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

Cognitive and brain morphological deviations in middle-to-old aged autistic adults: A systematic review and meta-analysis

Cognitive challenges and brain structure variations are common in autism spectrum disorder (ASD) but are rarely explored in middle-to-old aged autistic adults. Cognitive deficits that overlap between young autistic individuals and elderlies with dementia raise an important question: does compromised cognitive ability and brain structure during early development drive autistic adults to be more vulnerable to pathological aging conditions, or does it protect them from further decline? To answer this question, we have synthesized current theoretical models of aging in ASD and conducted a systematic literature review (Jan 1, 1980 - Feb 29, 2024) and meta-analysis to summarize empirical studies on cognitive and brain deviations in middle-to-old aged autistic adults. We explored findings that support different aging theories in ASD and addressed study limitations and future directions. This review sheds light on the poorly understood consequences of aging question raised by the autism community to pave the way for future studies to identify sensitive and reliable measures that best predict the onset, progression, and prognosis of pathological aging in ASD.

When mind and measurement diverge; the interplay between subjective cognitive complaints (SCCs), objective cognition, age, and depression in autistic adults

While the increased incidence of dementia and subjective cognitive complaints (SCCs) suggests that autistic adults may face cognitive challenges at older age, the extent to which SCCs predict (future) cognitive functioning remains uncertain. This uncertainty is complicated by associations with variables like depression. The current study aims to unravel the interplay of age, depression, cognitive performance, and SCCs in autism. Using a large cross-sectional cohort of autistic (n=202) and non-autistic adults (n=247), we analyzed associations of SCCs with age, depression, and cognitive performance across three domains (visual memory, verbal memory, and fluency). Results showed a strong significant association between depression and SCCs in both autistic and non-autistic adults. Cognitive performance was not significantly associated with SCCs, except for a (modest) association between visual memory performance and SCCs in autistic adults only. Follow-up regression tree analysis indicated that depression and being autistic were considerably more predictive of SCCs than objective cognitive performance. Age nor sex was significantly associated with SCCs. These findings indicate that self-reported cognitive functioning does not equal cognitive performance, and should be interpreted with care, especially in individuals with high rates of depression. Longitudinal investigations are needed to understand SCCs' role in dementia and cognitive health in autism.

Self-Reported Executive Function in Hospitalized Cardiac Patients and Associations With Patient Characteristics and Cardiac Rehabilitation Attendance

PURPOSE

Executive function (ExF), the ability to do complex cognitive tasks like planning and refraining from impulsive behavior, is associated with compliance with medical recommendations. The present study identified associations between self-reported ExF and demographics of patients with cardiac disease as well as with cardiac rehabilitation (CR) attendance.

METHODS

Self-reported ExF impairment was measured using the Behavior Rating Inventory of Executive Function (BRIEF) on 316 individuals hospitalized for CR-qualifying cardiac events. Scores were calculated for a global measure (Global Executive Composite [GEC]) and the two BRIEF indices: Behavioral Regulation Index and Metacognition Index (MCI). Participants were followed up post-discharge to determine CR attendance. Univariate logistic regressions between ExF measures and demographic variables were conducted, as were multiple logistic regressions to identify significant, independent predictors. Analyses were conducted using clinical (T scores ≥ 65) and subclinical (T scores ≥ 60) criteria for significant ExF impairment as outcomes. One-way analyses of variance were performed between ExF impairment and CR attendance.

RESULTS

Self-reported ExF deficits were relatively rare; 8.9% had at least subclinical scores on the GEC. Using the subclinical criterion for the MCI, having diabetes mellitus (DM) and being male were significant, independent predictors of MCI impairment. No significant relationship was found between ExF and CR attendance.

CONCLUSION

Using the subclinical criterion only, individuals with DM and males were significantly more likely to have MCI impairment. No significant effect of ExF impairment on CR attendance was found, suggesting that self-reported ExF measured in the hospital may not be an appropriate measure for predicting behavioral outcomes.

Measuring flexibility in autistic adults: Exploring the factor structure of the flexibility scale self report

Cognitive flexibility differences are common for autistic individuals and have an impact on a range of clinical outcomes. However, there is currently a lack of well validated measurement tools to assess flexibility in adulthood. The Flexibility Scale was originally designed as a parent-report measure of real-world flexibility challenges in youth. The original Flexibility Scale provides a total score and five subscales: Routines and Rituals, Transitions and Change, Special Interests, Social Flexibility, and Generativity. In this study, we evaluate the factorial validity of the Flexibility Scale as a self-report (Flexibility Scale Self Report) measure of cognitive flexibility, adapted from the original Flexibility Scale, for use by autistic adults. This study includes both a primary sample (n = 813; mean age = 40.3; 59% female) and an independently recruited replication sample (n = 120; mean age = 32.8; 74% female) of individuals who completed the Flexibility Scale Self Report. The analysis consisted of an initial confirmatory factor analysis (CFA) of the original Flexibility Scale structure, followed by exploratory factor analysis (EFA) and factor optimization within a structural equation modeling framework to identify the optimal structure for the questionnaire in adults. The identified structure was then replicated through CFA in the replication sample. Our results indicate an alternative optimal scale structure from the original Flexibility Scale, which includes fewer items, and only three (Routines/Rituals, Transitions and Change, Special Interests) of the five subscales contributing to the flexibility total score. Comparisons revealed no structural differences within the scale based on sex assigned at birth. Here the Generativity and Social Flexibility scales are treated as independent but related scales. The implications for measurement of cognitive flexibility in clinical and research settings, as well as theoretical underpinnings are discussed.

Prepotent response inhibition in autism: Not an inhibitory deficit?

Research outcomes on prepotent response inhibition in neurodevelopmental conditions during adulthood seem inconsistent, especially in autism. To gain further insight in these inconsistencies, the current study investigates inhibitory performance, as well as task strategies such as adaptive behavior during inhibitory tasks in autistic adults. As Attention-Deficit/Hyperactivity Disorder (ADHD) is often co-occurring in autism and associated with differences in both inhibition and adaptation, the role of ADHD symptoms is explored. Additionally, prior research is extended to middle- and late-adulthood, and the role of cognitive aging is assessed. Hundred-and-five autistic adults and 139 non-autistic adults (age: 20-80 yrs) were compared on a Go-NoGo task. No significant group differences in inhibitory difficulties (commission errors) or adaptation (post error slowing) were observed, and both did not relate significantly to ADHD symptoms. However, when controlling for reaction time autistic individuals made significantly more inhibitory errors than non-autistic individuals, yet the effect size was modest (Cohen's d = .27). Exploratory analyses showed that adaption significantly related to inhibition in non-autistic individuals only, possibly hinting at altered adaptive behavior during inhibitory tasks in autistic adults. ADHD symptoms related to response variability in the autism group only. Furthermore, task strategy changed with older age in both groups, with slower and more cautious responses at older age. Taken together, although minor differences may exist, autistic and non-autistic people show largely similar patterns of inhibitory behavior throughout adulthood. Differences in task timing and strategy seem relevant for future longitudinal studies on cognitive aging across neurodevelopmental conditions.

Self-reported cognitive decline among middle and older age autistic adults

Very little is known about autistic adults as they age. Early evidence suggests a potentially high risk for dementia and atypical cognitive decline in autistic middle and older age adults. Research in the general population indicates that self-reported cognitive decline may predict future dementia earlier than performance-based measures. Nevertheless, self-report dementia screeners have not been used to date in autism research. In a sample of middle and older age autistic adults (N = 210), participants completed a self-rated dementia screener, the AD8, to describe the rate of cognitive decline, examine associations of cognitive decline with age, educational level, sex designated at birth, and autistic traits, and document the psychometrics of a dementia screener in autistic adults. We found high rates of cognitive decline with 30% of the sample screening positive. The most common symptoms were declining interest in leisure activities, and increases in everyday problems with thinking, memory, and judgment. There was evidence that autistic individuals designated female at birth may be more vulnerable to cognitive decline than autistic individuals designated male at birth. Notably, reports of cognitive decline did not vary by age or educational level. Modestly elevated autistic traits were found in those screening positive versus negative for cognitive decline. Finally, the dementia screener showed good psychometrics, including convergent validity with an independent measure of current memory problems. These results could signal an emerging public health crisis in autistic adults as they age, and support the potential utility of self-report measures for early screening for cognitive decline in this population.

The cognitive profile of middle-aged and older adults with high vs. low autistic traits

Cognitive differences in memory, information processing speed (IPS), and executive functions (EF), are common in autistic and high autistic trait populations. Despite memory, IPS and EF being sensitive to age-related change, little is known about the cognitive profile of older adults with high autistic traits. This study explores cross-sectional memory, IPS and EF task performance in a large sample of older adults in the online PROTECT cohort (n = 22,285, aged 50-80 years), grouped by high vs. low autistic traits. Approximately 1% of PROTECT participants (n = 325) endorsed high autistic traits [henceforth Autism Spectrum Trait (AST) group]. Differences between AST and age-, gender-, and education-matched comparison older adults (COA; n = 11,744) were explored on memory, IPS and EF tasks and questionnaires administered online. AST had lower performance than COA on tasks measuring memory, working memory, sustained attention, and information processing. No group differences were observed in simple attention or verbal reasoning. A similar pattern of results was observed when controlling for age, and current depression and anxiety symptoms. In addition, AST self-reported more cognitive decline than COA, but this difference was not significant when controlling for current depression symptoms, or when using informant-report. These findings suggest that autistic traits are associated with cognitive function in middle-aged and later life. Older adults with high autistic traits experienced more performance difficulties in a range of memory, IPS and EF tasks compared with the low autistic traits comparison group. Further longitudinal work is needed to examine age-related change in both older autistic and autistic trait populations.

Executive functions in daily living skills: A study in adults with autism spectrum disorder

Introduction

Adults with autism and adults with schizophrenia show difficulties in adaptive skills, especially those related to daily functioning. Some studies suggest that adaptive skills are associated with deficits in executive functions (EF), while others indicate that intelligence quotient (IQ) might also play a role. Literature suggests that autistic symptoms further affect adaptive skills. The interest of the current study, therefore, was to explore to what extent IQ, EFs as well as core autistic symptoms predict adaptive skills.

Methods

To do this, 25 controls, 24 adults with autism, and 12 with schizophrenia were assessed on IQ (Wechsler Adult Intelligence Scale), and executive functioning. The EF was measured with neuropsychological tasks (inhibition, updating, and task switching) and with the Dysexecutive-Spanish Questionnaire (DEX-Sp) which assessed everyday life EF problems. Core ASD symptoms were measured using the Autism Diagnostic Observation Schedule, the Autism Spectrum Quotient-Short version (AQ-S), and the Repetitive Behavior Questionnaire - 3 (RBQ-3).

Results

The results indicated EF difficulties in both, autism and schizophrenia. The IQ explained a high percentage of the variance found in adaptive skills, but only in the autism group. We can conclude, therefore, that high IQ is associated with low adaptive skills levels and EFs affect adaptive functioning in people with autism; however, this does not explain the difficulties in adaptive functioning in the schizophrenia group. Core features of autism assessed with self-report questionnaires (but not the ADOS-2) predicted low scores on the adaptive skills, only in the autism group.

Discussion

Both EF measures predicted adaptive skills scores in autism, but not in schizophrenia. Our results suggest that different factors affect the adaptive functioning in each disorder. For instance, the EFs should be a central focus for improvement, especially for individuals with autism.

Neuropsychological profile of executive functions in autism spectrum disorder and schizophrenia spectrum disorders: a comparative group study in adults

As assessed by numerous neuropsychological tasks, individuals with autism spectrum disorder (ASD) and schizophrenia spectrum disorders (SSDs) have similar impairments related to executive functions (EFs). The neuropsychological profile of these two conditions was examined using the three-component EFs' framework of Miyake and Friedman (Cogn Psychol 41(1):49-100, 2000). This approach assesses Inhibition (suppression of unwanted and irrelevant information/responses), Updating (use and control of contents of working memory), and Shifting (disengagement between activities or mental tasks) using nine different tasks. In line with previous research, we expected greater performance deficits in ASD in all three components compared to SSD, as well as faster responses for the SSD group. A self-paced task format allowed us to examine whether unlimited time given for a task would lead to better performance. The sample was constituted by the control group (N = 25), ASD group (N = 24), and SSD group (N = 12). Groups did not differ on Inhibition performance. In Updating, individuals with SSD performed poorer than the other groups. As for Shifting, both groups demonstrated poorer performance compared to controls, with the SSD group presenting the greatest difficulties. In terms of reaction time (RT), SSD participants' RT were the slowest on Inhibition and Shifting tasks. There was a positive correlation between performance and time spent on Inhibition and Shifting only for the SSD group, which demonstrates that their performance improves when there are no time constraints. Our work provides a better understanding of spared and impaired EFs, which could be useful for designing strategies aimed at improving specific EFs in each group.

Computer-Based Assessment and Self-Report Measures of Executive Functions in High-Functioning Adults with Autism

This study analyzes the profile of executive functions (EF) in high-functioning adults with autism (HFA), both in terms of performance on four computer-based tasks, as well as how these functions are perceived by the individuals through self-reporting measures. The study included 64 participants: 32 individuals with HFA, and 32 typically developing controls. Four CANTAB tasks were used (assessing spatial working memory, planning, visual memory, and inhibition), as well as a self-reported measure of executive functions (BDEFS) and a scale for the severity of autism symptoms (RAADS-R). The participants in the ASD group performed significantly lower than the control group on all four computer-based tasks, as measured by the total number of errors made (for the spatial working memory, visual memory, and inhibition tasks) and the number of problems solved at the first choice (for the planning task). No correlation was found in the ASD group between the severity of autism symptoms and the computer-based measures. These findings provide evidence that HFA adults may have various executive functioning impairments, and subsequent daily life problems, but these deficits do not necessarily correlate with the severity of core ASD symptoms.

Differences in daily life executive functioning between people with autism and people with schizophrenia

This is a comparative analysis of everyday executive functioning between individuals with Autism Spectrum Disorder (ASD), Schizophrenia Spectrum Disorders (SSD) and controls using Dysexecutive Questionnaire-Spanish (DEX-Sp), to identify patterns of difficulties. Also we assessed the relationship between EF and adaptive behavior as measured by the Vineland Adaptive Behavioral Scale-II. Common areas of everyday executive functions were established as problematic in individuals with ASD and SSD related to Disinhibition and Apathy, while Disorganization and Impulsivity was gravely affected in ASD group only. The degree of Dysexecutive Syndrome was predictive of adaptive behavior in ASD group only. These suggest that DEX-Sp could be a useful tool in differentiating areas of strength and weaknesses in clinical groups such as ASD and SDD.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL IMPLICATIONS

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

Subjective cognition in adults with common psychiatric classifications; a systematic review

The aim is to assess whether instruments developed to measure subjective cognitive complaints (SCCs) and in neurology and aging can reliably be used in ADHD and other common psychiatric classifications. MEDLINE, PsycINFO, CINAHL and EMBASE+EMBASE CLASSIC were searched for relevant work on SCCs in psychiatric classifications (ADHD, autism, mood disorders, schizophrenia) in two phases: 1 identify instruments, 2 relevant studies. 35 studies with varying study quality were included. SCCs are most commonly studied in ADHD and mood disorders, but are found in all psychiatric classifications. SCCs show inconsistent and low associations to objective cognition across disorders, but higher and consistent relations are found with behavioral outcomes. SCCs are not qualitatively different for ADHD compared to other psychiatric classifications, and should thus not be seen as analogous to well validated measures of objective cognition. However, SCCs do reflect suffering, behavioral difficulties and problems experienced by across those with psychiatric problems in daily life.

Adding the missing voice: How self-report of autistic youth self-report on an executive functioning rating scale compares to parent report and that of youth with attention deficit hyperactivity disorder or neurotypical development

LAY ABSTRACT

Executive functions are often impaired in autistic people and relate to important outcomes such as mental health, success in school and work, and quality of life. Evaluating executive functions helps autistic people, clinicians, and families identify targets for external supports and skill building. Youth self-report of executive function has not been studied, yet we know that self-report from autistic youth is key to understanding other cognitive/behavioral phenomena in autism such as anxiety, obsessions/compulsions, sensory sensitivities, and repetitive behaviors. We investigated self- and parent-report of executive function problems in 197 autistic youth without intellectual disability (ages 11-18 years), including the magnitude and profiles of executive function problems autistic youth report across subdomains of executive function. We compared autistic self-report with that of 114 youth with attention deficit hyperactivity disorder without intellectual disability and 197 neurotypical youth. We found that autistic youth report significant executive function problems compared to neurotypical youth and a distinctive profile of challenges in comparison to attention deficit hyperactivity disorder youth. Parents and their autistic children diverged regarding the magnitude of the youth's executive function difficulties, but both identify inflexibility as the most impaired executive function subdomain. Autistic youth and their parents were somewhat more concordant in their report of executive function problems than youth with attention deficit hyperactivity disorder and their parents, but only showed moderate concordance at best. These findings elevate the importance of asking autistic youth directly about their executive functioning when engaging them in assessment and intervention, or researching executive functions in autism.

Flexibility in autism during unpredictable shifts of socio-emotional stimuli: Investigation of group and sex differences

LAY ABSTRACT

Flexibility difficulties in autism might be particularly common in complex situations, when shifts (i.e. the switch of attentional resources or strategy according to the situation) are unpredictable, implicit (i.e. not guided by explicit rules) and the stimuli are complex. We analyzed the data of 101 autistic and 145 non-autistic adults, without intellectual deficiency, on two flexibility tasks performed online. The first task involved unpredictable and non-explicit shifts of complex socio-emotional stimuli, whereas the second task involved predictable and explicit shifts of character stimuli. Considering the discrepancies between laboratory results and the real-life flexibility-related challenges faced by autistic individuals, we need to determine which factor could be of particular importance in flexibility difficulties. We point out that the switch cost (i.e. the difference between shift and non-shift condition) was larger for autistic than for non-autistic participants on the complex flexibility task with unpredictable and non-explicit shifts of socio-emotional stimuli, whereas this was not the case when shifts were predictable, explicit and involved less complex stimuli. We also highlight sex differences, suggesting that autistic females have better social skills than autistic males and that they also have a specific cognitive profile, which could contribute to social camouflaging. The findings of this work help us understand which factors could influence flexibility difficulties in autism and are important for designing future studies. They also add to the literature on sex differences in autism which underpin better social skills, executive function, and camouflaging in autistic females.

Parallel age-related cognitive effects in autism: A cross-sectional replication study

Findings on age-related cognitive effects in autism in adulthood are inconsistent across studies. As these studies substantially differ in their methodology, replication studies are needed. In this replication study frequentist (i.e., null-hypothesis significance testing), and Bayesian statistics were used to investigate the hypothesis that in autistic adults compared to non-autistic adults mostly parallel, but also protective age-related cognitive effects can be observed. Participants were 88 autistic adults, and 88 non-autistic matched comparisons (age range: 30-89 years, mean age: 55 years). Cognitive measures were administered on the following six domains: verbal memory, visual memory, working memory, Theory of Mind (ToM), verbal fluency, and processing speed, and self-reported cognitive failures. Non-autistic adults outperformed autistic adults on ToM, verbal fluency, and verbal memory, but only the first two were confirmed with Bayesian replication analyses. Also, more cognitive failures were reported by autistic adults. No interactions between group and age were observed, suggesting a parallel age-related effect on all cognitive domains. In sum, previously observed difficulties in ToM and verbal fluency were replicated which seem to persist at older age. Previously reported parallel age-related cognitive patterns were replicated, yet no evidence for protective age-related patterns was found. LAY SUMMARY: We investigated whether our previous findings on cognitive aging in autism could be confirmed in a new study measuring the cognitive effects of age in autistic and non-autistic adults. As expected, tasks that younger autistic adults had difficulties with (theory of mind, fluency) were also difficult for older autistic adults, and the effect of age itself was similar in autistic and non-autistic adults. Unexpectedly, we observed no protective effects (less cognitive aging) in autism.

A review of executive functioning challenges and strengths in autistic adults

Objective: There has been a steady rise in research characterizing executive functioning (EF) impairments in autistic individuals but limited research investigating EF strengths. This review provides a summary of current EF research in autistic adults with a focus on EF challenges and strengths and potential sources of heterogeneity in research findings. New avenues for addressing gaps in our understanding of EF strengths are proposed.Method: A review of the EF literature was conducted. One hundred twenty-four studies of inhibition, working memory, cognitive flexibility, fluency, planning, decision-making, and subjective measures of EF in autistic adults were included.Results: Autistic adults with average intellectual functioning demonstrate difficulties with cognitive flexibility, phonemic fluency, and working memory. Strengths in planning, decision-making, and semantic verbal fluency were evident in some but not all studies. Findings regarding inhibition are inconclusive. Key findings across each EF domain are discussed and sources of potential heterogeneity across studies were evaluated. The type of measure used appears to contribute to heterogeneous findings. Subjective EF measures revealed more consistent findings of deficits in autistic adults than objective EF measures.Conclusions: Research reveals areas of EF weaknesses as well as strengths in autistic adults. Unlike EF challenges, EF strengths are not well understood. Future research identifying EF strengths is needed to improve services and supports for autistic adults. Further investigation of potential factors that interact with or constrain EF such as comorbid disorders, verbal ability, sensory processing, and other factors specific to autism will be critical to move the field forward and increase understanding of how EF is related to everyday functioning in autistic adults.

The Relationship of Age with the Autism-Spectrum Quotient Scale in a Large Sample of Adults

Background: The historical focus on autism as a childhood disorder means that evidence regarding autism in adulthood lags significantly behind research in other age groups. Emerging studies on the relationship of age with autism characteristics do not target older adult samples, which presents a barrier to studying the important variability that exists in life span developmental research. This study aims to further our understanding of the relationship between the Autism-Spectrum Quotient Scale and age in a large adult sample. Methods: The present study examines the relationship of Autism-Spectrum Quotient Scale (AQ) scores with age in 1139 adults, ages 18-97 years. Participants came from three distinct samples-a sample of primarily students, a sample of MTurk participants, and a sample of primarily community dwelling older adults. The majority of the participants did not self-report an autism diagnosis (91%), were female (67%), and identified as White (81%). Participants completed the AQ primarily via online surveys. Researchers scored the AQ following six common scoring practices. Results: Results of preregistered analyses indicate that autism characteristics measured by the AQ are not strongly associated with age (r values from -0.01 to -0.11). Further findings indicate that the measurement of autism characteristics is consistent across age into late life using both multiple groups and local structural equation modeling approaches to measurement invariance (comparative fit indices = 0.82-0.83, root mean square error = 0.06) as well as reliability analysis. Finally, demographic and autism-related variables (sex, race, self-identified autism spectrum disorder diagnosis, and degree of autism characteristics) did not moderate the relationship between age and autism characteristics. Conclusion: These results suggest that self-reports of autism characteristics using the AQ do not vary strongly by age in this large age-representative sample. Findings suggest that the AQ can potentially serve as a useful tool for future research on autism across the life span. Important limitations on what we can learn from these findings point toward critical avenues for future research in this area.

Lay summary

Why was this study done?: Self-report questionnaires of autism characteristics are a potentially important resource for studying autism in adulthood. This study sought to provide additional information about one of the most commonly used self-report questionnaires, the Autism-Spectrum Quotient Scale (AQ), across adulthood.What was the purpose of this study?: This study intended to determine if there is a relationship between scores on the AQ and age. Researchers also worked to identify which of the multiple different ways of scoring the AQ worked best across adulthood.What did the researchers do?: Researchers collected data from over a thousand participants aged 18-97 years. Participants from three different age groups completed online surveys to self-report their levels of autism characteristics on the AQ. Researchers tested the relationship between AQ scores and age with six different commonly used ways to calculate AQ scores. Researchers used multiple statistical techniques to evaluate various measurement properties of the AQ.What were the results of the study?: The results indicate that autism characteristics measured by the AQ are not strongly associated with age. Along with that, there is evidence that certain approaches to measuring of autism characteristics are consistent across age into late life and do not vary with demographic and autism-related factors.What do these findings add to what was already known?: These results add to the growing evidence that self-reports of autism characteristics using the AQ in general samples are not strongly associated with age across adulthood. These findings also provide guidance about ways of scoring the AQ that work well through late life.What are potential weaknesses in the study?: While the AQ has a degree of relationship with autism diagnoses, this is far from perfect and has not been evaluated in the context of aging research. Therefore, findings from the present research must be carefully interpreted to be about autism characteristics not diagnoses. The sample was also limited in a number of other ways. As in any studies including a broad age range of individuals, the oldest participants are likely quite healthy, engaged individuals. This may particularly be the case given the higher mortality rates and health challenges seen with autism. Similarly, as with any self-report research, this research is limited to those individuals who could answer questions about their autism characteristics. The sample was also predominantly White and nonautistic. Finally, the research was limited to one point in time and so cannot tell us about how autism characteristics may change across adulthood.How will these findings help autistic adults now or in the future?: These findings support the potential for the AQ to be a useful tool for future research on autism in adulthood. For example, researchers can use measures such as the AQ to study how autism characteristics change over time or are associated with aging-related issues such as changes in physical health and memory. Such research may be able to provide a better understanding of how to support autistic individuals across adulthood.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

Defining quality of life for individuals with neurodevelopmental disorders: Challenges within an inpatient population

PURPOSE

The concept of Quality of Life (QoL) for people with neurodevelopmental disorders primarily focuses on deinstitutionalisation and community inclusion. This population, however, often presents with comorbid diagnoses and is sectioned to treatment facilities under the Mental Health Act. The aim of this paper is to review the existing literature on QoL and discuss the consideration of this specialised population and the environment when measuring QoL.

METHODS

Databases were searched using specific inclusion and exclusion criteria to ensure literature reviewed was relevant to the defined population. The challenges identified from the literature were categorised into interpersonal and intrapersonal factors.

RESULTS

A total of 30 articles were retrieved and considered in this review.

CONCLUSIONS

This paper discusses how these individuals present with different behaviours and opportunities, which subsequently make it difficult to apply existing knowledge of QoL. The need to further examine the QoL in this specific population is discussed.

The Transition to Adulthood for Young People with Autism Spectrum Disorder

The transition to adulthood for individuals with autism spectrum disorder is difficult and outcomes are suboptimal. Social cognition deficits and executive dysfunction continue to be barriers to young people's success, lack of societal acceptance and loss of previous support can exacerbate the condition, and mental health issues increase. All areas of adult functioning are affected. To help manage the transition and improve outcomes for this population, psychiatrists and other health care providers need to be aware of the issues and possible interventions, including social skills training, educational transition programs, and supported employment programs.

Brief Report: Using Cognitive Screeners in Autistic Adults

By comparing 51 autistic adults and 49 age-matched controls (aged 30-73 years) we tested if (1) the Montreal Cognitive Assessment (MoCA) is more sensitive in measuring cognitive impairments than the Mini Mental State Examination (MMSE) and (2) if we can replicate the MoCA-findings of Powell et al. (2017) with the Dutch MoCA(-NL). Results showed that: (1) The MoCA-NL is more sensitive, and (2) like Powell, no group differences were observed on the MoCA-NL. However, in contrast to Powell, we did not observe that older autistic adults show more impairment than controls on the MoCA-NL. Nonetheless, as the MoCA-NL is more sensitive to cognitive impairment, it is the recommended screener for older autistic adults.

Correlates of daily functioning in older adults with autism spectrum disorder

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

The Transition to Adulthood for Young People with Autism Spectrum Disorder

The transition to adulthood for individuals with autism spectrum disorder is difficult and outcomes are suboptimal. Social cognition deficits and executive dysfunction continue to be barriers to young people's success, lack of societal acceptance and loss of previous support can exacerbate the condition, and mental health issues increase. All areas of adult functioning are affected. To help manage the transition and improve outcomes for this population, psychiatrists and other health care providers need to be aware of the issues and possible interventions, including social skills training, educational transition programs, and supported employment programs.

Executive Functioning in 60+ Autistic Males: The Discrepancy Between Experienced Challenges and Cognitive Performance

As executive functioning (EF) is especially sensitive to age-related cognitive decline, EF was evaluated by using a multi-method assessment. Fifty males (60-85 years) with a late adulthood autism spectrum condition (ASC) diagnosis and 51 non-ASC males (60-83 years) were compared on cognitive tests across EF domains (cognitive flexibility, planning, processing speed, and working memory) and a self- and proxy report of the Behavior Rating Inventory of Executive Function-Adult Version. While no objective performance differences emerged, autistic males and their proxies did report more EF challenges than non-ASC males on the subjective measure. In order to know how to support the older autistic men who received their ASC diagnosis in late adulthood with their daily life EF challenges, it is important to understand what underlies these subjective EF problems.

Aging in Autism Spectrum Disorder

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

Comparing Intellectual and Memory Abilities of Older Autistic Adults with Typically Developing Older Adults Using WAIS-IV and WMS-IV

This study aimed to compare cognitive and memory abilities between older adults with and without autism over the age of 50. Twenty-eight individuals with autism and 29 typically developing (TD) older adults took part in the current study. Participants’ cognitive and memory abilities were assessed by WAIS-IV and WMS-IV. Older autistic adults were found to have poorer performance in processing speed and visual working memory, but they performed at a similar level as TD controls in all other domains. Poorer processing speed and visual working memory are also often found to be associated with age-related decline in neurotypical adults. Longitudinal studies are warranted to explore how the combination of ageing and autism affects cognitive functioning in older adults.

Thinning Faster? Age-Related Cortical Thickness Differences in Adults with Autism Spectrum Disorder

BACKGROUND

Over the course of the last 30 years, autism spectrum disorder (ASD) diagnoses have increased, thus identifying a large group of aging individuals with ASD. Currently, little is known regarding how aging will affect these individual's neuroanatomy, compared to the neurotypical (NT) population. Because of the anatomical overlap of ASD-related cortical pathology and age-related cortical thinning, both following an anterior-to-posterior severity gradient, we hypothesize adults with ASD will show larger age-related cortical thinning than NT adults.

METHODS

We analyzed cortical measurements using available data from the multi-site Autism Brain Imaging Data Exchange I (ABIDE I; n=282) and our own cohort of middle-age to older adults with and without ASD (n=47) mostly available in ABIDE II (n=35). We compared correlations between cortical measures and age in right-handed adults with ASD (n=157) and similar NT adults (n = 172), controlling for IQ and site. Participants were 18 to 64 years of age (mean=29.8 years; median=26 years).

RESULTS

We found significant differences between diagnosis groups in the relationship between age and cortical thickness for areas of left frontal lobe (pars opercularis), temporal lobe (inferior gyrus, middle gyrus, banks of the superior temporal sulcus, and entorhinal cortex), parietal lobe (inferior gyrus), and lateral occipital lobe. For all areas, adults with ASD showed a greater negative correlation between age and cortical thickness than NT adults.

CONCLUSION

As hypothesized, adults with ASD demonstrated exacerbated age-related cortical thinning, compared to NT adults. These differences were the largest and most extensive in the left temporal lobe. Future longitudinal work is warranted to investigate whether differences in brain age trajectories will translate to unique behavioral needs in older adults with ASD.

The influence of age and ASD on verbal fluency networks

BACKGROUND

The integrity and connectivity of the frontal lobe, which subserves fluency, may be compromised by both ASD and aging. Alternate networks often integrate to help compensate for compromised functions during aging. We used network analyses to study how compensation may overcome age-related compromised in individuals with ASD.

METHOD

Participants consisted of middle-aged (40-60; n=24) or young (18-25; n=18) right-handed males who have a diagnosis of ASD, and age- and IQ-matched control participants (n=20, 14, respectively). All performed tests of language and executive functioning and a fluency functional MRI task. We first used group individual component analysis (ICA) for each of the 4 groups to determine whether different networks were engaged. An SPM analysis was used to compare activity detected in the network nodes from the ICA analyses.

RESULTS

The individuals with ASD performed more slowly on two cognitive tasks (Stroop word reading and Trailmaking Part A). The 4 groups engaged different networks during the fluency fMRI task despite equivalent performance. Comparisons of specific regions within these networks indicated younger individuals had greater engagement of the thalamus and supplementary speech area, while older adults engaged the superior temporal gyrus. Individuals with ASD did not disengage from the Default Mode Network during word generation.

CONCLUSION

Interactions between diagnosis and aging were not found in this study of young and middle-aged men, but evidence for differential engagement of compensatory networks was observed.

Age Group Differences in Executive Network Functional Connectivity and Relationships with Social Behavior in Men with Autism Spectrum Disorder

BACKGROUND

Research suggests adults with autism spectrum disorder (ASD) may use executive functions to compensate for social difficulties. Given hallmark age-related declines in executive functioning and the executive brain network in normal aging, there is concern that older adults with ASD may experience further declines in social functioning as they age. In a male-only sample, we hypothesized: 1) older adults with ASD would demonstrate greater ASD-related social behavior than young adults with ASD, 2) adults with ASD would demonstrate a greater age group reduction in connectivity of the executive brain network than neurotypical (NT) adults, and 3) that behavioral and neural mechanisms of executive functioning would predict ASD-related social difficulties in adults with ASD.

METHODS

Participants were a cross-sectional sample of non-intellectually disabled young (ages 18-25) and middle-aged (ages 40-70) adult men with ASD and NT development (young adult ASD: n=24; middle-age ASD: n=25; young adult NT: n=15; middle-age NT: n=21). We assessed ASD-related social behavior via the self-report Social Responsiveness Scale-2 (SRS-2) Total Score, with exploratory analyses of the Social Cognition Subscale. We assessed neural executive function via connectivity of the resting-state executive network (EN) as measured by independent component analysis. Correlations were investigated between SRS-2 Total Scores (with exploratory analyses of the Social Cognition Subscale), EN functional connectivity of the dorsolateral prefrontal cortex (dlPFC), and a behavioral measure of executive function, Tower of London (ToL) Total Moves.

RESULTS

We did not confirm a significant age group difference for adults with ASD on the SRS-2 Total Score; however, exploratory analysis revealed middle-age men with ASD had higher scores on the SRS-2 Social Cognition Subscale than young adult men with ASD. Exacerbated age group reductions in EN functional connectivity were confirmed (left dlPFC) in men with ASD compared to NT, such that older adults with ASD demonstrated the greatest levels of hypoconnectivity. A significant correlation was confirmed between dlPFC connectivity and the SRS-2 Total Score in middle-age men with ASD, but not young adult men with ASD. Furthermore, exploratory analysis revealed a significant correlation with the SRS-2 Social Cognition Subscale for young and middle-aged ASD groups and ToL Total Moves.

CONCLUSIONS

Our findings suggest that ASD-related difficulties in social cognition and EN hypoconnectivity may get worse with age in men with ASD and is related to executive functioning. Further, exacerbated EN hypoconnectivity associated with older age in ASD may be a mechanism of increased ASD-related social cognition difficulties in older adults with ASD. Given the cross-sectional nature of this sample, longitudinal replication is needed.

Patterns of Nonsocial and Social Cognitive Functioning in Adults With Autism Spectrum Disorder: A Systematic Review and Meta-analysis

IMPORTANCE

Many studies have investigated impairments in cognitive domains in adults with autism spectrum disorder (ASD). Yet, to date, a comprehensive overview on the patterns of cognitive functioning is lacking.

OBJECTIVE

To provide an overview of nonsocial and social cognitive functioning in various domains in adults with ASD, allowing for comparison of the severity of deficits between different domains.

DATA SOURCES

A literature search performed in an academic medical setting was conducted using PubMed, PsycINFO, Embase, and Medline databases with the combination of the following free-text and Medical Subject Headings where applicable: [cogniti* OR neurocogniti* OR neuropsycholog* OR executive function* OR IQ OR intelligence quotient OR social cognition OR emotion perception OR affect perception OR emotion recognition OR attribution OR ToM OR mentalising OR mentalizing OR prosody OR social knowledge OR mind reading OR social cue OR social judgment] AND [autis* OR ASD OR Asperger OR Asperger's OR PDD OR pervasive developmental disorder]. The search was further limited to studies published between 1980 (first inclusion of autism diagnosis in the DSM-III) and July 2018.

STUDY SELECTION

Studies included were published as a primary peer-reviewed research article in English, included individuals with ASD 16 years or older, and assessed at least 1 domain of neurocognitive functioning or social cognition using standard measures.

DATA EXTRACTION AND SYNTHESIS

Of 9892 articles identified and screened, 75 met the inclusion criteria for the systematic review and meta-analysis.

MAIN OUTCOMES AND MEASURES

Hedges g effect sizes were computed, and random-effects models were used for all analyses. Moderators of between-study variability in effect sizes were assessed using meta-regressions.

RESULTS

The systematic review and meta-analysis included 75 studies, with a combined sample of 3361 individuals with ASD (mean [SD] age, 32.0 [9.3] years; 75.9% male) and 5344 neurotypical adults (mean [SD] age, 32.3 [9.1] years; 70.1% male). Adults with ASD showed large impairments in theory of mind (g = -1.09; 95% CI, -1.25 to -0.92; number of studies = 39) and emotion perception and processing (g = -0.80; 95% CI, -1.04 to -0.55; n = 18), followed by medium impairments in processing speed (g = -0.61; 95% CI, -0.83 to -0.38; n = 21) and verbal learning and memory (g = -0.55; 95% CI, -0.86 to -0.25; n = 12). The least altered cognitive domains were attention and vigilance (g = -0.30; 95% CI, -0.81 to 0.21; n = 5) and working memory (g = -0.23; 95% CI, -0.47 to 0.01; n = 19). Meta-regressions confirmed robustness of the results.

CONCLUSIONS AND RELEVANCE

Results of this systematic review and meta-analysis suggest that adults with ASD show impairments in social cognitive domains and in specific nonsocial cognitive domains. These findings contribute to the understanding of the patterns of cognitive functioning in adults with ASD and may assist in the identification of targets for cognitive interventions.

Exploratory Study of Executive Function Abilities Across the Adult Lifespan in Individuals Receiving an ASD Diagnosis in Adulthood

Little is known about cognition in autism spectrum disorder (ASD) across adulthood. We examined executive function abilities and autism traits in 134 adults receiving a first diagnosis of ASD. Participants aged 18–75 years with abilities in the normal range were assessed on executive function and self-report autism traits. Results suggest that for some abilities relying on speed and sequencing (Trails A and B; Digit Symbol), late-diagnosed individuals with ASD may demonstrate better performance than typical age-norms. On other executive measures (Digit Span, Hayling and Brixton tests) age-related correlations were similar to typical age-norms. Different domains of executive function may demonstrate different trajectories for ageing with ASD, with patterns of slower, accelerated or equivalent age-related change being observed across different measures.

Atypical longitudinal development of functional connectivity in adolescents with autism spectrum disorder

Autism spectrum disorder (ASD) is consistently associated with alterations in brain connectivity, but there are conflicting results as to where and when individuals with ASD display increased or reduced functional connectivity. Such inconsistent findings may be driven by atypical neurodevelopmental trajectories in ASD during adolescence, but no longitudinal studies to date have investigated this hypothesis. We thus examined the functional connectivity of three neurocognitive resting-state networks-the default mode network (DMN), salience network, and central executive network (CEN)-in a longitudinal sample of youth with ASD (n = 16) and without ASD (n = 22) studied during early/mid- and late adolescence. Functional connectivity between the CEN and the DMN displayed significantly altered developmental trajectories in ASD: typically developing (TD) controls-but not youth with ASD-exhibited an increase in negative functional connectivity between these two networks with age. This significant interaction was due to the ASD group displaying less negative functional connectivity than the TD group during late adolescence only, with no significant group differences in early/mid-adolescence. These preliminary findings suggest a localized age-dependency of functional connectivity alterations in ASD and underscore the importance of considering age when examining brain connectivity. Autism Research 2019, 12: 53-65. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Brain connectivity may develop differently during adolescence in youth with autism spectrum disorder (ASD). We looked at changes in brain connectivity over time within individuals and found that, for some brain regions, adolescents with ASD did not show the same changes in brain connectivity that typically developing adolescents did. This suggests it is important to consider age when studying brain connectivity in ASD.

Patterns of Age-Related Cognitive Differences in Adults with Autism Spectrum Disorder

Little is known about age-related cognitive differences in autism spectrum disorder (ASD). However, given the overlap in cognitive impairments in ASD to those seen in typical aging, it is possible that adults with ASD will face even greater cognitive difficulties as they age. The current study used a cross-sectional design to examine age-related cognitive differences in adults with ASD and age and IQ-matched adults with typical development (age range 30-67 years). Results indicated that both age and diagnosis were related to poorer cognitive performance. However, adults with ASD exhibited pronounced age effects on measures related to executive functioning compared to adults with typical development, suggesting that aging in ASD may disproportionately affect specific cognitive processes.

Changing ASD-ADHD symptom co-occurrence across the lifespan with adolescence as crucial time window: Illustrating the need to go beyond childhood

Literature on the co-occurrence between Autism Spectrum Disorder (ASD) and Attention-Deficit/Hyperactivity Disorder (ADHD) is strongly biased by a focus on childhood age. A review of the adolescent and adult literature was made on core and related symptoms of ADHD and ASD. In addition, an empirical approach was used including 17,173 ASD-ADHD symptom ratings from participants aged 0 to 84 years. Results indicate that ASD/ADHD constellations peak during adolescence and are lower in early childhood and old age. We hypothesize that on the border of the expected transition to independent adulthood, ASD and ADHD co-occur most because social adaptation and EF skills matter most. Lower correlations in childhood and older age may be due to more diffuse symptoms reflecting respectively still differentiating and de-differentiating EF functions. We plea for a strong research focus in adolescence which may -after early childhood- be a second crucial time window for catching-up pattern explaining more optimal outcomes. We discuss obstacles and oppportunities of a full lifespan approach into old age.