Ageing in people with autistic spectrum disorder

The adult experience of being diagnosed with autism spectrum disorder: A qualitative meta-synthesis

LAY ABSTRACT

There is little research looking at the experience of individuals diagnosed with autism spectrum disorder as adults. Adults diagnosed with autism spectrum disorder face different challenges than children, and more research is needed to better understand those challenges. For this review, autistic and non-autistic researchers looked at research on the experience of receiving a diagnosis of autism spectrum disorder as an adult. We looked for themes in people's experience leading up to diagnosis, going through the diagnostic process, and living their life after diagnosis. We analyzed 24 studies and found three overarching themes that captured thirty-two themes describing the experience of diagnosis. The three overarching themes expressed issues with identity and relationships before and after the diagnosis and identified that the diagnosis of autism spectrum disorder in adulthood impacted people's adaptation to and assimilation (i.e. the making sense of and internalizing the diagnosis) of autism spectrum disorder. While the diagnostic process itself was confusing and disappointing for many, it often led to a sense of relief and clarity regarding past experiences and had effects on identity and self-esteem. It created opportunities to connect with other autistic individuals and to access services, though appropriate supports were widely lacking. Recommendations are made that the impact of the diagnosis on people's identity and choices about telling others about their diagnosis, and whether and how people want to make adaptations, should be discussed and thought through in the process of diagnosis.

Epidemiological Screening for the Risk of Mental, Behavioral and Developmental Disorders, Including Autism, in Early Childhood: Data for Russia 2017-2019

We aimed to screen children aged 18-48 months in the general population of nine Russian regions for risk of mental, behavioral and developmental disorders (MBDDs) including autism spectrum disorders (ASD) using an original screening tool. The prevalence of the risk for MBDDs is 1307:10,000 (13.07%), the prevalence of clinically verified cases of MBDDs is 151:10,000 (1.51%), whereas the prevalence of ASD among them is 18:10,000 (0.18%). Basing on our results, the screening procedures are already integrated into the Russian primary care system since the end of 2019. Screening of the risk for MBDDs including ASD in Russia among children in the general pediatric population is a promising area of preventive medicine.

Well-being spectrum traits are associated with polygenic scores for autism

Individuals with autism spectrum disorder (ASD) tend to experience lower well-being as demonstrated mostly for children and adolescents in epidemiological studies. A further investigation of inclusive well-being, in terms of five well-being spectrum (5-WBS) traits including neuroticism, depression, loneliness, life satisfaction, and positive affect, among adults with ASD may deepen our understanding of their well-being, and lead to the possibility to further modify societal supportive mechanisms for individuals with ASD. This study aims to investigate if a genetic predisposition for ASD is associated with 5-WBS traits using polygenic risk score (PRS) analysis. PRS for ASD were calculated based on the latest genome-wide association study of ASD by the Psychiatric Genetics Consortium (18,381 cases, 27,969 controls) and were created in the independent cohort UK Biobank. Regression analyses were performed to investigate the association between ASD PRS and 5-WBS traits in the UK Biobank population including 337,423 individuals. ASD PRS were significantly associated with all 5-WBS traits, showing a positive association with the negative WBS traits, neuroticism (max R2  = 0.04%, p < 1 × 10-4 ), depression (max R2  = 0.06%, p < 1 × 10-4 ), loneliness (max R2  = 0.04%, p < 1 × 10-4 ), and a negative association with the positive WBS traits, life satisfaction (max R2  = 0.08%, p < 1 × 10-4 ), positive affect (max R2  = 0.10%, p < 1 × 10-4 ). The findings suggest that adults carrying a high load of risk single nucleotide peptides (SNPs) for ASD are more likely to report decreased well-being. The study demonstrates a considerable connection between susceptibility to ASD, its underlying genetic etiology and well-being.

Is quality of life related to high autistic traits, high ADHD traits and their Interaction? Evidence from a Young-Adult Community-Based twin sample

This study explored whether high autistic traits, high attention deficit hyperactivity disorder (ADHD) traits and their interaction were associated with quality of life (QoL) in a sample of 556 of young-adult twins (Mean age 22 years 5 months, 52% Female). Four participant groups were created: high autistic traits, high ADHD traits, high autistic/ADHD traits, and low ADHD/autistic traits. High autistic traits were associated with lower QoL across domains (physical, psychological, social, and environmental). High ADHD traits associated with lower physical, psychological, and environmental QoL. The interaction of autistic and ADHD traits was not significant in any domain. While mental health difficulties were associated with lower QoL, after accounting for mental health, most relationships between autistic traits, ADHD traits and QoL remained.

Neurotypicals with higher autistic traits have delayed visual processing of an approaching life-sized avatar's gait: an event-related potentials study

Introduction

Autism spectrum disorder (ASD) is a neurodevelopmental disorder, which is reportedly related to difficulties in the visual processing of human motion, such as biological motion and gestures. Moreover, neurotypical (here, we mention it as individuals without a diagnosis) adults with autistic traits are clumsier than those without autistic traits when passing by others. It is still unclear whether the clumsiness derived from atypical visual processing of another's approaching gait motion. We aim to address this question by investigating the association between autistic traits in neurotypical adults and the visual processing of an approaching life-sized avatar's gait.

Methods

We clarified a typical visual motion processing and autistic traits in daily life in 26 neurotypical adults by analyzing the subthreshold autism trait questionnaire (SATQ) score, a 24-item self-report scale of ASD, and event-related potentials (ERPs) in response to walking motion of a passing avatar. Videos of walking life-sized virtual avatars approaching and retreating were presented as visual stimuli.

Results and discussion

The association between the participants' SATQ scores and the latencies and amplitudes of the ERPs was examined. ERP components (N170 and P200) components were identified at T5 and T6 electrodes. Participants reporting higher SATQ scores had longer latencies of P200 at T6 and lower amplitudes of P200 at T5 and T6 electrodes for the approaching avatar than those reporting lower SATQ scores. These findings indicate that adults with autistic traits have delayed and less sensitive visual processing of the approaching avatar. It suggests that while passing another person, these individuals have atypical visual processing of their approach. This study may contribute to elucidating autistic traits from the perspective of visual processing in an environment simulating daily life.

Epidemiological Study on the Early Detection of Mental Disorders in Young Children in Russia

BACKGROUND

Assessing the risk of children developing mental, behavioral, and developmental disorders (MBDDs), including autism spectrum disorders (ASDs), as well as achieving early detection of such disorders, has become one of the most important undertakings for public mental health professionals worldwide.

AIM

This study aims to evaluate the risk of developing MBDDs and the prevalence of MBDDs among young children (18-48 months old) in Russia.

METHODS

A two-level epidemiological screening approach was developed and adopted for the purposes of this study. At the first level, the parents of all children between 18 and 48 months old were questioned using Russian national validated Screening Checklist for Parents for Identification of the Risk of Mental, Behavioral, and Developmental Disorders in Early Childhood in nine regions of Russia (Volgograd, Kirov, Moscow, Novosibirsk, Orenburg, Tver, Chelyabinsk, Yaroslavl, and Stavropol). At the second level, children identified at the first level of screening as being at risk of developing MBDDs were assessed by a child psychiatrist on a voluntary basis and diagnosed according to the International Classification of Diseases, Tenth Revision criteria.

RESULTS

The present study revealed that the risk of developing MBDDs stands at 13.07% or 1,307 cases per 10,000 child population aged 18-48 months, whereas the prevalence of confirmed MBDDs is 1.51% or 151 cases per 10,000 among a Russian child population aged 18-48 months.

CONCLUSION

Screening for the risk of developing MBDDs, including ASDs, in Russia among very young children is a promising area of preventive medicine. This initiative allows us to develop optimal algorithms for specialized care measures that could help prevent the development and aggravation of children mental health issues.

Views about primary care health checks for autistic adults: UK survey findings

BACKGROUND

Compared with the general population, autistic adults experience higher rates of physical and mental health conditions, premature morbidity and mortality, and barriers to health care. A health check for autistic people may improve their health outcomes.

AIM

To establish the views of autistic people towards a primary care health check for autistic people.

DESIGN & SETTING

Cross-sectional questionnaire study in England and Wales.

METHOD

A questionnaire was sent to autistic adults with physical health conditions in England and Wales. A total of 458 people (441 autistic adults and 17 proxy responders) completed the questionnaire.

RESULTS

Most responders (73.4%, n = 336) thought a health check is needed for all autistic people. Around half of the participants thought a health check should be offered from childhood and the health check appointment should last between 15 and 30 minutes. Autistic people were positive about providing primary care staff with contextual information regarding their health and the reasonable adjustments they would like before their health check appointment. Training about autism and the health check was considered important, alongside adequate time for discussions in the health check appointment (all by over 70% of responders). The clinician's autism knowledge, seeing a familiar clinician, environmental adaptations, appropriate information, and accessible appointments were considered particularly important in making a health check accessible.

CONCLUSION

Autistic people and relatives were supportive of a primary care health check for autistic people. Information gathered was used to support the design of a primary care health check for autistic adults.

Aging and autism: Do measures of autism symptoms, co-occurring mental health conditions, or quality of life differ between younger and older autistic adults?

Previous research has indicated that autistic adults experience higher rates of co-occurring mental health difficulties and poorer quality of life (QoL) than their non-autistic peers. Little is known, however, about these aspects in older age or whether younger and older autistic adults experience similar patterns This cross-sectional study investigated potential age-related effects on autism symptoms, self-reported mental health, and QoL in younger and older autistic adults (n = 79, aged 19-71 years) compared to a non-autistic control group (n = 57) matched for gender, age and IQ. Results showed that autistic adults had higher levels of self-reported autism symptoms and poorer QoL than controls. There were no significant age effects on autism symptoms or on most self-rated mental health symptoms. However, significantly more autistic adults in the younger versus older group scored above the clinical threshold for anxiety, somatoform disorders and eating disorders. Older autistic adults rated social QoL as significantly better than younger autistic adults; there was no significant age difference in the control group. Self-reported QoL was best predicted by self-ratings of severity of depressive symptoms in both groups. Further research is needed to track autism and co-occurring mental health symptomatology across the lifespan, so that service provision can be tailored accordingly. LAY SUMMARY: Young autistic adults have reported more psychological difficulties and poorer quality of life (QoL) than the general population. We investigated whether these difficulties continue into older age. Autism symptoms and mental health problems were common in autistic adults, with no difference between age groups, except for anxiety, physical and eating problems. Although QoL was poorer in both younger and older autistic compared to non-autistic adults, older autistic adults reported better social QoL than those who were younger.

Older Age Autism Research: A Rapidly Growing Field, but Still a Long Way to Go

Background

There is a paucity of research involving older autistic people, as highlighted in a number of systematic reviews. However, it is less clear whether this is changing, and what the trends might be in research on autism in later life.

Methods

We conducted a broad review of the literature by examining the number of results from a search in three databases (PubMed, Embase, PsycINFO) across four age groups: childhood, adolescence, adulthood, and older age. We also examined the abstracts of all the included articles for the older age group and categorized them under broad themes.

Results

Our database search identified 145 unique articles on autism in older age, with an additional 67 found by the authors (hence, the total number of articles in this review is 212). Since 2012, we found a 392% increase in research with older autistic people, versus 196% increase for childhood/early life, 253% for adolescence, and 264% for adult research. We identify 2012 as a point at which, year-on-year, older age autism research started increasing, with the most commonly researched areas being cognition, the brain, and genetics. However, older adult research only accounted for 0.4% of published autism studies over the past decade.

Conclusions

This increase reflects a positive change in the research landscape, although research with children continues to dominate. We also note the difficulty of identifying papers relevant to older age autism research, and propose that a new keyword could be created to increase the visibility and accessibility of research in this steadily growing area.

Features and Needs of Autistic Older Adults: A Delphi Study of Clinical Experiences

OBJECTIVES

In geriatric psychiatry Autism Spectrum Disorders (ASD) are increasingly recognized. This study explores what clinicians know about diagnostic and/or therapeutic aspects of autistic older adults and how aging plays a role in the course of ASD.

METHODS

A Delphi study outlines the point of view of 11 clinical experts in the Netherlands and Belgium (Flanders).

RESULTS

Regarding diagnostics, age-specific aspects need to be considered. Age-related characteristics (cognitive differences, life events, co-occurring conditions) influence detecting autistic features in older adults. Regarding treatment, counseling methods need to be adapted. Psychoeducation, family therapy, couples therapy, behavioral counseling and psychopharmaca can be helpful in meeting the needs of autistic older adults. There was no consensus on the effects of aging on autistic older adults.

CONCLUSIONS

Diagnosis and treatment of ASD need adaptation for autistic older adults. Further research is needed on the validation of measurement tools, recorded treatment, therapy, psychoeducation, and the effects of aging among people on the autism spectrum.

CLINICAL IMPLICATIONS

Available knowledge helps clinicians to detect ASD in older adults and adapt to the specific features and needs of autistic older adults. The effects of aging on the course of ASD are unclear yet.

Utilization of health services among adults with autism spectrum disorders: Stakeholders' experiences

BACKGROUND

Autism spectrum disorder (ASD) is a lifelong disorder, beginning in early childhood, which often accompanies with several healthcare challenges. There is a need for consistent and continued healthcare services throughout the life of an individual with ASD. The majority of previous studies have examined healthcare services in children with ASD and there is limited evidence about healthcare needs of adults with ASD.

OBJECTIVE

The aim of this project was to capture the experiences of stakeholders including adults with ASD in receiving healthcare services.

METHOD

We interviewed 22 stakeholders, including adults with ASD (n = 13), parents of adults with ASD (n = 5), and service providers (n = 4). Open-ended questions were used to explore their experiences with the healthcare system. We analysed the data thematically to develop the overarching themes.

RESULTS

Three themes emerged from interviews including a) availability and accessibility of healthcare services, b) provision of quality healthcare and service delivery, and c) striving for better health outcomes.

CONCLUSION

This study found that many adults with ASD can experience a continued lack of access to services and the care they receive is often of limited quality. The unmet healthcare needs lead stakeholders to feel stress, frustration, exhaustion, and possible burnout. The detrimental cost of limited services not only impacts adults with ASD but also their caregivers.

The Mental and Physical Health Profiles of Older Adults Who Endorse Elevated Autistic Traits

OBJECTIVES

The mental and physical health profile of autistic people has been studied in adolescence and adulthood, with elevated rates of most conditions being reported. However, this has been little studied taking a dimensional approach to autistic traits and in older age.

METHODS

A total of 20,220 adults aged 50-81 years from the PROTECT study reported whether they experienced persistent sociocommunicative traits characteristic of autism. Approximately 1%, 276 individuals, were identified as endorsing elevated autistic traits in childhood and currently, henceforth the "Autism Spectrum Trait" (AST) group. An age- and gender-matched comparison group was formed of 10,495 individuals who did not endorse any autistic behavioral traits, henceforth the "Control Older Adults" (COA) group. Differences between AST and COA groups were explored in self-reported psychiatric diagnoses, self-reported symptoms of current depression and anxiety, and self-reported physical health diagnoses. Associations were also examined between autistic traits and health across the whole sample.

RESULTS

The AST group reported significantly elevated rates of psychiatric diagnoses compared to the COA group. Additionally, the AST group showed significantly higher self-reported symptoms of current depression and anxiety than the COA group. However, few differences were observed in individual physical health conditions, and no differences in total co-occurring physical diagnoses between groups. Similar associations between autistic traits and health were also found taking a dimensional approach across the whole sample.

DISCUSSION

These findings suggest that older adults with elevated autistic traits may be at greater risk of poorer mental, but not physical, health in later life. Future studies should incorporate polygenic scores to elucidate the possible genetic links between the propensity to autism/high autistic traits and to psychiatric conditions, and to explore whether those with elevated autistic traits experience particular barriers to mental health care.

Criss-crossing autism spectrum disorder and adult neurogenesis

Autism spectrum disorder (ASD) comprises a group of multifactorial neurodevelopmental disorders primarily characterized by deficits in social interaction and repetitive behavior. Although the onset is typically in early childhood, ASD poses a lifelong challenge for both patients and caretakers. Adult neurogenesis (AN) is the process by which new functional neurons are created from neural stem cells existing in the post-natal brain. The entire event is based on a sequence of cellular processes, such as proliferation, specification of cell fate, maturation, and ultimately, synaptic integration into the existing neural circuits. Hence, AN is implicated in structural and functional brain plasticity throughout life. Accumulating evidence shows that impaired AN may underlie some of the abnormal behavioral phenotypes seen in ASD. In this review, we approach the interconnections between the molecular pathways related to AN and ASD. We also discuss existing therapeutic approaches targeting such pathways both in preclinical and clinical studies. A deeper understanding of how ASD and AN reciprocally affect one another could reveal important converging pathways leading to the emergence of psychiatric disorders.

Ageing and heterogeneity regarding autism spectrum conditions: a protocol paper of an accelerated longitudinal study

INTRODUCTION

Autism spectrum conditions (ASC) develop early in life and are thought to last a lifetime. However, ASC research has two major knowledge gaps that hinder progression in understanding the concept of ASC and in providing proper support for autistic adults: (1) the majority of knowledge about ASC mainly stems from childhood studies so little is known about older autistic adults and (2) while it is broadly recognised that ASC is a heterogeneous condition, we do not yet understand the differences in trajectories leading to their future outcome. We aim to fill both knowledge gaps.

METHODS AND ANALYSIS

A multistage overlapping cohort design assessing (cognitive) ageing in ASC is designed to obtain an accelerated longitudinal data set. Data, including a multitude of questionnaires, diagnostics and cognitive tests, are collected over four waves within a 10-year time frame. This will provide information regarding actual changes in quality of life, co-occurring health conditions and cognition as well as the possibility to test external validity and temporal stability in newly formed behavioural subtypes. Participants consist of three groups of adults aged 20-90 years: (1) with a clinical diagnosis of ASC, (2) with a clinical diagnosis of attention deficit hyperactivity disorder (ADHD) but no ASC, (3) no ASC/ADHD (ie, comparison group). The sample size differs between waves and instruments. Detailed analysis plans will be preregistered in AsPredicted or at the Open Science Framework.

ETHICS AND DISSEMINATION

Ethical approval for this study was obtained from the ethical review board of the Department of Psychology of the University of Amsterdam (wave 1 2011-PN-1952 and 2013-PN-2668, wave 2 2015-BC-4270, waves 3 and 4 2018-BC-9285). In line with the funding policies of the grant organisation funding this study, future papers will be published open access.

Real-World Experiences in Autistic Adult Diagnostic Services and Post-diagnostic Support and Alignment with Services Guidelines: Results from the ASDEU Study

Research providing an evidence-base for autistic adult services is sparse. The Autism Spectrum Disorders in the European Union (ASDEU) network implemented an on-line survey to determine gaps in autistic adult diagnostic evaluation and post-diagnostic support services. More than 55% in all groups experienced most of the recommended features for diagnostic evaluation for autistic adults. In contrast, < 2% of adults or carers, and < 21% of professionals experienced each of the recommended features for post-diagnostic support. In contrast to 61% of professionals, only about 30% of autistic adults and carers had knowledge of good local services models for autism diagnosis in adulthood. There are major differences between good practice guidelines for diagnostic and post-diagnostic care for autistic adults, and what is actually experienced by services users and professionals.

Diagnosis of Autism Spectrum Disorder Across the Lifespan

Although autism spectrum disorder (ASD) is one of the most common neurodevelopmental disorders it is also one of the most heterogeneous conditions, making identification and diagnosis complex. The importance of a stable and consistent diagnosis cannot be overstated. An accurate diagnosis is the basis for understanding the individual and establishing an individualized treatment plan. We present those elements that should be included in any assessment for ASD and describe the ways in which ASD typically manifests itself at various developmental stages. The implications and challenges for assessment at different ages and levels of functioning are discussed.

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.

Strain differences in behaviour and immunity in aged mice: Relevance to Autism

The BTBR mouse model has been shown to be associated with deficits in social interaction and a pronounced engagement in repetitive behaviours. Autism spectrum disorder (ASD) is the most prevalent neurodevelopmental condition globally. Despite its ubiquity, most research into the disorder remains focused on childhood, with studies in adulthood and old age relatively rare. To this end, we explored the differences in behaviour and immune function in an aged BTBR T + Itpr3tf/J mouse model of the disease compared to a similarly aged C57bl/6 control. We show that while many of the alterations in behaviour that are observed in young animals are maintained (repetitive behaviours, antidepressant-sensitive behaviours, social deficits & cognition) there are more nuanced effects in terms of anxiety in older animals of the BTBR strain compared to C57bl/6 controls. Furthermore, BTBR animals also exhibit an activated T-cell system. As such, these results represent confirmation that ASD-associated behavioural deficits are maintained in ageing, and that that there may be need for differential interventional approaches to counter these impairments, potentially through targeting the immune system.

Correlates of daily functioning in older adults with autism spectrum disorder

Objectives: Studies of adults with autism spectrum disorder (ASD) have demonstrated poor outcomes related to independence and everyday living skills compared to the general population. In a sample of 74 adults with ASD who require a high level of support we sought to identify correlates of daily functioning.Methods: We administered questionnaires to residential staff and identified participants' independence level in basic and instrumental activities of daily living.Results: There was no association of age with daily functioning. Higher daily functioning was associated with a better general medical health rating. Functional independence was greater in participants with IQ range of 55 to 65 compared to those with IQ below 55. Language difficulties and behavioral disturbances were not significantly correlated with independence in daily living skills. In this sample, individual had held a median of three different types of jobs in supported employment.Conclusion: Daily functioning in adults with autism generally does not decline with age, but because this was cross-sectional data, this requires further confirmation. Community programs designed for adults with ASD who require a high level of support should focus on overall medical health and promotion of daily living skill building.

Healthcare access for autistic adults: A systematic review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

ETHICS AND DISSEMINATION

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

REGISTRATION AND STATUS

PROSPERO 2018 CRD42018116093.

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.

Diagnosis of Autism Spectrum Disorder Across the Lifespan

Although autism spectrum disorder (ASD) is one of the most common neurodevelopmental disorders it is also one of the most heterogeneous conditions, making identification and diagnosis complex. The importance of a stable and consistent diagnosis cannot be overstated. An accurate diagnosis is the basis for understanding the individual and establishing an individualized treatment plan. We present those elements that should be included in any assessment for ASD and describe the ways in which ASD typically manifests itself at various developmental stages. The implications and challenges for assessment at different ages and levels of functioning are discussed.

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.

An overview of autism in the elderly

The overall improvement in quality of health care in many countries across the globe will likely see an increase in the number of elderly patients with ASDs (Autism Spectrum Disorders) and will result in a need for extra and more adaptive educational, occupational, social, and environmental supports. An earlier diagnosis will auger well for better long-term outcomes in ASD. Therefore, better and more evidence based screening and diagnostic tools are needed. The lack of research and studies surrounding ASD in the elderly raises many real concerns about the wellbeing of those diagnosed with ASD as adults as they enter old age. This review will help provide information on prevalence, available screening tools and diagnostic instruments along with symptoms and manifestations, patients' quality of life related issues and current interventions. We will also highlight research needs and help create a clearer understanding of ASD and the challenges patients and professionals face and are confronted with.

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.

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.

Age at death and comorbidity of dementia-related disorders among individuals with autism spectrum disorder

Purpose

Autism spectrum disorder (ASD) is a lifelong disorder that requires intervention and support services for a growing geriatric population. The purpose of this paper is to examine the mean age at death of individuals with ASD and subsequent comorbidity with Alzheimer’s disease, and any form of dementia, as a whole and according to sex.

Design/methodology/approach

Data consisted of 1,754 individuals who had an ASD listed as one of the causes of deaths from the National Vital Statistics System with data from 1999 to 2015. In the current study, the authors present contradictory results with a mean age at death for individuals with ASD was 68 years by adjusting for changing prevalence rates.

Findings

Females with ASD had a higher mean age at death than males with ASD; consistent with the trend in the sex differences in the general population. The results of the current study also indicate that individuals with ASD were, in fact, less likely than the general population to have Alzheimer’s disease or a form of dementia. However, males with ASD were significantly more likely to have acquired Alzheimer’s disease or a form of dementia as compared to females with ASD.

Originality/value

Guan and Li (2017) reported a mean age at death of 36 years old for individuals with ASD, which was subsequently reported in the mass media, most notably CNN. The authors contend that this study provides a more accurate estimate mean age at death.

Theory of mind performance in younger and older adults with elevated autistic traits

Little is known about the impact of aging with Autism Spectrum Disorder on theory of mind (ToM). While ToM difficulties appear to abate with age in older autistic populations, this has yet to be explored in the Broad Autism Phenotype (BAP). The current study examined ToM performance among younger (n = 49, aged 18-46) and older adults (n = 47, aged 60-91) who were classified as on the BAP (younger n = 18; older n = 21) or not (younger n = 31; older n = 26) using the BAP Questionnaire. ToM was assessed using the ecologically valid Strange Stories Film Task (SSFT) and the dynamic Happé-Frith Triangle Animations task (TA). A 2 × 2 analysis of variance examined the effects of autistic traits (BAP vs. non-BAP) and age (young vs. old). For both SSFT and TA, results showed autistic trait main effects on task performance (non-BAP > BAP). Age main effects were observed for some but not all metrics on TA (younger better than older), with no differences in SSFT. An interaction of autistic traits and age was observed in TA Intentionality, with younger non-BAP and younger BAP performing similarly but older non-BAP performing better than older BAP. Results show that younger and older adults with elevated autistic traits show poorer ToM performance. Despite ToM difficulties being common in later life in the general population, this effect was not observed when using a ToM task designed to reflect real-world scenarios. However, results suggest that autistic traits and age could interact to increase risk for poor ToM performance in older adults who endorse elevated autistic traits. Autism Res 2020, 13: 751-762. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: The behaviors and characteristics commonly found in autism spectrum disorders have been linked to differences in understanding social situations. Similar difficulties have also been found in older age. We assessed social understanding in younger and older adults from the general population. Both younger and older adults who report more autism-like characteristics experience more difficulties with social understanding. However, few differences were found between younger and older adults.

Older Adults with Autism Spectrum Disorders in Sweden: A Register Study of Diagnoses, Psychiatric Care Utilization and Psychotropic Medication of 601 Individuals

In a Swedish sample of persons eligible for disability services and aged 55 years or older in 2012, persons (n = 601) with autism spectrum disorder diagnoses registered in specialist care were identified. Register data concerning diagnoses of other psychiatric disorders, psychiatric care, and psychiatric medication were reviewed. More than 60% had been in contact with psychiatric care. The majority had no intellectual disability (ID) diagnosis recorded during the study period. Apart from ID, affective disorders, anxiety and psychotic disorders were most commonly registered; alcohol/substance abuse disorders were uncommon. Psychotropic drug prescriptions were very common, especially in the ID group. Professionals need awareness of this vulnerable group; studies concerning their life circumstances and service requirements should be conducted.

A Systematic Review of What Barriers and Facilitators Prevent and Enable Physical Healthcare Services Access for Autistic Adults

Autistic people are more likely to: be diagnosed with a range of physical health conditions (i.e. cardio-vascular disease); experience premature mortality (for most disease categories); and experience barriers to effectively accessing healthcare. This systematic review sought to identify studies that report on barriers and facilitators to physical healthcare access for autistic people. A total of 3111 records were screened and six studies were included: two quantitative, two qualitative, and two mixed-methodology studies. Patient-provider communication, sensory sensitivities, and executive functioning/planning issues emerged as important barriers to healthcare. Recommendations for clinicians and those planning services are discussed.

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

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

Cognitive impairment and homelessness: A scoping review

This paper reports the findings of a scoping review designed to identify research which has explored the relationship between cognitive impairment and homelessness. A systematic search of databases for articles published between 2007 and 2017 was conducted using keywords relating to cognitive impairments and homelessness. Sources were expanded using manual searches of citations and grey literature. Forty studies represented in 45 papers were selected for review using predefined inclusion criteria. Sources were subject to quality appraisal and data were extracted in line with review questions. Prevalence studies were over-represented in the review, while qualitative data were lacking. Aetiology of impairments was delineated by acquired and developmental causes. A variety of measures were employed by studies which were not validated in homeless populations. Studies did not give sufficient consideration to co-occurring disorders and overlapping symptoms between aetiologies. Because of these factors, it was difficult to conclude that all studies had accurately measured what they set out to; however, the evidence suggested that cognitive impairment was disproportionately over-represented in homeless populations. Cognitive impairment was found to be both a risk factor to and perpetuator of homelessness. Risk factors for homelessness were similar to those of the general population, though exaggerated by sequelae of certain cognitive impairments. The results of this review suggest that more attention needs to be paid to the underlying socioeconomic disadvantages, persons with cognitive impairments face which may lead to homelessness. Further research should prioritise the voice of homeless persons with cognitive impairments, to better understand both causes of homelessness and effective methods of rehabilitation.

Screening of Autism Spectrum Disorders in Geriatric Psychiatry

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

Demographic and Cognitive Profile of Individuals Seeking a Diagnosis of Autism Spectrum Disorder in Adulthood

Little is known about ageing with autism spectrum disorder (ASD). We examined the characteristics of adults referred to a specialist diagnostic centre for assessment of possible ASD, 100 of whom received an ASD diagnosis and 46 did not. Few demographic differences were noted between the groups. Comorbid psychiatric disorders were high in individuals with ASD (58 %) and non-ASD (59 %). Individuals who received an ASD diagnosis had higher self-rated severity of ASD traits than non-ASD individuals. Within the ASD group, older age was associated with higher ratings of ASD traits and better cognitive performance. One interpretation is that general cognitive ability and the development of coping strategies across the lifespan, do not necessarily reduce ASD traits but may mitigate their effects.

Gray Matter Characteristics in Mid and Old Aged Adults with ASD

It is widely acknowledged that the brain anatomy of children and adolescents with autism spectrum disorder (ASD) shows a different developmental pattern then typical age-matched peers. There is however, a paucity of studies examining gray matter in mid and late adulthood in ASD. In this cross-sectional neuroimaging study, we, performed vertex-wise whole-brain and region-of-interest analyses of cortical volume, thickness, surface area, and gyrification index in 51 adults with and 49 without ASD, between 30 and 75 years. There was significant age-related volume loss and cortical thinning, but there were no group differences. The lack of significant anatomical differences between intellectual able individuals with and without ASD, suggests that ASD is not (strongly) related to gray matter morphology in mid and late adulthood.

Executive Functions in Older Adults With Autism Spectrum Disorder: Objective Performance and Subjective Complaints

Although deficits in Executive Functioning (EF) are reported frequently in young individuals with Autism Spectrum Disorders (ASD), they remain relatively unexplored later in life (>50 years). We studied objective performance on EF measures (Tower of London, Zoo map, phonetic/semantic fluency) as well as subjective complaints (self- and proxy reported BRIEF) in 36 ASD and 36 typically developed individuals (n = 72). High functioning older adults with ASD reported EF-impairments in metacognition, but did not deviate in EF task performance, except for a longer execution time of the Tower of London. The need for additional time to complete daily tasks may contribute to impairments in daily life and may be correlated to a higher level of experienced EF-difficulties in ASD.

A systematic review of quality of life of adults on the autism spectrum

Autism spectrum disorder is associated with co-existing conditions that may adversely affect an individual's quality of life. No systematic review of quality of life of adults on the autism spectrum has been conducted. Our objectives were as follows: (1) review the evidence about quality of life for adults on the autism spectrum; (2) critically appraise current practice in assessing quality of life of adults on the autism spectrum. We searched bibliographic databases and other literature to identify studies using a direct measure of quality of life of adults on the autism spectrum. Hand searching of reference lists, citation searching and personal communication with field experts were also undertaken. In total, 827 studies were identified; 14 were included. Only one quality of life measure designed for use with the general autism spectrum population was identified. Quality of life of adults on the autism spectrum is lower than that of typically developing adults, when measured with tools designed for the general population. There are no comprehensive autism spectrum disorder-specific quality of life measurement tools validated for use with representative samples of adults on the autism spectrum. There is a pressing need to develop robust measures of quality of life of autistic adults.

Measurement properties of screening and diagnostic tools for autism spectrum adults of mean normal intelligence: A systematic review

BACKGROUND

The autism spectrum (AS) is a multifaceted neurodevelopmental variant associated with lifelong challenges. Despite the relevant importance of identifying AS in adults for epidemiological, public health, and quality of life issues, the measurement properties of the tools currently used to screen and diagnose adults without intellectual disabilities (ID) have not been assessed.

OBJECTIVES

This systematic review addresses the accuracy, reliability, and validity of the reported AS screening and diagnostic tools used in adults without ID.

METHODS

Electronic databases and bibliographies were searched, and identified papers evaluated against inclusion criteria. The PRISMA statement was used for reporting the review. We evaluated the quality of the papers using the COSMIN Checklist for psychometric data, and QUADAS-2 for diagnostic data. For the COSMIN assessment, evidence was considered to be strong when several methodologically good articles, or one excellent article, reported consistent evidence for or against a measurement property. For the QUADAS ratings, evidence was considered to be "satisfactory" if at least one study was rated with a low risk of bias and low concern about applicability.

RESULTS

We included 38 articles comprising 32 studies, five reviews, and one book chapter and assessed nine tools (three diagnostic and six screening, including eight of their short versions). Among screening tools, only AQ-50, AQ-S, and RAADS-R and RAADS-14 were found to provide satisfactory or intermediate values for their psychometric properties, supported by strong or moderate evidence. Nevertheless, risks of bias and concerns on the applicability of these tools limit the evidence on their diagnostic properties. We found that none of the gold standard diagnostic tools used for children had satisfactory measurement properties.

CONCLUSION

There is limited evidence for the measurement properties of the screening and diagnostic tools used for AS adults with a mean normal range of measured intelligence. This may lessen the validity of conclusions and public health decisions on an important fraction of the adult autistic population. This not only justifies further validation studies of screening and diagnostic tools for autistic adults, but also supports the parallel use of self-reported information and clinical expertise with these instruments during the diagnostic process.

Effects of therapeutic recreation on adults with ASD and ID: a preliminary randomized control trial

BACKGROUND

The purpose of this research was to examine effects of a therapeutic recreation (TR) program designed to increase executive function (EF), social skills, adaptive behaviours and well-being of adults with autism spectrum disorder (ASD) and intellectual disability (ID).

METHOD

A preliminary pre-test, post-test randomized control group experimental design was used to measure effects of a 40-week TR program designed to increase EF (TR-EF). The TR-EF used instructional electronically based games delivered during 200 1-h sessions (5/week).

RESULTS

Participants (experimental group, n = 19; wait-list group, n = 18) were evaluated at baseline and 10 months later. There was a positive and direct impact of the program on several EF and indirect effect on social skills, adaptive behaviour and personal well-being.

CONCLUSIONS

Findings provide support for inclusion of EF enrichment as a way to enhance effects of TR interventions for adults with ASD and ID. Preliminary results of this study can be considered in planning TR services in the future. In addition to TR-EF program primary effects on EF, there were indirect benefits on adaptive behaviours, personal well-being and social skills.

'Suddenly the first fifty years of my life made sense': Experiences of older people with autism

Research on the experience of growing older with autism is very limited. In this study, 13 people with autism aged over 50 years participated in semi-structured interviews about their experiences of diagnosis, social support and getting older. Interviews were analysed using thematic analysis. Three overarching themes were generated: difference, life review and longing for connection. Prior to diagnosis, individuals had awareness of their difficulties, attributed these to intrinsic difference and engaged in a deliberate process of reducing the visibility of this difference. Diagnosis prompted a process of life review and externalisation, whereby past negative experiences were reattributed to autism as opposed to the self. Loneliness, isolation and yearning for interpersonal connection were ubiquitous and longstanding. Autism support and social groups were highly valued, offering opportunities for belonging, acceptance and social comparison. Results highlight the similarity to younger age groups in terms of lived experience and need for greater support, particularly with respect to reducing isolation and improving access to diagnosis.

Comorbidity prevalence, healthcare utilization, and expenditures of Medicaid enrolled adults with autism spectrum disorders

A retrospective data analysis using 2000-2008 three state Medicaid Analytic eXtract was conducted to examine the prevalence and association of comorbidities (psychiatric and non-psychiatric) with healthcare utilization and expenditures of fee-for-service enrolled adults (22-64 years) with and without autism spectrum disorders (International Classification of Diseases, Ninth Revision-clinical modification code: 299.xx). Autism spectrum disorder cases were 1:3 matched to no autism spectrum disorder controls by age, gender, and race using propensity scores. Study outcomes were all-cause healthcare utilization (outpatient office visits, inpatient hospitalizations, emergency room, and prescription drug use) and associated healthcare expenditures. Bivariate analyses (chi-square tests and t-tests), multinomial logistic regressions (healthcare utilization), and generalized linear models with gamma distribution (expenditures) were used. Adults with autism spectrum disorders (n = 1772) had significantly higher rates of psychiatric comorbidity (81%), epilepsy (22%), infections (22%), skin disorders (21%), and hearing impairments (18%). Adults with autism spectrum disorders had higher mean annual outpatient office visits (32_ASD vs 8_noASD) and prescription drug use claims (51_ASD vs 24_noASD) as well as higher mean annual outpatient office visits (US$4375_ASD vs US$824_noASD), emergency room (US$15,929_ASD vs US$2598_noASD), prescription drug use (US$6067_ASD vs US$3144_noASD), and total expenditures (US$13,700_ASD vs US$8560_noASD). The presence of a psychiatric and a non-psychiatric comorbidity among adults with autism spectrum disorders increased the annual total expenditures by US$4952 and US$5084, respectively.

Age-related differences in autism: The case of white matter microstructure

Autism spectrum disorder (ASD) is typified as a brain connectivity disorder in which white matter abnormalities are already present early on in life. However, it is unknown if and to which extent these abnormalities are hard-wired in (older) adults with ASD and how this interacts with age-related white matter changes as observed in typical aging. The aim of this first cross-sectional study in mid- and late-aged adults with ASD was to characterize white matter microstructure and its relationship with age. We utilized diffusion tensor imaging with head motion control in 48 adults with ASD and 48 age-matched controls (30-74 years), who also completed a Flanker task. Intra-individual variability of reaction times (IIVRT) measures based on performance on the Flanker interference task were used to assess IIVRT-white matter microstructure associations. We observed primarily higher mean and radial diffusivity in white matter microstructure in ASD, particularly in long-range fibers, which persisted after taking head motion into account. Importantly, group-by-age interactions revealed higher age-related mean and radial diffusivity in ASD, in projection and association fiber tracts. Subtle dissociations were observed in IIVRT-white matter microstructure relations between groups, with the IIVRT-white matter association pattern in ASD resembling observations in cognitive aging. The observed white matter microstructure differences are lending support to the structural underconnectivity hypothesis in ASD. These reductions seem to have behavioral percussions given the atypical relationship with IIVRT. Taken together, the current results may indicate different age-related patterns of white matter microstructure in adults with ASD. Hum Brain Mapp 38:82-96, 2017. © 2016 Wiley Periodicals, Inc.