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

Sex Differences in the Relationship between PTSD Spectrum Symptoms and Autistic Traits in a Sample of University Students

BACKGROUND

While growing literature is stressing the link between Autistic Traits (AT) and trauma-/stress-related disorders, in both conditions significant differences have been separately reported.

OBJECTIVE

This study aims to evaluate the relationship between AT and trauma-/stress-related symptoms with respect to sex.

METHODS

178 university students were assessed with the Structured Clinical Interview for DSM-5, the Trauma and Loss Spectrum (TALS) and the Adult Autism Subthreshold Spectrum (AdAS). In order to evaluate sex differences in trauma-/stress-related symptoms among subjects with higher or lower AT, the sample was split in two groups with an equal number of subjects on the basis of the median score reported on AdAS Spectrum ("AdAS high scorers" and "AdAS low scorers").

RESULTS

Females reported significantly higher TALS total score, Loss events and Grief reaction domain scores than males in the whole sample, while AdAS high scorers reported significantly higher TALS total and domain scores than AdAS low scorers. A significant interaction between high/low AdAS score and sex emerged for TALS domains, with females scoring significantly higher than males only among AdAS low scorers, specifically on Loss events, Grief reaction, Re-experiencing and Personal characteristics/Risk factors domains. Finally, among AdAS high scorers a significantly higher rate of subjects fulfilled symptomatological criteria for PTSD than among AdAS low scorers, without sex differences.

CONCLUSION

Our results confirm a significant relationship between AT and trauma-/stress-related symptoms, which seems to prevail on sex differences among high-risk subjects.

Few Differences in the Externalizing and Criminal History of Young Violent Offenders With and Without Autism Spectrum Disorders

Autism spectrum disorders (ASDs) are known to be associated with an increased risk of aggression and challenging behavior. In this study, we have mapped the externalizing history of a nationally representative cohort of young violent offenders with ASD, compared with offenders without ASD. Two hundred and sixty-nine violent offenders were assessed for prevalence of ASD, and participated in a thorough assessment of previous externalizing problems and criminal history. Twenty-six offenders met consensus clinical DSM-IV criteria for ASD and they were compared to offenders without ASD from the same cohort. Overall, we found a very high prevalence of externalizing and antisocial behaviors in the history of these offenders and there were few differences between the groups. Placements in foster homes were overrepresented in the ASD group and the ASD-offenders had significantly more often been diagnosed with a neurodevelopmental disorder (i.e. ASD or ADHD) by a clinician before the study. At index conviction, ASD offenders were overrepresented in sex crimes with a child victim. Though offenders without ASD had more previous convictions, in particular drug crimes, we found no difference in terms of total number of prosecuted crimes. Substance use disorders were more common among offenders without ASD. The ASD offenders scored higher compared to the non-ASD offenders on the Affective facet of the Psychopathy Checklist-Revised (PCL-R) but there were no differences in terms of total PCL-R scores. Our results provide important knowledge of the developmental history of offenders with ASD. Though this is a small and atypical phenotype it poses significant challenges to the criminal justice system and we need to understand more of it to be able to prevent these individuals from committing crimes but also to provide a fair judicial treatment, to assess exculpatory factors and improve our forensic treatment models.

Two Sides of the Same Coin: A Case Report of First-Episode Catatonic Syndrome in a High-Functioning Autism Patient

Background: Catatonic phenomena such as stupor, mutism, stereotypy, echolalia, echopraxia, affective flattening, psychomotor deficits, and social withdrawal are characteristic symptoms of both schizophrenia and autism spectrum disorders (ASD), suggesting overlapping pathophysiological similarities such as altered glutamatergic and dopaminergic synaptic transmission and common genetic mutations. In daily clinical practice, ASD can be masked by manifest catatonic or psychotic symptoms and represent a diagnostic challenge, especially in patients with unknown or empty medical history. Unclear diagnosis is one of the main factors for delayed treatment. However, we are still missing diagnostic recommendations when dealing with ASD patients suffering from catatonic syndrome. Case presentation: A 31-year-old male patient without history of psychiatric disease presented with a severe catatonic syndrome and was admitted to our closed psychiatric ward. After the treatment with high-dose lorazepam and intramuscular olanzapine, catatonic symptoms largely remitted, but autistic traits persisted. Following a detailed anamnesis and a thorough neuropsychological testing, we diagnosed the patient with high-functioning autism and catatonic schizophrenia. The patient was discharged in a remitted state with long-acting injectable olanzapine. Conclusion: This case represents an example of diagnostic and therapeutic challenges of catatonic schizophrenia in high-functioning autism due to clinical and neurobiological overlaps of these conditions. We discuss clinical features together with pathophysiological concepts of both conditions. Furthermore, we tackle social and legal hurdles in Germany that naturally arise in these patients. Finally, we present diagnostic "red flags" that can be used to rationally select and conduct current recommended diagnostic assessments if there is a suspicion of ASD in patients with catatonic syndrome in order to provide them with the most appropriate treatment.

Gender Identity in Autism: Sex Differences in Social Affiliation with Gender Groups

High rates of gender variance have been reported in autistic people, with higher variance in autistic females than males. The social component of gender identity may be affected, with autistic females experiencing lower identification with and feeling less positively about their gender groups than controls. We measured gender identification, gender self-esteem, and aspects of gender expression (masculinity and femininity) in autistic natal males and females, and controls (N = 486). We found that autistic people had lower gender identification and gender self-esteem than controls, and autistic natal females had lower gender identification than autistic natal males and natal female controls. In conclusion, autistic people, particularly natal females, had lower social identification with and more negative feelings about a gender group.

Temperament and character in men with autism spectrum disorder: A reanalysis of scores on the Temperament and Character Inventory by individual case matching

BACKGROUND

Interest in autism spectrum disorders (ASD) in adulthood is increasing. Although a person may be diagnosed with ASD, the diagnosis reveals little about the individual's temperament, character, and personality. Also, relatively little is known about the personality of adults with ASD.

METHOD

A reanalysis of scores on the Temperament and Character Inventory (TCI) administered to a group of 66 normally intelligent men aged 18-63 years, diagnosed with ASD, by individual case matching to a comparison group of 66 men from the general population drawn from the TCI manual.

RESULTS

Compared to the comparison group, men with ASD scored significantly higher on the scale for Harm Avoidance, and lower on Novelty Seeking, Reward Dependence, Self-Directedness, and Cooperativeness.

CONCLUSIONS

In this study the score pattern for temperament and character found in men with ASD by individual case matching confirms and strengthens earlier general group matching findings emerging from our 2012 study and from studies from Sweden and the Netherlands.

Genetic Diagnostic Evaluation of Trio-Based Whole Exome Sequencing Among Children With Diagnosed or Suspected Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a group of clinically and genetically heterogeneous neurodevelopmental disorders. Recent tremendous advances in the whole exome sequencing (WES) enable rapid identification of variants associated with ASD including single nucleotide variations (SNVs) and indels. To further explore genetic etiology of ASD in Chinese children with negative findings of copy number variants (CNVs), we applied WES in 80 simplex families with a single affected offspring with ASD or suspected ASD, and validated variations predicted to be damaging by Sanger sequencing. The results showed that an overall diagnostic yield of 8.8% (9.2% in the group of ASD and 6.7% in the group of suspected ASD) was observed in our cohort. Among patients with diagnosed ASD, developmental delay or intellectual disability (DD/ID) was the most common comorbidity with a diagnostic yield of 13.3%, followed by seizures (50.0%) and craniofacial anomalies (40.0%). All of identified de novo SNVs and indels among patients with ASD were loss of function (LOF) variations and were slightly more frequent among female (male vs. female: 7.3% vs. 8.5%). A total of seven presumed causative genes (CHD8, AFF2, ADNP, POGZ, SHANK3, IL1RAPL1, and PTEN) were identified in this study. In conclusion, WES is an efficient diagnostic tool for diagnosed ASD especially those with negative findings of CNVs and other neurological disorders in clinical practice, enabling early identification of disease related genes and contributing to precision and personalized medicine.

Transcranial direct current stimulation (tDCS) over right temporoparietal junction (rTPJ) for social cognition and social skills in adults with autism spectrum disorder (ASD)

Social deficits are core to autism spectrum disorder (ASD). Current treatments are extremely time- and labor-intensive. Transcranial direct current stimulation (tDCS) may be a promising treatment modality to safely enhance treatments targeting social cognition and social skills. This pilot study investigates the effectiveness of social skills treatment interventions paired with anodal tDCS for six adults 18-58 years with ASD. Differences were predicted on the verbal fluency (VF) test and a test of social skills (TASSK-M) for verum (2.0 mA) vs. sham tDCS, which was randomly assigned in a within-subjects, double-blinded design in adults with ASD with normal or higher cognitive functioning. The anode electrode was placed over right temporoparietal (CP6) and cathode over ipsilateral deltoid. Wilcoxon signed-rank tests for paired data indicated that participants received a significantly higher score on the VF test after receiving verum tDCS compared to sham tDCS, with no significant differences found on the TASSK-M. Post-hoc analysis showed that the emotion-word portion of the VF test, specifically, indicated significant differences when comparing verum to sham tDCS conditions. These findings provide optimism for the use of tDCS as delivered in the current study paired with social skills treatment interventions for ASD, particularly for improving skills of emotion verbal fluency.

Novel four-session treatment intervention for anxiety and high-functioning autism: A single case report for Externalizing Metaphors Therapy

TOPIC

The Brief Services psychotherapy paradigm has evolved to produce cost-effective and clinically significant outcomes in children's mental health. Though its clinical evaluation is still in its infancy, it has been utilized to a much lesser degree with autism spectrum disorders, which typically require a longer-term approach to psychotherapy treatment.

PURPOSE

The current paper introduces a novel, four-session intervention that aims to decrease anxiety experienced by clients presenting with high-functioning autism. Externalizing Metaphors Therapy is based upon the externalization of problems, transformation of metaphoric imagery, shifting of maladaptive emotional schemas, and the generalization of problems. A case study is utilized to visually aid in the understanding of this new treatment intervention.

SOURCE

A composite literature review was conducted with regards to significant works in Narrative Therapy, treatment interventions for anxiety and high functioning autism, evidence-based treatments for anxiety, and practice based approaches in psychotherapy. Works were selected based on their relevance to the research filed of anxiety and autism.

CONCLUSIONS

This clinical research challenges the children's mental health field in addressing anxiety and high-functioning autism from a brief framework. Further clinical research is needed to clinically evaluate the current model.

Genetic risk for schizophrenia and autism, social impairment and developmental pathways to psychosis

While psychotic experiences (PEs) are assumed to represent psychosis liability, general population studies have not been able to establish significant associations between polygenic risk scores (PRS) and PEs. Previous work suggests that PEs may only represent significant risk when accompanied by social impairment. Leveraging data from the large longitudinal IMAGEN cohort, including 2096 14-year old adolescents that were followed-up to age 18, we tested whether the association between polygenic risk and PEs is mediated by (increasing) impairments in social functioning and social cognitive processes. Using structural equation modeling (SEM) for the subset of participants (n = 643) with complete baseline and follow-up data, we examined pathways to PEs. We found that high polygenic risk for schizophrenia (p = 0.014), reduced brain activity to emotional stimuli (p = 0.009) and social impairments in late adolescence (p < 0.001; controlling for functioning in early adolescence) each independently contributed to the severity of PEs at age 18. The pathway between polygenic risk for autism spectrum disorder and PEs was mediated by social impairments in late adolescence (indirect pathway; p = 0.025). These findings point to multiple direct and indirect pathways to PEs, suggesting that different processes are in play, depending on genetic loading, and environment. Our results suggest that treatments targeting prevention of social impairment may be particularly promising for individuals at genetic risk for autism in order to minimize risk for psychosis.

The Prevalence of Autism Spectrum Disorders in Adult Psychiatric Inpatients: A Systematic Review

Background:

Whilst the prevalence of autism spectrum disorders in adults within the community setting is well-established, less is known about the prevalence among adults based within a psychiatric inpatient setting.

Objective:

To conduct a systematic literature review pertaining to the prevalence of autism spectrum disorders among the adult psychiatric inpatient population.

Method:

Eligibility criteria included: (a) investigation of the prevalence of autism spectrum disorders (b) adult psychiatric inpatient study population (c) published in English language. Electronic databases accessed included PubMed, Medline, CINAHL, PsycINFO and EMBASE. Additionally, the ancestry method was utilised for the references of eligible papers, as well as grey literature searches and consultation with experts in the field.

Results:

From the search, 4 studies were identified which satisfied the inclusion criteria, conducted in a variety of inpatient psychiatric settings, including secure forensic and intellectual disability units and a state psychiatric hospital. There were significant differences in methodological approaches, including the screening tests, diagnostic instruments and diagnostic criteria utilised. Autism spectrum disorder prevalence estimates varied considerably, from 2.4-9.9%.

Conclusion:

From the limited research data currently available, it appears that the prevalence of autism spectrum disorders is increased in inpatient psychiatric settings relative to the general population. There is a need for further high quality research in this patient group, to add to this limited evidence base, as well as in developing effective strategies to identify patients with a high likelihood of autism spectrum disorders within this setting.

Psychosocial Treatments Targeting Anxiety and Depression in Adolescents and Adults on the Autism Spectrum: Review of the Latest Research and Recommended Future Directions

PURPOSE OF REVIEW

This synthesis of treatment research related to anxiety and depression in adolescents and adults with autism spectrum disorder (ASD) focuses on the scientific support for various forms of psychosocial interventions, useful adaptations to standard interventions, and engagement of candidate therapeutic mechanisms.

RECENT FINDINGS

There is considerable evidence for the efficacy of cognitive-behavioral therapy (CBT) to treat co-occurring problems with anxiety, but there has been relatively little research on treatment of co-occurring depression. Multiple mechanisms of treatment effect have been proposed, but there has been little demonstration of target engagement via experimental therapeutics. Comorbidity between ASD and anxiety and/or mood problems is common. Although there is evidence for the use of CBT for anxiety, little work has addressed how to effectively treat depression. There is emerging support for alternative treatment approaches, such as mindfulness-based interventions. We encourage rigorous, collaborative approaches to identify and manipulate putative mechanisms of change.

Prenatal influenza vaccination rescues impairments of social behavior and lamination in a mouse model of autism

Background

Prenatal infection is a substantial risk factor for neurodevelopmental disorders such as autism in offspring. We have previously reported that influenza vaccination (VAC) during early pregnancy contributes to neurogenesis and behavioral function in offspring.

Results

Here, we probe the efficacy of VAC pretreatment on autism-like behaviors in a lipopolysaccharide (LPS)-induced maternal immune activation (MIA) mouse model. We show that VAC improves abnormal fetal brain cytoarchitecture and lamination, an effect associated with promotion of intermediate progenitor cell differentiation in MIA fetal brain. These beneficial effects are sufficient to prevent social deficits in adult MIA offspring. Furthermore, whole-genome analysis suggests a strong interaction between Ikzf1 (IKAROS family zinc-finger 1) and neuronal differentiation. Intriguingly, VAC rescues excessive microglial Ikzf1 expression and attenuates microglial inflammatory responses in the MIA fetal brain.

Conclusions

Our study implies that a preprocessed influenza vaccination prevents maternal bacterial infection from causing neocortical lamination impairments and autism-related behaviors in offspring.

Electronic supplementary material

The online version of this article (10.1186/s12974-018-1252-z) contains supplementary material, which is available to authorized users.

Pupil response to social-emotional material is associated with rumination and depressive symptoms in adults with autism spectrum disorder

Background

Autism spectrum disorder (ASD) is marked by repetitive thinking and high rates of depression. Understanding the extent to which repetitive negative thinking in ASD reflects autistic stereotypy versus general depressive thinking patterns (e.g., rumination) could help guide treatment research to improve emotional health in ASD. We compared associations between rumination, depressive symptoms, and pupil response to social-emotional material in adults with ASD and typically developing (TD) adults with and without depression.

Methods

N = 53 verbally fluent young adults were recruited to three cohorts: ASD, n = 21; TD-depressed, n = 13; never-depressed TD-controls, n = 19. Participants completed Ruminative Response Scale and Beck Depression Inventory self-reports and a passive-viewing task employing emotionally-expressive faces, during which pupillary motility was assessed to quantify cognitive-affective load. Main and interactive effects of cohort, emotion condition, and time on pupil amplitude were tested via a linear mixed effects analysis of variance using restricted maximum likelihood estimation. Similar procedures were used to test for effects of rumination and depressive symptoms on pupil amplitude over time within ASD.

Results

Responsive pupil dilation in the ASD cohort tended to be significantly lower than TD-depressed initially but increased to comparable levels by trial end. When viewing sad faces, individuals with ASD who had higher depression scores resembled TD-depressed participants’ faster, larger, and sustained pupil response. Within ASD, depressive symptoms uniquely predicted early pupil response to sad faces, while rumination and depression scores each independently predicted sustained pupil response.

Conclusions

People with elevated depressive symptoms appear to have faster and greater increases in pupil-indexed neural activation following sad stimuli, regardless of ASD status, suggesting the utility of conceptualizing rumination as depression-like in treatment. Ruminative processes may increase more slowly in ASD, suggesting the potential utility of interventions that decrease reactions before they are uncontrollable. Findings also reinforce the importance of testing for effects of internalizing variables in broader ASD research.

Association Between Autism Spectrum Disorders With or Without Intellectual Disability and Depression in Young Adulthood

IMPORTANCE

Depression is a frequently occurring mental disorder and may be common in adults with autism spectrum disorders (ASD), but there is a lack of longitudinal population-based studies examining this association. Whether any increased risk of depression in ASD has a shared familial basis and whether it differs by co-occurring intellectual disability is not well known.

OBJECTIVES

To examine whether individuals with ASD are more likely to be diagnosed as having depression in adulthood than the general population and their nonautistic siblings and to investigate whether these risks differ by the presence or absence of intellectual disability.

DESIGN, SETTING, AND PARTICIPANTS

Population-based cohort study with a nested sibling comparison. The Stockholm Youth Cohort is a total population record linkage study that includes all children and young people (age range, 0-17 years) who were ever resident in Stockholm County, Sweden, between January 2001 and December 2011 (n = 735 096). Data analysis was conducted between January 5 and November 30, 2017, in Stockholm County, Sweden.

MAIN OUTCOMES AND MEASURES

Clinical diagnosis of depressive disorders was identified using the Stockholm County Adult Psychiatric Outpatient Register and the Swedish National Patient Register.

RESULTS

Participants were 223 842 individuals followed up to age 27 years by 2011, of whom 4073 had diagnosed ASD (mean [SD] age, 21.5 [2.7] years; 65.9% male; 2927 without intellectual disability and 1146 with intellectual disability) and 219 769 had no ASD (mean [SD] age, 22.1 [2.8] years; 50.9% male). By age 27 years, 19.8% (n = 808) of individuals diagnosed having ASD had a diagnosis of depression compared with 6.0% (n = 13 114) of the general population (adjusted relative risk [RR], 3.64; 95% CI, 3.41-3.88). The risk of a depression diagnosis was higher in ASD without intellectual disability (adjusted RR, 4.28; 95% CI, 4.00-4.58) than in ASD with intellectual disability (adjusted RR, 1.81; 95% CI, 1.51-2.17). Nonautistic full-siblings (adjusted RR, 1.37; 95% CI, 1.23-1.53) and half-siblings (adjusted RR, 1.42; 95% CI, 1.23-1.64) of individuals with ASD also had a higher risk of depression than the general population. Compared with their nonautistic full-siblings, individuals with ASD had more than a 2-fold risk of a depression diagnosis (adjusted odds ratio, 2.50; 95% CI, 1.91-3.27) in young adulthood.

CONCLUSIONS AND RELEVANCE

According to this study's results, ASD, particularly ASD without intellectual disability, is associated with depression by young adulthood compared with the general population. It appears that this association is unlikely to be explained by shared familial liability. Future research to identify modifiable pathways between ASD and depression may assist in the development of preventive interventions.

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.

Emotion regulation in autism spectrum disorder: Where we are and where we need to go

Emotion dysregulation is a common issue experienced by individuals with autism spectrum disorder (ASD) and has been associated with a wide range of negative mental and physical health outcomes. This commentary highlights the role emotion dysregulation plays in ASD by first considering the literature on emotion regulation (ER) in the general population and then summarizing the ER research in ASD. Based on the evaluation of previous research findings, we conclude that individuals with ASD have more ER difficulties and consistently self-report or demonstrate a less adaptive pattern of ER strategy use. In addition, the higher prevalence of internalizing and externalizing issues seen in ASD are associated with the greater habitual use of some ER strategies and less habitual use of others. Conceptual and methodological limitations are discussed, including the use of coping measures and single-method approaches, and ASD gender distribution. We propose a set of new directions for investigating ER in ASD, incorporating knowledge from other literatures on the role of flexibility in healthy adaptation, overlaps between flexibility and executive function deficits, the adaptive value of up-regulation of positive emotions, and the importance of emotional self-awareness. Increasing our capacity for identifying the mechanisms underlying co-morbid affective disorders can ultimately inform the design of effective interventions to maximize the wellbeing of individuals with ASD. Autism Res 2018, 11: 962-978. © 2018 International Society for Autism Research, Wiley Periodicals, Inc.

LAY SUMMARY

Research has shown that people diagnosed with autism tend to have difficulties with regulating their own emotions. This commentary article summarizes the main information from emotion regulation research conducted both in autism and in other populations. We make suggestions on how we can improve emotion regulation research in autism, with the ultimate goal being to use the learning gained from research to design effective interventions that can improve the wellbeing of people with autism.

Risk and protective factors underlying depression and suicidal ideation in Autism Spectrum Disorder

BACKGROUND

People with Autism Spectrum Disorder (ASD) are at significantly increased risk of suicidal thoughts and behavior. Given that social difficulties in ASD often lead to social isolation, which can in turn increase the risk for depression, this study examined loneliness and social support as potential risk and protective factors associated with depression and suicidal ideation.

METHOD

The sample comprised 185 people (92 females) with ASD aged 14 to 80 years who were participating in a national survey.

RESULTS

Forty-nine percent of participants returned scores in the clinical range for depression and 36% reported recent suicidal ideation. Females, comprising almost 50% of the sample, returned higher depression scores than males, however no differences were identified between males and females in terms of suicidal ideation. Regression analyses revealed that loneliness, satisfaction with social support, and ASD traits predicted depression scores. Satisfaction with social support predicted suicidal ideation, however, it was no longer a significant predictor after the effects of depression were taken into account. Path analysis showed that ASD trait severity was independently related to depression, that the effect of number of social supports on depression was mediated by loneliness and satisfaction with social support, and that effects of loneliness and satisfaction with social support on suicidal ideation were mediated by depression. The pattern of relationships was nearly identical for males and females.

CONCLUSIONS

This study supports a model whereby loneliness and social support operate respectively as protective and risk factors for depression and suicidal ideation in ASD.

Sociability deficits after prenatal exposure to valproic acid are rescued by early social enrichment

Background

Autism spectrum disorder (ASD) is characterized by impaired social interactions and repetitive patterns of behavior. Symptoms appear in early life and persist throughout adulthood. Early social stimulation can help reverse some of the symptoms, but the biological mechanisms of these therapies are unknown. By analyzing the effects of early social stimulation on ASD-related behavior in the mouse, we aimed to identify brain structures that contribute to these behaviors.

Methods

We injected pregnant mice with 600-mg/kg valproic acid (VPA) or saline (SAL) at gestational day 12.5 and evaluated the effect of weaning their offspring in cages containing only VPA animals, only SAL animals, or mixed. We analyzed juvenile play at PD21 and performed a battery of behavioral tests in adulthood. We then used preclinical PET imaging for an unbiased analysis of the whole brain of these mice and studied the function of the piriform cortex by c-Fos immunoreactivity and HPLC.

Results

Compared to control animals, VPA-exposed animals play less as juveniles and exhibit a lower frequency of social interaction in adulthood when reared with other VPA mice. In addition, these animals were less likely to investigate social odors in the habituation/dishabituation olfactory test. However, when VPA animals were weaned with control animals, these behavioral alterations were not observed. Interestingly, repetitive behaviors and depression-related behaviors were not affected by social enrichment. We also found that VPA animals present high levels of glucose metabolism bilaterally in the piriform cortex (Pir), a region known to be involved in social behaviors. Moreover, we found alterations in the somatosensory, motor, and insular cortices. Remarkably, these effects were mostly reversed after social stimulation. To evaluate if changes in glucose metabolism in the Pir correlated with changes in neuronal activity, we measured c-Fos immunoreactivity in the Pir and found it increased in animals prenatally exposed to VPA. We further found increased dopamine turnover in the Pir. Both alterations were largely reversed by social enrichment.

Conclusions

We show that early social enrichment can specifically rescue social deficits in a mouse model of ASD. Our results identified the Pir as a structure affected by VPA-exposure and social enrichment, suggesting that it could be a key component of the social brain circuitry.

Electronic supplementary material

The online version of this article (10.1186/s13229-018-0221-9) contains supplementary material, which is available to authorized users.

Emotion regulation in autism: Reappraisal and suppression interactions

Emotion regulation has been proposed to be a transdiagnostic factor in the development and maintenance of psychopathology in the general population, yet the nature of the relationships between emotion regulation strategy use and psychological well-being has not been comprehensively explored in individuals with autism spectrum disorder (ASD). The aim of this study was to assess how the individual differences in self-reported emotion regulation strategy use relate to levels of both positive and negative psychological well-being. In total, 56 individuals with ASD aged 14-24 years (M_age = 18.15; SD_age = 2.30) completed Emotion Regulation Questionnaire, Diagnostic and Statistical Manual of Mental Disorders-5 Generalized Anxiety Disorder Dimensional Scale, Patient Health Questionnaire-9, Warwick-Edinburgh Mental Well-being Scale and Autism-Spectrum Quotient - Short. Individuals were grouped into four clusters based on their Emotion Regulation Questionnaire subscale scores. Individuals in the high suppression and low reappraisal group expressed higher depressive symptoms and lower positive well-being when compared with the low suppression and high reappraisal group. Interestingly, individuals who self-reported using both high suppression and reappraisal expressed relatively high positive well-being and low depression symptoms. We suggest that the maladaptive effect of habitual suppression usage may be buffered by the habitual use of reappraisal, and this interaction between adaptive and maladaptive emotion regulation strategy use has clinical implications.

A Pilot Randomized Controlled Trial of the ACCESS Program: A Group Intervention to Improve Social, Adaptive Functioning, Stress Coping, and Self-Determination Outcomes in Young Adults with Autism Spectrum Disorder

The purpose of this pilot randomized controlled trial was to investigate the acceptability and efficacy of the Acquiring Career, Coping, Executive control, Social Skills (ACCESS) Program, a group intervention tailored for young adults with autism spectrum disorder (ASD) to enhance critical skills and beliefs that promote adult functioning, including social and adaptive skills, self-determination skills, and coping self-efficacy. Forty-four adults with ASD (ages 18-38; 13 females) and their caregivers were randomly assigned to treatment or waitlist control. Compared to controls, adults in treatment significantly improved in adaptive and self-determination skills, per caregiver report, and self-reported greater belief in their ability to access social support to cope with stressors. Results provide evidence for the acceptability and efficacy of the ACCESS Program.

Community Mental Health Services for Autistic Adults: Good News and Bad News

Many autistic adults experience psychiatric conditions such as anxiety and depression. However, autistic adults often do not receive effective and affordable mental health (MH) treatment. Untreated psychiatric conditions in autistic adults are associated with a host of negative outcomes, including adaptive functioning impairments, difficulties with employment and independent living, and poor quality of life. The purpose of this Perspectives piece is to shed light on the current state of community MH services in the United States for autistic adults with co-occurring psychiatric conditions. Drawing on the available research and clinical experiences, we aim to (1) highlight positive developments in community mental healthcare for autistic adults; (2) summarize the barriers that continue to exist for autistic adults in need of MH services; and (3) provide recommendations for autistic adults and their families, community MH clinicians, and MH systems administrators to consider. Significant work is needed to provide autistic adults with affordable quality MH services. This Perspectives piece presents a summary of the needed changes and specific methods to continue to improve community MH services for autistic adults.

The co-occurrence of autistic traits and borderline personality disorder traits is associated to increased suicidal ideation in nonclinical young adults

BACKGROUND

The co-occurrence of Autism Spectrum Disorder (ASD) and Borderline Personality Disorder (BPD) is not rare and has been linked to increased suicidality. Despite this significant comorbidity between ASD and BPD, no study had examined the co-occurrence of autistic traits and borderline personality disorder traits in the general population. The aim of the present study was to examine the co-occurrence of autistic and borderline traits in a non-clinical sample of young adults and its influence on the levels of suicidal ideation and depressive symptomatology.

PROCEDURES

Participants were 474 college students who completed self-report questionnaires. Data were analysed using correlation and cluster analyses.

MAIN FINDINGS

Borderline personality traits and autistic traits were weakly correlated. However, cluster analysis yielded four groups: a low traits group, a borderline traits group, an autistic traits group, and a group characterized by high levels of both traits. Cluster analysis revealed that autistic and borderline traits can co-occur in a significant proportion of young adults. The high autistic and borderline traits group constituted 17% of the total sample and had higher level of suicidal ideation than the borderline traits group, despite similar levels of depressive symptoms.

CONCLUSION

This result suggests that the higher suicidality observed in patients with comorbid ASD and BPD may extent to non-clinical individuals with high levels of co-occurrent autistic and borderline traits.

Education and employment status of adults with autism spectrum disorders in Germany - a cross-sectional-survey

BACKGROUND

Adults with autism spectrum disorders (ASD) experience challenges in participating in the labour market and struggle to achieve and maintain appropriate professional positions, possibly due to impairments of communication and social interaction. Studies have shown high rates of unemployment as well as evidence of inadequate employment. As knowledge on the participation in the German labour market is scarce, the aim of our study was to examine employment status, type of occupation and inadequate employment in a sample of clinically mostly late-diagnosed and most likely not intellectually disabled adults with ASD in Germany.

METHODS

We conducted a cross-sectional-survey in clinically mostly late-diagnosed adults with ASD. Employment status, type of occupation, and the level of formal education and training were examined through a postal questionnaire. Inadequate employment regarding participants' current and longest practised occupation was assessed by transforming participants' information into skill levels of the "Classification of Occupations 2010" of the German Federal Employment Agency, and comparing these with participants' level of formal education and training.

RESULTS

The response rate was 43.2% (N = 185 of N = 428 potential participants). 94.6% were first-time diagnosed when being 18 years of age or older. 56.8% held a general university entrance-level qualification and 24.9% had obtained a Masters' or diploma degree as their highest vocational qualification. 94.1% had been employed at some time. Of these, 68.4% reported being currently employed, 13.5% being currently unemployed and 17.0% being retired for health reasons. Regarding the longest-practised and the current occupation, the highest proportion of participants was found in the occupational area "health and social sector, teaching and education" (22.4% and 23.3%, respectively). With respect to inadequate employment, 22.1% were found to be overeducated in relation to their longest-practised occupation and 31.3% in relation to their current occupation. This is significantly higher than the percentage of overeducation in the general population.

CONCLUSIONS

Despite largely high formal qualifications, the clinically mostly late-diagnosed adults with ASD represented in our sample are disadvantaged regarding their participation in the German labour market, especially with respect to rates of unemployment, early retirement and overeducation. Employment support programs should be developed to improve employment outcomes.

Transcranial Direct Current Stimulation to the Right Temporoparietal Junction for Social Functioning in Autism Spectrum Disorder: A Case Report

OBJECTIVES

While there is evidence of improved social functioning after applying transcranial direct current stimulation (tDCS) at the right temporoparietal junction (rTPJ) in individuals who are healthy, no current studies have investigated the use of tDCS at the rTPJ to improve social functioning in individuals with autism spectrum disorder (ASD). This case investigates the use of tDCS applied to the rTPJ to target social functioning in a high-functioning adult with ASD.

METHODS

The authors present a case of an 18-year old patient with ASD treated successfully with tDCS; 1.5 mA of tDCS was applied once a day for 30 minutes for 8 consecutive days with the anode electrode over rTPJ (CP6 in the 10/10 electroencephalogram system) and the cathode electrode placed on the ipsilateral deltoid. Behavioral outcome was assessed using the Autism Treatment Evaluation Checklist prior to tDCS, after the final tDCS session, and at 2 months after tDCS. An additional, informal follow-up was also made 1 year after tDCS.

RESULTS

Autism Treatment Evaluation Checklist showed substantial improvement in social functioning from baseline to post-tDCS, which was maintained at 2 months. The patient also reported lessened feelings of anger and frustration over social disappointments. Informal follow-up 1 year after stimulation indicates that the patient continues to maintain many improvements.

CONCLUSIONS

Anodal tDCS to the rTPJ may represent an effective treatment for improving social functioning in ASD, with a larger clinical trial needed to validate this effect.

Polysubstance and Behavioral Addictions in a Patient with Bipolar Disorder: Role of Lifetime Subthreshold Autism Spectrum

This case report draws attention to the potential relevance of undetected autism spectrum symptoms in a bipolar patient with high work functioning showing a peculiar addictive profile with impulsive and antisocial behaviors. A 23-year-old man with a diagnosis of Bipolar Disorder (BD) and Substance Use Disorder (SUD) was hospitalized at the Psychiatric Clinic of the University of Pisa for diuretics and β-2 adrenergic agonist abuse in a remission phase of benzodiazepines and substance abuse. He reported a history of behavioral addictions in the framework of a global high work functioning with particular skills in computer science. When assessed for adult autism spectrum symptoms, despite not fulfilling a DSM-5 diagnosis of Autism Spectrum Disorder (ASD), he reported a score of 93/240 at the Ritvo Autism and Asperger Diagnostic Scale (RAADS-r) and of 88/160 at the Adult Autism Subthreshold Spectrum (AdAS Spectrum), both indicative of ASD. We argue the possible role of adult subthreshold autism spectrum features, generally disregarded in adult psychiatry, in the peculiar addictive profile developed by this patient with BD that may deserve appropriate treatment.

Co-occurring psychiatric conditions in autism spectrum disorder

Individuals with autism spectrum disorder (ASD) are at increased risk for experiencing one or more co-occurring psychiatric conditions. When present, these conditions are associated with additional impairment and distress. It is therefore crucial that clinicians and researchers adequately understand and address these challenges. However, due to symptom overlap, diagnostic overshadowing, and ambiguous symptom presentation in ASD, the assessment of co-occurring conditions in ASD is complex and challenging. Likewise, individual difference factors, such as age, intellectual functioning, and gender, may influence the presentation of co-occurring symptoms. Relatedly, a transdiagnostic framework may offer utility in assessing and treating co-occurring conditions. However, with the exception of anxiety disorders, treatment research for co-occurring psychiatric conditions in ASD is relatively limited. Therefore, the present paper aims to summarize and review available research on the most common co-occurring psychiatric disorders in ASD, with a focus on estimated population-based prevalence rates, diagnostic challenges, the influence of individual differences, and assessment guidelines. The utility of a transdiagnostic framework for conceptualizing co-occurring disorders in ASD is discussed, and the state of treatment research for co-occurring disorders is summarized. This study concludes with a summary of the extant literature, as well as recommendations for future research.

Psychosocial interventions for internalizing disorders in youth and adults with ASD

Internalizing disorders are common in individuals with ASD. Psychosocial interventions targeting these disorders in the ASD population have burgeoned in the last decade. Cognitive-behavioural therapy, modified for ASD, is the most frequently investigated model, although other interventions, including behaviour therapy, third-wave interventions, models targeting transdiagnostic constructs, and alternative interventions and treatment delivery methods are now emerging. This review provides a summary of the efficacy of these interventions in treating internalizing disorders in youth and adults with ASD. The barriers to accessing these treatments, which are experienced by many individuals with ASD and their families, as well as future research directions, are also discussed.

Facilitating Neurofeedback in Children with Autism and Intellectual Impairments Using TAGteach

Individuals with autism and intellectual impairments tend to be excluded from research due to their difficulties with methodological compliance. This study focuses on using Teaching with Acoustic Guidance-TAGteach-to behaviorally prepare children with autism and a IQ ≤ 80 to participate in a study on neurofeedback training (NFT). Seven children (ages 6-8) learned the prerequisite skills identified in a task analysis in an average of 5 h of TAGteach training, indicating that this is a feasible method of preparing intellectually-impaired children with autism to participate in NFT and task-dependent electroencephalography measures. TAGteach may thus have the potential to augment this population's ability to participate in less accessible treatments and behavioral neuroscientific studies.

Measurement properties of tools used to assess depression in adults with and without autism spectrum conditions: A systematic review

Depression is the most commonly experienced mental health condition in adults with autism spectrum conditions (ASC). However, it is unclear what tools are currently being used to assess depression in ASC, or whether tools need to be adapted for this group. This systematic review therefore aimed to identify tools used to assess depression in adults with and without ASC, and then evaluate these tools for their appropriateness and measurement properties. Medline, PsychINFO and Web of Knowledge were searched for studies of depression in: (a) adults with ASC, without co‐morbid intellectual disability; and (b) adults from the general population without co‐morbid conditions. Articles examining the measurement properties of these tools were then searched for using a methodological filter in PubMed, and the quality of the evidence was evaluated using the COSMIN checklist. Twelve articles were identified which utilized three tools to assess depression in adults with ASC, but only one article which assessed the measurement properties of one of these tools was identified and thus evaluated. Sixty‐four articles were identified which utilized five tools to assess depression in general population adults, and fourteen articles had assessed the measurement properties of these tools. Overall, two tools were found to be robust in their measurement properties in the general population—the Beck Depression Inventory (BDI‐II), and the patient health questionnaire (PHQ‐9). Crucially only one study was identified from the COSMIN search, which showed weak evidence in support of the measurement properties of the BDI‐II in an ASC sample. Implications for effective measurement of depression in ASC are discussed. Autism Res2018, 11: 738–754. © 2018 The Authors Autism Research published by International Society for Autism Research and Wiley Periodicals, Inc.

Lay Summary

Depression is the most common mental health problem experienced by adults with autism. However, the current study found very limited evidence regarding how useful tools developed for the general population are for adults with autism. We therefore suggest how these tools could be adapted to more effectively assess depression in adults with autism, and improve these individuals access to mental health assessment and support.

Early intervention in psychosis: clinical aspects of treatment

Engaging patients in first-episode psychosis services is critical in maximising the effect of early intervention and establishing a framework for longer-term treatment. Biopsychosocial assessments determine a working diagnosis and inform evidence-based treatment. Atypical antipsychotics should be used at doses that maximise therapeutic benefit and adherence while minimising side-effects. Patients are helped to construct a narrative of their illness, including a shared understanding of the contribution of biological and environmental risks, and early warning signs. Common comorbid conditions, including depression, suicidal ideation, substance misuse and anxiety, should be addressed. Management of comorbid borderline and antisocial personality disorders is difficult; their nexus with psychosis is discussed. Cognitive–behavioural therapy is a mainstay of treatment, with specific interventions developed for problems typical in first-episode presentations. Core psychosocial interventions include psychoeducation, vocational and educational support, family interventions and multimodal group programmes.

Adapting Psychological Therapies for Autism - Therapist Experience, Skills and Confidence

BACKGROUND

Psychological interventions informed by cognitive behavioural theory have proven efficacy in treating mild-moderate anxiety and depression. They have been successfully adapted for autistic children and adults who experience disproportionately high rates of co-occurring emotional problems. There has been little research into the perspectives and experience of psychological therapists adapting cognitive behavioural therapy (CBT) as part of routine clinical practice. We surveyed therapist skills, experience and confidence in working psychologically with autistic people, in order to highlight gaps and needs, as well as strengths in terms of therapist skills when working with this group.

METHOD

Fifty therapists attending a training event completed a survey about their experience of adapting CBT for autistic clients, alongside a measure of therapist confidence.

RESULTS

Almost all therapists reported making adaptations to CBT practice when working with autistic clients. Key challenges identified were rigidity in thinking and pacing sessions appropriately. Therapists were relatively confident about core engagement and assessment skills but reported less confidence in using their knowledge to help this group. Therapist confidence was not associated with years of practice or number of adaptations made, but was positively associated with level of therapy training received.

CONCLUSIONS

This study highlights a need for training and ongoing supervision to increase therapist confidence in and ability to make appropriate adaptations to CBT treatment protocols for autistic people.

Autism spectrum disorder: Consensus guidelines on assessment, treatment and research from the British Association for Psychopharmacology

An expert review of the aetiology, assessment, and treatment of autism spectrum disorder, and recommendations for diagnosis, management and service provision was coordinated by the British Association for Psychopharmacology, and evidence graded. The aetiology of autism spectrum disorder involves genetic and environmental contributions, and implicates a number of brain systems, in particular the gamma-aminobutyric acid, serotonergic and glutamatergic systems. The presentation of autism spectrum disorder varies widely and co-occurring health problems (in particular epilepsy, sleep disorders, anxiety, depression, attention deficit/hyperactivity disorder and irritability) are common. We did not recommend the routine use of any pharmacological treatment for the core symptoms of autism spectrum disorder. In children, melatonin may be useful to treat sleep problems, dopamine blockers for irritability, and methylphenidate, atomoxetine and guanfacine for attention deficit/hyperactivity disorder. The evidence for use of medication in adults is limited and recommendations are largely based on extrapolations from studies in children and patients without autism spectrum disorder. We discuss the conditions for considering and evaluating a trial of medication treatment, when non-pharmacological interventions should be considered, and make recommendations on service delivery. Finally, we identify key gaps and limitations in the current evidence base and make recommendations for future research and the design of clinical trials.

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.