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

Sex/gender differences and autism: setting the scene for future research

OBJECTIVE

The relationship between sex/gender differences and autism has attracted a variety of research ranging from clinical and neurobiological to etiological, stimulated by the male bias in autism prevalence. Findings are complex and do not always relate to each other in a straightforward manner. Distinct but interlinked questions on the relationship between sex/gender differences and autism remain underaddressed. To better understand the implications from existing research and to help design future studies, we propose a 4-level conceptual framework to clarify the embedded themes.

METHOD

We searched PubMed for publications before September 2014 using search terms "'sex OR gender OR females' AND autism." A total of 1,906 articles were screened for relevance, along with publications identified via additional literature reviews, resulting in 329 articles that were reviewed.

RESULTS

Level 1, "Nosological and diagnostic challenges," concerns the question, "How should autism be defined and diagnosed in males and females?" Level 2, "Sex/gender-independent and sex/gender-dependent characteristics," addresses the question, "What are the similarities and differences between males and females with autism?" Level 3, "General models of etiology: liability and threshold," asks the question, "How is the liability for developing autism linked to sex/gender?" Level 4, "Specific etiological-developmental mechanisms," focuses on the question, "What etiological-developmental mechanisms of autism are implicated by sex/gender and/or sexual/gender differentiation?"

CONCLUSIONS

Using this conceptual framework, findings can be more clearly summarized, and the implications of the links between findings from different levels can become clearer. Based on this 4-level framework, we suggest future research directions, methodology, and specific topics in sex/gender differences and autism.

Freiburg Questionnaire of linguistic pragmatics (FQLP): psychometric properties based on a psychiatric sample

BACKGROUND

Asperger's Syndrome (AS) is an autism spectrum disorder that is characterized by significant difficulties in social interaction and nonverbal communication, and restricted and repetitive patterns of behavior and interests. Difficulties with respect to pragmatic speech, reading emotional and social cues, differentiating between fact and fiction, and taking into account the influence of context on a statement are commonly described features. However, hitherto established questionnaires did not focus on these symptoms.

METHODS

In this study we present a short (11 questions) questionnaire which focuses on self-rated pragmatic speech abilities, the Freiburg Questionnaire of linguistic pragmatics (FQLP). Psychometric properties of the questionnaire were explored in a sample of 57 patients with Asperger's Syndrome, 66 patients with other psychiatric disorders, and a convenience sample of 56 people.

RESULTS

Reliability analysis showed a high Cronbach's α. Strong correlations could be demonstrated for the FQLP with the Autism Quotient and the Empathy Quotient. Concerning divergent validity a moderate correlation was found between the FQLP and self-rated symptoms of personality disorders. No significant correlation was found between the FQLP and the vocabulary skills. The receiver operating characteristics curve showed an excellent diagnostic accuracy of the FQLP (.97).

CONCLUSIONS

As the control group consisted of people without mental disorder and patients with different psychiatric disorders, the results indicate that the construct examined by the FQLP is quite specific to the peculiarities of AS. The FQLP is a reliable, brief and valid instrument. First results regarding sensitivity and specificity are highly promising.

Disturbed cingulate glutamate metabolism in adults with high-functioning autism spectrum disorder: evidence in support of the excitatory/inhibitory imbalance hypothesis

Over the last few years, awareness of autism spectrum disorder (ASD) in adults has increased. The precise etiology of ASD is still unresolved. Animal research, genetic and postmortem studies suggest that the glutamate (Glu) system has an important role, possibly related to a cybernetic imbalance between neuronal excitation and inhibition. To clarify the possible disruption of Glu metabolism in adults with high-functioning autism, we performed a magnetic resonance spectroscopy (MRS) study investigating the anterior cingulate cortex (ACC) and the cerebellum in adults with high-functioning ASD. Twenty-nine adult patients with high-functioning ASD and 29 carefully matched healthy volunteers underwent MRS scanning of the pregenual ACC and the left cerebellar hemisphere. Metabolic data were compared between groups and were correlated with psychometric measures of autistic features. We found a significant decrease in the cingulate N-acetyl-aspartate (NAA) and the combined Glu and glutamine (Glx) signals in adults with ASD, whereas we did not find other metabolic abnormalities in the ACC or the cerebellum. The Glx signal correlated significantly with psychometric measures of autism, particularly with communication deficits. Our data support the hypothesis that there is a link between disturbances of the cingulate NAA and Glx metabolism, and autism. The findings are discussed in the context of the hypothesis of excitatory/inhibitory imbalance in autism. Further research should clarify the specificity and dynamics of these findings regarding other neuropsychiatric disorders and other brain areas.

Increased putamen volume in adults with autism spectrum disorder

Basal ganglia (BG) abnormalities are implicated in the pathophysiology of autism spectrum disorder (ASD). However, studies measuring the volume of the entire BG in individuals with ASD have reported discrepant findings, and no study conducted volume measurement of the entire substructures of the BG (the caudate, putamen, nucleus accumbens, and globus pallidus) in individuals with ASD. We delineated the BG substructures and measured their volumes in 29 adults with ASD without intellectual disabilities and 29 age- and gender-matched typically developed adult controls. We acquired T1-weighted anatomical images and performed semiautomated delineation and volume measurements of the above-mentioned subregions. Total cerebral volumes, sex, and ages were partialed out. Compared with controls, the putamen was significantly larger in the ASD group. The increased volume of the putamen found in high-functioning adults with ASD suggests that structural or histological abnormalities of the putamen may underlie the pathologies of ASD, such as repetitive and stereotyped behaviors and impaired social interactions.

ADHD symptoms, autistic traits, and substance use and misuse in adult Australian twins

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder frequently co-occur. Several studies show increased risk of substance use disorders in ADHD, yet there is limited information related to how ADHD symptoms, autistic traits, and their combined effects are associated with nicotine, alcohol, and cannabis use and use disorders in the general population.

METHOD

Cross-sectional interview and self-report questionnaire data from 3,080 young adult Australian twins (mean age 31.9 years) were used to assess ADHD symptoms, autistic traits, substance use, and substance use disorders. Substance use disorders-based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria-were assessed in the full sample as well as in those who reported substance use. Logistic regression analyses were used for comparing the associations between ADHD symptoms, autistic traits, substance use, and substance misuse after conduct disorder, sex, age, and zygosity were controlled for.

RESULTS

Greater ADHD symptoms and autistic traits scores were associated with elevated levels of regular smoking; cannabis use; and nicotine, alcohol, and cannabis use disorders, even after conduct disorder was adjusted for. In contrast, for alcohol use, those with high autistic traits scores were less likely to report drinking to intoxication. However, upon initiation, and similar to the findings for nicotine and cannabis, they were at elevated risk for developing alcohol dependence.

CONCLUSIONS

Increased liability to ADHD and elevated autistic traits scores were associated with substance use and misuse, with the exception of alcohol use. Given the social underpinnings of drinking, persons with autistic traits may be less likely to engage in it; however, upon engagement in drinking, their vulnerability to alcohol dependence is elevated.

Verification of the utility of the social responsiveness scale for adults in non-clinical and clinical adult populations in Japan

BACKGROUND

Recently great attention has been paid to the still unmet clinical needs of most adults with autism spectrum disorder (ASD) who live in the community, an increasing number of whom visit psychiatric clinics to seek accurate diagnosis and treatment of concurrent psychiatric symptoms. However, different from the case of children diagnosed with ASD in childhood, it is difficult in adults to identify the ASD symptoms underlying psychopathology and to differentiate ASD from other psychiatric disorders in general psychiatric practice. This study aimed to verify the utility of the Social Responsiveness Scale-Adult version (SRS-A), a quantitative measure for identifying ASD symptoms, in non-clinical and clinical adult populations in Japan.

METHODS

The total sample aged 19 to 59 years consisted of a non-clinical population (n =592) and clinical population with and without ASD (n =142). We examined score distributions of the Japanese version of the scale, and the effects of gender, age, and rater on the distribution. We analyzed factor structure and internal consistency in the non-clinical normative sample, and analyzed convergent, divergent, and discriminative validities in the clinical sample. We applied receiver operator characteristic (ROC) analysis to determine optimal cutoff scores discriminating the ASD clinical population from the non-ASD clinical population.

RESULTS

The score distributed continuously, which replicated findings in children. For non-clinical adults, except in men aged 19 to 24 years, we found no or few gender, age, or rater effects. Both single- and two-factor models were supported for adults. Total SRS-A scores demonstrated high internal consistency and capably discriminated adults with ASD from those with non-ASD psychiatric disorders such as major depressive disorder, schizophrenia, and bipolar disorder with an overlap across diagnoses. Moderate to high correlations of the SRS-A with other-rated ASD measures indicated sufficient convergent validity. Based on the ROC analysis, we recommend cutoff points by gender for use in clinical settings.

CONCLUSION

This study provides additional supportive evidence that the Japanese version SRS-A can reliably and validly measure ASD symptoms in non-clinical and clinical adult populations, and thus can serve as a useful tool for ASD research as well as for secondary screening in Japanese adults.

Autism spectrum disorder among first-visit depressed adult patients: diagnostic clues from backgrounds and past history

OBJECTIVE

The present study aimed to extract discriminating indicators for diagnosis of autism spectrum disorder (ASD) from personal backgrounds and past history among depressed adult outpatients.

METHODS

Subjects were 430 depressed adults, consisting of patients with ASD (n=70) and those without ASD (n=360). Group comparison and discriminant analysis was conducted with regard to backgrounds (age, gender, education, marriage, living alone, physical diseases and family history of mood disorders) and past history (school non-attendance, bullied experience, psychotic-like experiences, conduct problems, suicide-related behaviors and interpersonal friction).

RESULTS

Six discriminating indicators (interpersonal friction, bullied experience, psychotic-like experiences, age under 32 years, school non-attendance and university educational level) were identified by stepwise discriminant analysis (P<.001). Absence of the first 4 indicators almost excluded ASD diagnosis with the highest negative predictive value (98%) and the least negative likelihood ratio (0.11) whereas one or more out of these 4 indicators showed low positive predictive value (32%) despite high sensitivity (93%).

CONCLUSIONS

The abovementioned 4 indicators may be useful clues to cover possible ASD subjects among depressed adults although further detailed ASD focused diagnostic procedure is absolutely necessary to specify true ASD subjects. Meanwhile, absence of these 4 indicators is probably helpful to rule out ASD diagnosis.

A review of rhythm and responsiveness of cortisol in individuals with autism spectrum disorders

Examination of the hypothalamic-pituitary-adrenal (HPA) axis via cortisol among individuals with autism spectrum disorder (ASD) has been a growing area of research interest. The following review includes investigations of cortisol conducted with cohorts of individuals with ASD across the lifespan over the past four decades. In general, studies find dysregulation when examining the diurnal rhythm as a whole in lower functioning children with ASD; however, limited evidence exists for alterations in higher functioning individuals and in specific aspects of the diurnal cycle (cortisol awakening response, daily decline, variability) relative to typically developing individuals. Studies examining the responsiveness of cortisol in ASD suggest an overall sluggishness of the HPA axis in responding to physiological or physical manipulation. Hypo-responsiveness was observed in stressors that involve social evaluative threat, however, hyper-responsiveness of the HPA axis was observed in situations involving unpleasant stimuli or relatively benign social situations. A number of important considerations when conducting studies of cortisol in ASD cohorts are discussed.

Overlap between autistic and schizotypal personality traits is not accounted for by anxiety and depression

Autism spectrum and schizophrenia spectrum disorders are classified separately in the DSM-5, yet research indicates that these two disorders share overlapping features. The aim of the present study was to examine the overlap between autistic and schizotypal personality traits and whether anxiety and depression act as confounding variables in this relationship within a non-clinical population. One hundred and forty-four adults completed the Autism Spectrum Quotient and the Schizotypal Personality Questionnaire and the Depression Anxiety Stress Scales-21. A number of associations were seen between autistic and schizotypal personality traits. However, negative traits were the only schizotypal feature to uniquely predict global autistic traits, thus highlighting the importance of interpersonal qualities in the overlap of autistic and schizotypal characteristics. The inclusion of anxiety and depression did not alter relationships between autistic and schizotypal traits, indicating that anxiety and depression are not confounders of this relationship. These findings have important implications for the conceptualisation of both disorders.

Group cognitive behavioural therapy program shows potential in reducing symptoms of depression and stress among young people with ASD

We examined the efficacy of cognitive behavioural therapy (CBT) delivered in groups on the reduction of symptoms of depression, anxiety and stress in young people on the autism spectrum. Utilising a quasi-experimental design, comparisons were made between individuals allocated to a group intervention program and individuals allocated to a waitlist. Following the intervention program, participants who were initially symptomatic reported significantly lower depression and stress scores on the Depression Anxiety Stress Scales in comparison to individuals on the waitlist. There was no significant change in anxiety related symptoms. The benefits were maintained at 3 and 9 month follow-up. Our findings demonstrate the potential of CBT in a small group setting for assisting young people with ASD who have symptoms of depression and stress.

Social participation among young adults with an autism spectrum disorder

Investigating social participation of young adults with an autism spectrum disorder (ASD) is important given the increasing number of youth aging into young adulthood. Social participation is an indicator of life quality and overall functioning. Using data from the National Longitudinal Transition Study 2, we examined rates of participation in social activities among young adults who received special education services for autism (ASD group), compared to young adults who received special education for intellectual disability, emotional/behavioral disability, or a learning disability. Young adults with an ASD were significantly more likely to never see friends, never get called by friends, never be invited to activities, and be socially isolated. Among those with an ASD, lower conversation ability, lower functional skills, and living with a parent were predictors of less social participation.

A review of the role of female gender in autism spectrum disorders

This paper reviews the literature exploring gender differences associated with the clinical presentation of autism spectrum disorders (ASD). The potentially mediating effect of comorbid psychopathology, biological and neurodevelopmental implications on these gender differences is also discussed. A vastly heterogeneous condition, while females on the lower-functioning end of the spectrum appear to be more severely affected, an altered clinical manifestation of the disorder among high-functioning females may consequently result in many being un- or mis-diagnosed. To date, there is strong bias in the literature towards the clinical presentation of ASD in males. It is imperative that future research explores gender differences across the autism spectrum, in order to improve researchers', clinicians' and the public's understanding of this debilitating disorder.

Validity Study of the CBCL 6-18 for the Assessment of Emotional Problems in Youth With ASD

Youth with autism spectrum disorder (ASD) often present with emotional problems such as anxiety and depression (American Psychiatric Association, 2013). A recent study of the Child Behavior Checklist 6-18 (CBCL; Achenbach & Rescorla, 2001) indicated good sensitivity but relatively low specificity for identifying emotional problems in youth with ASD. The current study examined the extent to which variance in the CBCL's Anxious/Depressed, Withdrawn/Depressed, Internalizing Domain, and Total Problems scales was accounted for by symptoms of emotional problems relative to ASD symptoms. Correlation and multiple regression analyses indicated that these scales measured anxiety and depression but a small statistically significant proportion of variance in Total Problems scores was also accounted for by ASD symptoms. Results contribute to the emerging evidence base for the inclusion of the CBCL in assessment protocols for assessing emotional and behavioral problems in youth with ASD.

Bipolar disorder in adults with Asperger׳s Syndrome: a systematic review

BACKGROUND

Asperger׳s Syndrome (AS) is a neurodevelopmental disorder included in the Autism Spectrum (ASD). The current literature shows growing evidence of a high rate of comorbidity between AS and other psychiatric disorders, particularly Bipolar Disorder (BD). We reviewed available epidemiological and clinical data on BD-AS comorbidity and its diagnostic and therapeutic implications

METHODS

A systematic review of the literature was conducted through PubMed, Scopus and Psych-Info using combinations of the following search terms: Asperger׳s Syndrome, Bipolar Disorder, depression, mood disorder, psychiatric comorbidity, treatment, mood stabilizers, anticonvulsants, antipsychotics, and antidepressants.

RESULTS

BD prevalence in adults with AS ranges from 6% to 21.4% of the cases. Relatives of patients with AS showed a doubled risk of being affected by BD and a BD prevalence near to 10%. When comorbid with AS, BD assumes peculiar features which might shape its under-recognition or misdiagnosis (especially schizophrenia when psychotic symptoms are prominent). Although controlled data on pharmacological treatments in BD-AS comorbidity are substantially lacking, information is derived by open observations, case series and chart reviews. Mood stabilizers should be considered the first choice, and antipsychotics, especially second generation drugs (SGA) with 5-HT2a antagonism, have been shown useful in controlling psychotic and behavioral symptoms and improving social withdrawal. Some evidence of efficacy for the treatment of anxiety, obsessive-compulsive symptoms and depression is reported for SSRI antidepressants. The use of these drugs should be carefully monitored, because activation with hypomanic or manic switches is reported up to 54% of the treated subjects.

CONCLUSION

BD in AS patients is frequent, usually it onsets during adolescence and is often characterized by atypical presentation, making its correct identification particularly difficult. A correct diagnosis of BD in AS individuals has relevant implications on the choice of adequate psychopharmacological, psycho-social and rehabilitative treatments.

Everyday life consequences of substance use in adult patients with a substance use disorder (SUD) and co-occurring attention deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD): a patient's perspective

BACKGROUND

Although the prevalence of substance use disorder (SUD) with co-occurring attention deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD) is relatively high in adult patients, there is hardly any knowledge about these dual diagnoses. A recent study reported met- and unmet needs for several life domains regarding these patient groups. To improve treatment, it is necessary to identify the everyday life consequences of SUD and co-occurring ADHD or ASD in adult patients.

METHODS

Qualitative study using in-depth interviews. 11 SUD + ADHD and 12 SUD + ASD patients participated in the study. The interview transcripts were coded and analysed according to the seven steps for descriptive phenomenology by Colaizzi.

RESULTS

Both patients with ADHD and patients with ASD can get caught in a jumble of thoughts and emotions which can often lead to agitation and impulsivity in the case of ADHD or passivity and melancholia in the case of ASD with co-occurring SUD in both cases. Initially substance use ameliorates the symptoms and related problems, but both patient groups can later experience even greater problems: difficulties with the structuring of daily life due to a lack of planning (SUD + ADHD) or due to a lack of initiative (SUD + ASD). Both groups indicate that structure helps them function better. They also recognize that substance use disorganizes their lives and that an absence of structure contributes to substance use in what becomes a vicious circle which needs to be broken for effective treatment and care.

CONCLUSIONS

This study provides insight into the daily life consequences of SUD with a co-occurring ADHD or ASD. Substance use is reported to solve some ADHD- or ASD-related problems in the short run but have negative consequences in the long run (i.e., contribute to already impaired cognitive functioning). Insight is provided into what clinicians can do to break this vicious circle and thus help ADHD patients to refrain from action and ASD patients to take action.

Mental health services for individuals with high functioning autism spectrum disorder

Adolescents and adults with an autism spectrum disorder (ASD) who do not have an intellectual impairment or disability (ID), described here as individuals with high-functioning autism spectrum disorder (HFASD), represent a complex and underserved psychiatric population. While there is an emerging literature on the mental health needs of children with ASD with normal intelligence, we know less about these issues in adults. Of the few studies of adolescents and adults with HFASD completed to date, findings suggest that they face a multitude of cooccurring psychiatric (e.g., anxiety, depression), psychosocial, and functional issues, all of which occur in addition to their ASD symptomatology. Despite this, traditional mental health services and supports are falling short of meeting the needs of these adults. This review highlights the service needs and the corresponding gaps in care for this population. It also provides an overview of the literature on psychiatric risk factors, identifies areas requiring further study, and makes recommendations for how existing mental health services could include adults with HFASD.

No significant brain volume decreases or increases in adults with high-functioning autism spectrum disorder and above average intelligence: a voxel-based morphometric study

Autism spectrum disorder (ASD) is increasingly being recognized as an important issue in adult psychiatry and psychotherapy. High intelligence indicates overall good brain functioning and might thus present a particularly good opportunity to study possible cerebral correlates of core autistic features in terms of impaired social cognition, communication skills, the need for routines, and circumscribed interests. Anatomical MRI data sets for 30 highly intelligent patients with high-functioning autism and 30 pairwise-matched control subjects were acquired and analyzed with voxel-based morphometry. The gray matter volume of the pairwise-matched patients and the controls did not differ significantly. When correcting for total brain volume influences, the patients with ASD exhibited smaller left superior frontal volumes on a trend level. Heterogeneous volumetric findings in earlier studies might partly be explained by study samples biased by a high inclusion rate of secondary forms of ASD, which often go along with neuronal abnormalities. Including only patients with high IQ scores might have decreased the influence of secondary forms of ASD and might explain the absence of significant volumetric differences between the patients and the controls in this study.

High self-perceived stress and poor coping in intellectually able adults with autism spectrum disorder

Despite average intellectual capacity, autistic traits may complicate performance in many everyday situations, thus leading to stress. This study focuses on stress in everyday life in intellectually able adults with autism spectrum disorders. In total, 53 adults (25 with autism spectrum disorder and 28 typical adults from the general population) completed the Perceived Stress Scale. Autistic traits were assessed using the Autism Spectrum Quotient. Adults with autism spectrum disorder reported significantly higher subjective stress and poorer ability to cope with stress in everyday life, as compared to typical adults. Autistic traits were associated with both subjective stress/distress and coping in this cross-sectional series. The long-term consequences of chronic stress in everyday life, as well as treatment intervention focusing on stress and coping, should be addressed in future research as well as in the clinical management of intellectually able adults with autism spectrum disorder.

[High-functioning autism spectrum disorders in adulthood]

The prevalence of autism spectrum disorders in the general population is approximately 1 %. Some individuals with high-functioning autism graduate from regular schools without autism having been diagnosed and problems only occur when the demands for social competence increase. Then patients often present with secondary psychiatric symptoms, such as depression, anxiety or interpersonal problems. At this time, typical autistic features, such as social interaction deficits, restricted interests and stereotypic behavior can be camouflaged by high compensatory skills, particularly in highly intelligent patients. Therefore, missed or wrong diagnoses are frequent. Interviews, questionnaires and neuropsychological tests might be used to support the diagnosis. In cases where there is evidence for a secondary cause of autistic symptoms, somatic disorders should be excluded. Pharmacological treatment should be symptom-oriented. Individualized psychotherapeutic approaches are becoming increasingly more available; however, pragmatic solutions often need to be deployed.

RETRACTED: An examination of the relationship between autism spectrum disorder, intellectual functioning, and comorbid symptoms in children

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor in Chief, after review by an independent panel of experts, due to evidence of a compromised peer review process and the failure of one author to disclose significant conflicts of interest. An independent peer-review process is a cornerstone of scientific integrity that allows for research to be scrutinized before publication to ensure that conclusions are anchored in sound methodology and objective interpretation of the results. Equally important is that the readership of research is fully informed about any potential competing interests that may have influenced the research process. This article is being retracted because it did not include a declaration of a conflict of interest of one author in relation to diagnostic tools which the paper endorses. The same author was also the Editor in Chief of the journal at the time of publication and evidence indicates that the paper was accepted without any independent peer review by external reviewers. The article is therefore retracted in accordance with the ethical guidelines of Elsevier: https://www.elsevier.com/about/policies/publishing-ethics and the Committee on Publication Ethics (COPE) https://publicationethics.org/files/retraction-guidelines.pdf.

Aspergers--different, not less: occupational strengths and job interests of individuals with Asperger's Syndrome

Rooted in the neurodiversity approach, this study provides an overview of the strengths and interests of individuals with Asperger's Syndrome. We interviewed136 individuals with Asperger's Syndrome and 155 neurotypical individuals via an online survey with regards to (a) demography, (b) occupational strengths, (c) general self-efficacy, (d) occupational self-efficacy, and (e) the job interest profile according to Holland. The vocational and educational fields of the individuals with Asperger's in the sample are more diverse than and surpass those classical fields stated in research and biographical literature. The comparison of both groups in cross-tables showed that the indicated strengths differ in several areas (Φ_Cramer = .02–.47), which means that a specific strength profile can be derived, and this profile goes beyond the clinical view of the diagnostic criteria. Individuals with Asperger's indicate lower self-efficacy, both general and occupational. Furthermore, a high concentration of individuals with Asperger's can be found in the areas I (Investigative) and C (Conventional) of Holland's RIASEC model.

The investigation and differential diagnosis of Asperger syndrome in adults

BACKGROUND

As a result of the increased public interest in autism spectrum disorders (ASD), certain core manifestations of ASD--impaired social interaction and communication, bizarre interests--are now commonly recognized as being typical of autism, not only in children, but in adults as well. More often than before, general practitioners, neurologists, and psychiatrists find themselves being asked whether a patient is suffering from previously unrecognized Asperger syndrome (AS). The prevalence of ASD is estimated at 1%, and the ratio of diagnosed to undiagnosed cases at about 3:2. Little is known about the diagnostic evaluation of AS in adulthood.

METHOD

We selectively searched the Medline database for pertinent literature, paying special attention to diagnostic manuals and to the guideline of the United Kingdom's National Institute for Health and Care Excellence (NICE).

RESULTS

Centrally important aspects of the diagnosis of AS include an assessment of the patient's ability to assume the emotional perspectives of others, non-verbal modes of expression, repetitive behavior patterns, and childhood social behavioral history. The autism quotient (AQ) is now established as a simple but nonspecific screening test. Up to 70% of all affected adults have comorbid disturbances, most often depression and anxiety disorders. The differential diagnosis includes personality disorders, anxiety disorders, obsessive-compulsive disorder, and attention deficit-hyperactivity disorder. The diagnostic assessment should proceed in stepwise fashion, starting from simple screening in primary care and then moving on to evaluation of the suspected diagnosis by a mental health care specialist, followed by extensive further investigation in an outpatient clinic specifically devoted to patients with autism spectrum disorders.

CONCLUSION

The diagnostic assessment of autism in adults requires knowledge of the core and accompanying manifestations of autism and of their differential diagnoses. More research is needed for the development of further screening tests and the precise determination of diagnosis rates, differential diagnoses, nd comorbidities.

Anxiety in Asperger's syndrome: Assessment in real time

Anxiety is a major problem for many people with Asperger's syndrome who may have qualitatively different fears from a non-Asperger's syndrome population. Research has relied on measures developed for non-Asperger's syndrome populations that require reporting past experiences of anxiety, which may confound assessment in people with Asperger's syndrome due to problems with autobiographical memory as are often reported in this group.Experience sampling methodology was used to record real-time everyday experiences in 20 adults with Asperger's syndrome and 20 neurotypical adults. Within-subject analysis was used to explore the phenomenology of thoughts occurring in people with Asperger's syndrome when they were anxious. Comparisons were made with the group that did not have Asperger's syndrome. The Asperger's syndrome group were significantly more anxious than the comparison group. Factors associated with feelings of anxiety in the Asperger's syndrome group were high levels of self-focus, worries about everyday events and periods of rumination lasting over 10 min. People in the Asperger's syndrome group also had a tendency to think in the image form, but this was not associated with feelings of anxiety. The results are discussed with reference to psychological models of Asperger's syndrome, cognitive models of anxiety and implications for psychological therapy for this group.

Prevalence of Asperger syndrome among patients of an Early Intervention in Psychosis team

BACKGROUND

There is a lack of systematic studies into comorbidity of Asperger syndrome and psychosis.

AIM

To determine the prevalence of Asperger syndrome among patients of an early intervention in psychosis service.

METHODS

This study was a cross-sectional survey consisting of three phases: screening, case note review and diagnostic interviews. All patients on caseload (n = 197) were screened using the Autism Spectrum Disorder in Adults Screening Questionnaire. The case notes of patients screened positive were then reviewed for information relevant to Asperger syndrome. Those suspected of having Asperger syndrome were invited for a diagnostic interview.

RESULTS

Thirty patients were screened positive. Three of them already had a diagnosis of Asperger syndrome made by child and adolescent mental health services. After case note review, 13 patients were invited to interview. Four did not take part, so nine were interviewed. At interview, four were diagnosed with Asperger syndrome. In total, seven patients had Asperger syndrome. Thus, the prevalence rate in this population is at least 3.6%.

CONCLUSIONS

The results suggest that the prevalence of Asperger syndrome in first-episode psychosis is considerably higher than that in the general population. Clinicians working in early intervention teams need to be alert to the possibility of Asperger syndrome when assessing patients.

Autism

Autism is a set of heterogeneous neurodevelopmental conditions, characterised by early-onset difficulties in social communication and unusually restricted, repetitive behaviour and interests. The worldwide population prevalence is about 1%. Autism affects more male than female individuals, and comorbidity is common (>70% have concurrent conditions). Individuals with autism have atypical cognitive profiles, such as impaired social cognition and social perception, executive dysfunction, and atypical perceptual and information processing. These profiles are underpinned by atypical neural development at the systems level. Genetics has a key role in the aetiology of autism, in conjunction with developmentally early environmental factors. Large-effect rare mutations and small-effect common variants contribute to risk. Assessment needs to be multidisciplinary and developmental, and early detection is essential for early intervention. Early comprehensive and targeted behavioural interventions can improve social communication and reduce anxiety and aggression. Drugs can reduce comorbid symptoms, but do not directly improve social communication. Creation of a supportive environment that accepts and respects that the individual is different is crucial.

Identifying the unmet needs of college students on the autism spectrum

The number of students entering college with high-functioning autism spectrum disorders (ASDs) is expected to surge in coming years. The diagnostic features and psychiatric risks of ASD, coupled with the transitions and stresses that define college life, present extraordinary challenges for these students, their parents, and institutions of higher education. This article applies a bioecological framework for conceptualizing the systemic strengths and barriers at the secondary and postsecondary levels of education in supporting students with ASD. This theoretical orientation is used to illustrate the importance of offering services and programs in a more coordinated and fluid manner within and between systems to support students more effectively. Evidence-based programs, practices, and interventions associated with successful academic and mental health outcomes for youth and young adults with ASD, as well as for college students with mental health and other challenges, are reviewed for their applicability to the target population. It is proposed that more fluid transitions and improved mental health and academic outcomes for college students with ASD can be achieved by integrating elements from secondary and postsecondary educational systems and also from existing, effective approaches with youth and young adults. Building upon the disjointed, but promising, evidence from youth, young adult, and college mental health literatures, recommendations for developing more effective transition plans for students with ASD are proposed.

Evidence-based guidelines for the pharmacological management of attention deficit hyperactivity disorder: update on recommendations from the British Association for Psychopharmacology

Attention deficit hyperactivity disorder (ADHD) is a common condition with a high societal burden. The present guidelines summarise current literature, generating expert consensus recommendations for the treatment of ADHD in children and adults. These guidelines also provide a review of recent research in the fields of neuroimaging, neuropsychology and genetics of ADHD. Novel discoveries in these areas have informed physiological models for the disease. Since the publication of the previous British Association for Psychopharmacology guidelines in 2008, new drugs have been licensed and further compounds are being investigated. The publication of randomised controlled trials of psychological interventions has contributed to the range of treatment options for ADHD. As the disorder has been diagnosed more frequently there has been greater focus on comorbid conditions and how they impact treatment. Services have continued to develop for the treatment of ADHD in adults and care agreements have been introduced to facilitate access to treatment.

The association between child autism symptomatology, maternal quality of life, and risk for depression

Parents raising children with autism spectrum disorders (ASDs) have been shown to experience high levels of stress and report a lower quality of life. The current study examined the association between child autism symptomatology, mother's quality of life, and mother's risk for depression in a sample of 1,110 mothers recruited from a web-based registry of families with children with an ASD. Higher autism symptomatology and a greater number of co-occurring psychiatric disorders in the child were associated with an increased risk for current treatment of maternal depression and a lower maternal quality of life. The results highlight the importance of screening for depression, particularly in mothers of children with ASD and mental health and behavioral challenges.

Neurocognitive functioning in adolescents with autism spectrum disorder

There is a paucity of research studying comprehensive neurocognitive profiles of adolescents with higher functioning autism spectrum disorders (ASD). This study compared the neurocognitive profiles of higher functioning adolescents with ASD (n = 30, mean age 13.5) with that of typically developing adolescents (n = 30; mean age 13.7). Adolescents with ASD demonstrated a significantly higher mean Verbal Intelligence Quotient compared to the standardized mean. However, the ASD group had significantly lower scores than the control group on the subtests Auditory Attention and Response Set, Memory for Faces, Visuomotor Precision, and Design Copying. Thus, particular strengths were seen in verbal reasoning, while weaknesses were observed in auditory attention, facial recognition memory, and visuomotor functions in adolescents with ASD.

Comorbid atypical autistic traits as a potential risk factor for suicide attempts among adult depressed patients: a case-control study

BACKGROUND

The present study aims to examine if autism spectrum disorder (ASD) is a risk factor for suicide attempts among adult depressed patients and to elucidate the characteristics of suicide attempts in adult depressed patients with ASD.

METHODS

We conducted a case-control study. Subjects consisted of 336 retrospectively recruited first-time visit patients to our outpatient clinic with a current major depressive episode; 31 of the 336 patients had attempted suicide. The demographic backgrounds (i.e., age, gender, personal/family history of suicidality); specific psychopathology like bipolarity, agitation, and psychotic features; and comorbidity such as physical diseases, alcohol abuse, cluster B personality disorder, and ASD including pervasive developmental disorder not otherwise specified (PDD-NOS) were examined as potential risk factors for suicide attempts. We compared these variables between the suicide attempters and non-attempters. In addition, we compared suicide attempters to non-attempters within the ASD group and non-ASD group. Binary logistic regression analysis was performed using the significant independent variables from the comparisons between the suicide attempters and non-attempters, and the odds ratios (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

Logistic regression analysis demonstrated that agitation during a depressive episode (OR = 7.15, 95% CI = 2.88-17.74), past suicidal behaviors (OR = 4.32, 95% CI =1.70-10.98), and comorbid PDD-NOS (OR = 4.04, 95% CI = 1.20-13.54) were significantly associated with suicide attempts. The most prevalent suicidal method was drug overdose (59.1%) among non-ASD attempters while hanging was the most prevalent (44.4%) in ASD attempters.

CONCLUSIONS

Depressed adults with comorbid atypical autistic traits are at higher risk for suicide attempts and may engage in methods that are more lethal.

Disruption of the ASTN2/TRIM32 locus at 9q33.1 is a risk factor in males for autism spectrum disorders, ADHD and other neurodevelopmental phenotypes

Rare copy number variants (CNVs) disrupting ASTN2 or both ASTN2 and TRIM32 have been reported at 9q33.1 by genome-wide studies in a few individuals with neurodevelopmental disorders (NDDs). The vertebrate-specific astrotactins, ASTN2 and its paralog ASTN1, have key roles in glial-guided neuronal migration during brain development. To determine the prevalence of astrotactin mutations and delineate their associated phenotypic spectrum, we screened ASTN2/TRIM32 and ASTN1 (1q25.2) for exonic CNVs in clinical microarray data from 89 985 individuals across 10 sites, including 64 114 NDD subjects. In this clinical dataset, we identified 46 deletions and 12 duplications affecting ASTN2. Deletions of ASTN1 were much rarer. Deletions near the 3' terminus of ASTN2, which would disrupt all transcript isoforms (a subset of these deletions also included TRIM32), were significantly enriched in the NDD subjects (P = 0.002) compared with 44 085 population-based controls. Frequent phenotypes observed in individuals with such deletions include autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), speech delay, anxiety and obsessive compulsive disorder (OCD). The 3'-terminal ASTN2 deletions were significantly enriched compared with controls in males with NDDs, but not in females. Upon quantifying ASTN2 human brain RNA, we observed shorter isoforms expressed from an alternative transcription start site of recent evolutionary origin near the 3' end. Spatiotemporal expression profiling in the human brain revealed consistently high ASTN1 expression while ASTN2 expression peaked in the early embryonic neocortex and postnatal cerebellar cortex. Our findings shed new light on the role of the astrotactins in psychopathology and their interplay in human neurodevelopment.

The strengths and difficulties questionnaire as a predictor of parent-reported diagnosis of autism spectrum disorder and attention deficit hyperactivity disorder

The Strengths and Difficulties Questionnaire (SDQ) is widely used as an international standardised instrument measuring child behaviour. The primary aim of our study was to examine whether behavioral symptoms measured by SDQ were elevated among children with autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) relative to the rest of the population, and to examine the predictive value of the SDQ for outcome of parent-reported clinical diagnosis of ASD/ADHD. A secondary aim was to examine the extent of overlap in symptoms between children diagnosed with these two disorders, as measured by the SDQ subscales. A cross-sectional secondary analysis of data from the Millennium Birth Cohort (n = 19,519), was conducted. Data were weighted to be representative of the UK population as a whole. ADHD or ASD identified by a medical doctor or health professional were reported by parents in 2008 and this was the case definition of diagnosis; (ADHD n = 173, ASD n = 209, excluding twins and triplets). Study children's ages ranged from 6.3-8.2 years; (mean 7.2 years). Logistic regression was used to examine the association between the parent-reported clinical diagnosis of ASD/ADHD and teacher and parent-reported SDQ subscales. All SDQ subscales were strongly associated with both ASD and ADHD. There was substantial co-occurrence of behavioral difficulties between children diagnosed with ASD and those diagnosed with ADHD. After adjustment for other subscales, the final model for ADHD, contained hyperactivity/inattention and impact symptoms only and had a sensitivity of 91% and specificity of 90%; (AUC) = 0.94 (95% CI, 0.90-0.97). The final model for ASD was composed of all subscales except the 'peer problems' scales, indicating of the complexity of behavioural difficulties that may accompany ASD. A threshold of 0.03 produced model sensitivity and specificity of 79% and 93% respectively; AUC = 0.90 (95% CI, 0.86-0.95). The results support changes to DSM-5 removing exclusivity clauses.

Attitude and risk of substance use in adolescents diagnosed with Asperger syndrome

BACKGROUND

Adolescence is a stage of development with increased risk of drug use. Individual personality traits are among those factors that influence the onset of substance use in adolescence and its psychiatric comorbidity. Little research has been done on the comorbidity between substance abuse risk and Asperger syndrome, and none specifically in adolescence. The objective of this study is to assess the risk of drug use by adolescents with Asperger syndrome and compare it with that risk in control subjects. A secondary objective was to analyze the personality factors that may be associated with substance use in the same two groups.

METHODS

We used three self-administered questionnaires, one for drug risk assessment (FRIDA) and the other two for personality trait assessment (MACI and SSS-V).

RESULTS

Adolescents diagnosed with Asperger syndrome are at less risk for drug use derived from family and access to drugs factors. Subjects with Asperger syndrome did score higher on introversive, inhibited, doleful, and borderline tendency prototypes than healthy controls, and scored lower on all sensation-seeking traits. Being male, a diagnosis of Asperger syndrome, and unruly, introversive, and sensation-seeking traits were all independently associated with the risk of drug abuse.

CONCLUSIONS

Both identified personality factors and other variables associated with the Asperger syndrome contribute to the low risk of drug abuse observed in this population. Exploring protective factors for drug use in these subjects may prove useful for interventions with adolescents at risk for consumption.

Toward the development of a supported employment program for individuals with high-functioning autism in Germany

Human-human interactions are of central relevance for the success in professional and occupational environments, which also substantially influence quality of life. This is especially true in the case of individuals with high-functioning autism (HFA), who experience deficits in social cognition that often lead to social exclusion and unemployment. Despite good education and high motivation, individuals with HFA do not reach employment rates that are substantially higher than 50 %. This is an alarmingly high rate of unemployment considering that the United Nations have recently emphasized the inclusion of handicapped persons as a mandatory human right. To date, the specific needs of autistic persons with respect to their working environment are largely unexplored. It remains moreover an open question how support systems and activities, including newly developed communication devices for professional environments of individuals with HFA, should look like. The German health and social care systems are not adequately prepared for the proper support of this population. This leads us to suggest that supported employment programs should be developed for adults with HFA that specifically address their needs and requirements. Such programs should comprise (1) the adequate assessment of HFA, including a neuropsychological profile and an individual matching of persons' preferences with requirements of the working place, (2) on-the-job coaching activities that include systematic communication and interaction training, and (3) instruction of non-autistic peers, including colleagues and supervisors, about weaknesses and strengths of HFA.

High-functioning autism spectrum disorder as a basic disorder in adult psychiatry and psychotherapy: psychopathological presentation, clinical relevance and therapeutic concepts

Autism spectrum disorder (ASD) is characterized by deficits in social cognition and competence, communication, highly circumscribed interests and a strong desire for routines. Besides, there are specific abnormalities in perception and language. Typical symptoms are already present in early childhood. Traditionally autism has been regarded as a severe form of neurodevelopmental disorder which goes along with overtly abnormal language, learning difficulties and low IQ in the majority of cases. However, over the last decades, it has become clear that there are also many patients with high-functioning variants of ASD. These are patients with normal language at a superficial level of description and normal and sometimes above average intelligence. In high-functioning variants of the disease, they may run unrecognized until late in adult life. High-functioning ASD is associated with a very high prevalence of comorbid classical psychiatric disorders such as depression, anxiety, ADHD, tics, psychotic symptoms or emotionally unstable syndromes. In many such cases, there is a causal relationship between ASD and the comorbid psychiatric conditions in that the specific ASD symptoms result in chronic conflicts, misunderstandings and failure in private and vocational relationships. These problems in turn often lead to depression, anxiety and sometimes psychosis-like stress reactions. In this constellation, ASD has to be regarded as a basic disorder with causal relevance for secondary psychiatric syndromes. In this paper, we summarize the classical presentation of high-functioning ASD in adult psychiatry and psychotherapy and suggest a nosological model to classify different ASD conditions instead. To conclude, we outline first treatment concepts in out- and in-patient settings.

Prefrontal activation during inhibitory control measured by near-infrared spectroscopy for differentiating between autism spectrum disorders and attention deficit hyperactivity disorder in adults

The differential diagnosis of autism spectrum disorders (ASDs) and attention deficit hyperactivity disorder (ADHD) based solely on symptomatic and behavioral assessments can be difficult, even for experts. Thus, the development of a neuroimaging marker that differentiates ASDs from ADHD would be an important contribution to this field. We assessed the differences in prefrontal activation between adults with ASDs and ADHD using an entirely non-invasive and portable neuroimaging tool, near-infrared spectroscopy. This study included 21 drug-naïve adults with ASDs, 19 drug-naïve adults with ADHD, and 21 healthy subjects matched for age, sex, and IQ. Oxygenated hemoglobin concentration changes in the prefrontal cortex were assessed during a stop signal task and a verbal fluency task. During the stop signal task, compared to the control group, the ASDs group exhibited lower activation in a broad prefrontal area, whereas the ADHD group showed underactivation of the right premotor area, right presupplementary motor area, and bilateral dorsolateral prefrontal cortices. Significant differences were observed in the left ventrolateral prefrontal cortex between the ASDs and ADHD groups during the stop signal task. The leave-one-out cross-validation method using mean oxygenated hemoglobin changes yielded a classification accuracy of 81.4% during inhibitory control. These results were task specific, as the brain activation pattern observed during the verbal fluency task did not differentiate the ASDs and ADHD groups significantly. This study therefore provides evidence of a difference in left ventrolateral prefrontal activation during inhibitory control between adults with ASDs and ADHD. Thus, near-infrared spectroscopy may be useful as an auxiliary tool for the differential diagnosis of such developmental disorders.

Outcomes of an acceptance and commitment therapy-based skills training group for students with high-functioning autism spectrum disorder: A quasi-experimental pilot study

Autism spectrum disorder is characterized by social impairments and behavioural inflexibility. In this pilot study, the feasibility and outcomes of a 6-week acceptance and commitment therapy-based skills training group were evaluated in a special school setting using a quasi-experimental design (acceptance and commitment therapy/school classes as usual). A total of 28 high-functioning students with autism spectrum disorder (aged 13–21 years) were assessed using self- and teacher-ratings at pre- and post-assessment and 2-month follow-up. All participants completed the skills training, and treatment satisfaction was high. Levels of stress, hyperactivity and emotional distress were reduced in the treatment group. The acceptance and commitment therapy group also reported increased prosocial behaviour. These changes were stable or further improved at the 2-month follow-up. Larger studies are needed to further evaluate the benefits of acceptance and commitment therapy for autism spectrum disorder.

"Autism-plus" spectrum disorders: intersection with psychosis and the schizophrenia spectrum

Patients are often encountered clinically who have autism spectrum disorders (ASD) and also have symptoms suggestive of a comorbid psychotic disorder. A careful assessment for the presence of comorbid disorders is important. However, the core deficits seen in ASD, in social reciprocity, communication, and restricted behaviors and interests, can be mistaken for psychosis. Also, there is a subset of patients who present with a complex neurodevelopmental disorder with impairments that cross diagnostic categories. This article reviews the connections between ASD and psychosis, and highlights the key points to consider in patients who present with these "autism-plus" disorders.

Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) in adult psychiatry. A 20-year register study

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are increasingly recognized in adults. This study aimed to assess trends in diagnostic practice, diagnostic delay and comorbidity regarding ADHD and ASD in adult psychiatric patients.

METHODS

Individuals with diagnosed ADHD or ASD were identified in an adult psychiatry register comprising 56,462 patients.

RESULTS

ADHD was diagnosed in up to 2.7% and ASD in 1.3% of the patients. Most cases were diagnosed within 2 years of first contact with adult psychiatry, but some patients were treated for 10 years or more before being diagnosed with ADHD or ASD. Seventy per cent of ADHD and 56% of ASD patients were treated as outpatients only. Other psychiatric diagnoses were registered in about 60%. Affective disorders were common in patients with ADHD. Psychoses and intellectual disability were more common in ASD patients. Psychoactive substance use-related disorders were considerably more common in those with ADHD. Concomitant ADHD and ASD were seldom diagnosed in this clinical material.

CONCLUSION

ADHD and ASD were probably much underdiagnosed in the studied group of psychiatric patients. Other psychiatric diagnoses were common, but not ADHD with concomitant ASD.

A longitudinal examination of 10-year change in vocational and educational activities for adults with autism spectrum disorders

The transition from adolescence to adulthood has been shown to be a time of amplified risk for individuals with autism spectrum disorders (ASD). It is unknown, however, whether problems in educational attainment and employment in the years after high school exit represent momentary perturbations in development or a turning point with long-lasting effects throughout adulthood. The present study addressed this question by examining 10-year trajectories of vocational and educational activities for adults with ASD, as well as the personal characteristics and environmental resources that predicted these activities. Participants were 161 adults with ASD (ages 18-52 years at the start of the study; M = 30.9) who were part of a larger longitudinal study. Data were collected at 6 time points over a 10-year period. Results indicated significant declines in the level of independence and engagement in vocational/educational activities over the study period, particularly for women. Greater independence in vocational activities was found for those with more independence in activities of daily living. After controlling for personal characteristics, receipt of more services was marginally related to greater improvement in vocational independence.