Trajectories of emotional and behavioral problems from childhood to early adult life

LAY ABSTRACT

Although mental health problems are common in autism, relatively little is known about their stability and the factors that influence their persistence or change over the life-course. To address this, we use data from the Special Needs and Autism Project (SNAP) cohort studied at three time-points from 12 to 23 years. Using the parent-reported Strengths and Difficulties Questionnaire (SDQ) domains of conduct, emotional, and ADHD symptoms, we evaluated the role of child, family, and contextual characteristics on these three trajectories. Symptoms decreased significantly over time for all three domains, but many participants still scored above the published disorder cutoffs. Individuals showed high levels of persistence. Higher initial adaptive function and language levels predicted a greater decline in conduct and ADHD symptoms. In contrast, higher language functioning was associated with higher levels of emotional symptoms, as was lower levels of autism symptom severity and higher parental education. Those with higher neighborhood deprivation had higher initial conduct problems but a steeper decline over time. Our findings highlight that it may be possible to accurately predict mental health trajectories over this time period, which could help parents and carers in planning and help professionals target resources more efficiently.

Objective Estimates of Direct-Medical Costs Among Persons Aged 3 to 38 Years With and Without Research-Defined Autism Spectrum Disorder Ascertained During Childhood: A Population-Based Birth-Cohort Study

OBJECTIVES

Accurate estimates of autism spectrum disorder (ASD)-associated medical costs are essential for predicting future care needs, allocating resources, identifying best practices, and modeling cost-effectiveness. Most existing studies have either employed subjective cost data or ascertained ASD using self-reported or International Classification of Diseases-coded diagnoses. Such ascertainment is especially problematic for identifying milder ASD among older individuals never diagnosed with ASD.

METHODS

This 1976 through 2000 population-based birth-cohort study was set in Olmsted County, Minnesota. ASD cases and age- and sex-matched unaffected controls were identified by applying uniform operational research criteria for ASD (using the guidelines of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision) after rigorous review of provider-linked medical and public, private, or home school records available for all members from birth to a maximum age of 21 years. Medical cost estimates for the 901 case-control pairs used line-item provider-linked billing data (including all payers) from 2003 through 2014 (ages 3-38 years). Outpatient pharmaceutical costs were unavailable. Temporal changes in diagnostic criteria, clinical practice, public awareness, and access were addressed by separating analyses into 5-year age group and 4-year calendar period cells. Unadjusted and adjusted (age and age plus co-occurring conditions) cost estimates were provided for cases, controls, and case-control differences. Additional factors (co-occurring conditions, percentage hospitalized, intellectual disability) were investigated using unadjusted descriptive analyses.

RESULTS

Cell sample sizes ranged from 93 to 402 for age groups 3 through 19 years and from 45 to 395 for age groups 20 through 38 years. Unadjusted, age-adjusted, and fully adjusted medical costs were significantly higher for cases versus controls in 100% of cells for age groups 3 through 19 years and in 50% (unadjusted), 38% (age adjusted), and 12% (fully adjusted) of cells for age groups 20 through 38 years.

CONCLUSIONS

These unique estimates can help inform the construction of cost-effectiveness models; decisions by payers, providers, and policy makers; and predictions of lifetime costs.

Prevalence of mental health conditions, sensory impairments and physical disability in people with co-occurring intellectual disabilities and autism compared with other people: a cross-sectional total population study in Scotland

OBJECTIVES

To investigate prevalence of mental health conditions, sensory impairments and physical disability in children, adults and older adults with co-occurring intellectual disabilities and autism, given its frequent co-occurrence, compared with the general population.

DESIGN

Whole country cohort study.

SETTING

General community.

PARTICIPANTS

5709 people with co-occurring intellectual disabilities and autism, compared with 5 289 694 other people.

OUTCOME MEASURES

Rates and ORs with 95% CIs for mental health conditions, visual impairment, hearing impairment and physical disability in people with co-occurring intellectual disabilities and autism compared with other people, adjusted for age, sex and interaction between age and co-occurring intellectual disabilities and autism.

RESULTS

All four long-term conditions were markedly more common in children, adults and older adults with co-occurring intellectual disabilities and autism compared with other people. For mental health, OR=130.8 (95% CI 117.1 to 146.1); visual impairment OR=65.9 (95% CI 58.7 to 73.9); hearing impairment OR=22.0 (95% CI 19.2 to 25.2); and physical disability OR=157.5 (95% CI 144.6 to 171.7). These ratios are also greater than previously reported for people with either intellectual disabilities or autism rather than co-occurring intellectual disabilities and autism.

CONCLUSIONS

We have quantified the more than double disadvantage for people with co-occurring intellectual disabilities and autism, in terms of additional long-term health conditions. This may well impact on quality of life. It raises challenges for staff working with these people in view of additional complexity in assessments, diagnoses and interventions of additional health conditions, as sensory impairments and mental health conditions in particular, compound with the persons pre-existing communication and cognitive problems in this context. Planning is important, with staff being trained, equipped, resourced and prepared to address the challenge of working for people with these conditions.

Addressing Needs of Hospitalized Patients With Autism: Partnership With Parents

Evidence suggests that improved health outcomes and reducing the hospital length of stay of individuals with autism require working in partnership between parents and health care professionals. Parents' ability to cope in their daily caregiving responsibilities to their child with autism and assessment of their hospital experience can have an impact on their participation with the care team. Nurses working in the inpatient setting can provide support to parents during their encounter with them. This article presented some of the helpful approaches that can help in building positive relationships with parents that may help facilitate addressing the needs of their child with autism. Suggestions that nurses can implement to support the parents cope with their daily challenges are presented. The approaches were discussed in relation to literature and suggestions from parents of individuals with autism spectrum disorder.

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

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

ECHO Autism Transition: Enhancing healthcare for adolescents and young adults with autism spectrum disorder

Transition-age youth and young adults with autism spectrum disorder have complex healthcare needs, yet the current healthcare system is not equipped to adequately meet the needs of this growing population. Primary care providers lack training and confidence in caring for youth and young adults with autism spectrum disorder. The current study developed and tested an adaptation of the Extension for Community Healthcare Outcomes model to train and mentor primary care providers (n = 16) in best-practice care for transition-age youth and young adults with autism spectrum disorder. The Extension for Community Healthcare Outcomes Autism Transition program consisted of 12 weekly 1-h sessions connecting primary care providers to an interdisciplinary expert team via multipoint videoconferencing. Sessions included brief didactics, case-based learning, and guided practice. Measures of primary care provider self-efficacy, knowledge, and practice were administered pre- and post-training. Participants demonstrated significant improvements in self-efficacy regarding caring for youth/young adults with autism spectrum disorder and reported high satisfaction and changes in practice as a result of participation. By contrast, no significant improvements in knowledge or perceived barriers were observed. Overall, the results indicate that the model holds promise for improving primary care providers' confidence and interest in working with transition-age youth and young adults with autism spectrum disorder. However, further refinements may be helpful for enhancing scope and impact on practice.

The Role of Diagnostic Instruments in Dual and Differential Diagnosis in Autism Spectrum Disorder Across the Lifespan

The heterogeneity inherent in autism spectrum disorder (ASD) makes the identification and diagnosis of ASD complex. We survey a large number of diagnostic tools, including screeners and tools designed for in-depth assessment. We also discuss the challenges presented by overlapping symptomatology between ASD and other disorders and the need to determine whether a diagnosis of ASD or another diagnosis best explains the individual's symptoms. We conclude with a call to action for the next steps necessary for meeting the diagnostic challenges presented here to improve the diagnostic process and to help understand each individual's particular ASD profile.

Weight Management in Primary Care for Children With Autism: Expert Recommendations

Research suggests that the prevalence of obesity in children with autism spectrum disorder (ASD) is higher than in typically developing children. The US Preventive Services Task Force and the American Academy of Pediatrics (AAP) have endorsed screening children for overweight and obesity as part of the standard of care for physicians. However, the pediatric provider community has been inadequately prepared to address this issue in children with ASD. The Healthy Weight Research Network, a national research network of pediatric obesity and autism experts funded by the US Health Resources and Service Administration Maternal and Child Health Bureau, developed recommendations for managing overweight and obesity in children with ASD, which include adaptations to the AAP's 2007 guidance. These recommendations were developed from extant scientific evidence in children with ASD, and when evidence was unavailable, consensus was established on the basis of clinical experience. It should be noted that these recommendations do not reflect official AAP policy. Many of the AAP recommendations remain appropriate for primary care practitioners to implement with their patients with ASD; however, the significant challenges experienced by this population in both dietary and physical activity domains, as well as the stress experienced by their families, require adaptations and modifications for both preventive and intervention efforts. These recommendations can assist pediatric providers in providing tailored guidance on weight management to children with ASD and their families.

Prevalence of physical and mental health conditions in Medicare-enrolled, autistic older adults

While there is emerging evidence on the prevalence of physical and mental health conditions among autistic adults, less is known about this population's needs during older adulthood (aged 65+). We conducted a cross-sectional retrospective cohort study of 2016-2017 Medicare data to compare the prevalence of physical and mental health conditions in a national sample of autistic older adults (N = 4685) to a matched population comparison (N = 46,850) cohort. Autistic older adults had significantly greater odds of nearly all physical health conditions including epilepsy (odds ratio = 18.9; 95% confidence interval = 17.2-20.7), Parkinson's disease (odds ratio = 6.1; 95% confidence interval = 5.3-7.0), and gastrointestinal conditions (odds ratio = 5.2; 95% confidence interval = 4.9-5.5). Most mental health conditions were more common among autistic older adults, including schizophrenia and psychotic disorders (odds ratio = 25.3; 95% confidence interval = 22.4-28.7), attention deficit disorders (odds ratio = 24.4; 95% confidence interval = 16.2-31.0), personality disorders (odds ratio = 24.1; 95% confidence interval = 17.8-32.5), and suicidality or self-inflicted injury (odds ratio = 11.1; 95% confidence interval = 8.9-13.8). Health conditions commonly associated with advanced age in the general population (e.g. osteoporosis, cognitive disorders, heart disease, cancer, cerebrovascular disease, osteoarthritis) were also significantly more common among autistic older adults. By highlighting the significant physical and mental health needs for which autistic older adults require care, our findings can inform healthcare systems, healthcare providers, and public health initiatives seeking to promote well-being in this growing population.

Competitive Integrated Employment for Youth and Adults with Autism: Findings from a Scoping Review

A scoping review was conducted to map existing literature on effective interventions for competitive employment for individuals with autism spectrum disorder. Empirical database searches were conducted. A filter for level of methodological rigor was implemented. A total of 25 articles met inclusion criteria. Findings were categorized by level of evidence. Findings revealed strong empirical support for a transition-to-work program called Project SEARCH plus ASD Supports and traditional supported employment services. Receipt of specific vocational rehabilitation and transition services in high school were also identified as effective interventions. Recommendations per level of evidence are provided in more detail.

Interviewing autistic adults: Adaptations to support recall in police, employment, and healthcare interviews

Recalling specific past experiences is critical for most formal social interactions, including when being interviewed for employment, as a witness or defendant in the criminal justice system, or as a patient during a clinical consultation. Such interviews can be difficult for autistic adults under standard open questioning, yet applied research into effective methods to facilitate autistic adults’ recall is only recently beginning to emerge. The current study tested the efficacy of different prompting techniques to support autistic adults’ recall of specific personal memories; 30 autistic and 30 typically developing adults (intelligence quotients > 85) were asked to recall specific instances from their past, relevant to criminal justice system, healthcare, and employment interviews. Questions comprised ‘open questions’, ‘semantic prompting’ (where semantic knowledge was used to prompt specific episodic retrieval) and ‘visual–verbal prompting’ (a pie-diagram with prompts to recall specific details, for example, who, what, and where). Half the participants received the questions in advance. Consistent with previous research, autistic participants reported memories with reduced specificity. For both groups, visual–verbal prompting support improved specificity and episodic relevance, while semantic prompting also aided recall for employment questions (but not health or criminal justice system). Findings offer new practical insight for interviewers to facilitate communication with typically developing and autistic adults.

The relative influence of intellectual disabilities and autism on sensory impairments and physical disability: A whole-country cohort of 5.3 million children and adults

BACKGROUND

Intellectual disabilities and autism are lifelong and often co-occur. Little is known on their extent of independent association with sensory impairments and physical disability.

METHODS

For Scotland's population, logistic regressions investigated age-gender-adjusted odds ratios (OR) of associations, independently, of intellectual disabilities and autism with sensory impairments and physical disability.

RESULTS

1,548,819 children/youth, and 3,746,584 adults. In children/youth, the effect size of intellectual disabilities and autism, respectively, was as follows: blindness (OR = 30.12; OR = 2.63), deafness (OR = 13.98; OR = 2.31), and physical disability (OR = 43.72; OR = 5.62). For adults, the effect size of intellectual disabilities and autism, respectively, was as follows: blindness (OR = 16.89; OR = 3.29), deafness (OR = 7.47; OR = 2.36), and physical disability (OR = 6.04; OR = 3.16).

CONCLUSIONS

Intellectual disabilities have greater association with the population burden of sensory impairments/physical disability, but autism is also associated regardless of overlap with intellectual disabilities. These may impact further on communication limitations due to autism and intellectual disabilities, increasing complexity of assessments/management of other health conditions. Clinicians need to be aware of these important issues.

Treating anxiety in autistic adults: study protocol for the Personalised Anxiety Treatment-Autism (PAT-A©) pilot randomised controlled feasibility trial

BACKGROUND

Anxiety is common in autistic adults and significantly limits everyday opportunities and quality of life. Evidence-based psychological therapies offered by mental health services often fail to meet the needs of autistic adults. The development of appropriate treatments for mental health conditions and, in particular, anxiety has been identified as a key priority by the autism community. The Personalised Anxiety Treatment-Autism (PAT-A©) trial aims to address this need by investigating the feasibility and acceptability of delivering an individualised psychological treatment for anxiety experienced by autistic adults.

METHODS/DESIGN

This is a pilot randomised controlled feasibility trial. Up to 40 autistic adults with clinically diagnosed anxiety will be randomised into one of two groups (either the PAT-A© intervention or Current Clinical Services Plus two emotional literacy skills sessions). Before randomisation, participants will receive a detailed clinical assessment to inform formulation and guide anxiety treatment. As part of the baseline assessment participants will also identify two personally important 'target situations' that cause significant anxiety and impact upon their daily life. Based upon the formulation and identified target situations, participants randomised to the PAT-A© intervention will receive up to 12 individualised, one-to-one therapy sessions. Initial emotional literacy training sessions will be followed by a bespoke, modular, needs-based treatment approach utilising one or more of the following approaches: Mindfulness, Coping with Uncertainty in Everyday Situations (CUES), social anxiety and graded exposure within Virtual Reality Environments. Participants in the control arm will receive two psycho-educational sessions focussing on understanding and describing emotions and be signposted to healthcare provision as required. Data will be collected through quantitative and qualitative methods.

DISCUSSION

This feasibility pilot trial serves as the first stage in the development and evaluation of a manualised personalised, evidence-based psychological therapy treatment for anxiety in autistic adults. Study outcomes will be used to inform an application for a fully powered multi-site intervention trial of adults and young people.

TRIAL REGISTRATION

ISRCTN, ID: 15881562. Retrospectively registered on 9 August 2019.

A Lifespan Approach to Patient-Reported Outcomes and Quality of Life for People on the Autism Spectrum

Autistic self-advocates, family members, and community organizations have called for greater emphasis on enhancing quality of life (QoL) for people with autism. Doing this is critical to understand how QoL unfolds across the life course and to clarify whether gender affects QoL, health, and functioning for people with autism. The purpose of this study was to curate and test a lifespan QoL measurement tool using freely available and well-constructed National Institutes of Health Parent-Reported Outcomes Measurement Information System (PROMIS). To develop the PROMIS Autism Battery-Lifespan (PAB-L), we identified PROMIS scales relevant for autism, reviewed each item, consulted with a panel of autism experts, and elicited feedback from autistic people and family members. This battery provides a comprehensive portrait of QoL for children ages 5-13 (through parent proxy), teens 14-17 (parent proxy and self-report), and adults 18-65 (self-report) with autism compared to the general population. Participants and parent informants (N = 912) recruited through a children's hospital and nationwide U.S. autism research registry completed the PAB-L online. Results indicate that compared to general population norms, people with autism of all ages (or their proxies) reported less desirable outcomes and lower QoL across all domains. Women and girls experienced greater challenges in some areas compared to men and boys with autism. The PAB-L appears to be a feasible and acceptable method for assessing patient-reported outcomes and QoL for autistic people across the life course. Autism Res 2020, 13: 970-987. © 2020 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: We developed a survey to measure the quality of life of children, teens, and adults with autism using free National Institutes of Health PROMIS questionnaires. People with autism and family members rated the PROMIS Autism Battery-Lifespan as useful and important. Some reported a good quality of life, while many reported that their lives were not going as well as they wanted. Women and girls reported more challenges in some areas of life than men and boys.

Evidence-based support for autistic people across the lifespan: maximising potential, minimising barriers, and optimising the person-environment fit

Autism is both a medical condition that gives rise to disability and an example of human variation that is characterised by neurological and cognitive differences. The goal of evidence-based intervention and support is to alleviate distress, improve adaptation, and promote wellbeing. Support should be collaborative, with autistic individuals, families, and service providers taking a shared decision-making approach to maximise the individual's potential, minimise barriers, and optimise the person-environment fit. Comprehensive, naturalistic early intervention with active caregiver involvement can facilitate early social communication, adaptive functioning, and cognitive development; targeted intervention can help to enhance social skills and aspects of cognition. Augmentative and alternative communication interventions show preliminary evidence of benefit in minimising communication barriers. Co-occurring health issues, such as epilepsy and other neurodevelopmental disorders, sleep problems, and mental health challenges, should be treated in a timely fashion. The creation of autism-friendly contexts is best achieved by supporting families, reducing stigma, enhancing peer understanding, promoting inclusion in education, the community, and at work, and through advocacy.

Development and Initial Utility of the Autism Clinical Interview for Adults: A New Adult Autism Diagnostic Measure

Background

Clinicians use diagnostic interviews to help them gather and organize information collected in the assessment of autism. Most instruments are developed for children and few measures have been developed that are reliable, valid, and appropriate for use in adulthood. This is a significant barrier to providing a high-quality, timely service for adults. The aim of this development study was to assess the initial utility of the recently developed Autism Clinical Interview for Adults (ACIA) for use in autism diagnostic clinical services before further large-scale testing and evaluation.

Methods

We invited adults who had received an autism spectrum diagnosis through a U.K. National Health Service (NHS) multidisciplinary adult autism assessment to participate. Seventeen autistic adults (8 women and 9 men, mean age of 37 years) and four relatives agreed to an interview. The semistructured ACIA interview comprises subject and informant versions, and a self-report preinterview questionnaire. In combination, the ACIA components cover topics relevant to autism and co-occurring condition assessment. We evaluated clinical utility and content validity via comparison with the Diagnostic and Statistical Manual Fifth Edition (DSM-5) and NHS diagnostic reports.

Results

Each interview took between 60 and 90 minutes to complete. Comparison with DSM-5 and the NHS autism diagnostic report demonstrated that the ACIA accurately identified information on core autism characteristics needed for a diagnosis, and identified co-occurring conditions. In response to participant suggestions we revised the interview.

Conclusions

These initial findings support the potential utility and validity of the ACIA for adult autism diagnostic clinical services. Further investigations of the acceptability, utility, and validity of this interview are planned.

Lay summary

Why was this study done?: Clinicians use diagnostic interviews during assessments to help gather and record information both from a person suspected to be on the autism spectrum and from an informant (someone who knows them well). However, most autism diagnostic interviews were originally developed for assessing autism in childhood, and few have been developed for use with adults. The lack of diagnostic interviews developed specifically for use with adults makes it difficult to provide a good-quality, consistent assessment.What was the purpose of this study?: The study tested a new semistructured diagnostic interview called the Autism Clinical Interview for Adults (ACIA). The ACIA includes a questionnaire for people to complete before their interview. This is followed by an interview that can be conducted with the person themselves and a separate version to be used with someone who knows them well (if permitted). The interview covers autism traits, strengths and difficulties, and co-occurring physical and mental health conditions. We wanted to find out if the interview is useful for autism diagnostic services by comparing information collected using the ACIA with clinical diagnostic reports.What did the researchers do?: We invited people who had received a diagnosis of autism from a U.K. National Health Service (NHS) assessment to take part in an interview. We asked them if we could also interview someone who knew them well, and if we could compare their NHS autism diagnostic report with information gathered using the ACIA.What were the results of the study?: Seventeen autistic adults (average age 37 years; 8 women and 9 men) and 4 relatives/supporters (2 parents, a spouse, and a cohabiting partner) agreed to be interviewed. Each interview took 60 to 90 minutes to complete. A comparison with clinical reports showed the ACIA identified autism traits relevant for a diagnosis, as well as co-occurring conditions (e.g., depression). Participants suggested some ways to improve the interview, and revisions were made.What do these findings add to what is already known?: There are few diagnostic interviews designed specifically for use with adults seeking a diagnosis of autism. The findings from this study show that the ACIA is a promising new interview.What are the potential weaknesses of the study?: The study is small. However, it is important to run an initial test study before involving more people and resources in larger studies. Building on these results, we aim to undertake further studies on the acceptability and usefulness of the new interview with a larger number of people, including people from a range of backgrounds.How will these findings help autistic people now or in the future?: The ACIA has potential for use in adult autism clinical assessment services and as a resource for research and training. The semistructured format helps gather important and relevant information, and the interview length supports feasibility in clinical and research settings. The ACIA has the potential to streamline autism assessments and speed up the process for adults who currently wait a long time for their diagnosis.

Annual Research Review: Looking back to look forward - changes in the concept of autism and implications for future research

The concept of autism is a significant contribution from child psychiatry that has entered wider culture and public consciousness, and has evolved significantly over the last four decades. Taking a rather personal retrospective, reflecting on our own time in autism research, this review explores changes in the concept of autism and the implications of these for future research. We focus on seven major changes in how autism is thought of, operationalised, and recognised: (1) from a narrow definition to wide diagnostic criteria; (2) from a rare to a relatively common condition, although probably still under-recognised in women; (3) from something affecting children, to a lifelong condition; (4) from something discreet and distinct, to a dimensional view; (5) from one thing to many 'autisms', and a compound or 'fractionable' condition; (6) from a focus on 'pure' autism, to recognition that complexity and comorbidity is the norm; and finally, (7) from conceptualising autism purely as a 'developmental disorder', to recognising a neurodiversity perspective, operationalised in participatory research models. We conclude with some challenges for the field and suggestions for areas currently neglected in autism research.

Aging in Autism Spectrum Disorder

Most research on autism spectrum disorder (ASD) has focused on younger individuals, but there is increasing awareness that more must be known about the clinical needs and outcomes of older adults with ASD. This article reviews what is known about barriers to recognition in the elderly, the prevalence of ASD over the lifespan, outcomes in adulthood in comparison to the general population, co-occurring psychiatric diagnoses, and healthcare needs in this population.

Development and Initial Evaluation of the Anxiety Scale for Autism-Adults

Background

Anxiety is highly prevalent in autistic adults and can cause a significant impact on functioning and quality of life. There are no existing measures of anxiety designed and validated specifically for autistic adults. In this study, we aimed to adapt an existing anxiety measure designed for autistic children, in collaboration with autistic adults and other professionals, to make it suitable for use for autistic adults and to examine the measurement properties of the newly designed measure.

Methods

Through consultation with autistic adults and professionals working with autistic people, we developed a preliminary self-report anxiety measure. Five hundred fifty-one autistic adults completed the measure and another measure of anxiety and depression (the Hospital Anxiety and Depression Scale). Participants completed measures again after 1 month to determine test/retest reliability. We split the sample to enable exploratory and confirmatory factor analyses to be undertaken on different samples. We conducted internal consistency and convergent and divergent validity analyses. We completed receiver operator curve (ROC) analyses to investigate sensitivity and specificity and identify an indicative clinical cutoff.

Results

Our findings indicate that the Anxiety Scale for Autism-Adults (ASA-A) has promising psychometric properties. Factor analysis indicated that a bifactor solution with orthogonal general and specific factors was an adequate fit and that minimal measurement bias would occur if the scale were treated as unidimensional, so the total score could be used as a valid measure of anxiety. We identified a General Anxiety factor and three group factors (Social Anxiety, Uncertainty, and Anxious Arousal). ROC analysis indicated a score of 28 could be considered an indicative clinical cutoff.

Conclusion

The ASA-A is the first self-report anxiety questionnaire specifically developed and validated for autistic adults. Preliminary evaluation of the measurement properties indicates that the scale will be a useful tool in research and clinical contexts.

Lay summary

Why was this study done?: Autistic adults commonly experience anxiety, which can have a huge impact on their quality of life. One way of identifying anxiety is by using questionnaires. Research shows that anxiety may be experienced differently by autistic people, and so, questionnaires that have been created for neurotypical adults may not be suitable for autistic adults. At present, there are no anxiety measures that have been adapted specifically for autistic adults.What was the purpose of this study?: Our team previously created an anxiety questionnaire for autistic children-the Anxiety Scale for Children-Autism Spectrum Disorder (ASC-ASD). We aimed to adapt this questionnaire to make it suitable for autistic adults.What did the researchers do?: We met with autistic people and professionals, and asked them how to change the ASC-ASD to make it suitable for measuring anxiety in autistic adults. We discussed whether the questions were appropriate for adults, if the questions were worded clearly, and if anything was missing. We then created the Anxiety Scale for Autism-Adults (ASA-A).What did we find?: Once the questionnaire was created, 551 autistic adults with anxiety completed it. We used this information to test whether the questionnaire was a good way of measuring anxiety. We also tested the questionnaire subscales, which were as follows: Anxious Arousal, Social Anxiety, and Uncertainty. We found that the questionnaire is useful in giving a total score for anxiety, and we found that a score of 28 indicated anxiety that was likely to have an impact on someone's daily life. Each subscale was also found to be useful for providing a "profile" of anxiety.What do these findings add to what was already known?: These findings suggest that the ASA-A is a good way of measuring anxiety in autistic adults. This is the first anxiety measure to be developed for autistic adults. This study is the first step toward testing out the usefulness of the measure. We hope that our questionnaire can be further tested and that in the future it will help to identify anxiety experienced by autistic adults more accurately. This would mean that the results of future studies are more likely to be valid, which should help improve what we know about the anxiety autistic people experience.What are potential weaknesses in the study?: We used another anxiety measure to measure anxiety levels when testing what the cutoff score should be on our measure. A clinical interview may have been a more accurate way, and should be done in the future to check that the cutoff of 28 on the ASA-A is still appropriate for identifying anxiety in autistic adults.We recruited autistic adults from a database of people who are interested in taking part in research. This helped us to get enough people to test the questionnaire, but we cannot tell how well these results apply to all autistic people. Testing the questionnaire with other autistic people, including those who may need some assistance with reading or who may need someone else to complete it on their behalf will let us know.How will these findings help autistic adults now or in the future?: The final questionnaire, the ASA-A, has been shown to accurately measure anxiety in autistic adults who do not have an intellectual disability. The questionnaire will be helpful in both clinical and research services.

Treatment of Adults with Autism and Major Depressive Disorder Using Transcranial Magnetic Stimulation: An Open Label Pilot Study

Patients with autism spectrum disorder (ASD) are at high risk for comorbid major depressive disorder (MDD), which can severely impair functioning and quality of life. Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive brain stimulation technique, which is Food and Drug Administration (FDA) cleared for the treatment of MDD in adults. Despite demonstrated efficacy in the treatment of depression, there are limited data on the use of rTMS in patients with ASD and comorbid MDD. We hypothesized that a standard rTMS protocol for MDD would reduce depressive symptoms for adults with ASD and MDD. Secondarily, we investigated whether this treatment would also reduce core ASD symptoms. Participants of 18-65 years old with ASD and MDD without any medication changes in the last month were eligible for this open-label trial. Participants underwent 25 sessions of rTMS (figure-of-eight coil, 100-120% resting motor threshold, 10 Hz, 3,000 pulses per session) applied to the left dorsolateral prefrontal cortex. Thirteen participants enrolled in the study, with two withdrawing due to tolerability, and one excluded from analysis. Overall, side effects were mild and rTMS was well tolerated. The Hamilton rating scale for depression (HAM-D17 ) improved 13.5 points (IQR 5-15), and 40% of participants achieved remission (HAM-D17  ≤ 7) after rTMS treatment. Informant clinical scales of core symptoms of autism also suggested improvement with rTMS, though no change was observed by the participants themselves. Thus, this open-label trial suggests that high-frequency rTMS is well tolerated by adults with autism and MDD, with improvement in depressive symptoms and possible effects on core autism symptoms. Autism Res 2020, 13: 346-351. © 2020 International Society for Autism Research,Wiley Periodicals, Inc. LAY SUMMARY: This study evaluated the safety and effects of repetitive transcranial magnetic stimulation (rTMS) on depression and autism symptoms in individuals with both major depressive disorder and autism spectrum disorder. rTMS was well tolerated by the participants, depression improved with treatment, and family members' assessment of autism symptoms improved as well. This study supports the need for further work to evaluate rTMS in individuals who have both autism and depression.

What Is Important in Measuring Quality of Life? Reflections by Autistic Adults in Four Countries

Relevant and valid measurement is crucial in determining whether interventions and supports have improved the quality of life (QoL) of autistic people. However, it is possible that researchers' and services' use of general population QoL tools may overlook issues of specific importance. To advance methodology, we conducted a preliminary exploration of the need and basis for cross-cultural development of additional autism-specific QoL questions. Nine consultation groups with autistic adults (n = 38) were held in Argentina, Australia, Singapore, and the United Kingdom to examine the items of the World Health Organization QoL questionnaire (WHOQOL-BREF) and the WHOQOL Disabilities add-on module. Each group discussion was transcribed and analyzed thematically to identify missing issues and nuances of particular significance to autistic people. Themes seen as important and particularly relevant to QoL of autistic people included a positive autistic identity, other people's lack of understanding of autism, sensory issues, and autistic people's contributions to society. There were notable similarities across sites indicating that creation of cross-cultural autism-specific items is likely to be possible; the themes identified could inform the focus of items for measurement of QoL. This project represents an initial step toward fuller international consultation, and subsequent development of an autism-specific module for addition to the core WHOQOL model.

Lay summary

Why was this project done?: Quality of life (QoL) refers to how satisfied a person is with their life now, taking into account their experiences and the conditions in which they live. There are questionnaires for the general public to rate their QoL, but these may ask questions in ways that are not important or relevant for autistic people; for example, some autistic people have few or no friends, but are fine with this. Also questionnaires miss out topics such as sensory overload that impact on QoL for autistic people.What was the purpose?: We wanted to try to understand whether the questions in the World Health Organization Questionnaire (WHOQOL-BREF for short), and in the optional add-on Disabilities questionnaire, were important and relevant to autistic people from different countries and cultures. We also wanted to find out whether autistic people thought there were other important topics missing from these questionnaires.What did the researchers do?: We held 9 consultation groups about the WHO questionnaire items, with 38 autistic people in 4 countries: the United Kingdom, Singapore, Australia, and Argentina. Researchers, including members of the autism community, read the typed out discussions a number of times to find common themes, especially what was particularly relevant, or topics and experiences that were missing. First we analyzed the four United Kingdom groups, and then the other five groups.What did the researchers find?: Autistic people we consulted thought that most of the existing items of the WHOQOL questionnaires were important. From the discussions, we found 13 themes that were identified as particularly relevant to QoL, including being positive about one's autistic identity, other people's (lack of) knowledge of autism, sensory issues, mental health difficulties, the nature of friendships, and supporting other people as carers or volunteers.What do these findings add to what was already known?: The discussions from the four countries were quite similar. The items from the WHO QoL questionnaires were mostly viewed as important and relevant by autistic people, but a number of issues are missing, which seem different in autism and should be included in any improved measurement of QoL.What are potential weaknesses?: The project was a first step in consultation about measuring autistic adults' QoL, involving only four countries, and all except one group conducted in English. Only one group included people with intellectual disability.How will these findings help autistic adults now or in the future?: Having good QoL is central for everyone. Our consultation found that some topics highly relevant for autistic people are not included in QoL questionnaires developed for the general population. Our findings suggest that it will be both important and possible to develop a set of internationally appropriate items for autistic people to add to the existing WHO QoL questionnaires. This would allow researchers and health workers to measure accurately the QoL of autistic adults and to be able to judge how helpful supports and services are in improving QoL.

Caregivers’ perspectives on health-care transition in autism

Purpose

Adults with autism spectrum disorder (ASD) experience significant health-care disparities across physical and mental health domains resulting in poorer health and quality of life. Poor transitions to adult care negatively impact the health of adults with ASD. Current research focuses on personal factors in research samples that lack diversity. The purpose of this study is to examine the lived health-care experiences of geographically and ethnically diverse young adults with ASD in adult care settings in the USA to understand provider and system-level factors affecting their health.

Design/methodology/approach

Nine caregivers of young adults with ASD participated in key informant interviews describing their experiences in navigating the health-care system. Data were analyzed using a grounded theory approach.

Findings

The data indicated that limited quantity of services, poor quality of services, and high cost of services had a negative effect on the health of adults with ASD. Issues cascaded to become more complex.

Practical implications

Practical implications for payors, providers, persons with ASD and their families are discussed in this paper.

Originality/value

To the best of the authors’ knowledge, this study answers the call to better understand system-level factors affecting the health of geographically and ethnically diverse people with ASD.

Incidence Rate of Advanced Chronic Kidney Disease Among Privately Insured Adults with Neurodevelopmental Disabilities

Purpose

Due to complex medical profiles, adults with neurodevelopmental disabilities (NDDs) may have a heightened risk for early development of chronic kidney disease (CKD) and accelerated CKD progression to advanced stages and kidney failure. The purpose of this study was to estimate the incidence rate of advanced CKD for adults with NDDs and compare the incidence rate to adults without NDDs.

Patients and Methods

Data were used from the Optum Clinformatics^® Data Mart to conduct this retrospective cohort study. The calendar year 2013 was used to identify eligible participants: individuals ≥18 years of age and without advanced CKD. Participants were followed from 01/01/2014 to advanced CKD, loss to follow-up, death, or end of the study period (12/31/2017), whichever came first. Diagnostic, procedure, and diagnosis-related group codes identified NDDs (intellectual disabilities, cerebral palsy, autism spectrum disorders), incident cases of advanced CKD (CKD stages 4+), diabetes, cardiovascular diseases, and hypertension present in the year 2013. Crude incidence rates (IR) of advanced CKD and IR ratios (IRR), comparing adults with vs without NDDs (with 95% CI) were estimated. Then, Cox regression estimated the hazard ratio (HR and 95% CI) for advanced CKD, comparing adults with NDDs to adults without NDDs while adjusting for covariates.

Results

Adults with NDDs (n=33,561) had greater crude IR of advanced CKD (IRR=1.32; 95% CI=1.24–1.42) compared to adults without NDDs (n=6.5M). The elevated rate of advanced CKD among adults with NDDs increased after adjusting for demographics (HR=2.19; 95% CI=2.04–2.34) and remained elevated with further adjustment for hypertension and diabetes (HR=2.01; 95% CI=1.87–2.15) plus cardiovascular disease (HR=1.84; 95% CI=1.72–1.97). Stratified analyses showed that the risk of advanced CKD was greater for all NDD subgroups.

Conclusion

Study findings suggest that adults with NDDs have a greater risk of advanced CKD than do adults without NDDs, and that difference is not explained by covariates used in our analysis.

The Mental and Physical Health of Older Adults With a Genetic Predisposition for Autism

Autism commonly aggregates in families, with twin studies estimating heritability to be around 80%. Subclinical autism-like characteristics have also been found at elevated rates in relatives of autistic probands. Physical and psychiatric conditions have been reported at elevated rates in autistic children and adults, and also in their relatives. However, to date, there has been no exploration of how aging may affect this pattern. This study examined cross-sectional data from the ongoing online PROTECT study. A total of 20,220 adults aged 50 years and older reported whether they have an autistic first-degree relative. In total, 739 older adults reported having an autistic first-degree relative (AFDR group) and 11,666 were identified as having no family history of any neurodevelopmental disorder (NFD group). The AFDR group demonstrated significantly higher frequencies of self-reported psychiatric diagnoses and a greater total number of co-occurring psychiatric diagnoses than the NFD group. Furthermore, the AFDR group reported elevated current self-report symptoms of depression, anxiety, traumatic experience, and post-traumatic stress than the NFD group. By contrast, few differences between AFDR and NFD groups were observed in physical health conditions, and no differences were observed in the total number of co-occurring physical health diagnoses. These findings suggest that adults who have an AFDR may be at greater risk of poor mental, but not physical, health in later life. Older adults with autistic relatives may benefit from close monitoring to mitigate this susceptibility and to provide timely intervention. Autism Res 2020, 13: 641-654. © 2020 The Authors. Autism Research published by International Society for Autism Research published by Wiley Periodicals, Inc. LAY SUMMARY: Children and adults with an autistic relative have been found to experience more psychiatric difficulties than those with no family links to autism. However, a few studies have explored what happens when these individuals get older. Examining over 20,000 adults age 50+, we found that older adults with an autistic relative experienced elevated rates of most psychiatric conditions but not physical conditions. Older adults with autistic relatives may benefit from close monitoring to mitigate this susceptibility and to provide timely intervention.

Practitioner Review: Twenty years of research with adverse childhood experience scores - Advantages, disadvantages and applications to practice

BACKGROUND

Adverse childhood experience (ACE) scores have become a common approach for considering childhood adversities and are highly influential in public policy and clinical practice. Their use is also controversial. Other ways of measuring adversity - examining single adversities, or using theoretically or empirically driven methods - might have advantages over ACE scores.

METHODS

In this narrative review we critique the conceptualisation and measurement of ACEs in research, clinical practice, public health and public discourse.

RESULTS

The ACE score approach has the advantages - and limitations - of simplicity: its simplicity facilitates wide-ranging applications in public policy, public health and clinical settings but risks over-simplistic communication of risk/causality, determinism and stigma. The other common approach - focussing on single adversities - is also limited because adversities tend to co-occur. Researchers are using rapidly accruing datasets on ACEs to facilitate new theoretical and empirical approaches but this work is at an early stage, e.g. weighting ACEs and including severity, frequency, duration and timing. More research is needed to establish what should be included as an ACE, how individual ACEs should be weighted, how ACEs cluster, and the implications of these findings for clinical work and policy. New ways of conceptualising and measuring ACEs that incorporate this new knowledge, while maintaining some of the simplicity of the current ACE questionnaire, could be helpful for clinicians, practitioners, patients and the public.

CONCLUSIONS

Although we welcome the current focus on ACEs, a more critical view of their conceptualisation, measurement, and application to practice settings is urgently needed.

Self-reported social impairments predict depressive disorder in adults with autism spectrum disorder

In adults with autism spectrum disorder, co-occurring psychiatric conditions are prevalent, and depression is one of the most common co-occurring disorders. This study examined the relationship between depression and cognitive ability, autism symptom severity, and self-reported social impairments in autism spectrum disorder. A total of 33 adults with autism spectrum disorder and 28 adults with typical development completed a standardized psychiatric interview, cognitive test, measure of clinician-rated autism symptom severity, and self-report of social impairments. Nine participants with autism spectrum disorder (27%) met the criteria for a depressive disorder (autism spectrum disorder + depressive disorder). Relatively more females with autism spectrum disorder had a co-occurring depressive disorder. The typical development group had a higher intelligence quotient than the autism spectrum disorder group, but the autism spectrum disorder + depressive disorder group did not differ from the typical development or autism spectrum disorder group. While the autism spectrum disorder + depressive disorder group had lower clinician-rated autism symptom severity than the autism spectrum disorder group, the autism spectrum disorder + depressive disorder group reported more social impairments than the autism spectrum disorder group. Self-reported social impairments predicted depression in adults with autism spectrum disorder when accounting for symptom severity and cognitive ability. These findings suggest that more self-perceived social impairments are related to depressive disorders in autism spectrum disorder, and may help clinicians identify individuals who are vulnerable in developing a co-occurring depressive disorder. Future directions include follow-up studies with larger cohorts and longitudinal designs to support inferences regarding directionality of these relationships.

Identification of biological mechanisms underlying a multidimensional ASD phenotype using machine learning

The complex genetic architecture of Autism Spectrum Disorder (ASD) and its heterogeneous phenotype makes molecular diagnosis and patient prognosis challenging tasks. To establish more precise genotype-phenotype correlations in ASD, we developed a novel machine-learning integrative approach, which seeks to delineate associations between patients' clinical profiles and disrupted biological processes, inferred from their copy number variants (CNVs) that span brain genes. Clustering analysis of the relevant clinical measures from 2446 ASD cases in the Autism Genome Project identified two distinct phenotypic subgroups. Patients in these clusters differed significantly in ADOS-defined severity, adaptive behavior profiles, intellectual ability, and verbal status, the latter contributing the most for cluster stability and cohesion. Functional enrichment analysis of brain genes disrupted by CNVs in these ASD cases identified 15 statistically significant biological processes, including cell adhesion, neural development, cognition, and polyubiquitination, in line with previous ASD findings. A Naive Bayes classifier, generated to predict the ASD phenotypic clusters from disrupted biological processes, achieved predictions with a high precision (0.82) but low recall (0.39), for a subset of patients with higher biological Information Content scores. This study shows that milder and more severe clinical presentations can have distinct underlying biological mechanisms. It further highlights how machine-learning approaches can reduce clinical heterogeneity by using multidimensional clinical measures, and establishes genotype-phenotype correlations in ASD. However, predictions are strongly dependent on patient's information content. Findings are therefore a first step toward the translation of genetic information into clinically useful applications, and emphasize the need for larger datasets with very complete clinical and biological information.

Aging with Autism Departs Greatly from Typical Aging

Autism has been largely portrayed as a psychiatric and childhood disorder. However, autism is a lifelong neurological condition that evolves over time through highly heterogeneous trajectories. These trends have not been studied in relation to normative aging trajectories, so we know very little about aging with autism. One aspect that seems to develop differently is the sense of movement, inclusive of sensory kinesthetic-reafference emerging from continuously sensed self-generated motions. These include involuntary micro-motions eluding observation, yet routinely obtainable in fMRI studies to rid images of motor artifacts. Open-access repositories offer thousands of imaging records, covering 5-65 years of age for both neurotypical and autistic individuals to ascertain the trajectories of involuntary motions. Here we introduce new computational techniques that automatically stratify different age groups in autism according to probability distance in different representational spaces. Further, we show that autistic cross-sectional population trajectories in probability space fundamentally differ from those of neurotypical controls and that after 40 years of age, there is an inflection point in autism, signaling a monotonically increasing difference away from age-matched normative involuntary motion signatures. Our work offers new age-appropriate stochastic analyses amenable to redefine basic research and provide dynamic diagnoses as the person's nervous systems age.

Autism Heterogeneity in a Densely Sampled U.S. Population: Results From the First 1,000 Participants in the RI-CART Study

The objective of this study was to establish a large, densely sampled, U.S. population-based cohort of people with autism spectrum disorder (ASD). The Rhode Island Consortium for Autism Research and Treatment (RI-CART) represents a unique public-private-academic collaboration involving all major points of service for families in Rhode Island affected by ASD. Diagnosis was based on direct behavioral observation via the Autism Diagnostic Observation Schedule, Second Edition. For the first 1,000 participants, ages ranged from 21 months to 64 years. Using Geographic Information System and published prevalence rates, the overall cohort is estimated to represent between 20% and 49% of pediatric age persons in Rhode Island with ASD, with demographics representative of U.S. Census. We observed a high rate of co-occurring medical and psychiatric conditions in affected individuals. Among the most prominent findings of immediate clinical importance, we found that females received a first diagnosis of ASD at a later age than males, potentially due to more advanced language abilities in females with ASD. In summary, this is the first analysis of a large, population-based U.S. cohort with ASD. Given the depth of sampling, the RI-CART study reflects an important new resource for studying ASD in a representative U.S. population. Psychiatric and medical comorbidities in ASD constitute a substantial burden and warrant adequate attention as part of overall treatment. Our study also suggests that new strategies for earlier diagnosis of ASD in females may be warranted. Autism Res 2020, 13: 474-488. © 2020 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: The Rhode Island Consortium for Autism Research and Treatment (RI-CART) represents a unique public-private-academic collaboration involving all major points of service for families in Rhode Island affected by autism spectrum disorder (ASD). In this article, we provide results from the first 1,000 participants, estimated to represent >20% of affected families in the state. Importantly, we find a later age at first diagnosis of ASD in females, which potentially calls attention to the need for improved early diagnosis in girls. Also, we report a high rate of co-occurring medical and psychiatric conditions in affected individuals.

Autism spectrum disorder

Autism spectrum disorder is a construct used to describe individuals with a specific combination of impairments in social communication and repetitive behaviours, highly restricted interests and/or sensory behaviours beginning early in life. The worldwide prevalence of autism is just under 1%, but estimates are higher in high-income countries. Although gross brain pathology is not characteristic of autism, subtle anatomical and functional differences have been observed in post-mortem, neuroimaging and electrophysiological studies. Initially, it was hoped that accurate measurement of behavioural phenotypes would lead to specific genetic subtypes, but genetic findings have mainly applied to heterogeneous groups that are not specific to autism. Psychosocial interventions in children can improve specific behaviours, such as joint attention, language and social engagement, that may affect further development and could reduce symptom severity. However, further research is necessary to identify the long-term needs of people with autism, and treatments and the mechanisms behind them that could result in improved independence and quality of life over time. Families are often the major source of support for people with autism throughout much of life and need to be considered, along with the perspectives of autistic individuals, in both research and practice.

Impaired motor skills and atypical functional connectivity of the sensorimotor system in 40- to 65-year-old adults with autism spectrum disorders

Impairments in fine and gross motor function, coordination, and balance in early development are common in autism spectrum disorders (ASDs). It is unclear whether these deficits persist into adulthood and whether they may be exacerbated by additional motor problems that often emerge in typical aging. We assessed motor skills and used resting-state functional magnetic resonance imaging to study intrinsic functional connectivity of the sensorimotor network in 40- to 65-year-old adults with ASDs (n = 17) and typically developing matched adults (n = 19). Adults with ASDs scored significantly lower on assessments of motor skills compared with an age-matched group of typical control adults. In addition, functional connectivity of the sensorimotor system was reduced and the pattern of connectivity was more heterogeneous in adults with ASDs. A negative correlation between functional connectivity of the motor system and motor skills, however, was only found in the typical control group. Findings suggest behavioral impairment and atypical brain organization of the motor system in middle-age adults with ASDs, accompanied by pronounced heterogeneity.

Study protocol: an investigation of the prevalence of autism among adults admitted to acute mental health wards: a cross-sectional pilot study

INTRODUCTION

Autism spectrum disorders (ASDs) are associated with difficulties in social interaction, communication and restricted, repetitive behaviours. Much is known about their community prevalence among adults, data on adult inpatients within an acute mental health setting is lacking.This pilot study aimed to estimate the prevalence of ASDs among adults admitted to acute mental health wards and to examine the association between ASDs and psychiatric and physical comorbidities within this group.

METHODS AND ANALYSIS

A multiple-phase approach will be used. Phase I will involve testing of 200 patients and corresponding informants, using the autism quotient (AQ), the informant version of the Social Responsiveness Scale, second edition-Adult, the self and informant versions of the Adult Social Behaviour Questionnaire and the EuroQol-5D-5L. Patients with intellectual disability (ID) will bypass Phase I.Phase II will involve diagnostic testing of a subgroup of 40 patients with the Diagnostic Interview for Social and Communication Disorders, the Autism Diagnostic Observation Schedule version 2 and the ASD interview within the Schedules for Clinical Assessment in Neuropsychiatry version 3. 25±5 patients will not have ID and be selected via stratified random sampling according to AQ score; 15±5 patients will have ID. Phase II patients will be interviewed with the Physical Health Conditions and Mental Illness Diagnoses and Treatment sections of the 2014 Adult Psychiatric Morbidity Survey.Prevalence estimates will be based on the proportion of Phase II participants who satisfy the 10th revision of the International Statistical Classification of Diseases and Related Health Problems Diagnostic Criteria for Research (ICD-10-DCR) and the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnostic criteria for ASD, adjusting for selection and non-response. Univariate analysis will be conducted for comorbidities to identify the level of their association with an ASD diagnosis.

ETHICS AND DISSEMINATION

Study oversight is provided by the University of Leicester. The National Health Service Health Research Authority have provided written approval. Study results will be disseminated via conference presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ISRCTN27739943.

Aging and Autism: Understanding, Intervention and Proposals to Improve Quality of Life

BACKGROUND

The population with autism spectrum disorder (ASD) has been increasing and is currently estimated to be 1 in 58 births. The increased prevalence of ASD together with the lack of knowledge on the processes of aging in this population, the support needed at this stage of life, and the associated risk factors, have led to an urgent need for further research.

METHODS

This study provides a review of the literature on social- and health-related conditions that may appear when persons with ASD grow old.

RESULTS

In addition to the autism-related conditions, different neurological, genetic, and environmental factors may be involved in the process of aging. In this complex setting, this study provides proposals that may guide the development of support services that may improve the quality of life for aging people with ASD.

CONCLUSION

Aging in ASD is emerging as a growing problem, which requires immediate planning and targetted treatment development.

Autistic-traits, not anxiety, modulate implicit emotional guidance of attention in neurotypical adults

Although autistic and anxious traits are positively correlated, high levels of autistic traits are associated with poorer emotional guidance of attention (EGA) whilst high levels of anxious traits are associated with greater EGA. In order to better understand how these two trait dimensions influence EGA, we simultaneously examined the effects of anxiety and autistic traits in neurotypical adults on target identification in an attentional blink task. Analyses indicated that implicit EGA is attenuated in individuals with higher levels of autistic traits, but largely unaffected by variation in anxious traits. Our results suggest that anxiety plays a comparatively limited role in modulating implicit EGA and reinforces the importance of disentangling correlated individual differences when exploring the effects of personality, including emotional predisposition, on attention.

Cohort profile: the Australian Longitudinal Study of Adults with Autism (ALSAA)

​PURPOSE: There is a significant knowledge gap regarding the lives of adults on the autism spectrum. Some literature suggests significant health and mental health inequalities for autistic adults, yet there is a lack of comprehensive longitudinal studies exploring risk factors. Further, most research does not include the perspective of autistic adults in its conduct or design. Here, we describe the baseline characteristics and inclusive research approach of a nationwide longitudinal study. ​PARTICIPANTS: The Autism Cooperative Research Centre for Living with Autism's Australian Longitudinal Study of Adults with Autism (ALSAA) is a questionnaire-based longitudinal study of autistic adults (25+ years old) with follow-up at 2-year intervals. Autistic advisors were involved in each stage of research apart from data analysis. Three questionnaires were developed: self-report, informant report (ie, proxy report) and carers (ie, carer experiences and characteristics). ​FINDINGS TO DATE: An inclusive research protocol was developed and agreed with autistic advisors. Baseline data were collected from 295 autistic adults (M=41.8 years, SD=12.0) including 42 informant responses, 146 comparison participants and 102 carers. The majority of autistic participants (90%) had been diagnosed in adulthood (M=35.3 years, SD=15.1). When compared with controls, autistic adults scored higher on self-report measures of current depression and anxiety. Participant comments informed ongoing data gathering. Participants commented on questionnaire length, difficulty with literal interpretation of forced response items and expressed gratitude for research in this area. ​FUTURE PLANS: A large comprehensive dataset relating to autistic adults and their carers has been gathered, creating a good platform for longitudinal follow-up repeat surveys and collaborative research. Several outputs are in development, with focus on health service barriers and usage, caregivers, impact of diagnosis in adulthood, further scale validations, longitudinal analyses of loneliness, suicidal ideation, mental illness risk factors and other areas. Baseline data confirm poorer mental health of autistic adults. The ALSAA demonstrates a working approach to inclusive research.

Guided self-help for depression in autistic adults: the ADEPT feasibility RCT

BACKGROUND

Co-occurring depression frequently occurs in autism. Evidence-based psychological interventions have been successfully adapted to treat co-occurring anxiety, but there is little evidence about the usefulness of adapted cognitive-behavioural therapy for depression. To the authors' knowledge, to date there have been no randomised trials investigating the usefulness of low-intensity cognitive-behavioural therapy for depression in autism.

OBJECTIVES

The objectives of the study were to (1) develop a low-intensity psychological intervention for depression adapted for autism, (2) assess the feasibility and patient and therapist acceptability of the intervention, (3) estimate the rates of recruitment and retention for a full-scale randomised controlled trial and (4) identify an appropriate measure of depression to be used in a full-scale randomised controlled trial.

DESIGN

The study comprised a randomised controlled trial (n = 70) with a nested qualitative evaluation (n = 21). Seventy eligible and consenting participants were randomly allocated to guided self-help or to treatment as usual.

SETTING

Adult autism services in two NHS regions.

PARTICIPANTS

Adults with a diagnosis of autism spectrum disorder with depression, that is, a Patient Health Questionnaire-9 items score of ≥ 10. People who had attended more than six sessions of cognitive-behavioural therapy in the previous 6 months were excluded.

INTERVENTIONS

The low-intensity intervention (guided self-help) comprised materials for nine individual sessions, based on behavioural activation adapted for autism, facilitated by therapist guides (coaches) who were graduate-level psychologists who attended training and regular supervision. Treatment as usual was standard NHS care for depression.

MAIN OUTCOME MEASURES

Outcomes were measured 10, 16 and 24 weeks post randomisation using self-report and interview measures of depression, anxiety, obsessive-compulsive symptoms, social function and quality of life, and a health-care and service use questionnaire. As this was a feasibility study also designed to identify the most appropriate measure of depression, it was not possible to specify the primary outcome measure or outcome point a priori.

RESULTS

The aims of the study were met in full. The guided self-help intervention was feasible and well received by participants and coaches. The majority of allocated participants attended the intervention in full. The most practical outcome point was determined to be 16 weeks. There were differential rates of attrition across the treatment groups: 86% of the guided self-help group remained in the study at 24 weeks, compared with 54% of treatment as usual group. The qualitative study suggested that guided self-help had enhanced credibility with participants at the point of randomisation. Inter-rater reliability of the interview measure of depression was less than adequate, limiting the conclusions that can be drawn from the prespecified sensitivity to change analyses.

CONCLUSIONS

The intervention was feasible and well received. Although this feasibility study was not a fully powered trial, it provided some evidence that the guided self-help intervention was effective in reducing depressive symptoms. A full-scale clinical effectiveness and cost-effectiveness trial of the intervention is warranted.

FUTURE WORK

Improvements to the intervention materials as a result of qualitative interviews. Stakeholder consultation to consider future trial design, consider strategies to improve retention in a treatment as usual arm and select a self-report measure of depression to serve as the primary outcome measure.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN54650760.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 68. See the NIHR Journals Library website for further project information. This study was also supported by the NIHR Biomedical Research Centre at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol.

Proof of concept: The TRANSITION program for young adults with autism spectrum disorder and/or attention deficit hyperactivity disorder

BACKGROUND

The support needs of people with neurodevelopmental disorders are not sufficiently met during the initial years of adulthood.

AIM

To evaluate feasibility and preliminary effects of a novel programme designed to empower young adults with autism spectrum disorder (ASD) and/or attention deficit hyperactivity disorder (ADHD) to make progress within significant life domains (i.e. work, education, finance, housing/household management, health, leisure/participation in society, and relationships/social network).

MATERIAL AND METHOD

TRANSITION is a 24-week programme that combines group-based workshops with personalised support based on goal attainment scaling. The study enrolled 26 young adults (50% females; age 17-24 years) in the normative intellectual range, diagnosed with ASD (n = 8), ADHD (n = 4), or both (n = 14). The intervention was delivered by the regular staff of publicly funded psychiatric services in Stockholm, Sweden.

RESULTS

The programme was possible to implement with minor deviations from the manual. Participants and staff generally viewed the intervention positively, but also provided feedback to guide further improvement. There was a high degree of attendance throughout, with 21 participants (81%) completing the programme. All completers exceeded their predefined goal expectations within at least one domain.

CONCLUSIONS

The TRANSITION-programme is a promising concept that deserves further evaluation.

The effect of low-trauma fracture on one-year mortality rate among privately insured adults with and without neurodevelopmental disabilities

BACKGROUND

Individuals with neurodevelopmental disabilities (NDDs) have poor development and preservation of skeletal health throughout the lifespan, and are especially vulnerable to low-trauma fracture and post-fracture health complications. However, no studies have examined if adults with NDDs have greater post-fracture mortality risk compared to adults without NDDs. The purpose of this study was to determine whether adults with NDDs have greater 12-month mortality rates following a low-trauma fracture compared to adults without NDDs.

METHODS

Data from 2011 to 2017 was leveraged from Optum Clinformatics® Data Mart; a nationwide claims database from a single private payer in the U.S. Data were extracted from adults (18+ years) with and without NDDs that sustained a low-trauma fracture between 01/01/2012-12/31/2016, as well as pre-fracture chronic diseases (i.e., cardiovascular diseases, cerebrovascular diseases, diabetes, chronic obstructive pulmonary diseases, cancer). Mortality rate was estimated for adults with and without NDDs, and the mortality rate ratio (RR) and 95% confidence interval (CI) was calculated. Cox regression was used to estimate hazard ratio (HR) and 95% CI for 1-, 3-, 6-, and 12-month post-fracture mortality rates between adults with and without NDDs after adjusting for age, sex, race, U.S. region, and pre-fracture chronic diseases.

RESULTS

Mean age (SD) at baseline was 56.7 (20.6) for adults with NDDs (n = 3749; 45.2% men) and 63.9 (19.2) for adults without NDDs (n = 585,910; 34.4% men). During the 12-month follow-up period, 182 adults with NDDs (mean age [SD] = 69.8 [14.7]; 46.2% men) and 25,456 adults without NDDs (mean age [SD] = 78.9 [9.8]; 38.3% men) died. Crude mortality rate was not different between adults with and without NDDs for any time points (e.g., 12-months: 5.40 vs. 4.96 per 100 person years; RR = 1.09; 95% CI = 0.94-1.26); however, it was greater for adults with intellectual disabilities compared to adults without NDDs (RR = 1.46; 95% CI = 1.23-1.79). After adjustments, adults with NDDs had greater post-fracture mortality rates for 3-, 6-, and 12-month time points (e.g., 12-months: HR = 1.46; 95% CI = 1.27-1.69). When stratified by the type of NDD, adults with intellectual disabilities and adults with autism spectrum disorders, but not adults with cerebral palsy, had greater 12-month post-fracture mortality risk. When stratified by fracture location, lower extremities were associated with greater crude mortality rate (RR = 1.69; 95% CI = 1.22-2.35) and adjusted mortality risk (HR = 2.41; 95% CI = 1.73-3.35), while upper extremities were associated with greater adjusted mortality risk (HR = 1.76; 95% CI = 1.23-2.50) for adults with vs. without NDDs.

CONCLUSIONS

Among privately insured adults with NDDs, low-trauma fracture is associated with greater mortality risk within 1 year of the fracture event, even after adjusting for pre-fracture chronic diseases. Study findings suggest the need for earlier fracture prevention strategies and improved post-fracture healthcare management.

DNA methylation profile is a quantitative measure of biological aging in children

DNA methylation changes within the genome can be used to predict human age. However, the existing biological age prediction models based on DNA methylation are predominantly adult-oriented. We established a methylation-based age prediction model for children (9-212 months old) using data from 716 blood samples in 11 DNA methylation datasets. Our elastic net model includes 111 CpG sites, mostly in genes associated with development and aging. The model performed well and exhibited high precision, yielding a 98% correlation between the DNA methylation age and the chronological age, with an error of only 6.7 months. When we used the model to assess age acceleration in children based on their methylation data, we observed the following: first, the aging rate appears to be fastest in mid-childhood, and this acceleration is more pronounced in autistic children; second, lead exposure early in life increases the aging rate in boys, but not in girls; third, short-term recombinant human growth hormone treatment has little effect on the aging rate of children. Our child-specific methylation-based age prediction model can effectively detect epigenetic changes and health imbalances early in life. This may thus be a useful model for future studies of epigenetic interventions for age-related diseases.

Do autistic patients change healthcare services utilisation through the transition age? An Italian longitudinal retrospective study

OBJECTIVES

This paper aims to provide an estimate of the prevalence rate of autism spectrum disorder (ASD) in 8-year-olds in 2017 based on administrative databases and to investigate the change in healthcare service use during the healthcare transition age of 18.

DESIGN

This research is based on a longitudinal retrospective cohort study.

SETTING

The data is drawn from the Italian Administrative Healthcare Database (2010-2017).

PARTICIPANTS

We identified 5607 ASD patients; 331 ASD patients from 2012 to 2015 in the calendar year of their 18th birthday were selected and their health service utilisation during a 5-year period-ranging from 2 years preceding and succeeding their 18th year-were investigated.

INTERVENTIONS

None.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence, incidence and proportion of ASD patients receiving specific healthcare services were included in the outcome measures.

RESULTS

Prevalence of ASD at age 8 was 5.4/1000. Global access to health and social services was lower both before and after age 18 (46.5% at 16; 68.0% at 18; 54.1% at 20). The percentage of patients receiving a neuropsychiatric consultation decreased after age 18 (30.8% at 18; 5.4% at 20). Community mental health services (CMHS) utilisation rate increased above 18 years of age. Regarding psychiatric visits, for both outpatient and CMHS, an increase was observed from 17.8% at age 18 to 25.4% at age 20. The utilisation of rehabilitation services decreased with age, dropping from 17.8% at age 16 to 1.8% at age 20. Psychiatric outpatient services remained stable across ages at about 14%.

CONCLUSION

Our findings suggest that ASD patients changed clinical reference services with age from neuropsychiatric and rehabilitative services towards psychiatric and community-based services as they transitioned from paediatric to adult healthcare services.

Modulation of brain activation during executive functioning in autism with citalopram

Adults with autism spectrum disorder (ASD) are frequently prescribed selective serotonin reuptake inhibitors (SSRIs). However, there is limited evidence to support this practice. Therefore, it is crucial to understand the impact of SSRIs on brain function abnormalities in ASD. It has been suggested that some core symptoms in ASD are underpinned by deficits in executive functioning (EF). Hence, we investigated the role of the SSRI citalopram on EF networks in 19 right-handed adult males with ASD and 19 controls who did not differ in gender, age, IQ or handedness. We performed pharmacological functional magnetic resonance imaging to compare brain activity during two EF tasks (of response inhibition and sustained attention) after an acute dose of 20 mg citalopram or placebo using a randomised, double-blind, crossover design. Under placebo condition, individuals with ASD had abnormal brain activation in response inhibition regions, including inferior frontal, precentral and postcentral cortices and cerebellum. During sustained attention, individuals with ASD had abnormal brain activation in middle temporal cortex and (pre)cuneus. After citalopram administration, abnormal brain activation in inferior frontal cortex was 'normalised' and most of the other brain functional differences were 'abolished'. Also, within ASD, the degree of responsivity in inferior frontal and postcentral cortices to SSRI challenge was related to plasma serotonin levels. These findings suggest that citalopram can 'normalise' atypical brain activation during EF in ASD. Future trials should investigate whether this shift in the biology of ASD is maintained after prolonged citalopram treatment, and if peripheral measures of serotonin predict treatment response.

Autism and depression are connected: A report of two complimentary network studies

Autism and depression often co-occur. Through network analysis, we seek to gain a better understanding of this co-occurrence by investigating whether (1) autism and depression share overlapping groups of symptoms and/or (2) are connected through a bridge of mastery or worry symptoms. This is addressed in two complimentary studies: (1) Study 1 focusing on depressed (N = 258) and non-depressed adults (N = 117), aged 60-90 years; (2) Study 2 focusing on autistic (N = 173) and non-autistic adults (N = 70), aged 31-89 years. Self-report questionnaire data were collected on autistic traits (AQ-28), depression symptoms (Study 1: Inventory of Depressive Symptomatology Self Report; Study 2: Symptom Checklist 90-Revised depression subscale), worry (Worry Scale-R) and mastery (the Pearlin Mastery Scale). For both studies, data were analysed by creating glasso networks and subsequent centrality analyses to identify the most influential variables in the respective networks. Both depressed and autistic adults are highly similar in the perceived amount of worries and lack of control. While caution is needed when interpreting the pattern of findings given the bootstrapping results, findings from both studies indicate that overlapping symptoms do not fully explain the co-occurrence of autism and depression and the perception of having control over your life, that is, mastery seems a relevant factor in connecting autism and depression.

Factors Influencing the Use of Cognitive-Behavioral Therapy with Autistic Adults: A Survey of Community Mental Health Clinicians

Cognitive-behavioral therapy (CBT) can improve anxiety and depression in autistic adults, but few autistic adults receive this treatment. We examined factors that may influence clinicians' use of CBT with autistic adults. One hundred clinicians completed an online survey. Clinicians reported stronger intentions (p = .001), more favorable attitudes (p < .001), greater normative pressure (p < .001), and higher self-efficacy (p < .001) to start CBT with non-autistic adults than with autistic adults. The only significant predictor of intentions to begin CBT with clients with anxiety or depression was clinicians' attitudes (p < .001), with more favorable attitudes predicting stronger intentions. These findings are valuable for designing effective, tailored implementation strategies to increase clinicians' adoption of CBT for autistic adults.

Risk of non-affective psychotic disorder or bipolar disorder in autism spectrum disorder: a longitudinal register-based study in the Netherlands

BACKGROUND

Individuals with autism spectrum disorder (ASD) appear to be at increased risk of non-affective psychotic disorder (NAPD) and bipolar disorder (BD). However, most previous studies examined the co-occurrence of ASD and NAPD or BD, ignoring possible diagnostic bias and selection bias. We used longitudinal data from Dutch psychiatric case registers to assess the risk of NAPD or BD among individuals with ASD, and compared the results to those obtained for the Dutch population in earlier studies.

METHODS

Individuals with ASD (n = 17 234) were followed up between 16 and 35 years of age. Kaplan-Meier estimates were used to calculate the risk of NAPD or BD. We conducted separate analyses to reduce possible bias, including an analysis among individuals diagnosed with ASD before age 16 years (n = 8337).

RESULTS

Of the individuals with ASD, 23.50% (95% confidence interval 21.87-25.22) were diagnosed with NAPD and 3.79% (3.06-4.69) with BD before age 35 years. The corresponding figures for the general population were 0.91% (0.63-1.28) and 0.13% (0.08-0.20). Risk estimates were substantially lower, but still higher than general population estimates, when we restricted our analyses to individuals diagnosed with ASD before age 16, with 1.87% (1.33-2.61) being diagnosed with NAPD and 0.57% (0.21-1.53) with BD before age 25 years. The corresponding figures for the general population were 0.63% (0.44-0.86) and 0.08% (0.05-0.12).

CONCLUSIONS

Individuals with ASD are at increased risk of NAPD or BD. This is likely not the result of diagnostic or selection bias.

"I wouldn't know where to start": Perspectives from clinicians, agency leaders, and autistic adults on improving community mental health services for autistic adults

LAY ABSTRACT

Most autistic adults struggle with mental health problems, such as anxiety and depression. However, they often have trouble finding effective mental health treatment in their community. The goal of this study was to identify ways to improve community mental health services for autistic adults. We interviewed 22 autistic adults with mental healthcare experience, 44 community mental health clinicians (outpatient therapists, case managers, and intake coordinators), and 11 community mental health agency leaders in the United States. Our participants identified a variety of barriers to providing quality mental healthcare to autistic adults. Across all three groups, most of the reported barriers involved clinicians' limited knowledge, lack of experience, poor competence, and low confidence working with autistic adults. All three groups also discussed the disconnect between the community mental health and developmental disabilities systems and the need to improve communication between these two systems. Further efforts are needed to train clinicians and provide follow-up consultation to work more effectively with autistic adults. A common suggestion from all three groups was to include autistic adults in creating and delivering the clinician training. The autistic participants provided concrete recommendations for clinicians, such as consider sensory issues, slow the pace, incorporate special interests, use direct language, and set clear expectations. Our findings also highlight a need for community education about co-occurring psychiatric conditions with autism and available treatments, in order to increase awareness about treatment options.