Psychiatric and psychosocial problems in adults with normal-intelligence autism spectrum disorders

Psychotropic medication prescribing in people with autism spectrum disorders with and without psychiatric comorbidity

Autism spectrum disorders (ASDs) are a group of lifelong neurodevelopmental disorders characterised by difficulties in social interactions and social communication, and restricted and repetitive behaviours. Relative to the general population, individuals with ASDs are likely to be overrepresented in secure psychiatric care and custodial settings. Outcomes vary and can be problematic in the context of co-occurring intellectual disability, psychiatric disorder and challenging behaviours. To date, there is little in the way of specialised clinical guidance on the prescription of psychotropic medicines for individuals with ASDs, particularly information on any differences in efficacy and/or tolerability of specific medications. This review summarises the key research to date on the prescription of psychotropic medication in ASD with and without comorbid psychiatric or neurodevelopmental disorders, within the context of the existing clinical guidance. Some critical analysis is provided to aid clinicians in following a safe, effective and individualised approach to prescribing for people with ASDs.

Examining the association between childhood autistic traits and adolescent hypomania: a longitudinal twin study

BACKGROUND

There is evidence that autism spectrum disorders (ASDs) co-occur with bipolar disorder (BD) relatively frequently. Individuals with BD often report symptoms of mania and hypomania during adolescence, prior to the age of onset for BD. It is unknown whether these symptoms are associated with ASDs. We examined whether diagnoses of ASDs and autistic traits were associated with hypomania in a large, population-based Swedish twin sample.

METHODS

Parental structured interviews assessed autistic traits, and were used to assign screening diagnoses of ASDs, when twins were aged 9 or 12 (N = 13 533 pairs). Parents then completed questionnaires assessing hypomania when the twins were aged 15 and 18 (N = 3852 pairs at age 15, and 3013 pairs at age 18). After investigating the phenotypic associations between these measures, we used the classical twin design to test whether genetic and environmental influences on autistic traits influence variation in adolescent hypomania.

RESULTS

Autistic traits and ASD diagnoses in childhood were associated with elevated scores on the measures of adolescent hypomania. Twin analyses indicated that 6-9% of the variance in hypomania was explained by genetic influences that were shared with autistic traits in childhood. When repeating these analyses for specific autistic trait domains, we found a stronger association between social interaction difficulties and hypomania than for other autistic trait domains.

CONCLUSIONS

These results indicate a genetic link between autistic traits and hypomania in adolescence. This adds to the growing evidence base of genetic factors associated with ASDs showing links with psychiatric outcomes across childhood and into adulthood.

FASTER and SCOTT&EVA trainings for adults with high-functioning autism spectrum disorder (ASD): study protocol for a randomized controlled trial

BACKGROUND

Autism spectrum disorder (ASD) is a chronic neurodevelopmental condition with a prevalence rate above 1%, characterized by deficits in social communication and interaction; restrictive, repetitive patterns of behavior, interests, or activities; and a preference for sameness and routines. The majority of adult ASD patients suffer from comorbid conditions such as depression and anxiety. Therapy options for adult ASD patients are lacking, with presently no available evidence-based interventions in Germany. Recently, two interventions to improve social responsiveness have been published. FASTER ("Freiburger Asperger-Spezifische Therapie für ERwachsene" = Freiburg Asperger-specific therapy for adults) is a manualized group psychotherapy program including three modules on psychoeducation, stress regulation management, and non-verbal and verbal social communication training with videotaped tasks. SCOTT&EVA ("Social Cognition Training Tool", and its enhancement "Emotionen Verstehen und Ausdruecken" = understanding and expressing emotions) is a computer-based training program to enhance social cognition including video and audio material of emotional expressions and complex real-life social situations. Initial studies for both programs have shown good feasibility and efficacy.

METHODS

Three hundred sixty adult participants with an autism spectrum disorder (ASD) will take part in a randomized controlled three-armed multi-center trial to prove the efficacy of manualized group psychotherapy and a manualized computer-based training program. Both interventions will be compared with a treatment as usual (TAU) group, aiming to establish evidence-based psychotherapy approaches for adult individuals with ASD. The primary outcome is evaluated by parents, spouses, or others who have sufficient insight into the respective participant's social communication and interaction, and will be measured with the Social Responsiveness Scale. First, each of both interventions will be compared to TAU. If at least one of the differences is significant, both interventions will be compared against each other. The primary outcome will be measured at baseline (T0) and 4 months after baseline (T1).

DISCUSSION

The trial is the first to validate psychiatric therapeutic and training interventions for adult ASD patients in Germany. A trial is needed because the prevalence of ASD in adulthood without intellectual disability is high, and no evidence-based intervention can be offered in Germany.

TRIAL REGISTRATION

German Clinical Trial Register DRKS00017817 . Registered on 20 April 2020.

The gap between IQ and adaptive functioning in autism spectrum disorder: Disentangling diagnostic and sex differences

LAY ABSTRACT

Adaptive functioning refers to skills that are vital to success in day-to-day life, including daily living (e.g. grocery shopping, food preparation, transportation use), communication (e.g. verbal expression of needs), and socialization skills (e.g. interpersonal skills, including expressing and recognizing emotions, and understanding turn-taking in conversation). Among autistic individuals without intellectual disability, adaptive functioning is not commensurate with intellectual ability (IQ), and instead a gap exists between these individuals' intellectual ability and their adaptive skills. Further, these autistic individuals show a widening of this gap with increasing age. Existing studies of the gap between IQ and adaptive functioning have studied predominantly male samples. Thus, we do not know if the gap also exists in autistic females. We therefore looked at adaptive functioning and the gap between IQ and adaptive functioning in a large sample of autistic girls and boys without intellectual disability. To disentangle effects of group (autistic vs typically developing) from effects of sex (girls vs boys), we compared autistic girls and boys to one another as well as to their same-sex typically developing peers. Analyses took into consideration differences in IQ between autistic and typically developing youth. We found autistic girls, like autistic boys, show lower adaptive functioning than their same-sex typically developing peers. Results underscore the need to evaluate adaptive functioning in autistic individuals without intellectual disability and to provide necessary supports. The large gap between intellectual ability and socialization skills, in particular, may be of critical importance in improving our understanding of outcomes and mental health difficulties among autistic females.

Heightened risk of posttraumatic stress disorder in adults with autism spectrum disorder: The role of cumulative trauma and memory deficits

BACKGROUND

Individuals with Autism Spectrum Disorder (ASD) are known to be at increased risk of exposure to traumas such as maltreatment and abuse, however less is known about possible susceptibility towards the development of Posttraumatic Stress Disorder (PTSD) and associated risk factors.

AIMS

This study investigated the rates of trauma exposure and PTSD, and the role of cumulative trauma exposure and memory as risk factors for PTSD in adults who self-reported having received an ASD diagnosis, compared to a typically developing (TD) comparison group.

METHODS

Questionnaires assessing self-reported frequency of trauma exposure (LEC), PTSD symptomology (PCL-S) and memory (EMQ- R and BRIEF-A) were completed online by 38 ASD adults and 44 TD adults.

RESULTS

Rates of trauma exposure and PTSD symptomatology were significantly higher in the ASD group, compared to the TD group, with deficits in working memory and everyday memory mediating this association. Interestingly, a cumulative effect of trauma exposure on PTSD symptom severity was only found in the ASD group.

CONCLUSIONS

High rates of trauma and probable PTSD in ASD adults highlight the importance of routine screening. Cumulative trauma exposure and memory deficits may act to increase risk of PTSD in ASD; longitudinal research is called for.

Gastrointestinal Issues and Autism Spectrum Disorder

Gastrointestinal disorders are one of the most common medical conditions that are comorbid with autism spectrum disorders. These comorbidities can cause greater severity in autism spectrum disorder symptoms, other associated clinical manifestations, and lower quality of life if left untreated. Clinicians need to understand how these gastrointestinal issues present and apply effective therapies. Effective treatment of gastrointestinal problems in autism spectrum disorder may result in marked improvements in autism spectrum disorder behavioral outcomes. This article discusses the gastrointestinal disorders commonly associated with autism spectrum disorders, how they present, and studied risk factors.

Higher levels of autistic traits associated with lower levels of self-efficacy and wellbeing for performing arts professionals

This study sought for the first time to identify the extent to which autistic people are pursuing careers in the performing arts, and to determine the nature of the relationship between individuals' autistic traits and their reported wellbeing. To address these aims, we recruited a self-selecting, community-based sample of individuals working in the performing arts and invited them to complete an online survey. A total of 1,427 respondents took part. We collected responses on participants' backgrounds, including diagnostic history as well as measures assessing their level of autistic traits, perceived occupational self-efficacy, quality of life, and mental health. They were also asked open-ended questions about support needed, received, or desired in their workplace. Eleven of the 1,427 professionals (1%) reported a clinical diagnosis of autism. Correlational analyses demonstrated that higher levels of autistic traits were significantly associated with lower levels of quality of life, lower levels of occupational self-efficacy and greater severity of mental health conditions. Almost half the sample of professionals (N = 621; 44%) reported a desire for more employment-based support, and autistic traits were significantly higher in those participants who wanted greater support. Within the community of those working in the performing arts, there are a minority of individuals who are autistic or who have high levels of autistic traits. We have demonstrated for the first time that these individuals may be especially vulnerable to lower wellbeing.

Low prevalence of risk drinking in adolescents and young adults with autism spectrum problems

Individuals with Autism Spectrum Disorder (ASD) have high rates of "comorbidity". Research on concurrent substance use (disorder) in ASD, however, is scarce and findings have been inconsistent. This study aims at assessing the prevalence of risk drinking in adolescent and young adult twins with and without autism spectrum problems. Data from a Swedish longitudinal nationwide twin study were analyzed. Across three age groups of 15- (N = 10,050), 18- (N = 7,931) and 24-year-olds (N = 2,882) prevalence rates of risk drinking were compared between twins with and without an ASD proxy diagnosis and between different ASD subgroups based on comorbid proxies for attention-deficit/hyperactivity disorder (ADHD) and/or Learning Disorder (LD). ASD, ADHD, and LD were assessed using the Autism-Tics, ADHD, and other Comorbidities inventory (A-TAC), and risk drinking was captured by the Alcohol Use Disorders Identification Test (AUDIT; age 18 and 24) and another set of self-report questions (age 15). In each age group, the prevalence of risk drinking in ASD was lower than in individuals without ASD, yet increasing continuously with age. Exploratory subgroup ASD analyses showed a trend towards risk drinking being more common among individuals with co-existing ADHD or LD problems than among those without "comorbidity", although sample sizes were too small to draw any certain conclusions. This study indicates low prevalence of risk drinking in adolescents and young adults with autism spectrum problems and highlights the need for further research on alcohol use in individuals with ASD and comorbid disorders.

Immediate-release methylphenidate for attention deficit hyperactivity disorder (ADHD) in adults

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is characterized by symptoms of inattention or impulsivity or both, and hyperactivity, which affect children, adolescents, and adults. In some countries, methylphenidate is the first option to treat adults with moderate or severe ADHD. However, evidence on the efficacy and adverse events of immediate-release (IR) methylphenidate in the treatment of ADHD in adults is limited and controversial.

OBJECTIVES

To evaluate the efficacy and harms (adverse events) of IR methylphenidate for treating ADHD in adults.

SEARCH METHODS

In January 2020, we searched CENTRAL, MEDLINE, Embase, eight additional databases and three trial registers. We also searched internal reports on the European Medicines Agency and the US Food and Drug Administration websites. We checked citations of included trials to identify additional trials not captured by the electronic searches.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing IR methylphenidate, at any dose, with placebo or other pharmacological interventions (including extended-release formulations of methylphenidate) for ADHD in adults. Primary outcomes comprised changes in the symptoms of ADHD (efficacy) and harms. Secondary outcomes included changes in the clinical impression of severity and improvement, level of functioning, depression, anxiety and quality of life. Outcomes could have been rated by investigators or participants.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently on the characteristics of the trials, participants, interventions; outcomes and financial conflict of interests. We resolved disagreements by discussion or consulting a third review author. We obtained additional, unpublished information from the authors of one included trial that had reported efficacy data in a graph. We calculated mean differences (MDs) or standardized MDs (SMDs) with 95% confidence intervals (CIs) for continuous data reported on the same or different scales, respectively. We summarized dichotomous variables as risk ratios (RRs) with 95% CI.

MAIN RESULTS

We included 10 trials published between 2001 and 2016 involving 497 adults with ADHD. Three trials were conducted in Europe and one in Argentina; the remaining trials did not report their location. The RCTs compared IR methylphenidate with placebo, an osmotic-release oral system (OROS) of methylphenidate (an extended-release formulation), an extended-release formulation of bupropion, lithium, and Pycnogenol® (maritime pine bark extract). Participants comprised outpatients, inpatients in addiction treatment, and adults willing to attend an intensive outpatient program for cocaine dependence. The duration of the follow-up ranged from 6 to 18 weeks. IR methylphenidate versus placebo We found very low-certainty evidence that, compared with placebo, IR methylphenidate may reduce symptoms of ADHD when measured with investigator-rated scales (MD -20.70, 95% CI -23.97 to -17.43; 1 trial, 146 participants; end scores; Adult ADHD Investigator Symptom Report Scale (AISRS), scored from 0 to 54), but the evidence is uncertain. The effect of IR methylphenidate on ADHD symptoms when measured with participant-rated scales was moderate, but the certainty of the evidence is very low (SMD -0.59, 95% CI -1.25 to 0.06; I² = 69%; 2 trials, 138 participants; end scores). There is very low-certainty evidence that, compared with placebo, IR methylphenidate may reduce the clinical impression of the severity of ADHD symptoms (MD -0.57, 95% CI -0.85 to -0.28; 2 trials, 139 participants; I² = 0%; change and end scores; Clinical Global Impression (CGI)-Severity scale (scored from 1 (very much improved) to 7 (very much worse))). There is low-certainty evidence that, compared with placebo, IR methylphenidate may slightly impact the clinical impression of an improvement in symptoms of ADHD (MD -0.94, 95% CI -1.37 to -0.51; 1 trial, 49 participants; end scores; CGI-Improvement scale (scored from 1 (very much improved) to 7 (very much worse))). There is no clear evidence of an effect on anxiety (MD -0.20, 95% CI -4.84 to 4.44; 1 trial, 19 participants; change scores; Hamilton Anxiety Scale (HAM-A; scored from 0 to 56); very low-certainty evidence) or depression (MD 2.80, 95% CI -0.09 to 5.69; 1 trial, 19 participants; change scores; Hamilton Depression Scale (HAM-D; scored from 0 to 52); very low-certainty evidence) in analyses comparing IR methylphenidate with placebo. IR methylphenidate versus lithium Compared with lithium, it is uncertain whether IR methylphenidate increases or decreases symptoms of ADHD (MD 0.60, 95% CI -3.11 to 4.31; 1 trial, 46 participants; end scores; Conners' Adult ADHD Rating Scale (scored from 0 to 198); very low-certainty evidence); anxiety (MD -0.80, 95% CI -4.49 to 2.89; 1 trial, 46 participants; end scores; HAM-A; very low-certainty evidence); or depression (MD -1.20, 95% CI -3.81 to 1.41, 1 trial, 46 participants; end scores; HAM-D scale; very low-certainty evidence). None of the included trials assessed participant-rated changes in symptoms of ADHD, or clinical impression of severity or improvement in participants treated with IR methylphenidate compared with lithium. Adverse events were poorly assessed and reported. We rated all trials at high risk of bias due to selective outcome reporting of harms and masking of outcome assessors (failure to blind outcome assessor to measure adverse events). Overall, four trials with 203 participants who received IR methylphenidate and 141 participants who received placebo described the occurrence of harms. The use of IR methylphenidate in these trials increased the risk of gastrointestinal complications (RR 1.96, 95% CI 1.13 to 2.95) and loss of appetite (RR 1.77, 95% CI 1.06 to 2.96). Cardiovascular adverse events were reported inconsistently, preventing a comprehensive analysis. One trial comparing IR methylphenidate to lithium reported five and nine adverse events, respectively. We considered four trials to have notable concerns of vested interests influencing the evidence, and authors from two trials omitted information related to the sources of funding and conflicts of interest.

AUTHORS' CONCLUSIONS

We found no certain evidence that IR methylphenidate compared with placebo or lithium can reduce symptoms of ADHD in adults (low- and very low-certainty evidence). Adults treated with IR methylphenidate are at increased risk of gastrointestinal and metabolic-related harms compared with placebo. Clinicians should consider whether it is appropriate to prescribe IR methylphenidate, given its limited efficacy and increased risk of harms. Future RCTs should explore the long-term efficacy and risks of IR methylphenidate, and the influence of conflicts of interest on reported effects.

Alterations in Rapid Social Evaluations in Individuals with High Autism Traits

Typically developing adults with low and high Autism Spectrum Quotient (AQ) scores made rapid social evaluations of neutral faces when these were primed by briefly presented emotional faces. High AQ participants rated neutral faces as more threatening than low AQ participants, regardless of the prime condition. Both groups rated target neutral faces as more threatening with fearful compared with neutral primes, while neither group demonstrated an effect of happy primes on the ratings of neutral target faces. These results demonstrate subtle anomalies in rapid visual processing of emotional faces across the broader autism spectrum. They suggest that higher autism traits may be associated with a generalized threat bias in rapid social evaluations.

Examining Effectiveness and Predictors of Treatment Response of Pivotal Response Treatment in Autism: An Umbrella Review and a Meta-Analysis

The current study aimed to provide a comprehensive appraisal of the current evidence on the effectiveness of Pivotal Response Training (PRT) for individuals with autism spectrum disorder (ASD) and to explore predictors of treatment response. We conducted a systematic review of the following electronic databases and registers: PsycINFO, Medline, Embase, Cochrane Central Register of Controlled Trials, ERIC, Linguistics and Language Behavior Abstracts. Six systematic reviews were identified, two with meta-analytic component. Identified reviews varied widely in terms of their aims, outcomes, and designs which precluded a unified and consistent set of conclusions and recommendations. Ten RCTs were identified. Eight of identified RCTs reported at least one language and communication-related outcome. Statistically significant effects of PRT were identified across a majority of identified RCTs for a range of language and communication skills. However, evidence for positive treatment effects of PRT on outcome measures assessing other domains was less robust and/or specific. Overall, both previous systematic reviews and new meta-analysis of the RCTs suggest that PRT shows promise for improving language and communication. Only four RCTs examined the association between baseline child characteristics and treatment outcomes, however, no consistent pattern emerged. This review has identified several key methodological and design improvements that are needed to enable our field to fully capitalize on the potential of RCT designs and characterize detailed profiles of treatment responders. These findings are essential for informing the development of evidence-based guidelines for clinicians on what works for whom and why.

Social Factors for Leading to Life Satisfaction among Residents with Developmental Disorders in Fukushima Prefecture

A developmental disorder is condition in which a person has deficiency in either physical, learning, language, or behavior, and people with developmental disorders often experience difficulties in their social lives. In Japan, no systematic surveys of developmental disorders targeting local residents have been reported, including working-age. Hence, we aimed to estimate the prevalence and determine the psychosocial factors associated with life satisfaction and psychological distress in the Fukushima prefecture. We conducted an Internet questionnaire survey among 4,030 residents (2,136 men and 1,894 women) aged 16-65 years who either had a job or were willing to work. Developmental disorders were defined based on participants' self-reported history diagnosed by a psychiatrist or their responses to screening questionnaires. The prevalence of developmental disorders was 9.6% (n = 386). Subsequently, a secondary survey (on a first-come, first-served basis) was conducted to assess psychosocial factors among those with developmental disorders, and responses were received from 121 men and 79 women aged 16-65. Being a regular employee and disclosing diagnosis at the workplace was associated with higher job satisfaction. The participants living with a spouse and/or their children tended to feel satisfied with their life (multivariable-adjusted odds ratio (OR): 3.55), job (OR: 3.20), and income (OR: 4.68), whereas those living with parents tended to not feel satisfied with their life, job, or income. Working as a regular employee, having co-workers who understand developmental disorders, and living with a spouse or children are important social factors that increase life satisfaction among people with developmental disorders.

Trait-Based Dimensions Discriminating Adults with Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD) and, Co-occurring ADHD/ASD

This study assessed the co-occurrence of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) in newly diagnosed adults of normal intelligence and the contribution of trait-based dimensions deriving from the Barkley Adult ADHD Rating Scale-IV (BAARS-IV), the Autism-Spectrum Quotient (AQ), and the Empathy Quotient (EQ) to the differentiation of patients with ADHD, ASD, and ADHD/ASD. A total of 16.1% of patients with ADHD received a co-occurring ASD diagnosis, while 33.3% of patients with ASD received an ADHD diagnosis. Subjects with ADHD or ADHD/ASD had higher scores in all ADHD traits compared to ASD subjects. Compared to the ADHD group, the ASD group had AQ scores that were significantly greater, except for attention to detail. ADHD/ASD co-occurrence significantly increased the score of attention to detail. The total EQ score was greater in the ADHD group. In the stepwise logistic regression analyses, past hyperactivity, current inattention and impulsivity, attention switching, communication, imagination, and total EQ score discriminated ADHD patients from ASD patients. Attention to detail, imagination, and total EQ score discriminated ADHD cases from ADHD/ASD cases, while past hyperactivity and current impulsivity discriminated ASD subjects from ADHD/ASD subjects. Our findings highlight the importance of particular trait-based dimensions when discriminating adults with ADHD, ASD, and co-occurring ADHD/ASD.

Suicidality in Adults with Autism Spectrum Disorder: The Role of Depressive Symptomatology, Alexithymia, and Antidepressants

People with autism spectrum disorder (ASD) have an increased risk of suicidality. However, the risk factors remain under-investigated. This study explored factors that increase suicidality risk in ASD. Through an online survey, 150 adults with ASD were compared to 189 control adults. Autistic traits, depressive symptomatology, alexithymia, and antidepressant intake were assessed on their contribution predicting suicidality. Among people with ASD, 63% scored above the cutoff for high suicidality risk. Increased autistic traits, depressive symptomatology, and antidepressant intake significantly predicted suicidality. Furthermore, among those with high levels of autistic traits, the risk of suicidality was increased if they also had high levels of alexithymia. These results highlight the importance of considering depression, antidepressants, and alexithymia to prevent suicidality in ASD.

Evaluating specialist autism teams’ provision of care and support for autistic adults without learning disabilities: the SHAPE mixed-methods study

Background

The National Institute for Health and Care Excellence recommends that every locality has a ‘Specialist Autism Team’: an specialist autism, community-based, multidisciplinary service that is responsible for developing, co-ordinating and delivering care and support. The National Institute for Health and Care Excellence recommended that this novel delivery model was evaluated.

Objectives

The objectives were to identify services fulfilling the National Institute for Health and Care Excellence’s description of a Specialist Autism Team; to describe practitioner and user experiences; to investigate outcomes; to identify factors associated with these outcomes; and to estimate costs and investigate cost-effectiveness of these services.

Design

During stage 1, desk-based research and a survey to identify Specialist Autism Teams were carried out. Stage 2 comprised a mixed-methods observational study of a cohort of Specialist Autism Team users, which was followed for up to 2 years from the assessment appointment. The cohort comprised users of a Specialist Autism Team not previously diagnosed with autism (the ‘Diagnosis and Support’ group) and those already diagnosed (the ‘Support-Only’ group). Stage 2 also involved a nested qualitative study of senior practitioners and an exploratory comparison of the Diagnosis and Support group with a cohort who accessed a service which only provided autism diagnostic assessments (‘Diagnosis-Only’ cohort).

Setting

The setting in stage 2 was nine Specialist Autism Teams; three also provided a regional diagnostic assessment service (used to recruit the Diagnosis-Only cohort).

Participants

There were 252 participants in the Specialist Autism Team cohort (Diagnosis and Support, n = 164; Support Only, n = 88) and 56 participants in the Diagnosis-Only cohort. Thirty-eight participants (across both cohorts) were recruited to the qualitative evaluation and 11 practitioners to the nested qualitative study.

Main outcome measures

The World Health Organization Quality of Life assessment, abbreviated version (psychological domain) and the General Health Questionnaire (12-item version).

Data sources

Self-reported outcomes, qualitative interviews with users and focus groups with practitioners.

Results

A total of 18 Specialist Autism Teams were identified, all for autistic adults without learning disabilities. Services varied in their characteristics. The resources available, commissioner specifications and clinical opinion determined service design. Practitioners working in Specialist Autism Teams recruited to stage 2 reported year-on-year increases in referral rates without commensurate increases in funding. They called for an expansion of Specialist Autism Teams’ consultation/supervision function and resources for low-intensity, ongoing support. For the Specialist Autism Team cohort, there was evidence of prevention of deterioration in outcomes and positive benefit for the Diagnosis and Support group at the 1-year follow-up (T3). Users of services with more professions involved were likely to experience better outcomes; however, such services may not be considered cost-effective. Some service characteristics were not associated with outcomes, suggesting that different structural/organisational models are acceptable. Findings suggest that one-to-one work for mental health problems was cost-effective and an episodic approach to delivering care plans was more cost-effective than managed care. Qualitative findings generally align with quantitative findings; however, users consistently connected a managed-care approach to supporting improvement in outcomes. Among the Diagnosis-Only cohort, no changes in mental health outcomes at T3 were observed. Findings from the interviews with individuals in the Diagnosis and Support group and Diagnosis-Only cohort suggest that extended psychoeducation post diagnosis has an impact on immediate and longer-term adjustment.

Limitations

Sample size prohibited an investigation of the associations between some service characteristics and outcomes. Comparison of the Diagnosis-Only cohort and the Diagnosis and Support group was underpowered. The economic evaluation was limited by incomplete costs data.

Conclusions

The study provides first evidence on the implementation of Specialist Autism Teams. There is some evidence of benefit for this model of care. Service characteristics that may affect outcomes, costs and cost-effectiveness were identified. Finding suggest that extended psychoeducation post diagnosis is a critical element of Specialist Autism Team provision.

Future work

We recommend a comparative evaluation of Specialist Autism Teams with diagnosis-only provision, and an evaluation of models of providing consultation/supervision and low-intensity support.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 48. See the NIHR Journals Library website for further project information.

An investigation of the effect of social reciprocity, social anxiety, and letter fluency on communicative behaviors in adults with autism spectrum disorder

In recent years, research focusing on childhood has reported that communication difficulties in autism spectrum disorder (ASD) are related to the social reciprocity difficulties inherent to ASD, as well as severe social anxiety and decreased verbal fluency. However, there have been no reports regarding these correlations and causal relationships in adulthood. The aim of this study was to reveal the effects of social reciprocity, social anxiety, and letter fluency on communicative behaviors in adults with ASD (n = 33, aged 18-43 years, mean age = 27.88 years) and to compare these to typically developing (TD) adults (n = 35, 19-40 years, mean age = 28.03 years). We validated a model using structural equation modeling in which social reciprocity not only directly affected communicative behaviors, but also indirectly affected communicative behaviors mediated by social anxiety and verbal fluency. The results of the structural equation modeling showed that communicative behaviors patterns differed between the ASD and TD groups, as the ASD group had high goodness of fit with the hypothesis model while the TD group had low goodness of fit. These findings signify that in ASD, in addition to problems in social reciprocity, social anxiety (fear) is a risk factor for worsening communicative behaviors difficulties.

Risk factors for in-patient admission among adults with intellectual disability and autism: investigation of electronic clinical records

Adults with intellectual disability or autism are at risk of psychiatric admission which carries personal, social and economic costs. We identified 654 adults with intellectual disability or autism in the electronic clinical records of one mental health trust. We investigated the demographic and clinical factors associated with admission and readmission after discharge. Young male patients with intellectual disability, schizophrenia and previous admissions are most at risk of the former, whereas affective and personality disorders predict the latter. Both community intellectual disability services and mental health crisis care must focus on providing effective support for those patients.

Qualification for upper secondary education in individuals with autism without intellectual disability: Total population study, Stockholm, Sweden

This study used the Stockholm Youth Cohort, a total population cohort (N = 364,957), to describe patterns and predictors of qualification for upper secondary education, defined by passing graduation grades in core compulsory school subjects in contemporary young individuals diagnosed with autism spectrum disorders without intellectual disability (n = 6138). At the expected age for graduation, 16 years, 29% (adjusted rate difference 95% confidence interval (28.0–30.0)) fewer autistic than non-autistic individuals were qualified for upper secondary education (57% and 86%, respectively). Comorbid attention-deficit hyperactivity disorder further increased this difference. Within the group of autistic students without intellectual disability, female sex and lower family income were associated with non-qualification for upper secondary education. The proportion of students with autism without intellectual disability who qualified for upper secondary education increased at age 20. These findings underline the need for improved support for students with a diagnosis of autism without intellectual disability in mainstream education.

Anxiety and Depression from Adolescence to Old Age in Autism Spectrum Disorder

This study examined age trends in anxious and depressive symptoms, from older adolescence to old age, and explored the association between anxious and depressive symptoms with gender, ASD severity, and socio-economic factors. Two hundred and fifty-five individuals with ASD (151 males, M_age = 33.52 years, SD_age = 14.98) took part. More than one-third of participants reported clinically significant anxiety (38.4%) or depression (38%). A slight trend for an increase in the severity of both anxiety and depression from adolescence to middle adulthood, and then a slight decline in older adulthood was found. Female gender and higher ASD severity predicted more anxiety and depression symptoms. Our findings emphasise the need to provide timely assessment and treatment of anxiety and depression in ASD.

Understanding the essential components and experiences of youth with autism spectrum disorders in peer mentorship programmes during the transition to adulthood: A qualitative meta-ethnography

Youth with an autism spectrum disorder (ASD) often require additional supports during the period of transition to from high school to post-secondary education or career paths. Peer mentorship (PM) programmes create opportunities to support youth with ASD in identifying their personal, academic and career goals after graduating from high school; however, there is limited insight about the components of these programmes that are valued by both participants and peer mentors and that are perceived to contribute to the overall success of a programme in achieving their goals. Our objective was to identify, describe and synthesize the components of PM programmes valued by youth with ASD and their peer mentors, as well as to document their experiences in these transitional support services. A meta-ethnography was conducted to synthesize qualitative and mixed methods studies of PM programmes for youth with ASD. A systematic search of seven databases yielded 142 nonduplicate articles. Data analysis and synthesis involved (1) extraction of raw data; (2) extraction of study authors' interpretations, followed by inductive coding; (3) synthesis of key themes and (4) schematic diagram development to illustrate the relationship of themes. Ten studies of PM programmes from Canada (2), United States (4), Australia (3) and United Kingdom (1) were included. Extracted data reflected experiences of 131 mentees and 82 mentors. The essential programme components identified were (1) mentorship, (2) skill building, (3) peer group and (4) facilitating transition. PM characterized by clear communication and connection between mentors and mentees was valuable to the success of the programme. Peer mentors played an essential role to facilitate the positive experiences that mentees had with programme components, including interactions with peer groups. Successful PM programmes created a safe environment for mentees to practice skills and helped mentees gain confidence to expand their roles to take leadership in their learning.

The role of loneliness as a mediator between autism features and mental health among autistic young adults

LAY ABSTRACT

Autistic adults commonly experience mental health concerns including social anxiety and depression, which can have negative effects on their quality of life. It is not completely clear, however, why rates of mental health concerns are so high. Some evidence suggests that social connectedness might play a key role. The goal of this study was to explore links between loneliness, mental health concerns, autism features, and social contact among autistic adults and test whether the links between mental health with autism features and social contact can be explained by loneliness. Researchers in this study collected data using questionnaires completed by 69 autistic young adults. Autistic adults who reported more autism features also reported more social and family loneliness, higher levels of social anxiety and depression, and fewer initiated social contacts. In addition, adults with more social contact initiations were likely to report lower levels of social and family loneliness and social anxiety but not depression. Results showed that the link from social engagement and autism features to social anxiety and depression symptoms could be mostly explained by loneliness. The results of this study expand previous findings by illustrating one factor (loneliness) that might be responsible for the high rates of mental health concerns among adults on the autism spectrum. These findings highlight the importance of studying factors related to mental health concerns among autistic adults and ways to best support social connectedness for the mental well-being of autistic young adults.

Herding in human groups is related to high autistic traits

Herding is ubiquitous throughout all social life forms, providing beneficial outcomes. Here, we examine whether herding emerges spontaneously in human groups and whether it adheres to the core principles of herding observed in the animal kingdom. Using a computerized paradigm involving the movements of circles, we tested the emergence of spontaneous and intentional herding of 136 participants assigned into groups of four participants. Herding was assessed by measuring directional synchrony in the movements of the circles, level of cohesion, and separation between circles. We found that human groups tend to spontaneously herd, particularly in terms of directional synchrony, supporting the notion of a human herding instinct. We further asked whether individuals with high traits of Autism Spectrum Disorder (ASD) exhibit differences in their herding tendencies. Results indicated that individuals with high ASD traits showed greater social separation from the group, compared to individuals with low ASD traits. Moreover, we found diminished spontaneous synchrony, but intact instructed synchrony in the high vs. the low ASD traits group. We contend that humans spontaneously herd with their group and suggest that the spontaneous tendency to synchronize with others is diminished in individuals with high ASD traits, though it is recovered when synchronization is intentional.

Which autistic traits are related to depressive symptoms in Japanese workers?

Individuals with autism spectrum disorders are at a high risk of experiencing depressive symptoms. However, the relationship between autistic traits and depressive symptoms is unclear. This study aimed to identify which autistic traits are related to depressive symptoms in Japanese workers. The study participants included 2,049 workers from all areas of Japan. Autistic traits and depressive symptoms were measured using an abridged Japanese version of the Autism-Spectrum Quotient (AQ-Short) and the Japanese version of the K6 scale, respectively. The AQ-Short comprises five autistic trait subcomponents that assess fascination for numbers/patterns, difficulties with imagination, preference for routine, difficulties with social skills, and attention-switching difficulties. Linear regression analyses were performed to estimate the association between total and subcomponent autistic trait scores and depressive symptoms. Participants with higher total autistic trait scores were significantly more likely to have depressive symptoms (p<0.001). When scores on the five autistic trait subcomponents were entered simultaneously into the model, participants with higher scores on all subcomponents other than 'difficulties with imagination' were significantly more likely to report depressive symptoms. Total autistic traits and autistic trait subcomponents could be used for early detection of the risk of depressive symptoms.

Exploring the Role of Empathy in Understanding the Social-Cognitive Profile for Individuals Referred for Autism Spectrum Disorders Assessment in Adulthood

This study explored the social-cognitive profile of 173 adults referred for an autism assessment. We considered key dimensional traits (autism, empathy and systemising) to understand social cognition in adults diagnosed with an autism spectrum condition compared with those who were referred for, but did not receive a diagnosis. There were no significant social cognitive differences between groups on measures of emotion recognition and social inference. Adults with a confirmed diagnosis, however, reported fewer empathising traits which were positively associated with social-cognitive understanding. Empathising partially mediated the relationship between diagnostic group and social-cognition. Lower empathising traits in individuals diagnosed in adulthood may be important in understanding challenges with social adaptability. The findings have implications for assessment and highlight the role of empathy in developing social understanding in autism.

Eating Problems in Men and Women with an Autism Spectrum Disorder

The presence of eating problems was assessed in 53 males and 36 females with an autism spectrum disorder (ASD), with and without housing and residential support. The results were compared to a neurotypical group of 30 men and 38 women. The results indicate that men and especially women with ASD experience various eating problems. Women with ASD also recognized symptoms of an eating disorder. Hence, it is important to be aware of eating problems and symptoms of an eating disorder in adults with ASD, to ensure they receive the care they need.

Enhanced social learning of threat in adults with autism

Background

Recent theories have linked autism to challenges in prediction learning and social cognition. It is unknown, however, how autism affects learning about threats from others “demonstrators” through observation, which contains predictive learning based on social information. The aims of this study are therefore to investigate social fear learning in individual with autism spectrum disorder (ASD) and to examine whether typically developing social cognition is necessary for successful observational learning.

Methods

Adults with ASD (n = 23) and neurotypical controls (n = 25) completed a social fear learning (SFL) procedure in which participants watched a “demonstrator” receiving electrical shocks in conjunction with a previously neutral conditioned stimulus (CS+), but never with a safe control stimulus (CS−). Skin conductance was used to measure autonomic responses of learned threat responses to the CS+ versus CS−. Visual attention was measured during learning using eye tracking. To establish a non-social learning baseline, each participant also underwent a test of Pavlovian conditioning.

Results

During learning, individuals with ASD attended less to the demonstrator’s face, and when later tested, displayed stronger observational, but not Pavlovian, autonomic indices of learning (skin conductance) compared to controls. In controls, both higher levels of attention to the demonstrator’s face and trait empathy predicted diminished expressions of learning during test.

Limitations

The relatively small sample size of this study and the typical IQ range of the ASD group limit the generalizability of our findings to individuals with ASD in the average intellectual ability range.

Conclusions

The enhanced social threat learning in individuals with ASD may be linked to difficulties using visual attention and mental state attributions to downregulate their emotion.

Validation of the 21-item Depression, Anxiety, and Stress Scales (DASS-21) in individuals with autism spectrum disorder

The purpose of the study was to examine the internal consistency and validity of the 21-item Depression Anxiety Stress Scale (DASS-21) in individuals with Autism Spectrum Disorder (ASD) and without intellectual disability (IQ >= 70). Participants (NN = 123) were consecutively recruited from the Brain and Mind Centre in New South Wales, Australia. Internal consistency was determined using Cronbach's alpha. Item-total correlations were evaluated by Pearson's product-moment correlation coefficient. The convergent validity of the DASS-21 was examined by measuring its associations with quality of life and other measures of depression and anxiety. Factorial validity was assessed using confirmatory factor analysis. The DASS-21 demonstrated good internal consistency, adequate convergent validity, and all items exhibited satisfactory item-total correlations. Considering fit indices and factor loadings, the confirmatory factor analysis results provided support for the original 3-factor oblique model consisting of depression, anxiety, and stress factors. The model fit could be further improved with some modifications. Overall, the results indicate that the DASS-21 is a viable self-report screening measure for depression, anxiety, and stress in individuals with ASD and without intellectual disability.

Negative memory bias as a transdiagnostic cognitive marker for depression symptom severity

BACKGROUND

Negative memory bias is a strong risk factor for the development and maintenance of depression. Recent evidence also found negative memory bias in other mental disorders. Here, we aim to: 1) assess the presence and strength of negative memory bias in a range of (comorbid) mental disorders, 2) investigate which disorder-specific symptoms are associated with negative memory bias, and 3) test whether negative memory bias might be a transdiagnostic mechanism.

METHODS

Negative memory bias was measured in patients with at least one diagnosis of a stress-related disorder (n = 86), a neurodevelopmental disorder (n = 53), or both (n = 68), and 51 controls. Depression, anxiety, attention-deficit/hyperactivity disorder, and autism spectrum disorder symptom severity was assessed using questionnaires. Groups were compared on negative memory bias and the associations between negative memory bias and symptom severity were made using linear regression models.

RESULTS

All patient groups showed stronger negative memory bias than the controls. Negative memory bias was individually associated with all symptom severity indices, but when added into a single model, only the association with depressive symptom severity remained. This persisted after controlling for diagnostic group.

LIMITATIONS

Due to the cross-sectional sectional study design, we could only look at the associations between negative memory bias and disorder-specific symptoms and not at the direction of the effects.

CONCLUSIONS

Negative memory bias is characteristic of a depressotypic processing style and present in different mental disorders. It might play a mechanistic role in the development of (subclinical) co-occurrence between mental disorders.

Sleep in adults with autism spectrum disorder and attention deficit/hyperactivity disorder: A systematic review and meta-analysis

Sleep-related problems have been frequently reported in neurodevelopmental disorders, with special emphasis in Autism Spectrum Disorder (ASD) and Attention Deficit/Hyperactivity Disorder (ADHD). The aim of the present study is to conduct a systematic review and meta-analysis on sleep disturbances in adults with ASD and/or ADHD (PROSPERO's CRD42019132916). PubMed and PsycINFO were searched for studies reporting data on sleep objective/subjective measures, as well as prevalence data of sleep disorders, in adults with ASD and/or ADHD. A manual search was conducted throughout reference lists of eligible studies. A total of 1126 studies and 66 references were identified by electronic and manual searches, respectively. Of these, 42 studies were included in the meta-analysis. Results showed that both disorders share a similar sleep-impaired profile with higher sleep onset latency, poorer sleep efficiency, greater number of awakenings during sleep, and a general lower self-perceived sleep quality compared with healthy controls. A higher proportion of N1 sleep was found in ASD participants, while a greater Periodic Limb Movements in Sleep is specific in ADHD adults. More studies are needed, especially those directly comparing ASD and ADHD participants. Controlling for medication, intellectual disability, and concurrent psychiatric disorders is mandatory.

Lifetime co-occurring psychiatric disorders in newly diagnosed adults with attention deficit hyperactivity disorder (ADHD) or/and autism spectrum disorder (ASD)

BACKGROUND

Co-occurring psychiatric disorders in adults with Attention Deficit Hyperactivity Disorder (ADHD) and/or Autism Spectrum Disorder (ASD) contribute to the burden of the healthcare and possibly to the delay of diagnosis. Aim of the study was to clinically assess the prevalence and compare lifetime co-occurring psychopathology in a sample of newly diagnosed ADHD and/or ASD adults and discuss the diagnostic challenges they pose.

METHODS

The lifetime prevalence rates of ten of the most frequently co-occurring psychiatric diagnoses was registered in 336 adults of normal intelligence who underwent a thorough clinical evaluation for the diagnosis of ADHD and/or ASD for the first time in their lives. Four study groups were formed: the ADHD (n = 151), the ASD (n = 58), the ADHD+ASD (n = 28) and the nonADHD/nonASD (NN) (n = 88) group.

RESULTS

At least one co-occurring psychopathology was found in 72.8% of the ADHD group, in 50% of the ASD group, in 72.4% of the ADHD+ASD group and in 76.1% of the NN group (p = 0.004). In all groups the most frequent psychiatric disorder was depressive disorder. The only significant difference regarding the patterns of psychiatric co-occurrence between the ADHD and the nonADHD groups (ASD and NN groups) was found for SUD (p = 0.001). Also, the proportion of subjects with Bipolar Disorder was significantly greater in the NN group as compared to those with ASD (p = 0.025).

CONCLUSIONS

Our results support the high prevalence of co-occurring psychiatric disorders in adults with ADHD and/or ASD with the ASD group presenting the lowest rate. The most marked difference between the ADHD and the nonADHD groups was found for SUD. Moreover, our findings highlight the need for a thorough clinical assessment of all referred patients both in the presence and absence of ADHD and/or ASD.

Social anxiety in adults with autism: a qualitative study

Purpose

Many individuals with autism experience social anxiety (SA), yet, to date, this has almost exclusively been investigated using quantitative research methods. We know very little about why individuals with autism perceive they develop SA, what they view the impact and consequences of symptoms to be, and which coping strategies they find helpful.

Methods

Using a qualitative study design, six men with autism (aged 23–52 years old) participated in individual semi-structured interviews. Data were transcribed verbatim and analysed using thematic analysis.

Results

Seven overarching themes were identified: (1) causal influences for SA; (2) anxiety-provoking social situations; (3) symptoms of SA; (4) chronicity; (5) coping; (6) impact; and (7) interventions.

Conclusions

Further studies are needed to more fully establish why individuals with autism are vulnerable to developing SA, to inform development of targeted interventions.

Central coherence in adults with a high-functioning autism spectrum disorder. In a search for a non-self-reporting screening tool

BACKGROUND

Autism spectrum disorder in adults, especially high-functioning ones, is often difficult to differentiate from other mental disorders. Therefore, many adults with ASD are misdiagnosed, and their social difficulties are not adequately addressed. Moreover, frequent comorbid issues make diagnosis a challenging prospect. Most of the available screening and diagnostic tools rely on self-reporting, which can be a biased method. Weak Central Coherence is one of the main cognitive theories of ASD. According to research, individuals with ASD are slower in comparison to typically developed control on the uptake of context. The study goal was to see if the central coherence tasks could be used as a reliable screening marker that differentiates between high-functioning ASD and typically developed controls.

METHOD

Thirty males with ASD (as in DSM-5) and 30 demographically matched controls were investigated with Central Coherence Inferences Tests. Tests' scores and reaction times needed to complete the tasks in both groups were compared.

RESULTS

High-functioning participants with ASD achieved a similar score in central coherence tests as the typically developed control group, but they needed significantly more time to solve them. The ROC analysis for both central coherence tests revealed AUC values of 0.73 in differentiating ASD from typically developed controls.

CONCLUSIONS

The results are discussed in reference to the clinical application of central coherence as a possible screening marker. Further research directions are proposed in terms of differential diagnosis of adults with ASD.

[Autism spectrum disorder in childhood and adults: diagnosis and differential diagnoses]

Autistic disorders are summarized in DSM‑5 under the term autism spectrum disorder (ASD) and are severe, lifelong, pervasive neurodevelopmental disorders. Core features manifested even in childhood are impairments in social interaction and communication as well as restricted and repetitive behavior. The intensity of symptoms, language and cognitive impairments vary but the majority of affected individuals have below average intelligence and 80% have at least one comorbid disorder. The diverse pathology and heterogeneity in phenotypes are caused by a complex genetic etiology, which is associated with a reduced synaptic plasticity of neural networks. The disorder is associated with a clearly reduced quality of life as well as a high familial burden. The differential diagnostics have a high relevance and the diagnosis should be carried out by specialized institutions. Behavioral therapeutic interventions are indicated.

Healthcare access for autistic adults: A systematic review

BACKGROUND

People with autism spectrum disorder (ASD) have an increased susceptibility for many chronic health conditions compared with their peers. An increasing number of adolescents are transitioning from pediatric to adult healthcare services. Thus, being able to access appropriate healthcare services that can not only address specific needs of the person but enable them to better manage healthcare conditions and decrease the development of preventable disease is necessary. A systematic review was conducted to identify barriers and enablers of healthcare access for autistic adults.

METHODS

The studies included in the review were quantitative and qualitative and were published between 2003 and 2019. The participants for the review are considered to be adults (over 18 years of age) with a primary diagnosis of ASD.

RESULTS

In total, 1290 studies were initially identified and 13 studies were included based on the inclusion and exclusion criteria outlined in a previous protocol paper. The analysis of these studies identified areas of concern to access appropriate healthcare, such as clinician knowledge, the environment, and life events.

CONCLUSION

Identifying the barriers to healthcare, highlights ways healthcare services can regulate scope of practice, the physical environment, and the process of managing health conditions, thus, autistic adults can strive for optimal health. This review contributes to peer-reviewed evidence for future research and up-to-date information when developing and piloting health interventions for autistic adults.

ETHICS AND DISSEMINATION

There are no human participants, data, or tissue being directly studied for the purposes of the review; therefore, ethics approval and consent to participate is not applicable.

REGISTRATION AND STATUS

PROSPERO 2018 CRD42018116093.

Autistic traits in young adults who gamble

BACKGROUND.

Little is known about the relationship between autistic traits and addictive behaviors such as problem gambling. Thus, the present study examined clinical characteristics and multiple facets of cognition in young adults who gamble and have autistic traits.

METHODS.

A total of 102 young adults who gamble were recruited from two Mid-Western university communities in the United States using media advertisements. Autistic traits were examined using the brief Autism-Spectrum Quotient (AQ-10). Clinician rating scales, questionnaires, and cognitive tests were completed. Relationships between AQ10 scores and demographic, gambling symptom, and neurocognitive measures were evaluated.

RESULTS.

Autistic traits were correlated with disordered gambling symptoms, attention-deficit/hyperactivity disorder (ADHD) symptoms, trait impulsivity, and some types of obsessive-compulsive symptoms. In regression, ADHD no longer significantly related to autistic traits once disordered gambling symptoms were accounted for; whereas the link between autistic traits and disordered gambling symptoms was robust even controlling for ADHD.

CONCLUSIONS.

These data suggest a particularly strong relationship between autistic traits and problem gambling symptoms, as well as certain aspects of impulsivity and compulsivity. The link between ADHD and autistic traits in some prior studies may have been attributable to disordered gambling symptoms, which was likely not screened for, and since individuals may endorse ADHD instruments due to other impulsive/compulsive symptom types (eg, gambling). The contribution of autistic traits to the emergence and chronicity of disordered gambling now requires further scrutiny, not only in community samples (such as this) but also in clinical settings.

Gastrointestinal issues and Autism Spectrum Disorder

Gastrointestinal disorders are one of the most common medical conditions that are comorbid with autism spectrum disorders. These comorbidities can cause greater severity in autism spectrum disorder symptoms, other associated clinical manifestations, and lower quality of life if left untreated. Clinicians need to understand how these gastrointestinal issues present and apply effective therapies. Effective treatment of gastrointestinal problems in autism spectrum disorder may result in marked improvements in autism spectrum disorder behavioral outcomes. This article discusses the gastrointestinal disorders commonly associated with autism spectrum disorders, how they present, and studied risk factors.

Autism in Adulthood: Clinical and Demographic Characteristics of a Cohort of Five Hundred Persons with Autism Analyzed by a Novel Multistep Network Model

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by deficits in communication and relational skills, associated with repetitive verbal and motor behaviors, restricted patterns of interest, need for a predictable and stable environment, and hypo- or hypersensitivity to sensory inputs. Due to the challenging diagnosis and the paucity of specific interventions, persons with autism (PWA) reaching the adult age often display a severe functional regression. In this scenario, the Regional Center for Autism in Adulthood in Turin seeks to develop a personalized rehabilitation and enablement program for PWA who received a diagnosis of autism in childhood/adolescence or for individuals with suspected adulthood ASD. This program is based on a Multistep Network Model involving PWA, family members, social workers, teachers, and clinicians. Our initial analysis of 500 PWA shows that delayed autism diagnosis and a lack of specific interventions at a young age are largely responsible for the creation of a “lost generation” of adults with ASD, now in dire need of effective psychosocial interventions. As PWA often present with psychopathological co-occurrences or challenging behaviors associated with lack of adequate communication and relational skills, interventions for such individuals should be mainly aimed to improve their self-reliance and social attitude. In particular, preparing PWA for employment, whenever possible, should be regarded as an essential part of the intervention program given the social value of work. Overall, our findings indicate that the development of public centers specialized in assisting and treating PWA can improve the accuracy of ASD diagnosis in adulthood and foster specific habilitative interventions aimed to improve the quality of life of both PWA and their families.

Autistic Traits in Men With Substance Use Disorder

There has been no study in the literature evaluating autistic traits (ATs) in men with substance use disorders (SUDs). Therefore, we performed the current study to evaluate whether there is a relation between the ATs among men with SUDs and normal controls. A total of 142 men with SUDs and 109 age and sex-matched healthy controls were included in the current study. Present attention deficit hyperactivity disorder (ADHD) symptoms of the participants were evaluated using the Adult ADHD Self-Report Scale. The autism spectrum quotient (AQ) was used to evaluate ATs. The current study found that higher AQ imagination and lower AQ attention to detail scores predicted SUDs after controlling for AQ subscales and present ADHD symptoms. This study shows that ATs may be engaged in the development of SUDs. To explore the connection between ATs and SUDs, more research is needed.

Autism: considerations for transitions of care into adulthood

PURPOSE OF REVIEW

The steady rise in number of youth diagnosed with autism spectrum disorder (ASD) has led to the need to examine transition of care considerations specific to ASD. Improved understanding and guidance addressing these needs will allow pediatric and adult providers to work together to optimize social, medical, and occupational outcomes for these patients.

RECENT FINDINGS

Health-care transition is a delicate time when children with ASD outgrow the services of pediatric programs and enter a fragmented healthcare system that is unfamiliar, insufficiently knowledgeable, and underfunded for their needs.

SUMMARY

Increasing autism prevalence and an aging population with autism lend urgency to improve outcomes in children transitioning to adult-care. Research reveals poor consequences in social support, education, vocational training and employment, housing, and healthcare. Specific considerations to address these issues and ensure successful transition from pediatric to adult care are needed.

Guidance for identification and treatment of individuals with attention deficit/hyperactivity disorder and autism spectrum disorder based upon expert consensus

BACKGROUND

Individuals with co-occurring hyperactivity disorder/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) can have complex presentations that may complicate diagnosis and treatment. There are established guidelines with regard to the identification and treatment of ADHD and ASD as independent conditions. However, ADHD and ASD were not formally recognised diagnostically as co-occurring conditions until the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) was published in 2013. Hence, awareness and understanding of both conditions when they co-occur is less established and there is little guidance in the clinical literature. This has led to uncertainty among healthcare practitioners when working with children, young people and adults who present with co-existing ADHD and ASD. The United Kingdom ADHD Partnership (UKAP) therefore convened a meeting of professional experts that aimed to address this gap and reach expert consensus on the topic that will aid healthcare practitioners and allied professionals when working with this complex and vulnerable population.

METHOD

UK experts from multiple disciplines in the fields of ADHD and ASD convened in London in December 2017. The meeting provided the opportunity to address the complexities of ADHD and ASD as a co-occurring presentation from different perspectives and included presentations, discussion and group work. The authors considered the clinical challenges of working with this complex group of individuals, producing a consensus for a unified approach when working with male and female, children, adolescents and adults with co-occurring ADHD and ASD. This was written up, circulated and endorsed by all authors.

RESULTS

The authors reached a consensus of practical recommendations for working across the lifespan with males and females with ADHD and ASD. Consensus was reached on topics of (1) identification and assessment using rating scales, clinical diagnostic interviews and objective supporting assessments; outcomes of assessment, including standards of clinical reporting; (2) non-pharmacological interventions and care management, including psychoeducation, carer interventions/carer training, behavioural/environmental and Cognitive Behavioural Therapy (CBT) approaches; and multi-agency liaison, including educational interventions, career advice, occupational skills and training, and (3) pharmacological treatments.

CONCLUSIONS

The guidance and practice recommendations (Tables 1, 4, 5, 7, 8 and 10) will support healthcare practitioners and allied professionals to meet the needs of this complex group from a multidisciplinary perspective. Further research is needed to enhance our understanding of the diagnosis, treatment and management of individuals presenting with comorbid ADHD and ASD.

A cross-syndrome approach to the social phenotype of neurodevelopmental disorders: Focusing on social vulnerability and social interaction style

BACKGROUND

Following Annette Karmiloff-Smith's approach to cognitive research, this study applied a cross-syndrome approach to the social phenotype, focusing on social vulnerability (SV) and the factors that contribute to it.

AIMS

To (i) identify syndrome-specific differences in SV across four neurodevelopmental disorder (NDD) groups, (ii) determine the contribution of intellectual disability (ID), age or gender to SV, and (iii) explore its relationship with social interaction style (SIS).

METHODS AND PROCEDURES

262 parents of children: Autism (n = 29), Williams syndrome (n = 29), Attention deficit hyperactivity disorder (n = 36), Fragile X syndrome (n = 18), and Neurotypical (n = 150) reported on their child's SV, quality of SIS and other factors (ID, age, gender).

OUTCOMES AND RESULTS

Heightened SV was not syndrome-specific. Instead it was found equally across NDD groups (and not in the neurotypical group), and independently of ID, age and gender. Different atypical SISs were also distributed across NDD groups and each were significantly related to SV, independent of the factors above and beyond neurodevelopmental diagnosis.

CONCLUSIONS AND IMPLICATIONS

The findings emphasise that social phenotypes are best understood as distributed across diagnostic boundaries and offer opportunities to further test the role of varied atypical SISs in the development of heightened SV.

Autism Spectrum Disorder and Post-Traumatic Stress Disorder: An unexplored co-occurrence of conditions

LAY ABSTRACT

People with Autism Spectrum Disorder show an increased risk of experiencing traumatic events, particularly social victimization. However, Autism Spectrum Disorder and Post-Traumatic Stress Disorder co-occurrence was hardly studied. We examined exposure to traumatic life events and Post-Traumatic Stress Disorder symptoms in adults with Autism Spectrum Disorder vs typical adults. Two groups took part in this study: Twenty-five adults with Autism Spectrum Disorder and 25 typical adults of similar age and male to female ratio. Participants completed questionnaires on potentially traumatic life events of social and non-social nature, as well as on Post-Traumatic Stress Disorder symptoms related to their most distressing event. Participants also filled out an autism traits questionnaire. Results showed a higher Post-Traumatic Stress Disorder rate in the Autism Spectrum Disorder group (32%) compared with the typical group (4%). Individuals with Autism Spectrum Disorder reported more Post-Traumatic Stress Disorder symptoms, particularly re-experiencing and increased physiological arousal, compared with typical adults, although the latter was elevated only in females with Autism Spectrum Disorder. Participants with Autism Spectrum Disorder, especially females, reported more negative life events, particularly social events, than typical adults. Sixty percent of Autism Spectrum Disorder participants, but only 20% of typical participants, chose a social event as their most distressing event. Individuals with Autism Spectrum Disorder who were also suspected as having Post-Traumatic Stress Disorder (based on their questionnaires) presented poorer social skills compared with those with Autism Spectrum Disorder alone. Results indicate that individuals with Autism Spectrum Disorder are more susceptible to trauma and Post-Traumatic Stress Disorder, particularly due to social stressors. Females with Autism Spectrum Disorder may be especially vulnerable to Post-Traumatic Stress Disorder.

Anxiety Disorders in Adults with Autism Spectrum Disorder: A Population-Based Study

Anxiety is common in children with ASD; however, the burden of specific anxiety disorders for adults with ASD is under-researched. Using the Stockholm Youth Cohort, we compared anxiety disorder diagnoses among autistic adults (n = 4049), with or without intellectual disability, and population controls (n = 217,645). We conducted additional sibling analyses. Anxiety disorders were diagnosed in 20.1% of adults with ASD compared with 8.7% of controls (RR = 2.62 [95% CI 2.47–2.79]), with greatest risk for autistic people without intellectual disability. Rates of almost all individual anxiety disorders were raised, notably obsessive–compulsive disorder and phobic anxiety disorders. Anxiety disorders were more common in full siblings and half-siblings of people with ASD. The implications of this are explored.