Autism symptoms and internalizing psychopathology in girls and boys with autism spectrum disorders

The relationship between distress tolerance and behavioral activation on anxiety and depression symptomatology in autistic youth: Leveraging self and caregiver perspectives

Anxiety and depression are prevalent among autistic adolescents and may be difficult to accurately diagnose and treat given various factors (e.g., diagnostic overshadowing, heterogeneity). Therefore, efforts to examine transdiagnostic factors (i.e., distress tolerance, behavioral activation) may afford more parsimonious means for assessment and treatment. To our knowledge, there has been little research on distress tolerance, behavioral activation, and depressive and anxiety symptoms in autistic adolescents to guide diagnostic practices and treatment planning. In the current study, we examined the interrelationships between these transdiagnostic factors and depressive and anxiety symptoms using ratings from 100 verbally fluent autistic adolescents without intellectual disability (Mage = 13.70, SDage = 2.23, Range: 11:00-17:11 years) and 100 of their caregivers. Many adolescents reported male sex assigned at birth (61%), cisgender (87%), not Hispanic/Latinx (90%), and White (80%) identities. A series of correlational analyses were employed to examine associations between these constructs from youth and caregiver perspectives, and multiple linear regression analyses were conducted to explore the mediating roles of distress tolerance and behavioral activation. Preliminary results show that low distress tolerance and behavioral activation were associated with more severe internalizing symptoms per self- and caregiver-report. Some differences by rater emerged, which highlight the importance of multi-informant ratings in autism. Results from mediation analyses may show that behavioral activation may be more salient to assessments and treatment planning for depression than distress tolerance, while distress tolerance may be important for both anxiety and depression; however, findings are preliminary given the cross-sectional nature of the data. Findings suggest that these transdiagnostic concepts may be important to individualizing treatment approaches, including the timing of certain approaches, for anxiety and/or depression in autistic adolescents.

Time is of the essence: Age at autism diagnosis, sex assigned at birth, and psychopathology

LAY ABSTRACT

Previous research has shown that girls/women are diagnosed later than boys/men with autism. Individuals who are diagnosed later in life, especially girls/women, have greater anxious and depressive symptoms. Previous research has been limited due to narrow inclusionary criteria for enrollment in studies. The present study uses two samples-one clinic-based, large "real-world" sample and another research-based sample with strict criteria for autism diagnosis-to understand the relationships between diagnostic age, sex assigned at birth, and symptoms of anxiety/depression. In both samples, those who were diagnosed later had greater anxious/depressive symptoms, and anxiety was not predicted by sex. In the clinic-based but not research-based sample, those assigned female at birth were diagnosed later than those assigned male at birth. In the clinic-based sample only, individuals assigned female at birth and who were later diagnosed experienced greater symptoms of anxiety/depression compared to those assigned male who benefited from earlier diagnostic timing. Within the research-based sample, those assigned female at birth had greater depressive symptoms than those assigned male. These findings highlight the importance of timely identification of autism, especially for girls/women who are often diagnosed later. Community-based samples are needed to better understand real-world sex-based and diagnostic age-based disparities in mental health.

Sex differences during development in cortical temporal processing and event related potentials in wild-type and fragile X syndrome model mice

BACKGROUND

Autism spectrum disorder (ASD) is currently diagnosed in approximately 1 in 44 children in the United States, based on a wide array of symptoms, including sensory dysfunction and abnormal language development. Boys are diagnosed ~ 3.8 times more frequently than girls. Auditory temporal processing is crucial for speech recognition and language development. Abnormal development of temporal processing may account for ASD language impairments. Sex differences in the development of temporal processing may underlie the differences in language outcomes in male and female children with ASD. To understand mechanisms of potential sex differences in temporal processing requires a preclinical model. However, there are no studies that have addressed sex differences in temporal processing across development in any animal model of ASD.

METHODS

To fill this major gap, we compared the development of auditory temporal processing in male and female wildtype (WT) and Fmr1 knock-out (KO) mice, a model of Fragile X Syndrome (FXS), a leading genetic cause of ASD-associated behaviors. Using epidural screw electrodes, we recorded auditory event related potentials (ERP) and auditory temporal processing with a gap-in-noise auditory steady state response (ASSR) paradigm at young (postnatal (p)21 and p30) and adult (p60) ages from both auditory and frontal cortices of awake, freely moving mice.

RESULTS

The results show that ERP amplitudes were enhanced in both sexes of Fmr1 KO mice across development compared to WT counterparts, with greater enhancement in adult female than adult male KO mice. Gap-ASSR deficits were seen in the frontal, but not auditory, cortex in early development (p21) in female KO mice. Unlike male KO mice, female KO mice show WT-like temporal processing at p30. There were no temporal processing deficits in the adult mice of both sexes.

CONCLUSIONS

These results show a sex difference in the developmental trajectories of temporal processing and hypersensitive responses in Fmr1 KO mice. Male KO mice show slower maturation of temporal processing than females. Female KO mice show stronger hypersensitive responses than males later in development. The differences in maturation rates of temporal processing and hypersensitive responses during various critical periods of development may lead to sex differences in language function, arousal and anxiety in FXS.

Sexually dimorphic phenotypes and the role of androgen receptors in UBE3A-dependent autism spectrum disorder

Autism spectrum disorders (ASDs) are characterized by social, communication, and behavioral challenges. UBE3A is one of the most common ASD genes. ASDs display a remarkable sex difference with a 4:1 male to female prevalence ratio; however, the underlying mechanism remains largely unknown. Using the UBE3A-overexpressing mouse model for ASD, we studied sex differences at behavioral, genetic, and molecular levels. We found that male mice with extra copies of Ube3A exhibited greater impairments in social interaction, repetitive self-grooming behavior, memory, and pain sensitivity, whereas female mice with UBE3A overexpression displayed greater olfactory defects. Social communication was impaired in both sexes, with males making more calls and females preferring complex syllables. At the molecular level, androgen receptor (AR) levels were reduced in both sexes due to enhanced degradation mediated by UBE3A. However, AR reduction significantly dysregulated AR target genes only in male, not female, UBE3A-overexpressing mice. Importantly, restoring AR levels in the brain effectively normalized the expression of AR target genes, and rescued the deficits in social preference, grooming behavior, and memory in male UBE3A-overexpressing mice, without affecting females. These findings suggest that AR and its signaling cascade play an essential role in mediating the sexually dimorphic changes in UBE3A-dependent ASD.

Male-Dominant Effects of Chd8 Haploinsufficiency on Synaptic Phenotypes during Development in Mouse Prefrontal Cortex

CHD8 is a high penetrance, high confidence risk gene for autism spectrum disorder (ASD), a neurodevelopmental disorder that is substantially more prevalent among males than among females. Recent studies have demonstrated variable sex differences in the behaviors and synaptic phenotypes of mice carrying different heterozygous ASD-associated mutations in Chd8. We examined functional and structural cellular phenotypes linked to synaptic transmission in deep layer pyramidal neurons of the prefrontal cortex in male and female mice carrying a heterozygous, loss-of-function Chd8 mutation in the C57BL/6J strain across development from postnatal day 2 to adulthood. Notably, excitatory neurotransmission was decreased only in Chd8+/- males with no differences in Chd8+/- females, and the majority of alterations in inhibitory transmission were found in males. Similarly, analysis of cellular morphology showed male-specific effects of reduced Chd8 expression. Both functional and structural phenotypes were most prominent at postnatal days 14-20, a stage approximately corresponding to childhood. Our findings suggest that the effects of Chd8 mutation are predominantly seen in males and are maximal during childhood.

Gender, assigned sex at birth, and gender diversity: Windows into diagnostic timing disparities in autism

LAY ABSTRACT

Later autism diagnosis is associated with risk for mental health problems. Understanding factors related to later autism diagnosis may help reduce mental health risks for autistic people. One characteristic associated with later autism diagnosis is female sex. However, studies often do not distinguish sex assigned at birth and gender identity. Gender diversity may be more common in autistic relative to neurotypical people, and autism is more common in gender-diverse populations. We studied age at autism diagnosis by sex assigned at birth, gender identity, and gender diversity (gender-diverse vs cisgender) status, separately. We studied three separate autistic samples, each of which differed in how they were diagnosed and how they were recruited. The samples included 193 persons (8.0-18.0 years) from a research-recruited academic medical center sample; 1,550 people (1.3-25.4 years) from a clinic-based sample; and 244 people (18.2-30.0 years) from a community-enriched sample. We found significant differences in the clinic-based and community-enriched samples. People assigned female sex at birth were diagnosed with autism significantly later than people assigned male at birth. People of female gender were diagnosed significantly later than people of male gender. Gender-diverse people were diagnosed significantly later than cisgender people. Sex assigned at birth, gender identity, and gender diversity may each show unique relationships with age of autism diagnosis. Differences in how autistic people are diagnosed and recruited are important to consider in studies that examine sex assigned at birth or gender identity. More research into autism diagnosis in adulthood is needed.

Characteristics of restricted interests in girls with ASD compared to boys: a systematic review of the literature

The existence of a female phenotype profile in autistic spectrum disorder is one of the current hypotheses to explain the diagnostic discrepancy between men and women. In this context, an international literature review was carried out to evidence and describe the characteristics of restricted interests found in girls with autistic spectrum disorder. A documentary search was conducted on PubMed and a systematic literature review was carried out based on the PRISMA methodology. We selected studies with a population of boys and girls diagnosed as autistic according to the DSM-IV or the DSM-5, in which quantitative and descriptive comparisons of restricted interests, according to gender were carried out. Nineteen studies were found to be relevant. Fifteen enabled a refining of the characteristics of restricted interests among females: fewer restricted interests were identified in comparison with boys, and the autistic girls' interests seem to be closer to those of neurotypical girls than to those of autistic boys, which thus led to more complex screening. Age and Intelligence quotient seem to be two factors that trigger variations in restricted interests differently according to gender. Representations among professionals also have an impact on diagnoses among girls. For future research, one of the perspectives could be a comparison between girls with autism and neurotypical girls to limit gender bias. The present results contribute to potentially extending knowledge of a female phenotypical profile in autism and show the need to improve the general population's awareness, to improve health professionals' training and possibly to revise the diagnostic tools.

Behavioral gender differences in school-age children with autism

This study examined differences in internalizing and externalizing behaviors between school-aged boys and girls diagnosed with autism spectrum disorder (ASD). Eighty-nine children between the ages of 8 and 16 years participated in this study: 17 girls (M = 11.5 years, SD = 2.3) and 72 boys (M = 11.3 years, SD = 2.2). Participants were matched on the Autism Diagnostic Observation Schedule, Second Edition and Full-Scale IQ (FSIQ > 64). The results indicated that, girls had higher reported instances of Bullying, less Anger Control, and poorer Emotional Self-Control than boys on the Behavior Assessment System for Children, Second Edition. Groups did not differ on subscales of the Social Communication Scale. While evidence of increased externalizing behaviors is less common in girls, there is evidence supporting these differing behaviors that warrant further research.

Irritability as a Transdiagnostic Risk Factor for Functional Impairment in Autistic and Non-autistic Toddlers and Preschoolers

Trait irritability in toddlerhood is a powerful risk factor for later internalizing and externalizing challenges in non-autistic children, but the predictive clinical utility of irritability is unknown in autism. Irritability is a trait-level emotional response (i.e., frustration) to a blocked goal and is one source of disruptive behavior. Irritability has two facets: Frustration is the degree to which emotion is elevated after a blocked goal, while soothability is the rate of recovery from peak distress. We aimed to: (1) compare and describe the two facets of irritability in non-autistic and young autistic children, and (2) assess whether children's reward sensitivity and executive function moderate the relation between irritability and clinical symptoms. Participants were 90 autistic (n=43) and non-autistic (n = 47) 2- and 4-year-olds. Autistic children did not have different levels of frustration but were more difficult to soothe compared to non-autistic children, according to parents. Further, frustration and soothability were less strongly correlated for autistic compared to non-autistic children. For all children, executive function (specifically, inhibition) moderated, or ameliorated the strength of, the relation between irritability (both soothability and frustration) and externalizing challenges. This study provides evidence for irritability as a transdiagnostic risk factor for clinically significant emotion regulation challenges. Further, the effect of trait irritability may be ameliorated by children's executive function in a transdiagnostic manner. Future work should examine the unique aspects of soothability to how irritability presents within autism, as well as evaluate and modify emotion regulation interventions for autistic toddlers and preschoolers.

Predictors of health-related quality of life for children with neurodevelopmental conditions

Neurodevelopmental conditions can be associated with decreased health-related quality of life; however, the predictors of these outcomes remain largely unknown. We characterized the predictors of health-related quality of life (HRQoL) in a sample of neurodiverse children and youth. We used a cross-sectional subsample from the Province of Ontario Neurodevelopmental Disorders Network (POND) consisting of those children and young people in the POND dataset with complete study data (total n = 615; 31% female; age: 11.28 years ± 2.84 years). Using a structural equation model, we investigated the effects of demographics (age, sex, socioeconomic status), core features (Social Communication Questionnaire, Toronto Obsessive Compulsive Scale, Strengths and Weaknesses of attention deficit/hyperactivity disorder (ADHD)-symptoms and Normal Behavior), co-occurring symptoms (Child Behaviour Checklist), and adaptive functioning (Adaptive Behaviour Assessment System) on HRQoL (KINDL). A total of 615 participants had complete data for this study (autism = 135, ADHD = 273, subthreshold ADHD = 7, obsessive-compulsive disorder (OCD) = 38, sub-threshold OCD = 1, neurotypical = 161). Of these participants, 190 (31%) identified as female, and 425 (69%) identified as male. The mean age was 11.28 years ± 2.84 years. Health-related quality of life was negatively associated with co-occurring symptoms (B = - 0.6, SE = 0.20, CI (- 0.95, - 0.19), p = 0.004)) and age (B = - 0.1, SE = 0.04, CI (- 0.19, - 0.01), p = 0.037). Fewer co-occurring symptoms were associated with higher socioeconomic status (B = - 0.5, SE = - 0.05, CI (- 0.58, - 0.37), p < 0.001). This study used a cross-sectional design. Given that one's experiences, needs, supports, and environment and thus HrQoL may change significantly over the lifespan and a longitudinal analysis of predictors is needed to capture these changes. Future studies with more diverse participant groups are needed. These results demonstrate the importance of behavioural and sociodemographic characteristics on health-related quality of life across neurodevelopmental conditions.

Characterizing individual differences in children and adolescents with autism spectrum disorder: a descriptive study

Introduction

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by a higher prevalence in male than in female participants. Recent studies have hypothesized the presence of different phenotypes in male and female participants with ASD. The present study aims to assess possible sex differences in cognitive and adaptive functioning, symptomatology of ASD, and psychopathological comorbidities in a large sample of children and adolescents with ASD.

Methods

The study included a total of 2,146 children and adolescents diagnosed with ASD, comprising 1785 boys (mean age 7.12 ± 3.69 years) and 361 girls (mean age 6.25 ± 3.30 years). The age of the participants ranged from 1.35 to 19.05 years (mean age 9.98 ± 3.64). The study sought to include all children and adolescents diagnosed with Autism or ASD.

Results

Present results showed that girls with ASD had lower IQs than boys but similar adaptive functioning. The severity of symptoms of ASD was greater in boys than in girls, as were scores on psychopathological measures. With increasing age, boys with ASD showed greater impairment in social communication skills than girls and increased psychopathological comorbidities. Older girls showed fewer restricted and repetitive behaviors.

Discussion

Exploring phenotypic differences in children and adolescents with ASD fosters an understanding of subtle diagnostic facets that may go unrecognized, allowing for increasingly individualized and tailored interventions.

The influence of sex on major psychiatric comorbidities and parental psychiatric disorders in 22,698 children and adolescents with ICD-9-CM-based autism spectrum disorder

It remains unclear how major psychiatric comorbidities and parental psychiatric disorders differ in males and females with autism spectrum disorder (ASD). Between 2001 and 2011, 17,627 children and 5071 adolescents with ASD (ICD-9-CM code: 299) were identified from Taiwan's National Health Insurance Research Database and assessed for major psychiatric comorbidities and parental psychiatric disorders. Compared with females with ASD, males with ASD were more likely to be diagnosed as having attention deficit hyperactivity disorder (relative risk [RR], 95% confidence interval [CI] 1.63, 1.51-1.75) and disruptive behavior disorder (1.38, 1.17-1.62) and less likely to be diagnosed as having schizophrenia (0.45, 0.36-0.56), bipolar disorder (0.58, 0.45-0.74), or intellectual disability (0.53, 0.49-0.58). Furthermore, compared with women, having a parental history of schizophrenia (RR, 95% CI 0.66, 0.49-0.89) or intellectual disability (0.34, 0.19-0.61) was less associated with ASD among men. However, the difference in ASD diagnosis between ICD-9-CM and ICD-10/11-CM systems may reflect the different, but surely overlapping, entity of ASD, which may limit the generalization of our results. Additional studies should be performed.

Towards system redesign: An exploratory analysis of neurodivergent traits in a childhood population referred for autism assessment

BACKGROUND

Children's health services in many countries are moving from single condition diagnostic silo assessments to considering neurodevelopment in a more holistic sense. There has been increasing recognition of the importance of clinical overlap and co-occurrence of different neurotypes when assessing neurodivergent children. Using a cross-sectional service evaluation design, we investigated the overlap of neurodivergences in a cohort of children referred for autism assessment, focusing on motor, learning, and attention/activity level domains. We aimed to determine what proportion of children in a cohort referred for an autism assessment showed traits of additional neurodivergences, and what proportion were further investigated.

METHODS

We evaluated anonymised medical records of children aged between two and 17 years referred for autism assessment. We used validated questionnaires to assess for neurodivergent traits. A weighted scoring system was developed to determine traits in each neurodevelopmental domain and a score above the median was considered to indicate a neurodivergent trait. Evidence of further investigations were recorded. We then examined the relationships between autism traits and traits of additional neurodivergence.

RESULTS

114 participants were included for evaluation. 62.3% (n = 71) had completed questionnaires for analysis. Of these, 71.8% (n = 51) scored greater than the median for at least one additional neurotype, indicating the presence of other neurodivergent traits, and 88.7% (n = 64) attracted a diagnosis of autism. Only 26.3% of children with evidence of additional neurotypes were further investigated beyond their autism assessment.

CONCLUSIONS

Our results demonstrate the extensive overlap between additional neurodivergent traits in a population of children referred with suspected autism and show that only a small proportion were further investigated. The use of standardised questionnaires to uncover additional neurodivergences may have utility in improving the holistic nature of neurodevelopmental assessments.

Research Review: A systematic review and meta-analysis of sex differences in narrow constructs of restricted and repetitive behaviours and interests in autistic children, adolescents, and adults

BACKGROUND

Evidence that autism often manifests differently between males and females is growing, particularly in terms of social interaction and communication, but it is unclear if there are sex differences in restricted and repetitive behaviours and interests (RRBIs) when rigorously focusing on the narrow construct level (i.e., stereotyped behaviour, restricted interests, insistence on sameness, and/or sensory experiences).

METHODS

We conducted a systematic review and four random effects meta-analyses investigating sex differences in narrow construct measures of RRBIs in autistic children, adolescents, and adults (Prospero registration ID: CRD42021254221). Study quality was appraised using the Newcastle-Ottawa Quality Assessment Scale.

RESULTS

Forty-six studies were narratively synthesised and 25 of these were included in four random effects meta-analyses. Results found that autistic males had significantly higher levels of stereotyped behaviours (SMD = 0.21, 95% confidence interval (CI) [0.09, 0.33], p < .001) and restricted interests (SMD = 0.18, 95% CI [0.07, 0.29], p < .001) compared to autistic females. In contrast, there were no significant sex differences for sensory experiences (SMD = -0.09, 95% CI [-0.27, 0.09], p = .32) and insistence on sameness (SMD = 0.01, 95% CI [-0.03, 0.05], p = .68). The findings from the narrative synthesis were generally consistent with those from the meta-analyses and also found qualitative sex differences in the way RRBIs manifest.

CONCLUSIONS

Our findings show significant differences in narrowly defined RRBIs in males and females. Practitioners need to be aware of such differences, which could be contributing to the under-recognition of autism in females and may not be captured by current diagnostic instruments.

Where I am from matters: factors influencing behavioral and emotional changes in autistic individuals during COVID-19 in Latin America

Background

The COVID-19 pandemic brought an increased incidence of disease and mortality in the world at large, making it a particularly salient and stressful life event. For those individuals residing in Latin America, the pandemic was met with fragmented healthcare systems, economic downturn, and sociopolitical crisis which puts autistic individuals at risk for more detrimental outcomes. Behavioral and emotional challenges experienced by autistic individuals at the beginning of the pandemic could later develop into more severe symptomatology as the pandemic progresses. The present study aimed to explore changes in dysregulated (overt and internalizing) behaviors and preoccupation with getting sick during the COVID-19 pandemic among autistic children in 7 Latin American countries.

Method

Sample consisted of 1,743 caregivers, residing in: Argentina (n = 677, 38.8%) Brazil (n = 156, 9%), Chile (n = 251, 14.4%), Dominican Republic (n = 171, 9.8%), Mexico (n = 126, 7.2%), Uruguay (n = 259, 14.9%) and Venezuela (n = 103, 5.9%). The majority of caregivers who completed the questionnaire were mothers (85.1%), and most had a male autistic child (81.6%). A series of independent sample t-tests were conducted to assess country differences in dysregulated behaviors and preoccupation with getting sick. Linear regressions were conducted to identify which demographic characteristics and micro-level contextual factors predicted dysregulated overt behaviors and psychological changes.

Results

Contextual factors, such as country of residence, were related to preoccupation with getting sick and dysregulated behavior. Particularly, residing in Mexico and Brazil were related to changes in preoccupation with getting sick and mental health concerns. Coexistence predicted dysregulated internalizing behaviors, while being older significantly predicted preoccupation with getting sick. Increased screen time only predicted anxiety.

Conclusion

Our findings highlight differences and predictions of behavioral challenges and psychological changes based on certain contextual factors and individual characteristics while experiencing severe life stressors such as a worldwide pandemic. This knowledge could help inform policies and decrees aimed at protecting those most vulnerable due to their increased difficulty adapting to change.

Sex differences in the age of childhood autism diagnosis and the impact of co-occurring conditions

Sex differences in the age of autism diagnosis during childhood have been documented consistently but remain poorly understood. In this study, we used electronic health records data from a diverse, academic medical center to quantify differences in the age of autism diagnosis between boys and girls and identify associations between the age of diagnosis and co-occurring neurodevelopmental, psychiatric, and medical conditions. An established computable phenotype was used to identify all autism diagnoses within the Duke University Health System between 2014 and 2021. Co-occurring neurodevelopmental and psychiatric diagnoses as well as visits to specific medical and supportive services were identified in the 2 years prior to the autism diagnosis. Cox proportional hazards models were fitted to quantify associations between diagnosis age and sex with and without controlling for the presence of each co-occurring diagnosis and visit type. Records from 1438 individuals (1142 boys and 296 girls) were included. Girls were more likely to be diagnosed either before age 3 (χ 2  = 497.720, p < 0.001) or after age 11 (χ 2  = 4.014, p = 0.047), whereas boys were more likely to be diagnosed between ages 3 and 11 (χ 2  = 5.532, p = 0.019). Visits for anxiety (χ 2  = 4.200, p = 0.040) and mood disorders (χ 2  = 7.033, p = 0.008) were more common in girls and associated with later autism diagnosis (HR = 0.615, p < 0.001; and HR = 0.493, p < 0.001). Visits for otolaryngology were more common in boys and associated with an earlier autism diagnosis (HR = 1.691, p < 0.001). After controlling for these conditions, associations between sex and diagnosis age were reduced and not statistically significant. These results show that the age of autism diagnosis differs in girls compared to boys, but these differences were neutralized when controlling for co-occurring neurodevelopmental and psychiatric conditions prior to autism diagnosis. Understanding sex differences and the possible mediating role of other diagnoses may suggest targets for intervention to promote earlier and more equitable diagnosis.

Similar overall expression, but different profiles, of autistic traits, sensory processing, and mental health between young adult males and females

Recent trends suggest that autism is more common in females than traditionally held. Additionally, some argue that females express autistic traits differently than males. Dimensional views of autism could shed light on these issues, especially with regards to understudied behavioral areas, such as sensory processing. We examined autistic traits, sensory processing, anxiety, and related behaviors in a large sample of neurotypical young adult males and females (n = 1,122; 556 female; ages 19-26). Participants completed an online survey containing questionnaires related to the above. Between groups statistical analyses, as well as within groups correlations and mediation analyses containing these constructs were then computed. We also carried out a cluster analysis to establish groups with behavioral similarities and estimate within-cluster male/female ratios. Results showed modest differences in the overall expression of autistic traits and sensory processing, if any, between males and females. Conversely, more detailed examination of survey subtests and mediation analyses revealed differing profiles between these groups. Cluster analysis uncovered a group comprised of both males (69.8%) and females (30.2%) who exhibited elevated degrees of autism-related behaviors, suggesting a higher proportion of females than would be predicted by traditional ratios. Taken together, these findings suggest that males and females may not differ as much as previously thought in their general levels of autistic traits or sensory processing, but may present with distinct profiles of such behaviors. These novel results add to our understanding of autistic traits in females and have the potential to positively influence diagnostic and support practices.

Autism Prevalence and the Intersectionality of Assigned Sex at Birth, Race, and Ethnicity on Age of Diagnosis

PURPOSE

An official autism diagnosis is required to access timely intervention and is associated with better long-term wellbeing and mental health. Certain demographic characteristics, such as being female or a racially or ethnically minoritized youth, have been associated with significant diagnostic lag. However, it remains unclear how assigned sex, race, and ethnicity interact with each other in predicting the prevalence and age of autism diagnosis.

METHODS

To examine the interactions between assigned sex, race, and ethnicity, we used data from the National Survey of Children's Health (NSCH; 2016 > 2021).

RESULTS

One in 38 children had an autism diagnosis and 3.8 males were diagnosed per 1 female. Hierarchical linear regressions yielded diagnostic delays in some females, particularly those who were non-Hispanic white, Black, and Asian. Ethnic and racial minority children had significantly earlier diagnoses than white and non-Hispanic children when not accounting for sex.

CONCLUSION

This study demonstrates slight increases in reported autism prevalence, a diagnostic lag in some autistic females that was strongly associated with ethnicity, and earlier diagnoses in racial and ethnic minority youth, a finding that may be explained by factors associated with phenotypic differences. This study has important implications for the diagnosis of minority autistic youth, particularly females and females who are non-Hispanic, who may experience a greater propensity for diagnostic delays.

Refining our Understanding of Anxiety in Autistic Youth: Examining the Role of Behavioral Inflexibility

Prior research has demonstrated that cognitive inflexibility is associated with anxiety in autistic individuals. Everyday patterns of behavioral inflexibility (e.g. observable inflexible behavior in the context of the need to change or adapt and that is manifested in real-world everyday settings) is common in autism and can be distinguished from performance on discrete cognitive tasks that tap flexible attention, learning, or decision-making. The purpose of this study was to extend this prior work on inflexibility in autism but with measures specifically developed with input from stakeholders (caregivers and clinicians) for autistic youth designed to measure everyday behavioral inflexibility (BI). We characterized anxiety in a large sample of autistic (N = 145) and non-autistic youth (N = 91), ages 3 to 17 years, using the Parent Rated Anxiety Scale for Autism Spectrum Disorder (PRAS-ASD). Further, we sought to understand how BI, measured via the Behavioral Inflexibility Scale (BIS), predicted anxiety compared to other variables known to increase anxiety in youth (chronological age, IQ, autism diagnosis, assigned sex at birth). Autistic youth had higher parent-related anxiety and BI compared to non-autistic youth. BI was the strongest predictor of anxiety scores, irrespective of diagnosis. Overall, our findings highlight the importance of BI to the understanding of anxiety in autistic youth.

Preconception and prenatal maternal stress are associated with broad autism phenotype in young adults: Project Ice Storm

Studies show associations between prenatal maternal stress (PNMS) and child autism, with little attention paid to PNMS and autism in young adulthood. The broad autism phenotype (BAP), encompassing sub-clinical levels of autism, includes aloof personality, pragmatic language impairment and rigid personality. It remains unclear whether different aspects of PNMS explain variance in different BAP domains in young adult offspring. We recruited women who were pregnant during, or within 3 months of, the 1998 Quebec ice storm crisis, and assessed three aspects of their stress (i.e., objective hardship, subjective distress and cognitive appraisal). At age 19, the young adult offspring (n = 33, 22F / 11M) completed a BAP self-report. Linear and logistic regressions were implemented to examine associations between PNMS and BAP traits. Up to 21.4% of the variance in BAP total score and in BAP three domains tended to be explained by at least one aspect of maternal stress, For example, 16.8% of the variance in aloof personality tended to be explained by maternal objective hardship; 15.1% of the variance in pragmatic language impairment tended to be explained by maternal subjective distress; 20.0% of the variance in rigid personality tended to be explained by maternal objective hardship and 14.3% by maternal cognitive appraisal. Given the small sample size, the results should be interpreted with caution. In conclusion, this small prospective study suggests that different aspects of maternal stress could have differential effects on different components of BAP traits in young adults.

Sex Differences on the ADOS-2

The sex difference in the prevalence of autism spectrum disorder (ASD) may be magnified by sex differences on diagnostic measures. The current study compared autistic males and females on items on the gold-standard diagnostic measure, the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2). In a sample of 8-to-17-year old autistic individuals from research (n = 229) and clinical settings (n = 238), females were less likely to show atypicalities on most items related to social-communication behaviors and on total and subscale scores. When controlling for overall intensity of symptomatology, no sex differences survived statistical corrections. Diagnostic criteria and/or gold-standard assessments may be less sensitive to female presentations of ASD and/or autistic females may exhibit fewer or less intense behaviors characteristic of ASD.

Sex differences in conduct and emotional outcomes for young people with hyperactive/inattentive traits and social communication difficulties between 9 and 16 years of age: a growth curve analysis

BACKGROUND

The purpose of this paper is to identify the trajectory of conduct and emotional problems for young people within the general population at four time points (between 9 years 7 months and 16 years 6 months), investigate their relationship with hyperactive/inattentive traits and explore the moderating effect of autistic social traits (ASTs).

METHODS

Data from 9305 individuals involved in The Avon Longitudinal Study of Parents and Children (ALSPAC) study were included. Conduct and emotional problems and hyperactive/inattentive traits were measured by the Strengths and Difficulties Questionnaire. ASTs were assessed using the Social Communication Disorder Checklist. Individual trajectories for conduct and emotional problems were identified via growth curve modelling. Hyperactive/inattentive traits were included within the growth curve model as a time-varying covariate to determine their effect on these outcomes. Finally, participants were split into two groups (below and above clinical threshold ASTs Groups) and multi-group invariance testing was conducted on the data to identify the moderating effect of ASTs on the relationship between hyperactive/inattentive traits and outcomes (i.e. conduct and emotional problems).

RESULTS

Hyperactive/inattentive traits were associated with higher rates of conduct and emotional problems for both boys and girls. The presence of ASTs moderated these relationships for boys, but not for girls, by increasing the risk of boys with hyperactive/inattentive traits developing greater conduct and emotional problems.

CONCLUSIONS

These findings underscore the importance of identifying hyperactive/inattentive traits and ASTs in young people and addressing the increased risk of conduct and emotional problems. Research and clinical implications are explored.

National screening for Egyptian children aged 1 year up to 12 years at high risk of Autism and its determinants: a step for determining what ASD surveillance needs

This study aimed to provide a national estimate of the prevalence of the high risk of autism spectrum disorder (ASD) and their determinants. A national screening survey was conducted for 41,640 Egyptian children aged 1 to 12 years in two phases. Tools used were Vineland's Adaptive Behavior Scales, Modified Checklist for Autism in Toddlers, Gilliam Autism Rating scale, and Denver II Developmental screening test. The overall prevalence of children at high risk of ASD was 3.3% (95% CI:3.1%-3.5%). Children living without mothers in homes, suffered from convulsions (AOR = 3.67; 95%CI:2.8-4.8), a history of cyanosis after birth (AOR = 1.87; 95% CI:1.35-2.59) or history of LBW babies (AOR = 1.53; 95% CI:1.23-1.89) carried higher odds of being at high risk of ASD.

National screening for Egyptian children aged 1 year up to 12 years at high risk of Autism and its determinants: a step for determining what ASD surveillance needs

This study aimed to provide a national estimate of the prevalence of the high risk of autism spectrum disorder (ASD) and their determinants. A national screening survey was conducted for 41,640 Egyptian children aged 1 to 12 years in two phases. Tools used were Vineland's Adaptive Behavior Scales, Modified Checklist for Autism in Toddlers, Gilliam Autism Rating scale, and Denver II Developmental screening test. The overall prevalence of children at high risk of ASD was 3.3% (95% CI:3.1%–3.5%). Children living without mothers in homes, suffered from convulsions (AOR = 3.67; 95%CI:2.8–4.8), a history of cyanosis after birth (AOR = 1.87; 95% CI:1.35–2.59) or history of LBW babies (AOR = 1.53; 95% CI:1.23–1.89) carried higher odds of being at high risk of ASD.

IQ trajectories in autistic children through preadolescence

BACKGROUND

We extended our study of trajectories of intellectual development of autistic individuals in early (mean age 3 years; T1), and middle childhood (mean age 5 years, 7 months; T2) into later middle childhood/preadolescence (mean age 11 years, 6 months; T3) in the longitudinal Autism Phenome Project cohort. Participants included 373 autistic children (115 females).

METHODS

Multivariate latent class growth analysis was used to identify distinct IQ trajectory subgroups. Baseline and developmental course group differences and predictors of trajectory membership were assessed using linear mixed effects models with repeated measures with pairwise testing, multinomial logistic regression models, and sensitivity analyses.

RESULTS

We isolated three IQ trajectories between T1 and T3 for autistic youth that were similar to those found in our prior work. These included a group with persistent intellectual disability (ID; 45%), a group with substantial increases in IQ (CHG; 39%), and a group with persistently average or above IQs (P-High; 16%). By T3, the groups did not differ in ADOS-2 calibrated severity scores (CSS), and there were no group differences between Vineland (VABS) communication scores in CHG and P-High. T1-T3 externalizing behaviors declined significantly for CHG, however, there were no significant T3 group differences between internalizing or externalizing symptoms. T1 correlates for CHG and P-High versus ID group membership included higher VABS communication and lower ADOS-2 CSS. A T1 to T2 increase in VABS communication scores and a decline in externalizing predicted CHG versus ID group membership at T3, while T1 to T2 improvement in VABS communication and reduction in ADOS-2 CSS predicted P-High versus ID group membership.

CONCLUSIONS

Autistic youth exhibit consistent IQ developmental trajectories from early childhood through preadolescence. Factors associated with trajectory group membership may provide clues about prognosis, and the need for treatments that improve adaptive communication and externalizing symptoms.

Sex Differences in the Developmental Trajectories of Autism Spectrum Disorder

Purpose of Review

Females and males are disproportionately diagnosed with autism, a sex difference that has historically represented this neurodevelopmental condition. The current review examines lifespan developmental trajectories of autism based on sex to elucidate behavioral phenotypic differences that may contribute to differential rates of diagnosis.

Recent Findings

We review sex differences in diagnostic criteria: social communication and restricted interests/repetitive behaviors (RRBs). Results suggest RRBs are more indicative of a diagnosis in males, whereas social differences are more indicative of a diagnosis in females. Factors contributing to a later diagnosis in females include social strengths (camouflaging) and diagnostic overshadowing.

Summary

Sex differences in diagnostic criteria may contribute to differential rates of identification in males and females. Sex differences are most pronounced when assessing naturalistic social communication instead of reliance on standardized measure. Numerous future directions are identified including increasing samples of sub-threshold autistic females and evaluating longitudinal sex differences.

Intellectual disabilities moderate sex/gender differences in autism spectrum disorder: a systematic review and meta-analysis

BACKGROUND

Girls/women with autism spectrum disorder (ASD) are suggested to exhibit different symptom profiles than boys/men with ASD. Accumulating evidence suggests that intellectual disability (ID) may affect sex/gender differences in ASD. However, a systematic review and meta-analysis on this topic is missing.

METHODS

Two databases (MEDLINE and PsycINFO) were used to search for studies reporting sex/gender differences (girls/women versus boys/men) in social communication and interaction, restrictive and repetitive behaviour and interests (RRBIs), sensory processing, and linguistic and motor abilities in ASD. The final sample consisted of 79 studies. The meta-analysis was performed with Review Manager using a random-effects model. Participants with ASD without and with ID were analysed as separate subgroups, and the effects in these two subgroups were also compared with each other.

RESULTS

Girls/women with ASD without ID displayed fewer RRBIs, more sensory symptoms and less problems in linguistic abilities than their boys/men counterparts. In contrast, girls/women with ASD with ID displayed more social difficulties and RRBIs, poorer linguistic abilities and more motor problems than boys/men with ASD with ID. Comparisons of groups of participants with ASD without ID versus participants with ASD with ID confirmed differences in sex/gender effects on social difficulties, sensory processing, linguistic abilities and motor abilities.

CONCLUSIONS

Our results clearly suggest that the female phenotype of ASD is moderated by ID. Among individuals with ASD with ID, girls/women seem to be more severely affected than boys/men, whereas among individuals with ASD without ID, girls/women with ASD may have less symptoms than boys/men. Such phenotypic differences could be a potential cause of underrecognition of girls/women with ASD, and it is also possible that observed phenotypic differences may reflect underdiagnosing of girls/women with ASD.

Structural and Pragmatic Language Impairments in Children Evaluated for Autism Spectrum Disorder (ASD)

Pragmatic language impairments are common in neurodevelopmental disorders, especially in autism spectrum disorder (ASD). The relationship between structural language skills and pragmatic competence in children with autistic symptoms, however, is largely unknown. We investigated this relationship based on the Children's Communication Checklist-2 and early language delay among children (N = 177, 19% females) clinically evaluated for ASD, differentiated into ASD (n = 148) and non-ASD (n = 29). Structural language deficits were common and associated with reduced pragmatic competence in both groups. Pragmatic language impairments were most profound in children with ASD. Early language delay and structural language deficits were less common in females. Our findings suggest that assessment of structural language skills should be included in the evaluation of children with suspected ASD.

Does the gender matter?: Anxiety symptoms and emotion dysregulation in adults with autism and intellectual disabilities

Research shows high rates of anxious symptoms in people autistic spectrum disorder (ASD). Finding factors related to the development of anxiety in ASD is necessary. Emotion regulation (ER) is associated with anxiety in ASD. Moreover, some studies find higher rates of anxiety in women with ASD. A total of 121 adults (M = 35.46 years, SD = 9.46) with ASD and intellectual disabilities were evaluated to verify moderating role of gender and mediating role of ER. A moderated mediation analysis supported the moderated role of gender in the relationship mediated by emotional dysregulation between ASD and anxiety. These findings suggest that interventions designed to prevent or reduce anxiety symptoms in women with ASD should include among their goals emotional regulation. LAY SUMMARY: If we want to reduce or prevent anxiety symptoms in women with ASD we must work on emotional regulation.

Friendship quality among autistic and non-autistic (pre-) adolescents: Protective or risk factor for mental health?

Autistic young people are often misunderstood by non-autistic young people, and this can lead to difficulties in their friendships. We know that friendship is very important for our mental health. For non-autistic young people, having good friendships is linked to better mental health and having problems in friendship can cause mental health problems. This study aimed to compare the positive and negative features of friendship that autistic non-autistic young people experience. The study also aimed to understand if having positive or negative friendship features is related to signs of mental health problems (anxiety and depression). 306 young people aged 9-16 took part in this study. These were 86 autistic boys, 18 autistic girls, 91 non-autistic boys and 111 non-autistic girls. The findings of this study showed that autistic young people have less positive friendship features than non-autistic young people. For all young people in the study, having more positive friendship features was related to fewer signs of depression, while having more negative friendship features was related to more signs of depression. Just for autistic girls, having more positive friendship features was related to more signs of anxiety. These findings show that support is needed to help autistic young people have more positive friendships. For example, by teaching non-autistic young people how to be supportive friends to their autistic peers.

Parent experiences of obtaining an autism diagnosis for their daughter: An interpretative phenomenological analysis

LAY ABSTRACT

Autistic females are often diagnosed later than males and are also more likely to be misdiagnosed with other conditions. Co-occurring conditions may also be diagnosed at the time of the assessment but their autism diagnosis is missed. The majority of research examining the parent experience of obtaining an autism diagnosis for their child has included predominantly or exclusively male children in their samples. This study examines the experiences of parents in obtaining an autism diagnosis for their daughters in Australia through interview data which allowed for an exploration of their lived experiences. Several of the parents reported positive feelings of excitement or curiosity in relation to the assessment process which are emotions that have not been reported in earlier studies. While recent research advances have improved our understanding of gender differences in autistic behaviours, the findings of this study suggest that some practitioners have obsolete knowledge which may lead to misdiagnosis or missed diagnosis in some females. Although the extent that these experiences are representative of parents in the wider community is unknown, the fact that they are still being reported in the present day suggests that a proportion of health professionals continue to practice with outdated conceptualisations of autism.

Understanding the heterogeneity of anxiety in autistic youth: A person-centered approach

The present study aimed to examine anxiety profiles among children and adolescents on the autism spectrum. It further aimed to characterize the association between the identified anxiety profiles and key clinical and developmental variables. The Spence Children's Anxiety Scale-Parent Version (SCAS-P) data from a large international pooled sample of 870 caregivers of autistic children and adolescents (M_age  = 11.6 years, SD_age  = 2.77; 107 females) was used. Latent profile analysis identified a three-anxiety profile solution exhibiting high entropy (0.80) and high latent profile probabilities, with good classification accuracy. Identified profiles fell along the severity spectrum and were named as the mild (n = 498), moderate (n = 272) and severe (n = 100) anxiety profiles. There were no statistically significant differences between the three anxiety profiles in terms of sex distribution. Participants in the mild profile were significantly younger than those in the severe profile, had significantly fewer social communication difficulties than youth in the moderate anxiety profile group and had significantly fewer restricted and repetitive behaviors and lower cognitive functioning scores compared to participants in moderate and severe anxiety profiles. This is the first study to move beyond identifying associations and group-level differences to exploring and identifying characteristics of anxiety-based subgroups at an individual level that differ on key clinical and developmental variables. The subgroups identified in this study are a preliminary, yet important, first step towards informing future assessment and individualized interventions aiming to support young people on the autism spectrum to reduce and manage anxiety. LAY SUMMARY: This study tried to understand if there are subgroups of autistic young people who may have similar anxiety profiles. We found that we could meaningfully group young people into three groups based on how severe the anxiety symptoms their caregivers reported were: a group with low levels of anxiety, those with moderate anxiety, and those with more severe anxiety. We also found that the young people in the mild group were younger, had fewer autism traits and lower levels of intellectual functioning than young people in the other two groups.

Sex Differences in Autism Spectrum Disorder: Diagnostic, Neurobiological, and Behavioral Features

Autism Spectrum Disorder (ASD) is a complex neurodevelopmental disorder with a worldwide prevalence of about 1%, characterized by impairments in social interaction, communication, repetitive patterns of behaviors, and can be associated with hyper- or hypo-reactivity of sensory stimulation and cognitive disability. ASD comorbid features include internalizing and externalizing symptoms such as anxiety, depression, hyperactivity, and attention problems. The precise etiology of ASD is still unknown and it is undoubted that the disorder is linked to some extent to both genetic and environmental factors. It is also well-documented and known that one of the most striking and consistent finding in ASD is the higher prevalence in males compared to females, with around 70% of ASD cases described being males. The present review looked into the most significant studies that attempted to investigate differences in ASD males and females thus trying to shade some light on the peculiar characteristics of this prevalence in terms of diagnosis, imaging, major autistic-like behavior and sex-dependent uniqueness. The study also discussed sex differences found in animal models of ASD, to provide a possible explanation of the neurological mechanisms underpinning the different presentation of autistic symptoms in males and females.

Sex- and age-related differences in autistic behaviours in children with neurofibromatosis type 1

This study investigated sex and age differences in autistic behaviours in children with neurofibromatosis type 1 (NF1) who scored within the clinical range on the Social Responsiveness Scale - Second Edition (T score ≥ 60). Thirty-four males and 28 females (3-16 years) were assessed with the Autism Diagnostic Observation Schedule - Second Edition and Autism Diagnostic Interview - Revised. Across both measures, males exhibited greater social communication deficits relative to females. Age-related abatement of social communication difficulties was observed for males but not females. Conversely, no sex differences were found for restricted/repetitive behaviours, which were stable over time for both males and females. The findings are discussed within the context of broader neurodevelopmental considerations that are common in NF1.

Sex/gender differences in children with autism spectrum disorder: A brief overview on epidemiology, symptom profile, and neuroanatomy

Autism spectrum disorders (ASD) are a heterogeneous group of neurodevelopmental conditions whose shared core features are impairments in social interaction and communication as well as restricted patterns of behavior, interests, and activities. The significant and consistent male preponderance in ASD prevalence has historically affected the scientific knowledge of autism in females as regards, inter alia, the clinical presentation, the genetic architecture, and the structural brain underpinnings. Indeed, females with ASD are under-investigated as samples recruited for clinical research typically reflect the strong male bias of the disorder. In the last years, the study of the various aspects of sex/gender (s/g) differences in ASD is gaining increased clinical and research interest resulting in a growing number of investigations on this topic. Here, I review and discuss evidence emerged from epidemiological, clinical, and neuroimaging studies in the last decade focusing on s/g differences in children with ASD. These studies are the prerequisites for the development of assessment and treatment practices which take into consideration s/g differences in ASD. Ultimately, a better understanding of s/g differences aims at improving healthcare for both ASD males and females.

Missed diagnoses and misdiagnoses of adults with autism spectrum disorder

Autism spectrum disorder (ASD) is a group of life-long neurodevelopmental disorders affecting 1.5% of the general population. The present study aimed to evaluate the psychiatric history of a group of adults who received the first diagnosis of ASD in two Italian university centers. Diagnoses of ASD were confirmed by a team of psychiatrists with wide expertise in the field, after the administration of standardized tools (i.e., ADOS-2, ADI-R). The sample comprised 161 participants, of which 114 (79.5%) were males. The median age of diagnosis was 23 years (range 18-55), with a median IQ of 100 (range 30-145). The first evaluation by a mental health professional was performed at a median age of 13 years, with a gap of 11 years between the first evaluation and the diagnosis of ASD. 33.5% of participants had never received a psychiatric diagnosis, while the rest of the sample had received one or more diagnoses different from ASD. The most common past diagnoses were intellectual disability, psychoses, personality disorders, and depression. Sex differences were detected in the age of diagnosis and ADOS-2 scores. Our results provide important information for both child and adult psychiatrists. Given the prevalence of autism and the high rates of co-occurrent psychiatric conditions, it is important for clinicians to consider ASD in the differential diagnostic process.

Self-Perceived Quality of Life in Spanish-Speaking Women with Autism Spectrum Disorders

Perceived personal wellbeing tends to be lower in individuals with autism spectrum disorders (ASD), especially in the case of women. To develop the present study, the Personal Wellbeing Index (PWI-A) was administered to a Spanish-speaking sample of women with ASD (N = 401) and self-diagnosed ASD (N = 343), women without ASD (N = 373) and men with ASD (N = 65) to compare their self-perceptions. Women with ASD showed significantly lower wellbeing rates than women in the control group for the total PWI-A and across all the domains, and there were no significant differences when compared with self-diagnosed women with ASD and men with ASD. Autism explained between 24 and 26% of the decline in the PWI-A total score, with life achievement, future security, safety and relationships being the domains most highly correlated with the total. These findings are an effective contribution to improving diagnosis and professional intervention in women with ASD.

Validity of the patient health questionnaire 9-item in autistic youths: a pilot study

BACKGROUND

Autistic adolescents have greater predisposition to depression and suicidality than neurotypical adolescents. Early detection is essential for timely treatment. The Patient Health Questionnaire 9-item (PHQ-9) is a brief screen for depression. The study examines the validity of the PHQ-9 for detecting major depressive disorder (MDD) in autistic youths.

METHODS

English speaking youths aged 10-18 years, with DSM-IV/DSM-5/ICD-10 diagnosis of Autism Spectrum Disorder (ASD), and their parents presenting to a child psychiatric service were invited to participate between May 2018 to August 2020. Participants completed the respective self- and parent-rated PHQ-9 independently. MDD was verified using the MINI-Kid (Mini-International Neuropsychiatric Interview, Kid version).

RESULTS

One hundred one youth, mean (SD) age 14.6 (2.3), were enrolled. 27 (27%) met criteria for current MDD. Mean total PHQ-9 scores, percentage ratings for severity of symptoms of depression, functional impairment, dysthymia and suicidality were compared. Areas under the ROC curve and statistically optimal cutoffs were determined. Parents rated depressive symptoms severity lower than their children. The PHQ-9 displayed low sensitivity with high false negative rates at conventional, adjusted and proposed cutoffs.

CONCLUSIONS

Future studies should improve on the validity and reliability of existing depression screening tools, or develop more appropriate screening methods of depression, for autistic youths.

In utero Exposure to Valproic-Acid Alters Circadian Organisation and Clock-Gene Expression: Implications for Autism Spectrum Disorders

Autism Spectrum Disorder (ASD) is a pervasive neurodevelopmental disorder characterised by restrictive patterns of behaviour and alterations in social interaction and communication. Up to 80% of children with ASD exhibit sleep-wake cycle disturbances, emphasising the pressing need for novel approaches in the treatment of ASD-associated comorbidities. While sleep disturbances have been identified in ASD individuals, little has been done to assess the contribution of the circadian system to these findings. The objective of this study is to characterise circadian behaviour and clock-gene expression in a valproic acid (VPA)-induced animal model of autism to highlight perturbations potentially contributing to these disturbances. Male and female VPA-exposed offspring underwent circadian challenges, including baseline light-dark cycles, constant dark/light and light pulse protocols. Baseline analysis showed that VPA-exposed males, but not females, had a greater distribution of wheel-running behaviour across light-dark phases and a later activity offset (p < 0.0001), while controls showed greater activity confinement to the dark phase (p = 0.0256). Constant light analysis indicated an attenuated masking response and an increase in the number of days to reach arrhythmicity (p < 0.0001). A 1-h light pulse (150 lux) at CT 15 after 6 days of constant dark showed that both sexes exposed to VPA exhibited a lesser phase-shift when compared to controls (p = 0.0043). Immunohistochemical and western-blot assays reveal no alterations in retinal organisation or function. However, immunohistochemical assay of the SCN revealed altered expression of BMAL1 expression in VPA-exposed males (p = 0.0016), and in females (p = 0.0053). These findings suggest alterations within the core clockwork of the SCN and reduced photic-entrainment capacity, independent of retinal dysfunction. The results of this study shed light on the nature of circadian dysregulation in VPA-exposed animals and highlights the urgent need for novel perspectives in the treatment of ASD-associated comorbidities.

Autism Through the Ages: A Mixed Methods Approach to Understanding How Age and Age of Diagnosis Affect Quality of Life

A significant proportion of autistic adults today were not diagnosed until later in life, a group referred to as the ‘lost generation,’ which may affect mental health. In Study 1 we explored quality of life and autistic trait levels in 420 autistic and TD adults, and in Study 2 we explored the experiences of 8 autistic adults diagnosed as adults. We found that autistic adults had lower quality of life outcomes and higher autistic trait levels which related to age of diagnosis, and qualitative findings indicated that while adults were empowered by their new diagnosis, they still require specialized supports. Our findings are discussed, emphasizing future directions and implications for the current care system in place for autistic adults.

Camouflaging in autism spectrum disorder: Examining the roles of sex, gender identity, and diagnostic timing

LAY ABSTRACT

Camouflaging in autism spectrum disorder refers to behaviors and/or strategies that mask the presentation of autism spectrum disorder features in social contexts in order to appear "non-autistic" (Attwood, 2007). Camouflaging modifies the behavioral presentation of core autism spectrum disorder features (e.g. social and communication differences), but the underlying autistic profile is unaffected, yielding a mismatch between external observable features and the internal lived experience of autism. Camouflaging could be an important factor in later diagnosis of individuals without co-occurring intellectual disability, especially among those designated female sex at birth. Little research to date has examined how gender identity impacts camouflaging, however. Furthermore, no study has compared groups that differ in diagnostic timing to directly investigate if later-diagnosed individuals show elevated camouflaging relative to those receiving an earlier diagnosis. We used the Camouflaging Autistic Traits Questionnaire subscales (Assimilation, Compensation, and Masking) and investigated the roles of sex, gender identity (gender diverse vs cisgender), and diagnostic timing (childhood/adolescent-diagnosed vs adult-diagnosed), and the interactions of these factors, in autistic adults (N = 502; ages 18-49 years). Main effects of sex, gender identity, and diagnostic timing were revealed. Autistic females reported more camouflaging across all three Camouflaging Autistic Traits Questionnaire subscales compared to males. Gender diverse adults reported elevated camouflaging on the Compensation subscale compared to cisgender adults. Adulthood-diagnosed individuals reported elevated Assimilation and Compensation compared to childhood/adolescence-diagnosed individuals. We discuss how the aspects of camouflaging may have unique implications for later diagnostic timing and for the intersection of neurodiversity and gender diversity.

Presenting age and features of females diagnosed with autism spectrum disorder

AIM

Autism spectrum disorder (ASD) is reportedly more prevalent in males than in females. Hypotheses for this gender imbalance include differing presentations in females. The aim of this study was to identify gender-based ASD differences in age at presentation, clinical features, comorbidities and severity levels.

METHODS

A cross-sectional study was conducted at a Child Development Unit. Children diagnosed with ASD during a 6-month period were analysed.

RESULTS

A total of 195 children were analysed with a male-to-female ratio of 2.8:1. No difference was found between gender and age at diagnosis. Males were more likely to display deficits in imaginative play and use repeated or learned phrases. Females were more likely to present with proprioception and vestibular issues, fears reflecting sensory avoidance and ASD of lesser severity.

CONCLUSION

Our study supports the hypothesis that gender-based differences exist within ASD presenting features. These differences should be considered when assessing for ASD in females to avoid under recognition.

Capacity of the CCC-2 to Discriminate ASD from Other Neurodevelopmental Disorders

The Children’s Communication Checklist (CCC-2) has demonstrated its usefulness as an instrument to assess discrepancies between the use of structural dimensions of language and the pragmatic and sociointeractive uses of language. The aims of the present paper are: (1) to test the capacity of the Galician adaptation of the CCC-2 to discriminate the linguistic profiles of children with different disorders and (2) to test whether the capacity of the CCC-2 to discriminate the linguistic abilities of children with different disorders is the same at different ages: earlier development and later development. The sample is of 117 children previously diagnosed with different disorders: autism spectrum disorder (ASD), developmental language disorder (DLD), attention deficit with hyperactivity disorder (ADHD), Down syndrome children (DS) and typically developing children (TD). The children were divided into two different age groups: from 4 to 6 and from 7 to 16 years of age. The results indicate that the Galician CCC-2 (1) accurately identified children with and without communicative impairments, (2) distinguished between profiles with a predominance of pragmatic (ASD and ADHD) and structural disorders (DS and DLD) and (3) distinguished between different profiles of pragmatic impairment. The CCC-2 equally identified these profiles at both earlier and later ages. The Galician CCC-2 seems to be a useful instrument for differentiating among different clinical groups and for assessing pragmatic disorders from an early age, which can be valuable for planning early intervention.

Anthropometric Analysis of the Orbital Region in Children With Autism Spectrum Disorder and Healthy Controls

ABSTRACT

It was aimed to examine the orbital region in children with autism spectrum disorder and comparison with the healthy controls in the present study. A total of 195 children and adolescents (101 of them were in the autism group, 94 of them were in healthy group) were evaluated. Anterior view photographs were taken, and endocanthion (en), exocanthion (ex), and pupil were determined bilaterally on the photographs. Outer canthal (ex-ex), intercanthal (ex-en), inner canthal (en-en) and interpupillary distances were measured and intercanthal index [(en-en / ex-ex) × 100] was calculated. There was a statistically significant difference between the groups for males for all parameters, while a statistically significant difference was not observed for females. All orbital region distances were higher in male autistic children. Although minor physical anomalies in children and adolescents with autism have been reported before, anthropometric measurements in individuals with autism may differ between genders. Further studies are needed to investigate the differences between genders in autism spectrum disorder.

Sex Differences in Autism Spectrum Disorder: Focus on High Functioning Children and Adolescents

Autism Spectrum Disorder (ASD) has historically been studied, known, and diagnosed in males. Females tend to remain unidentified, especially those with average intelligence abilities. This sex/gender difference might be partially explained by biological risk factors, but it is probably also bound to methodological issues. The present study aims to examine phenotypic characteristics (cognitive, emotive, socio-communicative, and academic) of a group of 54 females with ASD matched to a group of 55 males with ASD (3-18 years), all without cognitive impairment. Results suggest that there are subtle, yet potentially meaningful, quantitative, and qualitative phenotypic differences between females and males that common screening tests are not always sensitive enough to recognize. Further studies to improve practice and course for the assessment of females, reducing sex/gender-based inequities in ASD care, are required.

An Exploration of Physical and Phenotypic Characteristics of Bangladeshi Children with Autism Spectrum Disorder

This study explored the physical and clinical phenotype of Bangladeshi children with autism spectrum disorder (ASD). A totally of 283 children who were referred for screening and administered Module 1 of the Autism Diagnostic Observation Schedule (ADOS) were included. Overall, 209 met the ADOS algorithmic cutoff for ASD. A trend for greater weight and head circumference was observed in children with ASD versus non-ASD. Head circumference was significantly (p < 0.03) larger in ASD males compared with non-ASD males. A trend was also observed for symptom severity, higher in females than males (p = 0.068), with further analyses demonstrating that social reciprocity (p < 0.014) and functional play (p < 0.03) were significantly more impaired in ASD females than males. The findings help understand sex differences in ASD.

Autism spectrum disorder: An examination of sex differences in neuropsychological and self-report measures of executive and non-executive cognitive function

LAY ABSTRACT

Research comparing females and males with a diagnosis of autism suggests that there are sex differences in some characteristics such as behaviour regulation. One area not studied in detail is whether females and males with autism perform differently in tests of cognitive ability. The results of previous research are quite mixed. One explanation may be that some research comparing females and males with autism did not include a neurotypical control group for comparison. As a result, it is not clear whether the sex differences in cognitive ability observed in people with autism are similar to differences between neurotypical males and females. To better understand whether there are unique differences between males and females with autism, it is important to also compare them with neurotypical males and females. In our research, we included a neurotypical group and compared males and females with and without a diagnosis of autism. We found that the sex differences in autism are similar to what we observe in males and females without autism. Our study showed that compared with males, females (with and without autism) do better in assessments of processing speed, cognitive flexibility, verbal learning and memory and semantic fluency. Our results suggest that although females show different cognitive performance to males, these sex differences were not specific to the group with a diagnosis of autism.