improved communication about experiences and goals between caregivers, adolescents, and the care team are needed. These findings can inform future interventions to better support adolescents' transition to adult health care.

The Medical Home and Health Care Transition for Youth With Autism

BACKGROUND

Our objective in this study was to describe the association between the receipt of health care transition services (HCTS) and having a medical home in youth with autism spectrum disorder (ASD). Youth with ASD receive HCTS less often than other youth with special health care needs but are in particular need of continuous, comprehensive health care.

METHODS

We used the National Survey of Children with Special Health Care Needs to describe the receipt of HCTS in youth with ASD and its association with presence of a medical home. Descriptive statistics are presented, and logistic regression is used to assess the association between medical home and HCTS.

RESULTS

Twenty-one percent of youth with ASD met the criteria for receiving HCTS. Youth with ASD and a medical home were almost 3 times as likely to receive HCTS as youth without a medical home, and youth who received family-centered care and have adequate care coordination within the medical home were more than twice as likely to receive HCTS as those who did not.

CONCLUSIONS

Youth with ASD are not receiving HCTS at the same rate as their peers. Increasing provider awareness of autism, the components of a medical home, and of the importance of HCTS could greatly help increase the percentage of youth who receive effective HCTS.

Social-Ecological Correlates in Adult Autism Outcome Studies: A Scoping Review

The transition into adulthood is a critical period in the life course that shapes later outcomes. Many adults on the autism spectrum fare poorly across a wide range of quality of life indicators. Understanding the multilevel factors that influence transition outcomes is necessary to develop strategies that promote better outcomes. In this scoping review, we characterize the use of social-ecological factors in adult autism outcome studies, identify understudied areas of research, and provide recommendations for future research. We conducted a literature search for studies in which the relationship between social-ecological factors and transition outcomes among transition-age youth with autism was assessed. We organized variables used in studies across 5 levels of influence: family-, interpersonal-, institutional-, community-, and policy-level factors. Our findings reveal that both breadth and depth of social-ecological factors usage in autism outcomes studies is limited because of the narrow inclusion of variables across social-ecological levels, the overreliance on a limited number of national data sets, and the overall lack of variation in research design. We propose 9 recommendations to inform the development of multilevel studies.

Prevalence and Correlates of Autism Spectrum Disorders in Quebec: Prévalence et corrélats des troubles du spectre de l'autisme au Québec

OBJECTIVE

To estimate the prevalence, comorbidities, and service use of people with autism spectrum disorders (ASDs) based on data from Quebec Integrated Chronic Diseases Surveillance System (QICDSS).

METHODS

We included all residents up to age 24 eligible for health plan coverage who were in Quebec for at least 1 day from January 1, 1996, to March 31, 2015. To be considered as having an ASD, an individual had to have had at least 1 physician claim or hospital discharge abstract from 2000 to 2015 indicating one of the following ASD diagnosis codes: ICD-9 codes 299.0 to 299.9 or their ICD-10 equivalents.

RESULTS

The QICDSS shows that the prevalence of ASD has risen steadily over the past decade to approximately 1.2% ( n = 16,940) of children and youths aged 1 to 17 years in 2014 to 2015. The same prevalence was obtained using Ministry of Education data. Common medical comorbidities included congenital abnormalities of the nervous system, particularly in the first year of life. Psychiatric comorbidity was much more highly prevalent, especially common mental disorders like anxiety and attention-deficit/hyperactivity disorder. Children and youths with ASDs made on average 2.3 medical visits per year compared with 0.2 in the general population. Between 18 and 24 years old, the mental health needs of individuals with ASDs were met less by medical specialists and more by general practitioners.

CONCLUSION

Information derived from this database could support and monitor development of better medical services coordination and shared care to meet the continuous and changing needs of patients and families over time.

Understanding the characteristics of friendship quality, activity participation, and emotional well-being in Taiwanese adolescents with autism spectrum disorder

BACKGROUND

Autism spectrum disorder (ASD) is a lifelong developmental disability characterized by deficits in social communication and social interaction across multiple contexts. Existing literature on social relationships and well-being among adolescents with ASD in Asian countries is scant.

AIMS

This study compared the perceptions of adolescents with ASD with those of their neurotypical peers toward their friendship quality, activity participation, and emotional well-being, and examined the relationships between friendship quality, activity participation, and emotional well-being.

METHODS

The study participants-101 adolescents with ASD and 101 neurotypical peers, aged 10-19 years-completed the following self-administered questionnaires: the Friendship Quality Questionnaire, the Child and Adolescent Scale of Participation, the Beck Anxiety Inventory, and the short-form UCLA loneliness scale.

RESULTS

Adolescents with ASD reported lower friendship quality, lower school participation, and higher levels of anxiety and loneliness compared to their neurotypical peers. Loneliness correlated negatively with friendship quality and school participation and positively with anxiety. Adolescents with ASD experienced increased levels of anxiety when low friendship quality was accompanied by greater loneliness.

CONCLUSIONS AND SIGNIFICANCE

These findings reveal that friendship quality, school participation, and loneliness have a considerable effect on the emotional well-being of adolescents with ASD, thus indicating the need for therapeutic interventions that address interpersonal relationships and emotional well-being.

Effects of State Autism Mandate Age Caps on Health Service Use and Spending Among Adolescents

OBJECTIVE

Many states with mandates requiring commercial insurers to cover autism spectrum disorder (ASD) health services specify upper age limits above which coverage is no longer mandated. It is unknown what effects these age caps have on health service use and spending among adolescents who have exceeded the age cap.

METHOD

Using administrative claims data from 3 national commercial insurers, a difference-in-differences approach was used to estimate effects of age caps on health service use and spending among adolescents with ASD. Statistical models compared changes in use and spending between those above versus below the age cap among individuals eligible versus ineligible for mandated coverage. The analytic sample included data from 2008 through 2012 on 7,845 individuals (151,976 person-months) ages 10 to 21 years in 11 states imposing mandate age caps going into effect during adolescence.

RESULTS

Age caps were associated with 4.2 percentage point (95% CI = -7.0, -1.5) lower probability of any ASD-specific service use in a month and $69 less (95% CI = -112, -$26) in average monthly spending on ASD-specific services than would have been expected given concomitant pre-post age cap differences among individuals in the same states who were never eligible for mandate-covered services. In addition, age caps were associated with $99 (95% CI = -$168, -$30) lower average monthly spending on all health care services.

CONCLUSION

Insurance mandates that include age caps going into effect during adolescence reduce health service use and spending among individuals with ASD during a critical phase of the life course.

Defining behavioral components of social functioning in adults with autism spectrum disorder as targets for treatment

There is increasing recognition that adults with autism spectrum disorder (ASD) would benefit from treatment to improve social functioning, a key factor in adults' overall quality of life. However, the various behavioral components of social functioning (i.e., categories of behaviors underlying social functioning), including social motivation, social anxiety, social cognition, and social skills, have not all been assessed together in any sample of adults with ASD, making it difficult to know the relative levels of impairment in these various categories, the relationships among these categories, or promising targets for treatments. We hypothesized there would be significant correlations among measures within the same category, but fewer correlations of measures between categories, indicating the heterogeneity of impairments in adults with ASD. Twenty-nine adults with ASD without co-occurring intellectual disability completed multiple assessments measuring social motivation, social anxiety, social cognition, and social skills, as well as measures of overall ASD symptom levels and community functioning. Results revealed significant positive correlations among measures within most categories; positive correlations between measures of social motivation and all other categories, except for social cognition; as well as positive cross-domain correlations between measures of anxiety and ASD phenotype; measures of social skills and community functioning; and measures of social skills and ASD phenotype. Further studies are warranted to determine causal relationships among these behavioral categories, across developmental stages. However, the lack of correlations between many categories suggests the potential importance of multidimensional treatments that target the particular components of social functioning most in need of improvement in individuals. Autism Res 2018, 11: 488-502. © 2017 International Society for Autism Research, Wiley Periodicals, Inc.

LAY SUMMARY

The goal of this study was to measure behaviors that contribute to social functioning difficulties in adults with ASD, with the ultimate goal of guiding treatment development. We found that motivation to interact with others was significantly related to social anxiety and social skill. Our results suggest that motivation may be important to target in treatment, and that treatments should be tailored to the areas most in need of improvement in each individual.

The relationship of parental expressed emotion to co-occurring psychopathology in individuals with autism spectrum disorder: A systematic review

Expressed emotion is a construct of the affective relationship between two people, with domains measuring criticism, hostility, warmth, relationship and emotional over-involvement. This review focuses on studies of Expressed Emotion in families of individuals with autism spectrum disorder and its association with co-occurring psychiatric disorders. A systematic search used the Psych-Info and Medline databases to identify articles available at or before September 2016. Eleven studies met the inclusion criteria. The included studies suggest that high levels of expressed emotion, including criticism, are associated with behavioural problems. However, the relationship between expressed emotion and emotional problems is presently unclear because findings were mixed. Also, there is presently little evidence regarding the impact of other components of expressed emotion on co-occurring disorders.

Transitioning Together: A Multi-family Group Psychoeducation Program for Adolescents with ASD and Their Parents

Currently there are few evidence-based programs available for families of individuals with ASD during the transition to adulthood. The present study provided a preliminary evaluation of a multi-family group psychoeducation intervention using a randomized waitlist control design (n = 41). Families in the intervention condition participated in Transitioning Together, an 8-week program designed to reduce family distress and improve social functioning for adolescents. Findings indicated significant improvements in parental depressive symptoms and problem solving from pre- to post-intervention for parents in the intervention condition but not for parents in the control condition. Social interactions also improved for youth in the intervention condition relative to controls. Parents reported satisfaction with the program and particularly valued the opportunity to interact with other families.

Multidimensional knowledge-based framework is an essential step in the categorization of gene sets in complex disorders

In complex disorders, collaborative role of several genes accounts for the multitude of symptoms and the discovery of molecular mechanisms requires proper understanding of pertinent genes. Majority of the recent techniques utilize either single information or consolidate the independent outlook from multiple knowledge sources for assisting the discovery of candidate genes. In any case, given that various sorts of heterogeneous sources are possibly significant for quality gene prioritization, every source bearing data not conveyed by another, we assert that a perfect strategy ought to give approaches to observe among them in a genuine integrative style that catches the degree of each, instead of utilizing a straightforward mix of sources. We propose a flexible approach that empowers multi-source information reconciliation for quality gene prioritization that augments the complementary nature of various learning sources so as to utilize the maximum information of aggregated data. To illustrate the proposed approach, we took Autism Spectrum Disorder (ASD) as a case study and validated the framework on benchmark studies. We observed that the combined ranking based on integrated knowledge reduces the false positive observations and boosts the performance when compared with individual rankings. The clinical phenotype validation for ASD shows that there is a significant linkage between top positioned genes and endophenotypes of ASD. Categorization of genes based on endophenotype associations by this method will be useful for further hypothesis generation leading to clinical and translational analysis. This approach may also be useful in other complex neurological and psychiatric disorders with a strong genetic component.

Circumscribed interests in adolescents with Autism Spectrum Disorder: A look beyond trains, planes, and clocks

Adolescence is a unique developmental period, characterized by physical and emotional growth and significant maturation of cognitive and social skills. For individuals with Autism Spectrum Disorder (ASD), it is also a vulnerable period as cognitive and social skills can deteriorate. Circumscribed interests (CIs), idiosyncratic areas of intense interest and focus, are a core symptom of ASD that may be associated with social development. Yet, relatively little is known about the expression of CIs in adolescents with ASD. Many studies investigating CIs have used images depicting items of special interest; however, it is not clear how images should be customized for adolescent studies. The goal of this study was to gain insight into the types of images that may be appropriate for studies of CIs in adolescents with ASD. To this end, we used a mixed methods design that included, 1) one-on-one interviews with 10 adolescents (4 with ASD and 6 TD), to identify categories of images that were High Autism Interest (‘HAI’) or High Typically Developing Interest (‘HTD’), and 2) an online survey taken by fifty-three adolescents with ASD (42 male) and 135 typically developing (TD) adolescents (55 male) who rated how much they liked 105 ‘HAI’ and ‘HTD’ images. Although we found a significant interaction between ‘HAI’ and ‘HTD’ categories and diagnosis, neither group significantly preferred one category over the other, and only one individual category ('Celebrities') showed a significant group effect, favored by TD adolescents. Males significantly preferred ‘HAI’ images relative to females, and TD adolescents significantly preferred images with social content relative to adolescents with ASD. Our findings suggest that studies investigating affective or neural responses to CI-related stimuli in adolescents should consider that stereotypical ASD interests (e.g. trains, gadgets) may not accurately represent individual adolescents with ASD, many of whom show interests that overlap with TD adolescents (e.g. video games).

The transition from youth to adult mental health services and the economic impact on youth and their families

The transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) can be challenging for youth, their families, and healthcare providers. The purpose of this study was to identify, summarize, and assess evidence found in scholarly literature regarding the economic impact on youth and their families during the transition from CAMHS to AMHS. Relevant studies were identified through a search of 7 electronic platforms. The search identified 829 articles; 5 of which met all inclusion criteria. Evidence from the included studies suggests that, when continuity of care is lacking, transitions from CAMHS to AMHS have substantial impacts on the financial demands of youth and their families. These demands are due to increases in the cost of care, loss of employment income and productivity, and changes in insurance coverage. However, there remains limited information in this area, which highlights the need for further research.

Characterizing Objective Quality of Life and Normative Outcomes in Adults with Autism Spectrum Disorder: An Exploratory Latent Class Analysis

This study aims to extend the definition of quality of life (QoL) for adults with autism spectrum disorder (ASD, n = 180, ages 23-60) by: (1) characterizing the heterogeneity of normative outcomes (employment, independent living, social engagement) and objective QoL (physical health, neighborhood quality, family contact, mental health issues); and (2) identifying predictors of positive normative outcomes and good objective QoL. Findings of an exploratory latent class analysis identified three groups of adults with ASD-Greater Dependence, Good Physical and Mental Health, and Greater Independence. Findings indicate that better daily living skills, better executive function, and more maternal warmth are associated with assignment to better outcome groups. Findings have implications for interventions designed to enhance achievement of normative outcomes and objective QoL.

Characteristics of Autism Spectrum Disorder in Sotos Syndrome

Sotos syndrome is a congenital overgrowth disorder with an incidence of approximately 1 in 14,000. This study investigated behavioural characteristics of ASD within a large cohort of individuals with Sotos syndrome (n = 78). As measured by the Social Responsiveness Scale, second edition (SRS-2), 65 participants (83.33 %) met clinical cut-off (T-score ≥60). There was no significant gender difference in symptom severity. There was a significant effect of age, with lower scores observed in early childhood and adulthood, compared to childhood. Furthermore, individuals with Sotos syndrome appear to display a trait profile that is similar to that identified in ASD. Overall, these findings indicate that the majority of individuals with Sotos syndrome display clinically significant behavioural symptomatology associated with ASD.

Mindfulness-Based Program for Children with Autism Spectrum Disorder and Their Parents: Direct and Long-Term Improvements

A combined mindfulness-based program for children and their parents (MYmind) was beneficial for adolescents with autism spectrum disorder (ASD). In this study, we investigated whether this program is also beneficial for younger children with ASD, whether effects last on the long-term, and whether it reduces common comorbid problems. Forty-five children referred with ASD aged 8 until 19 years old, and their parents participated. Repeated measures of children's and parents' social communication problems, emotional and behavioral functioning, mindful awareness, and of parenting were conducted pre-intervention, post intervention, 2-month follow-up, and 1-year follow-up. While children did not report significant changes in mindful awareness, their social communication problems decreased, and their emotional and behavioral functioning improved. Results were not consistent at each occasion; improvements reported by children were most substantial at a 2-month follow-up and only partly remained at a 1-year follow-up, while all children's improvements as reported by parents were present on all occasions. Parents themselves reported improved emotional and behavioral functioning, improved parenting, and increased mindful awareness on all occasions. Parents' social communication problems reduced only directly after the intervention. Most improvements were supported by the qualitative investigation of children's and parents' experienced change as reported on open-ended questions. This study suggests that children, including adolescents, with ASD and their parents can benefit from a mindfulness-based program with parallel sessions for children and parents.

A Replication and Extension of the PEERS® for Young Adults Social Skills Intervention: Examining Effects on Social Skills and Social Anxiety in Young Adults with Autism Spectrum Disorder

Young adults with ASD experience difficulties with social skills, empathy, loneliness, and social anxiety. One intervention, PEERS® for Young Adults, shows promise in addressing these challenges. The present study replicated and extended the original study by recruiting a larger sample (N = 56), employing a gold standard ASD assessment tool, and examining changes in social anxiety utilizing a randomized controlled trial design. Results indicated improvements in social responsiveness (SSIS-RS SS, p = .006 and CPB, p = .005; SRS, p = .004), PEERS® knowledge (TYASSK, p = .001), empathy (EQ, p = .044), direct interactions (QSQ-YA, p = .059), and social anxiety (LSAS-SR, p = .019). Findings demonstrate further empirical support for the intervention for individuals with ASD.

Social Skills Intervention Participation and Associated Improvements in Executive Function Performance

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by impairments in social communication. It has been postulated that such difficulties are related to disruptions in underlying cognitive processes such as executive function. The present study examined potential changes in executive function performance associated with participation in the Social Competence Intervention (SCI) program, a short-term intervention designed to improve social competence in adolescents with ASD. Laboratory behavioral performance measures were used to separately evaluate potential intervention-related changes in individual executive function component processes (i.e., working memory, inhibitory control, and cognitive flexibility) in a sample of 22 adolescents with ASD both before and after intervention. For comparison purposes, a demographically matched sample of 14 individuals without ASD was assessed at identical time intervals. Intervention-related improvements were observed on the working memory task, with gains evident in spatial working memory and, to a slightly lesser degree, verbal working memory. Significant improvements were also found for a working memory-related aspect of the task switching test (i.e., mixing costs). Taken together, these findings provide preliminary support for the hypothesis that participation in the SCI program is accompanied by changes in underlying neurocognitive processes such as working memory.

Embedded Figures Test Performance in the Broader Autism Phenotype: A Meta-analysis

People with autism show superior performance to controls on the Embedded Figures Test (EFT). However, studies examining the relationship between autistic-like traits and EFT performance in neurotypical individuals have yielded inconsistent findings. To examine the inconsistency, a meta-analysis was conducted of studies that (a) compared high and low Autism-Spectrum Quotient (AQ) groups, and (b) treated AQ as a continuous variable. Outcomes are consistent with superior visual search forming part of the broader autism phenotype, but in existing literature, this is evident only when comparing extreme groups. Reanalysis of data from previous studies suggests findings are unlikely to be driven by a small number of high scorers. Monte Carlo simulations are used to illustrate the effect of methodological differences on results.

Conceptualising compensation in neurodevelopmental disorders: Reflections from autism spectrum disorder

Within research into neurodevelopmental disorders, little is known about the mechanisms underpinning changes in symptom severity across development. When the behavioural presentation of a condition improves/symptoms lessen, this may be because core underlying atypicalities in cognition/neural function have ameliorated. An alternative possibility is 'compensation'; that the behavioural presentation appears improved, despite persisting deficits at cognitive and/or neurobiological levels. There is, however, currently no agreed technical definition of compensation or its behavioural, cognitive and neural characteristics. Furthermore, its workings in neurodevelopmental disorders have not been studied directly. Here, we review current evidence for compensation in neurodevelopmental disorders, using Autism Spectrum Disorder as an example, in order to move towards a better conceptualisation of the construct. We propose a transdiagnostic framework, where compensation represents the processes responsible for an observed mismatch between behaviour and underlying cognition in a neurodevelopmental disorder, at any point in development. Further, we explore potential cognitive and neural mechanisms driving compensation and discuss the broader relevance of the concept within research and clinical settings.

Toward the identification of adaptive functioning intervention targets for intellectually-able, transition-aged youth with autism: An examination of caregiver responses on the Vineland-II

Little is known about specific adaptive functioning impairments in intellectually-able individuals with autism spectrum disorder. In adolescents (n = 22) and young adults (n = 22) matched on composite IQ scores, this study examined profiles of cognitive and adaptive functioning, and caregiver responses on individual Vineland-II items. Adaptive functioning standard scores were significantly lower than IQ scores, and the adult group had significantly lower adaptive functioning standard scores than the adolescent group. Examination of caregiver responses to individual Vineland-II items identified more than 100 potential intervention targets. Differences favoring the adult group were observed on only 16 items across all three adaptive functioning domains, suggesting that little skill development is occurring during the transition to adulthood. Future research will examine the relevance of identified intervention targets to optimal outcomes. Autism Res 2017, 10: 2023-2036. © 2017 International Society for Autism Research, Wiley Periodicals, Inc.

LAY SUMMARY

Adolescents and young adults with autism spectrum disorder (ASD) without intellectual disability demonstrated impaired adaptive functioning skills (i.e., age appropriate skills necessary for independent living). Development of adaptive functioning skills appears to slow with age among individuals without intellectual disability. Findings clarify the specific adaptive functioning skills that transition-aged youth with ASD have difficulty completing independently and will inform the development of interventions to increase the likelihood of independent living in adulthood.

Pathological game use in adults with and without Autism Spectrum Disorder

This study tested whether adults with autism spectrum disorder (ASD) are at higher risk for pathological game use than typically developing (TD) adults. Participants included 119 adults with and without ASD. Participants completed measures assessing daily hours of video game use, percent of free time spent playing video games, and symptoms of pathological game use. The results indicated that adults with ASD endorsed more symptoms of video game pathology than did TD adults. This relationship was strong, enjoying 300,000-to-1 odds in Bayesian model comparison. Results also showed that adults with ASD spent more daily hours playing video games and spent a higher percent of their free time playing video games than did TD adults. Even after adjustment for these differences in daily video game hours and proportion of free time spent on games, model comparisons found evidence for a difference in game pathology scores associated with ASD status. Additionally, escapism motives for playing video games was associated with game pathology scores in both ASD and TD adults, replicating and extending a previous report. In conclusion, the risk for pathological game use appears larger in adults with ASD compared with TD adults. These findings point to pathological game use as a potentially important focus of clinical attention in adults with ASD.

Repetitive Transcranial Magnetic Stimulation for the Treatment of Executive Function Deficits in Autism Spectrum Disorder: Clinical Trial Approach

OBJECTIVE

Executive function (EF) deficits in patients with autism spectrum disorder (ASD) are ubiquitous and understudied. Further, there are no effective, neuroscience-based treatments to address this impairing feature of ASD. Repetitive transcranial magnetic stimulation (rTMS) has demonstrated promise in addressing EF deficits in adult neuropsychiatric disorders. This article will outline the design of a novel randomized-controlled trial of bilateral, 20 Hz, rTMS applied to the dorsolateral prefrontal cortex (DLPFC) for treatment of EF deficits in ASD that is currently ongoing. We describe prior therapeutic rTMS research for ASD and prior rTMS trials targeting EFs in adult neuropsychiatric disorders. A neurophysiological rationale for rTMS treatment of EF deficits in ASD is presented.

METHODS

An ongoing protocol will enroll participants aged 16-35 with ASD and no intellectual disability. Psychotropic medications will be continued during the 4-week trial of active 20 Hz versus sham rTMS applied to the DLPFC. Twenty, active treatment sessions consisting of 25 stimulation trains at a 90% motor threshold will be administered. The primary outcome measure is the Cambridge Neuropsychological Test Automated Battery (CANTAB) spatial working memory task. At present, recruitment, enrollment, and treatment within the described clinical trial are ongoing.

CONCLUSIONS

EF deficits are common and impairing symptoms of ASD. There are no evidence-based treatments for EF deficits in ASD. The protocol described here will provide important preliminary data on the feasibility and efficacy of 20 Hz rTMS to DLPFC for EF deficits in ASD.