High-functioning autism and Asperger's disorder: utility and meaning for families

Autistic identity: A systematic review of quantitative research

Autism can be considered both a personal and social identity. Identifying the factors contributing to positive Autistic identity development is crucial given the potential implications for mental health and wellbeing. In this systematic review, we aimed to synthesize quantitative literature on Autistic identity to identify the (individual and environmental) factors associated with Autistic identity, and to ascertain the relationship between Autistic identity and mental health and wellbeing. A total of 3,617 studies were screened and 20 met our inclusion criteria. Results indicated that people developed a more positive Autistic identity when receiving external autism acceptance and external support. The association between individual factors and Autistic identity were largely nonsignificant or inconclusive, highlighting the need for broad support that meets the needs of a range of Autistic people, rather than specific subgroups. Importantly, positive Autistic identity was associated with improved mental health and wellbeing. Peer support and/or self-directed support resources may be valuable mechanisms for supporting Autistic people to cultivate a positive Autistic identity. The evaluation of such support, including the long-term impacts on identity development, will be a critical avenue for future research.

May Female Autism Spectrum Be Masked by Eating Disorders, Borderline Personality Disorder, or Complex PTSD Symptoms? A Case Series

Introduction: The prevalence of Autism Spectrum Disorder (ASD) is four times higher in males than females; however, females are significantly more likely to go undiagnosed due to the existence of a "female autistic phenotype", a manifestation unique to females that conflicts with conventional, masculine conceptualizations of ASD. Furthermore, subthreshold autistic traits, which exert a significantly negative impact on quality of life and represent a vulnerability factor for the development of other psychopathological conditions, may remain even more under-recognized. Subsequently, many women with ASD may never receive a diagnosis or any resulting care, with serious consequences for their health. Aims: We aimed to describe two brief cases in order to confirm the diagnostic difficulties that ASD female undergo during their clinical evaluation and the possible alternative phenotype that they can manifest. Methods: We reported the cases of two young women on the autism spectrum that came to clinical attention only after the development of severe symptomatology attributed to other mental disorders, overlooking the presence of underlying autism spectrum features and a brief résumé of the literature on this topic. Results: These cases confirm the need for a timely and proper identification of females on the autism spectrum in order to prevent complications and improve the outcome. Conclusions: Research on gender differences could lead to a reexamination of the sex ratio in the prevalence of ASD and provide a better understanding of several psychiatric conditions that are frequently diagnosed in women, supporting the neurodevelopmental approach to psychopathology.

Mapping the Dilemmas Parents Face with Disclosing Autism Diagnosis to their Child

The diagnosis of autism is often delivered solely to the parents, a practice that forces them to confront the dilemma of whether, when and how they should disclose it to the child. The present study seeks to probe deeper into the phenomenon of diagnosis disclosure and lead to a clearer understanding of the dilemmas parents? face. This article presents an analysis of a focus group and an online survey conducted with parents. The analysis produced a model that maps parents' dilemmas regarding diagnosis disclosure to their child. The dilemmas, found to be complex and interconnected, concern the invisible nature of autism, the word autism and stigma, time motif, child's environment, the act of disclosure itself, and the child's personal narrative.

Cognitive behavior therapy for autistic adolescents, awareness and care for my autistic traits program: a multicenter randomized controlled trial

BACKGROUND

Autistic people demonstrate focused interests, sensitivity to sensory stimulation, and, compared with the general population, differences in social communication and interaction. We examined whether a combination of the Awareness and Care for My Autistic Traits (ACAT) program and treatment-as-usual is more effective than only treatment-as-usual in increasing the understanding of autistic attributes, reducing treatment stigma, and improving mental health and social adaptation among autistic adolescents and their parents/guardians.

METHODS

Forty-nine adolescents and their parents/guardians were randomly assigned to either a combination of ACAT and treatment-as-usual or only treatment-as-usual. The combined group received six weekly 100-minute ACAT sessions, while the treatment-as-usual group received no additional intervention. The primary outcome was the change in understanding of autistic attributes (Autism Knowledge Quiz-Child), administered from pre- to post-intervention. The secondary outcomes included the change in Autism Knowledge Quiz-Parent, reduced treatment stigma, and improved mental health and social adaptation among autistic adolescents and their parents/guardians. A primary outcome measure scale was scored by assessors who were blind to the group assignment.

RESULTS

The combined group (both autistic adolescents and their parents/guardians) showed an increase in Autism Knowledge Quiz scores compared to those in the treatment-as-usual group. Autistic adolescents in the combined group also demonstrated a decrease in treatment-related stigma and an improvement in general mental health compared to those in the treatment-as-usual group, while there were no group differences in the change in social adaptation. For parents/guardians, there were no group differences in the change in treatment-related stigma, general mental health, adaptive skills, or attitudes toward their children.

CONCLUSIONS

The ACAT program could be an effective treatment modality to increase the understanding of autistic attributes among both autistic adolescents and their parents/guardians. The ACAT program positively affects self-understanding, reduces treatment stigma, and stabilizes behavioral issues for autistic adolescents as a part of mental health measures, but it does not effectively reduce treatment barriers or improve mental health for parents/guardians. Further research should consider whether additional support for parents/guardians could be beneficial.

TRIAL REGISTRATION

The study was registered in UMIN (UMIN000029851, 06/01/2018).

The Diagnostic Process for Children with Autism Spectrum Disorder: A Preliminary Study of Jordanian Parents' Perspectives

Although extensive research has been conducted worldwide to investigate the diagnostic process of Autism Spectrum Disorder (ASD), Jordanian parents' experiences have been overlooked. This study explored parents' journeys toward receiving diagnoses for their children with ASD. In particular, it aimed to provide a clear picture of the process for obtaining these diagnoses for children in Jordan.

METHODS

Eighteen semi-structured interviews were carried out with 12 mothers and six fathers of children with ASD aged 5 to 11 years old.

RESULTS

The coding process was based on a thematic analysis method and resulted in the identification of three overlapping themes: dissatisfaction with professionals' abilities to approach parents, an unstructured diagnostic process, and perspectives on diagnosis tools.

CONCLUSIONS

Our data upheld the idea that parental satisfaction with the diagnostic process is influenced by the duration of the process, the information provided, the support offered, and the communication approach used by professionals. Within the local cultural context, parents were significantly impacted by the societal stigma associated with disability when they sought diagnoses for their children with ASD.

Autistic women's experiences of self-compassion after receiving their diagnosis in adulthood

Knowledge of autistic individuals' experiences of self-compassion is very limited. This study investigated autistic women's experiences of self-compassion after receiving their diagnosis in adulthood. Eleven autistic women were interviewed about their experiences of receiving their diagnosis in adulthood and their experiences of self-compassion. Systematic analysis of the interview transcripts revealed common themes in the participants' experiences. Participants reported that their autism diagnosis helped them to better understand themselves, particularly when reflecting on problematic past experiences. After receiving an autism diagnosis, participants described being able to relate to themselves with greater self-kindness compared to previous self-criticism; this included allowing themselves to assert their needs and engage in self-care activities. Participants spoke about having difficult social experiences, including feeling pressure to conform to expectations in society and often feeling misunderstood. The findings highlight the barriers autistic women face obtaining their diagnoses and demonstrate the need for autism training for professionals to support early identification. Findings from this study suggest that interventions aimed at developing self-compassion could support and enhance autistic women's well-being.

A comparison of self-report and discrepancy measures of camouflaging: Exploring sex differences in diagnosed autistic versus high autistic trait young adults

Camouflaging describes masking or compensating for autistic traits and/or related difficulties. Some evidence suggests autistic females camouflage more than autistic males, potentially contributing to delayed or missed diagnosis. Studies predominantly adopt self-report measures of camouflaging, potentially reflecting a person's intent to camouflage without accurately measuring effectiveness (i.e., success in fulfilling the intended effect of minimizing the appearance of autistic traits) of camouflaging. Discrepancy scores between underlying cognitive difficulties (e.g., theory of mind) and observed autistic traits (henceforth camoToM ), or between self-reported autistic traits and observed autistic traits (henceforth camoSRS ), may provide a more accurate measure of camouflaging effectiveness. Three measures of camouflaging administered to autistic males (n = 46) and females (n = 40), and adults with equally high levels of autistic traits but no diagnosis (n = 45 males, n = 43 females) recruited from a large population-based sample were compared. Self-report measures of camouflaging were significantly correlated with camoSRS scores only. Both discrepancy scores were correlated with each other. Adults with high autistic traits, but no diagnosis, had higher discrepancy camouflaging scores than diagnosed adults, but self-reported scores were similar. Diagnosed females scored higher than diagnosed males across all camouflaging measures, but no sex difference occurred in the high trait group. This might indicate that autistic females have higher intentions and greater effectiveness when camouflaging, compared with autistic males. For camoSRS only, high trait males scored significantly higher than diagnosed males; no group difference occurred for females. These results suggest that, despite all participants intending to camouflage to some extent, effective camouflaging as measured by discrepancy scores is higher in undiagnosed high autistic trait individuals. One interpretation is that effective camouflaging reduces the likelihood of autism diagnosis in males and females with high autistic traits.

“I Always Knew I Was Different”: Experiences of Receiving a Diagnosis of Autistic Spectrum Disorder in Adulthood—a Meta-Ethnographic Systematic Review

A broadening of diagnostic criteria and increased awareness of autism has led to a large number of individuals whose difficulties remained undetected until adulthood. This systematic review aimed to synthesise empirical evidence of the experience of individuals who received their diagnosis of autism in adulthood. Eight studies met the inclusion criteria. A meta-ethnographic approach was used to synthesise the findings. Analysis revealed two meta-themes: feeling “like an alien” and the “not guilty” verdict, each with three associated subthemes. The findings indicate the need for timely diagnosis and provision of post-diagnostic support to alleviate the mental health implications of not having a framework to understand one’s experiences and to support the process of adjustment to the diagnosis.

Autism-related language preferences of English-speaking individuals across the globe: A mixed methods investigation

Over the past two decades, there have been increasing discussions around which terms should be used to talk about autism. Whilst these discussions have largely revolved around the suitability of identity-first language and person-first language, more recently this debate has broadened to encompass other autism-related terminology (e.g., 'high-functioning'). To date, academic studies have not investigated the language preferences of autistic individuals outside of the United Kingdom or Australia, nor have they compared levels of endorsement across countries. Hence, the current study adopted a mixed-methods approach, employing both quantitative and qualitative techniques, to explore the linguistic preferences of 654 English-speaking autistic adults across the globe. Despite variation in levels of endorsement between countries, we found that the most popular terms were similar-the terms 'Autism', 'Autistic person', 'Is autistic', 'Neurological/Brain Difference', 'Differences', 'Challenges', 'Difficulties', 'Neurotypical people', and 'Neurotypicals' were consistently favored across countries. Despite relative consensus across groups, both our quantitative and qualitative data demonstrate that there is no universally accepted way to talk about autism. Our thematic analysis revealed the reasons underlying participants' preferences, generating six core themes, and illuminated an important guiding principle-to respect personal preferences. These findings have significant implications for informing practice, research and language policy worldwide.

Phenomenology of gender dysphoria in autism: a multiperspective qualitative analysis

BACKGROUND

Autistic people are overrepresented in gender clinic settings, but limited evidence is available to guide clinical decision making for this patient group. We aimed to generate a comprehensive understanding of the phenomenology of gender dysphoria in autistic people.

METHODS

We conducted a multi-perspectival interpretative phenomenological analysis (IPA), from five different perspectives; autistic young people and adults with experience of gender dysphoria, parents of young people, and clinicians working with autistic people with gender dysphoria in both adult and young person settings (n = 68).

RESULTS

IPA analysis resulted in two themes, 'discovering gender identity' and 'the complexities of moving towards gender comfort'. Participants agreed that there was often an interaction between gender dysphoria and features of autism such as sensory sensitivities. There was relative consensus across groups about the need for autism adaptations to be made in gender clinics. Autistic adults were more likely to see autism as an important identity than young people, but both groups were clear that autism did not impair their understanding of gender. In contrast, some parents and clinicians working with young people expressed concern that autism did impact self-understanding.

DISCUSSION

While the groups tended to agree on the ways in which particular features of autism can compound gender dysphoria, there were a range of perspectives on the ways in which autism impacted on self-knowledge.

CONCLUSION

Recommendations for adaptations when working with autistic people with gender dysphoria are presented.

Neurodiversity and Autism Intervention: Reconciling Perspectives Through a Naturalistic Developmental Behavioral Intervention Framework

Proponents of autism intervention and those of the neurodiversity movement often appear at odds, the former advocating for intensive treatments and the latter arguing that autism must be accepted as a form of diversity. The history of behavioral intervention has understandably outraged many in the Autistic community, though many still value supports focused on quality of life. This commentary argues that Naturalistic Developmental Behavioral Interventions (NDBIs) hold promise for bridging the gap between early intervention and the neurodiversity movement. However, we recognize NDBIs have much room to grow and suggest multiple strategies for improvement. We believe these updates are not only feasible for clinicians and researchers to implement but will ultimately lead to improved quality of life for Autistic individuals.

The forensic implications of camouflaging: a study into victimisation and offending associated with autism and pathological demand avoidance

Purpose

This study aims to investigate the influence of social camouflaging on victimisation and offending in relation to autism and pathological demand avoidance (PDA) traits. Camouflaging aims to overcome or conceal difficulties in social and communication skills. Autistic individuals report camouflaging in response to threat and being verbally and physically assaulted when they have not camouflaged. Thus, camouflaging could be associated with victimisation. Camouflaging could also impact on specialist support available to an individual, potentially increasing the risk of victimisation or offending.

Design/methodology/approach

Cross-sectional study was conducted using 220 participants from the general population who completed online questionnaires measuring victimisation and offending, autism and PDA traits, camouflaging and symptoms of depression and anxiety.

Findings

Correlational analysis found positive associations between camouflaging and victimisation, and camouflaging and lifetime offending. Greater camouflaging and PDA traits predicted greater offending, whereas greater autism traits predicted fewer offending behaviours. While correlated, camouflaging was not significantly predictive of victimisation. Victimisation was predicted by symptoms of depression and PDA traits.

Originality/value

To the best of the authors’ knowledge, this study is the first to consider camouflaging as an influencing factor on offending and victimisation in autistic and PDA individuals.

Realist evaluation of Autism ServiCe Delivery (RE-ASCeD): which diagnostic pathways work best, for whom and in what context? Findings from a rapid realist review

OBJECTIVES

Waiting times in the UK for an autism diagnostic assessment have increased rapidly in the last 5 years. This review explored research (including 'grey' literature) to uncover the current evidence base about autism diagnostic pathways and what works best, for whom and in what circumstances, to deliver high quality and timely diagnosis.

DESIGN

We performed a Rapid Realist Review consistent with recognised standards for realist syntheses. We collected 129 grey literature and policy/guidelines and 220 articles from seven databases (January 2011-December 2019). We developed programme theories of how, why and in what contexts an intervention worked, based on cross comparison and synthesis of evidence. The focus was on identifying factors that contributed to a clearly defined intervention (the diagnostic pathway), associated with specific outcomes (high quality and timely), within specific parameters (Autism diagnostic services in Paediatric and Child & Adolescent Mental Health services in the UK). Our Expert Stakeholder Group, including representatives from local parent forums, national advocacy groups and clinicians, was integral to the process.

RESULTS

Based on 45 relevant articles, we identified 7 programme theories that were integral to the process of diagnostic service delivery. Four were related to the clinical pathway: initial recognition of possible autism; referral and triaging; diagnostic model; and providing feedback to parents. Three programme theories were pertinent to all stages of the referral and diagnostic process: working in partnership with families; interagency working; and training, service evaluation and development.

CONCLUSIONS

This theory informed review of childhood autism diagnostic pathways identified important aspects that may contribute to efficient, high quality and family-friendly service delivery. The programme theories will be further tested through a national survey of current practice and in-depth longitudinal case studies of exemplar services.

TRIAL REGISTRATION NUMBER

NCT04422483.

“We are different, that’s a fact, but they treat us like we’re different-er”: Understandings of autism and adolescent identity development

Purpose

A key development in early adolescence is the active construction of individual identity; for autistic young people, integrating the idea of “being autistic” forms part of this process. The purpose of this paper is to explore identity development from a contextualist perspective, foregrounding young people’s experiences within mainstream educational settings.

Design/methodology/approach

A longitudinal, qualitative methodology was used: semi-structured interviews were conducted annually with 14 autistic young people, their parents and teachers between school years 6 and 9.

Findings

Young people felt different from their neurotypical peers and their acceptance of their diagnosis changed over time as they managed their developing personal and public identities. In pursuit of being treated “normally,” many camouflaged their differences at school, which sometimes involved opting out of school-based support. Adults described their own understandings of autism and discussed the responses of others in the school environment to autistic differences.

Originality/value

The influence of sociocultural discourses of autism on young people’s identity development is discussed and implications for both school based and post-diagnostic support for young people and their families explored.

Exploring an e-learning community's response to the language and terminology use in autism from two massive open online courses on autism education and technology use

LAY ABSTRACT

Within the neurodiversity movement, one recent divergence is in the semantic choice of language when describing autism, as members of the autism and autistic community preferred to use identity-first language (autistic person), whereas professionals were more likely to use person-first language (person with autism). This study explored 803 e-learners' responses from their comments across two massive open online courses on autism education held between 2017 and 2019. Learners agreed that autistic individuals should guide others on which terminology to use when describing autism, and although identity-first language acknowledges autism as part of an individual's identity, it can also conjure up negative stereotypes and be stigmatising. Although family, friends and professionals highlighted that the diagnostic label is a way to facilitate understanding across stakeholder groups and help autistic individuals gain access to support, autistic self-advocates found the process of disclosing autism as a form of disability to conflict with their sense of identity, and broader terms such as 'autism spectrum' failed to capture individual strengths and weaknesses. Semantic language choices may matter less as long as the person's difficulties are clearly acknowledged, with adaptations made to meet their specific needs. Adding to a growing body of literature on terminology use in autism research and practice, we highlight that language used when describing autism should follow the autistic individual's lead, with the primary focus on communicating an individual's strengths and difficulties, to foster a sense of positive autism identity and inclusivity, and enable access to appropriate support.

The Feedback Session of an Autism Assessment: A Scoping Review of Clinical Practice Guideline Recommendations

This review aimed to assess the quality and content of recommendations for delivering an autism diagnosis, published internationally within clinical practice guidelines. Seventeen relevant guidelines were identified. When methodological information was provided, recommendations for feedback were predominantly formed through consensus. Recommendations consistently included who should attend feedback, the timing and mode of delivery, the clinician's manner, and what should be discussed and/or included in an accompanying report. Specific recommendations were not consistent however, and a number of gaps were identified, such as the inclusion of educators and educational specific recommendations. Although individual variation is necessary for autism diagnosis disclosure, agreement on minimum standards of practice is warranted. Further investigation is required to establish best practice.

Self-reported impediments at home, school, and community: autistic adults' first-person accounts of their life trajectories and derived pathways

Objectives: Despite suggestions of strengths and abilities of autistic people, it has been an underexplored area in autism research, the primary focus of which has been on examining differences and atypicalities as deficits rather than strengths. Understanding the self-reported impediments via first-person accounts of autistic adults for facilitating the strengths is an important prerequisite for an in-depth comprehension of the unique diversities and potentialities of autistic people, and roadmap development. Methods: The study is based on qualitative phenomenological inductive thematic analysis through in-depth interviews with 10 verbally- and cognitively-able autistic adults, following purposive and snowball sampling. Results: The impediments at home, school, and communities are presented through the five inductively extracted themes. Additionally, the study proposes future pathways for fostering an effective environment to nurture the innate potentialities of autistic people via a strength-focused lens. Conclusion: The study endorses the paradox of strength and atypicalities and advocates a shift from a deficit-focused approach to a strength-focused approach of support, and promotes the neurodiverse model of acceptance and embrace.

A preliminary study of schema therapy for young adults with high-functioning autism spectrum disorder: a single-arm, uncontrolled trial

OBJECTIVE

Psychological problems associated with isolation and mistrust are common among young adults with autism spectrum disorder (ASD). Schema therapy (ST) has recently been shown to be effective against chronic personality problems of various mental disorders, including personality disorders. This pilot clinical trial aimed to explore the feasibility and acceptability of ST in young adults with high-functioning ASD.

RESULTS

Following the intervention, a significant reduction in early maladaptive schemas and improvements in quality of life and social adjustment were observed. ST may be feasible and is applicable to young adults with HF-ASD. Trial registration UMIN000014535; registered on July 11, 2014.

The Actor-Partner Effects of Parenting Stress on Quality of Life Among Parents of Children with ASD: The Mediating Role of Mental Quality of Life

The present study investigated the actor-partner effects of parenting stress (PS) on quality of life (QoL) among parents (96 couples) of children with autism spectrum disorder (ASD). Data were collected using the QoL Scale and the PS Index. Structural equation modeling was also utilized to test the hypothesis. The results revealed the effects of PS in each parent on mental QoL of that parent. Maternal PS further shaped physical QoL in mothers. However, PS in one parent did not influence QoL of his or her partner. Accordingly, mental QoL had a mediating role between PS and physical QoL. It was ultimately suggested to take account of QoL among parents in addition to the treatment of children with ASD.

Cognitive-behavioral family therapy as psychoeducation for adolescents with high-functioning autism spectrum disorders: Aware and Care for my Autistic Traits (ACAT) program study protocol for a pragmatic multisite randomized controlled trial

Background

One aim of an autism spectrum disorder (ASD) diagnosis is to obtain special support for the disorder, though this does not guarantee practical support. We developed a psychoeducational program using cognitive-behavioral therapy (CBT) and Aware and Care for my Autistic Traits (ACAT) for Japanese adolescents with high-functioning ASD and their parents.

Methods

This multisite study is a randomized controlled trial. In total, 24 participants will be assigned to the ACAT group and 24 to the treatment-as-usual (TAU) group. The ACAT group will receive a weekly 100-min session for 6 weeks, regular medical care, and one follow-up session. In this ongoing clinical trial, we will compare the scores of the measures recorded in the pre- and post-intervention stages between the ACAT and TAU groups. A total of 41 patients out of a target of 48 have participated in the trial to date. The primary outcome measure is the Autism Knowledge Questionnaire. Secondary outcome measures include Barriers to Access to Care Evaluation 3rd Edition, the Strengths and Difficulties Questionnaire, the Vineland Adaptive Behavior Scales second edition, the Parenting Resilience Elements Questionnaire, the General Health Questionnaire 12, and the Depression Self-Rating Scale for Children assessments, as well as an electroencephalographic recording.

Discussion

It is expected that participants in the ACAT group will significantly increase their self-understanding and awareness of ASD symptoms compared to those in the TAU group. Additionally, the ACAT group is expected to exhibit improved social adaptation and mental health if children and parents are able to better understand the ASD characteristics through sessions. This intervention will contribute to the establishment of an effective evidence-based treatment strategy for adolescents with ASD.

Trial registration

UMIN Register 000029851. Registered on January 06, 2018

Speaking the Same Language? A Preliminary Investigation, Comparing the Language and Communication Skills of Females and Males with High-Functioning Autism

Understanding the nature of language and communication disorders in High-Functioning Autism Spectrum Disorder (HFASD) populations may provide insight into why females are more likely than males to go undiagnosed. Language and communication skills were compared between 13 females and 13 males (aged 8.11–11.06) with HFASD. Gender-normative data was also ascertained from 26 typically developing children (TD) matched for age and gender. All children had typical range PIQ, slight variation here was controlled for in analysis. Results show females outperforming males in pragmatic and semantic tasks and in certain language-of-emotion tasks. TDs outperformed HFASDs in above-sentence level tasks, but not in basic vocabulary or sentence level tasks. This study highlights specific strengths/weaknesses in language and communication for female HFASD, which could aid more accurate identification of the female autistic phenotype. It indicates the need for larger follow up studies in this area.

Parents' multi-layered expectations when requesting an Autism Spectrum Disorder assessment of their young child: an in-depth interview study

BACKGROUND

Parents are valued stakeholders in research, clinical practice and policy development concerning autism spectrum disorder (ASD). However, little is known about what drives and moves parents besides their obvious worries and help request when they ask for a diagnostic ASD assessment of their child.

METHODS

Seventeen Flemish parents of 11 young children participated in a longitudinal study consisting of three in-depth interviews before and after their child's diagnostic ASD assessment. Data were analysed in Nvivo 11 according to the procedures of Interpretative Phenomenological Analysis.

RESULTS

In this paper we report the results of the first series of interviews which were conducted after parents had asked for an ASD assessment of their young child, and before this assessment started. The pre-assessment experiences of the parents were dominated by the anticipation of various implications of an ASD diagnosis, comprising both positive and negative expectations. The theme of positive expectations consisted of two equally prominent subthemes: treatment-related implications but also expectations pertaining to their psychological and relational experiences.

CONCLUSIONS

This study suggests important issues for clinicians to bear in mind during a consultation with parents who request an ASD assessment of their young child. We argue that attending to and communicating about parents' expectations prior to their child's ASD assessment may help clinicians to better understand parents' requests for help, and to address their needs more effectively.

Patterns and Outcomes of Diagnosis Disclosure to Youth with Autism Spectrum Disorder

OBJECTIVE

Although the benefits of diagnosis disclosure have been recognized for a number of pediatric medical conditions, there is a paucity of research about the process by which youth with autism spectrum disorder (ASD) are informed about their diagnosis. The aim of this study was to systematically characterize the antecedents, correlates, and outcomes of diagnosis disclosure to youth with ASD.

METHODS

In this cross-sectional study, parents and guardians of youth with ASD (ages 8-25) completed a detailed online questionnaire about their experiences with diagnosis disclosure. The perceived impact of disclosure on affected youth was also assessed.

RESULTS

Five hundred seventy-five parents of youth with ASD (mean age: 14 years) completed the questionnaire, of whom 81% reported their affected child had been told that he or she had ASD. Most youth who had been told about their diagnosis (86%) were currently aware that they had ASD, according to the parent report. Youth awareness of the diagnosis was reported to be associated with improved self-advocacy skills (60%), enhanced self-awareness of personal strengths (69%) and weaknesses (68%), and other benefits. Youth who had sought information about ASD from support groups and other individuals with ASD had better outcomes regarding self-esteem [adjusted odds ratio = 2.73, 95% confidence interval: (1.34, 3.98)] and acceptance of the diagnosis (p = 0.001) than those who exclusively learned about ASD from other sources.

CONCLUSION

Given the numerous potential benefits of diagnosis disclosure, there is a need for physicians and other professionals to support parents in educating youth with ASD about their diagnosis.

Determinants of an autism spectrum disorder diagnosis in childhood and adolescence: Evidence from the UK Millennium Cohort Study

This study aimed to identify determinants of a late autism spectrum disorder diagnosis, including diagnoses made 'very late' (i.e., in adolescence), using the Millennium Cohort Study, a nationally representative population-based cohort in the United Kingdom. Children diagnosed with autism spectrum disorder by age 14 (N = 581) were included and grouped by the parent-reported timing of diagnosis: before school (up to age 5), during primary school (age 5-11) and during secondary school (age 11-14). Predictors of diagnostic timing, at the child, family and school levels, were investigated using multinomial logistic regression. Most (79%) children with autism spectrum disorder were diagnosed after school entry, and 28% were not diagnosed until secondary school. Among those not diagnosed until secondary school, 75% had been identified at age 5 years by a parent and/or teacher as having socio-behavioural difficulties. Being diagnosed after starting school was predicted by living in poverty (adjusted relative risk ratio: primary = 1.90, 95% confidence interval: 1.03-3.53; secondary = 2.15, 1.05-4.42) and/or having no initial parental concerns (primary = 0.32, 0.15-0.70; secondary = 0.19, 0.09-0.43). Having typical-range intelligence also predicted diagnosis during secondary school. The result indicates that those without cognitive delays and poorer children were at risk of 'very late' (i.e. adolescent) diagnosis. Strategies to promote earlier identification, targeting age at primary school entry, could help those more likely to be diagnosed late.Lay abstractDespite policy emphasis on early identification, many children with autism spectrum disorder are diagnosed late, with some being diagnosed as late as in adolescence. However, evidence on what determines the timing of autism spectrum disorder diagnosis including children diagnosed in adolescence is lacking. Understanding these determinants, particularly in those diagnosed later than is ideal, can inform the development of effective strategies to improve earlier identification of autism spectrum disorder. This study used a nationally representative population-based cohort in the United Kingdom to explore child, family and school level predictors of timing of autism spectrum disorder diagnosis. In the United Kingdom, 79% of the children with autism spectrum disorder were diagnosed after entering primary school and 28% during secondary school. Among those not diagnosed until secondary school, 75% had shown social difficulties noticed by parents and/or teachers at age 5 years. The results suggest that healthcare providers should be aware that, even for universal systems of care, those living in poverty and having higher intelligence are most likely to miss out on a timely diagnosis. Strategies to promote earlier identification among school-aged children, including targeting primary school entry age (i.e. around age 5) and that encouraging referrals for a formal assessment at the first report of concerns over the child's social development may benefit those children who would otherwise be diagnosed later.

Is disclosing an autism spectrum disorder in school associated with reduced stigmatization?

Evidence suggests disclosing an autism diagnosis is associated with reduced stigmatization for autistic adults. However, it is unknown whether this is true for autistic adolescents. We used a vignette-and-questionnaire design to study stigmatizing attitudes with adolescents (aged 11-12 and 14-16 years, total N = 250) in a UK school. We investigated the effect of disclosing that a fictional adolescent had an autism diagnosis on stigmatizing attitudes of peers by testing the effect of disclosure of diagnosis on the social and emotional distance pupils wanted to maintain from the autistic adolescent. We also tested the effect of disclosure on peers' assessment of the adolescent's responsibility for their own behaviour. We checked to see if the effects were moderated by gender and age-group. Disclosing autism did not affect the social and emotional distance peers wanted to maintain from the autistic adolescent, but was associated with significant reduction in personal responsibility attributed to the adolescent's behaviour. Boys attributed more personal responsibility to the autistic adolescent than girls, but this gender effect was reduced when autism was disclosed. These findings suggest that disclosing autism to other pupils may be of limited use in reducing stigmatization by peers in UK schools.

"I don't feel different. But then again, I wouldn't know what it feels like to be normal": Perspectives of Adolescents with Autism Spectrum Disorder

There is minimal research regarding the personal experiences and perceptions of youth with autism spectrum disorder (ASD). Yet, the positive and negative perceptions that youth internalize about their diagnoses are crucial, as they may have a strong impact on individuals' self-concept and well-being. This paper utilizes mixed methods to describe the perceptions of 38 adolescents with ASD about their diagnoses, as elicited via semi-structured interviews. Quantitative analyses explore links between youths' perceptions and other aspects of their social-emotional well-being. Implications are highlighted regarding the importance of shifting the narrative that individuals with ASD develop about themselves and their diagnoses.

Biographical disruption or cohesion?: How parents deal with their child's autism diagnosis

Currently, we are witnessing a precipitous rise in autism diagnoses among children, and several bodies of sociological research are attempting to explain this development. However, the experiences within parental contexts have been inadequately examined; that is, how parents feel about and act upon the awareness of their child's autism diagnosis. Drawing upon a qualitative study among Danish parents of 20 children recently diagnosed with autism, this paper contributes with situated insights into parents' experiences. We identify a spectrum of feelings towards the autism diagnosis, including both relief and grief. In the absence of theoretical notions drawing attention to how a child's diagnosis influences parents' self-conceptions and understandings of their child, we develop the concept of 'parent-biographical disruption': the parents' rethinking of themselves and their child that might be caused by a chronic condition such as autism. Based on the variety of findings, we discuss what we call 'parent-biographical cohesion' as a counterpart to 'disruption'. By 'cohesion' we refer to the diagnostic awareness potentially creating clarification for parents about the past, present and future parenting of their child instead of disrupting their self-understandings as parents. In this way, through the notion of a parental-biographical spectrum of disruption and cohesion, we emphasize the diversity in how parents deal with a child's autism diagnosis and the variety of needs for rethinking parental biographies in the wake of a diagnosis.

What Drives Detection and Diagnosis of Autism Spectrum Disorder? Looking Under the Hood of a Multi-stage Screening Process in Early Intervention

U.S. guidelines for detecting autism emphasize screening and also incorporate clinical judgment. However, most research focuses on the former. Among 1,654 children participating in a multi-stage screening protocol for autism, we used mixed methods to evaluate: (1) the effectiveness of a clinical decision rule that encouraged further assessment based not only on positive screening results, but also on parent or provider concern, and (2) the influence of shared decision-making on screening administration. Referrals based on concern alone were cost-effective in the current study, and reported concerns were stronger predictors than positive screens of time-to-complete referrals. Qualitative analyses suggest a dynamic relationship between parents' concerns, providers' concerns, and screening results that is central to facilitating shared decision-making and influencing diagnostic assessment.

Parents' views and experiences of talking about autism with their children

The way an autism diagnosis is disclosed to parents has been found to play a crucial role in their acceptance of, and the way they cope with, their child's diagnosis. Yet, research into parents' subsequent experiences of disclosing a diagnosis to their children, and talking to their families about autism more generally, is limited. Using an online survey, the current study examined 558 parents' experiences of talking about autism with their autistic and non-autistic children. Results demonstrated that most parents (n = 379, 67.9%) had told their autistic children about their diagnosis. Despite few parents (n = 163, 20.4%) receiving advice or support regarding the disclosure of the diagnosis, those that had disclosed felt satisfied with the process (n = 319, 84.2%) and felt confident in talking about autism with their children (n = 339, 92.4%). Those who had not told their autistic children about the diagnosis largely planned to discuss this with their child in the future (n = 100, 73.5%), felt confident in doing so (n = 95, 70.9%) and were satisfied with their decision (n = 95, 70.4%). Analysis of open-ended data, using thematic analysis, highlighted the importance of openness and the need to tailor explanations to individual children's needs, while acknowledging that disclosure could often be challenging for parents.

How Families Make Sense of Their Child's Behaviour When on an Autism Assessment and Diagnosis Waiting List

Families waiting for an Autism Spectrum Condition assessment often experience difficulties explaining, or making sense of, the referred young person's behaviour. Little is known about this sense making, or how clinicians might support this ambiguity. This paper explored finite details of how five families do 'sense-making' in conversations with each other, while on the waiting list for an ASC assessment. A Discursive Psychology analysis of these conversations found that sense making was affected by (1) an interactional pattern of interruptions impeding the progress of sense making narratives; (2) face saving to maintain positive identities and shared understanding; and (3) difficulties in word finding within sense making narratives. These practices challenged the production of a coherent family sense making narrative.

The Experiences of Late-diagnosed Women with Autism Spectrum Conditions: An Investigation of the Female Autism Phenotype

We used Framework Analysis to investigate the female autism phenotype and its impact upon the under-recognition of autism spectrum conditions (ASC) in girls and women. Fourteen women with ASC (aged 22–30 years) diagnosed in late adolescence or adulthood gave in-depth accounts of: ‘pretending to be normal’; of how their gender led various professionals to miss their ASC; and of conflicts between ASC and a traditional feminine identity. Experiences of sexual abuse were widespread in this sample, partially reflecting specific vulnerabilities from being a female with undiagnosed ASC. Training would improve teachers’ and clinicians’ recognition of ASC in females, so that timely identification can mitigate risks and promote wellbeing of girls and women on the autism spectrum.

Family functioning, parenting stress and quality of life in mothers and fathers of Polish children with high functioning autism or Asperger syndrome

The aim of the study was to investigate the perception of the family functioning in parents of children with autism spectrum disorders (ASD) with normal-range intelligence and the relationships between family functioning, parenting stress and quality of life. Dyads of parents of children with ASD without intellectual disability and parents of typically developing children (controls) completed a set of self-report questionnaires. Parents of children with ASD reported lower functioning of the family as a whole and their own functioning as family members; they exhibited higher levels of parenting stress and lower quality of life. Mothers of children with ASD experienced more stress in personal domain than fathers. Relationships between family functioning, parenting stress and quality of life have been established. There were also moderate to strong correlations in mother-father dyads between their assessments of family functioning, parenting stress and QoL in social relationships and environmental domains.

A Strengths-Based Approach to Autism: Neurodiversity and Partnering With the Autism Community

The autism community represents a broad spectrum of individuals, including those experiencing autism, their parents and/or caregivers, friends and family members, professionals serving these individuals, and other allies and advocates. Beliefs, experiences, and values across the community can be quite varied. As such, it is important for the professionals serving the autism community to be well-informed about current discussions occurring within the community related to neurodiversity, a strengths-based approach to partnering with autism community, identity-first language, and concepts such as presumed competence. Given the frequency with which speech-language pathologists (SLPs) serve the autism community, the aim of this article is to introduce and briefly discuss these topics.

Which terms should be used to describe autism? Perspectives from the UK autism community

Recent public discussions suggest that there is much disagreement about the way autism is and should be described. This study sought to elicit the views and preferences of UK autism community members – autistic people, parents and their broader support network – about the terms they use to describe autism. In all, 3470 UK residents responded to an online survey on their preferred ways of describing autism and their rationale for such preferences. The results clearly show that people use many terms to describe autism. The most highly endorsed terms were ‘autism’ and ‘on the autism spectrum’, and to a lesser extent, ‘autism spectrum disorder’, for which there was consensus across community groups. The groups disagreed, however, on the use of several terms. The term ‘autistic’ was endorsed by a large percentage of autistic adults, family members/friends and parents but by considerably fewer professionals; ‘person with autism’ was endorsed by almost half of professionals but by fewer autistic adults and parents. Qualitative analysis of an open-ended question revealed the reasons underlying respondents’ preferences. These findings demonstrate that there is no single way of describing autism that is universally accepted and preferred by the UK’s autism community and that some disagreements appear deeply entrenched.

The effect of diagnostic labels on the affective responses of college students towards peers with ‘Asperger’s Syndrome’ and ‘Autism Spectrum Disorder’

Given the removal of Asperger’s Syndrome label in Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition, the impact of clinical labels upon the affective responses of college students was explored. A total of 120 college students read two vignettes depicting social interactions typical of a person with autism spectrum disorder. In one vignette, they were informed that the character was a typical college student and in the other, the character had a clinical disorder (either autism spectrum disorder, Asperger’s Syndrome or Schizophrenia). Participants’ affective responses were measured on the Positive and Negative Affect Scale. No significant differences in positive and negative affective responses were found between the clinical labels. However, affective responses were significantly more positive and less negative towards behaviours associated with clinical groups compared to the typical college student. The implications for students disclosing their diagnosis at university are discussed.

A randomised controlled trial of PEGASUS, a psychoeducational programme for young people with high-functioning autism spectrum disorder

BACKGROUND

Psychoeducation is an essential component of postdiagnostic care for people with ASD (autism spectrum disorder), but there is currently no evidence base for clinical practice. We designed, manualised and evaluated PEGASUS (psychoeducation group for autism spectrum understanding and support), a group psychoeducational programme aiming to enhance the self-awareness of young people with ASD by teaching them about their diagnosis.

METHODS

This single-blind RCT (randomised control trial) involved 48 young people (9-14 years) with high-functioning ASD. Half were randomly assigned to PEGASUS, administered in six weekly group sessions, with the others receiving no additional intervention. ASD-related self-awareness, the primary outcome, was evaluated using the bespoke Autism Knowledge Quiz (AKQ). Secondary outcome measures included the Rosenberg Self-Esteem Scale. All measures were collected during home visits and scored by researchers blind to group assignment. The trial is registered on ClinicalTrials (NCT01187940, http://www.clinicaltrials.gov) and was funded by the Baily Thomas Charitable Trust.

RESULTS

Bootstrap multiple regression showed ASD knowledge (β = .29, p < .001, 95% CIs [0.13, 0.44]) and ASD self-awareness (β = .42, p = .001, 95% CIs [0.17, 0.67]), measured by number of ASD-related personal strengths and difficulties listed by participants, increased for those who attended PEGASUS (n = 24) compared with controls (n = 24). There was no effect of PEGASUS on self-esteem by self-report (β = .10, p = .404, 95% CIs [-0.14, 0.35]) or parent report (β = .12, p = .324, 95% CIs [-0.12, 0.36]).

CONCLUSIONS

After PEGASUS, participants had more general knowledge about ASD, and showed a greater awareness of their collection of unique strengths and difficulties associated with ASD. Psychoeducation did not lower self-esteem. This RCT provides initial evidence for PEGASUS's efficacy as a psychoeducation programme for people with ASD.

Service provision for autism in mainland China: preliminary mapping of service pathways

Few data on healthcare services for individuals with Autism Spectrum Conditions (ASC) are available from mainland China. This article is based on findings from 69 semi-structured interviews with parents of children with ASC in three intervention centres. The respondents are from 19 regions in mainland China. A service-mapping questionnaire containing 50 questions is developed and used as an interview schedule for service mapping. The pathway to diagnosis and intervention for children with ASC is presented according to parents' experience. The findings report considerable delay along the pathway which may be partly due to the under-developed service system. Several cultural issues are identified which may also contribute to the delay, such as the perception of mental illness, folk beliefs equating delayed development of language skills in early childhood with future high intelligence, and the state-imposed one-child policy. Delays in recognising ASC and a lack of support are also considered to be associated with the considerable financial burden placed on parents of children with ASC in mainland China.

Grandparents of Grandchildren with Autism Spectrum Disorders (ASD): Strengthening Relationships through Technology Activities

This study of grandparent-grandchild relationships was embedded in the context of technology workshops offered for young children on the autism spectrum. The purpose of this research was to examine the perspectives of six involved grandparents regarding their social interactions with their grandchildren in the context of this shared technology experience. Content analysis of transcribed focus group sessions with the grandparents indicated two key themes: expectations were reframed and communication bridges were built through shared interests. Grandparents perceived that their grandchildren learned technological skills, and increased their social interactions with peers, family members (parents, siblings), and grandparents themselves. The positive experience the grandparents perceived their grandchildren to have in the program gave them hope for future educational and employment opportunities for their grandchildren. The grandparents also indicated that the shared interests in the computer program facilitated communication opportunities with their grandchildren, with other grandparents of grandchildren with ASD, and with their adult sons and daughters.

Healthcare providers' perceptions of breastfeeding peer counselors in the neonatal intensive care unit

In this qualitative descriptive study we examined the perceptions of 17 neonatal intensive care unit (NICU) healthcare providers (nurses, neonatologists, lactation consultants, and dietitians) about the role of breastfeeding peer counselors who were mothers of former NICU infants and who provided primary lactation care in the NICU. Findings revealed that the healthcare providers respected the peer counselors' lactation expertise and identified three critical elements that contributed to the effectiveness of the peer counseling program: having a champion for the program, counselors being mothers of former NICU infants, and a NICU culture supportive of using human milk. Healthcare providers thought the peer counselors enhanced care of the infant by empowering mothers to provide milk and by facilitating and modeling positive patterns of maternal-infant interactions.

Annual research review: re-thinking the classification of autism spectrum disorders

BACKGROUND

The nosology of autism spectrum disorders (ASD) is at a critical point in history as the field seeks to better define dimensions of social-communication deficits and restricted/repetitive behaviors on an individual level for both clinical and neurobiological purposes. These different dimensions also suggest an increasing need for quantitative measures that accurately map their differences, independent of developmental factors such as age, language level and IQ.

METHOD

Psychometric measures, clinical observation as well as genetic, neurobiological and physiological research from toddlers, children and adults with ASD are reviewed.

RESULTS

The question of how to conceptualize ASDs along dimensions versus categories is discussed within the nosology of autism and the proposed changes to the DSM-5 and ICD-11. Differences across development are incorporated into the new classification frameworks.

CONCLUSIONS

It is crucial to balance the needs of clinical practice in ASD diagnostic systems, with neurobiologically based theories that address the associations between social-communication and restricted/repetitive dimensions in individuals. Clarifying terminology, improving description of the core features of ASD and other dimensions that interact with them and providing more valid and reliable ways to quantify them, both for research and clinical purposes, will move forward both practice and science.