The Relationship Between Adverse Childhood Events, Resiliency and Health Among Children with Autism

Resilience in the face of neurodivergence: A scoping review of resilience and factors promoting positive outcomes

Neurodivergent individuals, including a range of conditions impacting neurological function, are at an increased likelihood of poor life outcomes, such as in functional adaptation, mental health, and well-being. Yet, many live meaningful and fulfilling lives. Resilience may provide some explanation for the heterogeneity in outcomes observed in neurodivergent populations. We conducted a scoping review embedded in a neurodiversity-affirmative approach to provide an understanding of resilience in neurodivergent populations. A total of 176 articles were included in this review and were synthesized using a two-phased process. First, findings were synthesized narratively to examine how resilience has been conceptualized and explored in neurodivergent populations. Second, to identify the bio-psycho-social factors important for resilience in neurodivergent individuals, we converted concepts identified in articles to the nomenclature of the World Health Organizations' International Classification of Functioning, Disability and Health (ICF) using a standardized linking process. We find considerable variability in how resilience is conceptualized and measured in neurodivergent populations. We identified 83 unique ICF categories representing resilience factors, of which only 20 appeared in more than 5% of the articles. Identified ICF categories highlight the importance of support systems such as families and friends, community participation and acceptance, and individual capabilities for resilience.

Association Between Positive Childhood Experiences and Caregiver-Reported ADHD Diagnosis and Severity

OBJECTIVE

Little is known about the prevalence of positive childhood experiences (PCEs), a counter to adverse childhood experiences, in children with an attention-deficit hyperactivity disorder (ADHD) diagnosis. The purpose of this study was to examine the relationship between PCEs and ADHD diagnosis and severity, adjusting for child, family, and household characteristics, using a nationally representative data set.

METHODS

Using the 2020 to 2021 National Survey of Children's Health, our sample included children 6 years of age or older, as this is the age at which PCE questions are asked (n = 56,224). Multivariable logistic regression was used to examine the association between PCE type and ADHD diagnosis and severity, controlling for child and household characteristics.

RESULTS

In multivariable regression analyses, children who had volunteered in their community had lower odds of a reported ADHD diagnosis than children who had not volunteered in their community (adjusted odds ratio [aOR] 0.83; 95% confidence interval [CI], 0.73-0.95). Children with a connected caregiver had a lower likelihood of ADHD diagnosis than children without a connected caregiver (aOR 0.66; 95% CI, 0.58-0.74). Children reporting moderate to severe ADHD were less likely to report exposure to any of the 7 PCEs examined, when compared with children reporting mild ADHD.

CONCLUSION

The findings from this study can be important for clinicians and families to mitigate the negative social and academic outcomes that children with ADHD may face.

Adverse childhood experiences exacerbate peripheral symptoms of autism spectrum disorder in adults

AIM

Adverse childhood experiences are potentially traumatic events with long-lasting effects on the health and well-being of patients with autism spectrum disorder (ASD). It is important to clarify which types of long-lasting autism-related symptoms are influenced by childhood experiences to design future intervention studies. However, few studies have examined the association between childhood experiences and autistic symptoms in large samples of adults with ASD and individuals with typical development (TD). In this study, we evaluate the effects of adverse childhood experiences on multiple ASD phenotypes among both individuals with ASD and those with TD.

METHOD

We combined questionnaire evaluations; Childhood Abuse and Trauma Scale, the Japanese version of the Autism-Spectrum Quotient, Conners' Adult ADHD Rating Scale, the Japanese version of the Impact of Event Scale-Revised, and the Japanese version of the Adolescent/Adult Sensory Profile.

RESULTS

Individuals with ASD and those with TD (n = 205 and 104, respectively) were included. There were significant correlations between the extent of adverse childhood experiences and severity of attention-deficit/hyperactivity disorder symptoms, posttraumatic stress disorder symptoms, and hypersensitivity in both participants with ASD and those with TD. By contrast, ASD core symptoms showed no significant correlation with adverse childhood experiences in either group. These results remained consistent after adjusting for age, sex, and the estimated intelligence quotient.

CONCLUSION

These findings suggest the need for a detailed disentanglement of ASD-related core and peripheral symptoms of adverse childhood experiences, which may help to appropriately set outcomes for future early interventions for the childhood experiences of individuals with ASD.

Impact of adverse childhood experiences and family resilience on sleep duration in autistic children

LAY ABSTRACT

Autistic children are more likely to have sleep difficulties and to experience adverse childhood experiences. Adverse childhood experiences can include parental divorce, bullying, or witnessing violence. We also know that children in families who are resilient (e.g. families who are connected, work together, and help each other) are less impacted by adverse childhood experiences. Our study examined whether there was a relationship between adverse childhood experiences and sleep duration in autistic children. We also wanted to find out whether family resilience protects from the negative impact of adverse childhood experiences on sleep duration. We used data from 3247 parent surveys about their children that we got from the National Survey of Children's Health. We found that children with adverse childhood experiences are more likely to get less sleep. We also found that children with resilient families were more likely to get more sleep. Our results show that family resilience helps weaken the relationship between adverse childhood experiences and sleep, so it is important to help families build resilience.

Behavior Analysts' Training and Practice Regarding Trauma-Informed Care

Discussion of trauma and trauma-informed practices continues to be elusive in behavior analytic research despite the consideration that 60% of men and 50% of women in the general public are estimated to experience at least one traumatic event in their lifetimes (National Center for PTSD, 2023). In addition, it is estimated that, beyond post-traumatic stress disorder, an estimated 61% of adults have experienced at least one adverse childhood experience (Centers for Disease Control & Prevention [CDC], 2019). It is clear from these statistics that neither trauma nor adverse experiences are uncommon. Further, these individual histories often affect future behavioral functioning, potentially resulting in the referral of the individual for behavioral services. The current study surveyed Board Certified Behavior Analysts to assess behavior analysts' current practices and perceptions of trauma-related concepts and to offer insight into how behavior analysts perceive their competence in this area of diversity. Descriptive and Ordinary Least Squares regression analyses were conducted to identify the perceptions and relationships between training and understanding of trauma-informed practices. The majority of respondents reported that training on trauma-related concepts is extremely important, yet further reported having little-to-no training on trauma-related concepts across their graduate coursework, fieldwork supervision, or continuing education. Implications and future research are discussed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40617-023-00836-7.

How to build resiliency in autistic individuals: an implication to advance mental health

INTRODUCTION

Individuals on the autism spectrum (ASD) often experience poor mental health and coping strategies compared to their peers due to social exclusion and co-occurring conditions. Resiliency has been identified as a key factor in preventing adverse outcomes and promoting mental health. Therefore, it is important to determine what strategies can be used to build resiliency among autistic individuals. The current paper is one of the first studies that aims to collect information from autistic individuals and their caregivers on potential strategies to enhance resiliency.

METHODS

We interviewed 18 participants from various provinces in Canada, comprising of 13 autistic individuals and 5 parents. We used thematic analysis to identify patterns in the data.

RESULTS

Thematic analysis revealed three themes to indicate strategies that could be used to enhance resiliency, including: (a) self-reliant strategies, (b) using community-based facilities, and (c) contextual and individual characteristics.

CONCLUSION

Although the body of literature on resiliency is evolving, this paper provides a unique perspective as it is one of the few studies that considers the experiences of individuals on the spectrum. In addition, this study focuses on identifying and describing specific strategies that can be used to enhance resiliency and mental health, which consequently can help address the existing gaps in knowledge and practice.

Adverse Childhood Experiences and Autism: A Meta-Analysis

Evidence suggests that autistic children have a higher probability of experiencing adverse childhood experiences (ACEs) compared to their non-autistic peers. This meta-analysis (PROSPERO: CRD42022262635) aimed to quantify the association of autism and ACEs. Eight databases and Google Scholar were searched for studies that reported dichotomous outcomes regarding the associations between ACEs and autistic individuals, compared to non-autistic individuals. A random-effects model was used to calculate the average Odds Ratio (OR) of the relationship between a diagnosis of autism and ACEs. A total of 40 studies with 5,619,584 participants were included, generating an overall average OR 2.11 (CI 1.61, 2.77). Significant differences in the magnitude of association were found across studies with regards to the type of ACEs studied, comparison groups, and population type. Overall, moderate certainty evidence (downgraded for bias) indicates that autistic individuals are at greater risk of experiencing ACEs, compared to non-autistic individuals. Appropriate support for autistic individuals and their families are required to prevent ACEs and treat the impact of ACEs.

The Role of Adverse Childhood Experience in the Relationship Between Autism Severity and Early Intervention and Special Education Plan

The purpose of this study is to examine the association between autism spectrum disorder (ASD) severity and having a special education or early intervention plan and the impact of adverse childhood experiences (ACEs) on this association. This study used the 2020-2021 National Survey of Children's Health (NSCH) and included 2,537 children aged 3-17 years old who currently have ASD. Multivariable logistic regression, controlling for demographic and family characteristics and health status, was used to explore the association between autism severity and having an early intervention plan. The analysis was stratified by the number of ACEs to explore their role in the association. Children with moderate or severe ASD were more likely to have a special education or early intervention plan than those with mild ASD in the crude and adjusted models. This association continued to be true for children who experienced 1 ACE (aOR: 2.28, 95%CI: 1.09-4.77) but not true for those who experienced no ACEs (aOR: 1.16, 95%CI: 0.70-1.94) and 2 or more ACEs (aOR: 1.84, 95%CI: 0.92-3.69). Results demonstrate that children with moderate or severe autism were more likely to receive early intervention or special education. This association changed depending on the number of ACEs experiences.

An Exploratory Study of Resilience to Stressful Life Events in Autistic Children

Background

Autistic children experience more stressful life events (SLEs) than their neurotypical peers, which are related to poor mental health outcomes in both neurotypical and autistic individuals. However, there is a lack of longitudinal research assessing the perceived impact of stressful life events on autistic children's mental health.

Method

Utilizing a novel statistical technique (Ratcliff et al., 2019), called 'area of resilience to stress events' or ARSE in R, we aimed to quantify aspects of resilience, growth, and non-resilience for 67 autistic children (6-13 years old) enrolled in a larger longitudinal study who experienced a SLE. Parents reported demographic information (e.g., child age, biological sex, household income) as well as the child's internalizing and externalizing symptoms and autism characteristics across multiple time points spaced one year apart (baseline, T2, T3, T4).

Results

There was substantial variability in the resilience process within the sample. Older children exhibited a less adaptive resilience process (i.e., higher total scaled scores or arsets). Perceived stress of the disruptive event was not correlated with resilience; however, there was a significant child age x stress severity interaction, suggesting that younger children in households that perceived the disruptive event as highly stressful exhibited more efficient resilience, or lower arsets scores, compared to other children.

Conclusions

This study introduces an innovative methodological approach to understanding the effects of stressful life events on the mental health of autistic children. Results have implications for family-based policy and practice and highlight for whom services may be most beneficial.

Impact of Adverse Childhood Experiences and Mental Health on School Success in Autistic Children: Findings from the 2016-2021 National Survey of Children's Health

PURPOSE

School is an important developmental setting for children. Adverse childhood experiences (ACEs) are linked to overall lower educational attainment and are more prevalent in children with Autism Spectrum Disorder (ASD) than in their neurotypical peers. The aim of this study is to test the association between ACEs and school outcomes among autistic children and whether mental health conditions explain this association.

METHODS

We combined 2016-2021 data from the National Surveys of Children's Health for children, ages 6-17, identified by parents as having ASD (N = 4,997), to examine the relationship between ACEs and school outcomes (grade progression, school attendance, and engagement). We analyzed depression and anxiety variables to investigate the extent to which mental health can explain the relationships between ACEs and school outcomes.

RESULTS

ACEs were significantly associated with school outcomes. With increased ACEs, autistic children experienced a significant decrease in the odds of school attendance, grade progression and school engagement (p < .05). Furthermore, although depression and anxiety symptoms were significantly associated with school outcomes, they cannot explain away the enduring, strong relationship between ACEs and level of grade progression, engagement, and school success index.

CONCLUSION

Our findings suggest ACEs predict school success among autistic children, with mental health conditions appearing to mediate the relationship between ACEs and key factors in school success. Efforts should be made to proactively identify and address the impact of ACEs and associated mental health conditions among autistic students.

Adverse Childhood Experiences and Health Outcomes Among Transition-Age Autistic Youth

BACKGROUND

Adverse childhood experiences (ACEs) have been associated with poor health outcomes in the general population. However, their impact on autistic youth remains unclear.

OBJECTIVE

The primary objective was to understand how childhood adversity is related to the general health, mental health, and physical health of transition-age autistic youth.

PARTICIPANTS AND SETTING

Using data from the 2018-2021 National Survey of Children's Health, this cross-sectional study involved 2056 autistic youth aged 12-17.

METHODS

Logistic regression was employed to test the association between three measures of ACEs - individual ACEs, cumulative ACEs, and grouped ACEs based on contexts, and health outcomes of autistic youth.

RESULTS

Our study observed a high prevalence of ACEs among autistic youth, with a substantially higher proportion experiencing multiple ACEs than their neurotypical peers. Individual ACEs were significantly associated with specific health issues. Cumulative ACEs demonstrated a clear dose-response relationship with health outcomes, with higher ACE counts increasing the likelihood of experiencing poor general health, mental health conditions, and physical health issues. Moreover, grouped ACEs associated with health differently, with community-based ACEs being particularly linked to general health status, mental health conditions, and physical health conditions, while family-based ACEs correlated more with more severe mental health conditions and being overweight.

CONCLUSION

These findings collectively emphasize the importance of addressing ACEs as a public health concern among transition-age autistic youth, highlighting the need for targeted interventions, prevention strategies, and support services to mitigate the negative impact of ACEs on the overall well-being of this growing community.

The impact of adverse childhood events on service support and educational outcomes of children who are autistic: A theory-guided analysis using structural equation modeling

Autistic children who have experienced adverse childhood experiences (ACEs) may have barriers to receiving special education or other developmental services-thus, impacting educational outcomes. Our objective was to model such a pathway using the 2016-2021 National Survey of Children's Health datasets. We extracted data for school outcomes, use of special education and autism-related specialty services and sociodemographic characteristics among autistic children within the data. Associations between sociodemographics and ACEs (categorized as 0, 1-3, and 4+) were tested using design-based X2 tests. We then used structural equation modeling to map the quasi-causal pathways. The sample for our analysis included 4717 autistic children-38.94% were aged 6-10 years, 35.73% of children aged 11-14 years, and 25.32% were between 15 and 17 years-with 88.70% living in metropolitan areas. The X2 showed significant relationships between ACEs and age, ethnoracial groups, and urbanicity among others. The SEM showed ACEs were directly associated with poorer school outcomes (β = -0.14 (0.04), p = 0.002) and through their inverse relationship with support services (β = -0.08 (0.04), p = 0.023)- when support services were increased, school outcomes improved (β = 0.62, p < 0.001). Findings suggested ACEs have a significant direct and indirect impact on school outcomes of autistic children, and 10.76% of children who are autistic have experienced four or more ACEs-which were more likely to occur with severe autism symptomatology and in rural areas. Results highlight the need for communities to recognize the potential long-term impact of ACEs on the academic outcomes of autistic children.

Adverse childhood experiences and psychotropic medication prescription among cancer patients

BACKGROUND

This study aimed at identifying and characterizing adverse childhood experiences (ACEs) in a sample of cancer patients and subsequently evaluating the relationship between ACEs and prescription of psychotropic medication among them. Individuals with ACEs have a higher risk of mental health conditions and are more likely to be prescribed psychotropic medications.

METHODS

A sample of 178 adult patients receiving Supportive Oncology & Survivorship (SOS) services at Huntsman Cancer Hospital in Utah was obtained. ACEs and Brief Resilient Coping Scale (BRCS) questionnaires were administered confidentially. A multivariable mixed effect model, adjusting for sex, age, and insurance type while controlling for zip-codes clustering were employed.

RESULTS

Compared to the prevalence of ACEs in the general population, from the CDC-Kaiser Permanente ACEs Study, we found no significant difference in the prevalence of people who had experienced an adverse childhood event (ACEs score > = 1) between our study of cancer patients and the CDC-Kaiser study (67.4% vs. 63.6%, p = 0.29372), but found a significant difference in the prevalence of people who had experienced severe adverse childhood experiences (ACES score > =4) (25.3% vs. 12.1%, p < 0.00001). Furthermore, this study reveals a significant association between an increase of one unit in the total ACEs score and the odds of psychotropic medication prescription in the past 12 months (OR: 1.233; 95% CI: 1.025, 1.483). Those with a total ACEs score of three or more were found to have 280% higher odds of being prescribed psychotropic medication compared to those with ACEs ≤ 2 (OR: 3.822; 95% CI: 1.404,10.407).

CONCLUSION

A significant proportion of cancer patients have a history of ACEs, and thus trauma-informed care approach is essential during their treatment.

Patterns of Adverse Childhood Experiences and Psychiatric Disorders Among Adolescents with ADHD: A Latent Class Analysis

There is limited existing research on whether specific combinations of Adverse Childhood Experiences (ACEs) are associated with different psychiatric disorders among adolescents with ADHD. This study aimed to address this gap by identifying classes of ACEs and examining their association with behavioral problems, anxiety, and depression in adolescents with ADHD aged 11-17 (n = 1,806), using data from the 2018 National Survey of Children's Health (NSCH). A latent class analysis revealed a four-class solution: (1) low-risk ACEs (61.6%), (2) moderate-risk ACEs (25.2%), (3) high discrimination and neighborhood violence exposure (7.6%), and (4) high-risk ACEs (5.6%). The "high-risk ACEs" and the "high discrimination and neighborhood violence exposure" class showed a higher likelihood of behavioral problems and depression, and anxiety and depression respectively. These findings provide some insight into the ACE patterns that are more likely to be associated with mental health problems among adolescents with ADHD.

CYP2D6 Genotype and Pharmacovigilance Impact on Autism Spectrum Disorder: A Naturalistic Study with Extreme Phenotype Analysis

The long-term use of psychopharmacology medications in autism spectrum disorder (ASD) hitherto remains controversial due to a lack of evidence about safety and tolerability. In this regard, genotyping the metabolizing enzyme cytochrome P450 (CYP) 2D6, especially its extreme phenotypes, could help to prevent drug-related adverse reactions or adverse events (AEs). There are several medications warranting CYP2D6 screening that are consumed by people with ASD, such as risperidone and aripiprazole to name a few. A naturalistic observational study was carried out in participants with ASD to analyze the influence of the CYP2D6 phenotype in drug tolerability using a local pharmacovigilance system created for this study. In this case, AEs were identified from participants' electronic health records (EHRs) and paper registries. Other variables were collected: socio-demographic information, comorbidities, and psychopharmacology prescriptions (polypharmacy defined as ≥4 simultaneous prescriptions) and doses. The genetic analysis included allelic discrimination (CYP2D6*1, *2, *3, *4, *5, *6, *10, *17, and *41) and copy number variations. All of these were used to determine theoretical phenotypes of the metabolic profiles: poor (PM); intermediate (IM); normal (NM); and ultra-rapid (UM). Sex differences were analyzed. A total of 71 participants (30 ± 10 years old, 82% male, 45% CYP2D6 NM phenotype (32 participants)) with a median of 3 (IQR 2-4) comorbidities per person, mainly urinary incontinence (32%) and constipation (22%), were included. CYP2D6 UM showed the highest rate of polypharmacy, whilst, IM participants had the highest rates of neurological and psychiatric AEs, even worse if a CYP2D6 inhibitor drug was prescribed simultaneously. CYP2D6 pharmacogenomics and the monitoring of new antipsychotic prescriptions may make a difference in medication safety in adults with ASD. Particularly in those with psychopharmacology polymedication, it can help with AE avoidance and understanding.

Early Life Stress, Hormones, and Neurodevelopmental Disorders

BACKGROUND

Early life stress (ELS) describes a broad spectrum of adverse and stressful prenatal events, namely, prenatal maternal stress (PMS), or early postnatal events, which can have detrimental long-term influences on the physiology, cognition, and behavior of an individual. There is abundant evidence indicating that ELS exerts its lasting effects on the physical and mental health of the individual, likely acting through a number of mediating mechanisms, including the disruption of developmental programming of the fetus. Neurodevelopmental disorders (NDDs), for example, attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD), are a group of conditions that typically manifest during infancy, childhood, or adolescence and are characterized by developmental deficits in various domains.

SUMMARY

The scope of the current mini-review is to provide an up-to-date summary of the findings regarding the association of ELS and NDDs and the possible hormonal mechanisms through which PMS exerts its impact on neurodevelopment. We focus on the available evidence regarding children and adolescents diagnosed with ADHD or ASD. ELS exposure during developmental vulnerability windows may increase the risk for either subclinical neuropsychological alterations or clinical conditions, such as NDDs. In fact, a large body of evidence underlies the association of ELS exposure and increased risk for NDDs in the offspring.

KEY MESSAGES

The majority of data suggest that ELS, including PMS, may be associated with ADHD and ASD in the offspring, although there is no consensus regarding the critical developmental periods. Carefully controlled prospective studies are needed to determine the possible causal processes and mechanisms underlying the association of ELS and NDDs.

“Realizing the problem wasn’t necessarily me”: the meaning of childhood adversity and resilience in the lives of autistic adults

Purpose

Methods

Results

Conclusion

Hospitalizations Among Children and Youth With Autism in the United States: Frequency, Characteristics, and Costs

National estimates of hospitalization diagnoses and costs were determined using the 2016 HCUP Kids' Inpatient Database. Children and youth with autism were hospitalized over 45,000 times at over $560 million in costs and 260,000 inpatient days. The most frequent principal diagnoses for hospitalizations of children and youth with autism were epilepsy, mental health conditions, pneumonia, asthma, and gastrointestinal disorders, which resulted in almost $200 million in costs and 150,000 inpatient days. Mental health diagnoses accounted for 24.8% of hospitalizations, an estimated $82 million in costs, and approximately 94,000 inpatient days. Children and youth with autism were more likely hospitalized for epilepsy, mental health diagnoses, and gastrointestinal disorders, and less likely for pneumonia and asthma compared to other children and youth.

Omar ZT, Segun E, Evbayekha EO, Abolurin A, Egberuare EO, Ezegbe HC, Adegbosin A, Adedeji AG, Angaye EG, Izundu IC, Oyelade BO. Impact of Adverse Childhood Experiences on Resilience and School Success in Individuals With Autism Spectrum Disorder and Attention-Deficit Hyperactivity Disorder

Adolescents with emotional and behavioral disorders face known academic challenges and poor life outcomes. It was imperative to explore and find if the new diagnostic criterion for diagnosing autism profoundly affects educational outcomes and resilience in individuals diagnosed with co-occurring autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD). The literature is robust on the impact of adverse childhood experiences (ACEs) on educational outcomes and resilience in adolescents with no history of disability. Still, there remains a dearth of literature explaining, with no ambiguity, the complex relationships between ACEs and resilience, school engagement, and success in individuals with co-occurring ASD and ADHD. This study reviews the existing scholarships on the topic. The significance of this review is that it informs healthcare providers, rehabilitation counselors, and educators about the need for early identification of individuals with ASD and ADHD with a background in ACEs. This will enable interventions early enough to ensure they are more resilient and can obtain improved success in school-related and outside-school activities and eventually improved quality of life.

A Pediatrician's Guide to Working with Children on the Autism Spectrum in Coronavirus Disease 2019 and Beyond: Retrospect and Prospect

The COVID-19 pandemic is an unprecedented event with devastating effects on children and families, highlighting and broadening disparities in the care of children with developmental disabilities, while simultaneously catalyzing innovation. Children are vulnerable to the impacts of COVID-19, resulting in increased stress, anxiety, isolation, and health challenges, further amplified in autistic children and children with other neurodevelopmental disabilities. These children are uniquely vulnerable due to communication impairments, comorbid medical disorders, reduced adaptability, and reliance on therapeutic interventions. Abrupt reduction in services and access to care during the pandemic compromised physical and mental health and led to missed intervention opportunities at critical times. It is important to examine the effects that the pandemic triggered, address deficiencies, and recognize new opportunities to improve systems of care to prepare for unforeseen futures.

Intergenerational trauma: Parental PTSD and parent-reported child abuse subtypes differentially relate to admission characteristics in the autism inpatient collection

Autistic youth experience high rates of maltreatment. Little research has considered how distinct abuse dimensions differentially relate to meaningful outcomes, nor taken an intergenerational approach to consider how caregiver trauma and child maltreatment are related. This study sought to identify how parent-reported child abuse subtypes and parent posttraumatic stress disorder (PTSD) relate to each other and to admission characteristics upon inpatient service entry. Autistic youth (N = 527; 79% White, 21.3% girls, mean age = 12.94 years) participated in the autism inpatient collection. Parents reported on child abuse subtypes (physical, sexual, emotional) and their own PTSD, child behavior and emergency services, and parenting stress. Youth of parents with PTSD were nearly three times more likely to have parent-reported physical and emotional abuse. Autistic girls were more likely to experience parent-reported sexual abuse and a higher number of subtypes. Lower income related to higher rates of parent-reported child emotional abuse and parent PTSD. Emotional abuse associated with child behavior whereas both child physical and emotional abuse related to emergency services. Reported parent PTSD associated with child behavior and parental distress. When considered jointly, parent PTSD and number of parent-reported child abuse subtypes differentially related to child behavior and interacted to predict psychiatric hospitalizations. Intergenerational continuity of trauma is important to consider among autistic youth, and both parent-reported child abuse and parent PTSD relate to admission characteristics. Critical limitations include reliance on binary parent reports of child abuse and parent PTSD and the low representation of youth of minoritized identities. Implications for trauma-informed care are discussed.

Impact of Social and Relational Adversity on Access to Services among US Children with Autism Spectrum Disorder 2016–2019

To explore the impact of social and relational adversity on access to key health services among US children with autism spectrum disorders (ASD), cross-sectional analyses of the 2016–2019 National Survey of Children’s Health assessed use of key health services by children with ASD, accounting for differences in demographic characteristics, medical needs, and experience of social and relational adversities. sUS children with ASD were more than twice as likely as peers without ASD to report two or more social adversities and more than three times as likely to report two or more relational adversities. In multivariable models, relational adversities were significantly associated with greater odds of medication use for ASD (OR 1.50, 95%CI:1.02, 2.17). Social adversities were neither associated with receipt of behavioral therapies nor prescription of medication to treat ASD. Screening for various forms of adversity among youth with ASD is of great importance; even one adverse experience may be enough to influence care of a child with ASD, with differences in effect according to the nature of the particular adversity. Further research should evaluate the role that childhood adversity plays in physical and mental health outcomes in ASD.

Behavioral and mental health problems in adolescents with ADHD: Exploring the role of family resilience

BACKGROUND

Family resilience and its role in behavioral and mental health problems has not been well documented among U.S. adolescents, especially those with ADHD.

METHODS

Using data from the 2016 and 2017 National Survey of Children's Health (NSCH), we examined associations between family resilience connection index (FRCI) and conduct problems, depression, anxiety, and substance abuse in adolescents with ADHD aged 11-17 (n=4,169). Data were analyzed using multivariate logistic regression and chi-square tests.

RESULTS

Adolescents with ADHD who had a lower FRCI score were more likely to have conduct problems (OR:1.64, CI:1.13-2.38) and depression (OR: 3.08, CI: 2.12-4.49). There were small differences between adjusted and unadjusted odds after controlling for adverse childhood experience and other covariates.

LIMITATION

We could not assert prediction or causation, only associations among variables, due to the cross-sectional design of the 2016-2017 NSCH; however, a major advantage of the NSCH is that it includes a nationally representative sample of children and allows inferences to be made for understanding of the adolescents with ADHD in the U.S.

CONCLUSION

Findings suggest that family resilience may serve as a protective factor that leads to decreasing conduct problems, despite experiencing adversity in childhood. Targeting family resilience, in terms of teaching families ways to cope with adversities such as: a child's diagnosis of ADHD; behavioral problems, and/or other adverse experiences in children's environments, has great potential to reduce adolescents' conduct and mental health problems.

General health status of youth with autism with and without intellectual disabilities transitioning from special education, and its relationship to personal and family circumstances: longitudinal cohort study

Objective: Transition from school to early adulthood incurs many changes and may be associated with deterioration in general health in youth with autism. We aimed to investigate this. Method: The National Longitudinal Transitions Study-2 is a USA nationally representative sample of youth receiving special education services, aged 13-17 at wave 1, followed-up over 10 years in five data collection waves. We conducted random-effects ordered logistic regressions to determine the odds ratios (OR) with 95% confidence intervals of wave, age, sex, ethnicity/race, additional intellectual disabilities, parental/guardian relationship status, and household income being associated with general health status in youth with autism. Results: Across waves, only between 74.3%-69.6% had excellent/very good health (71.7%-58.8% in those with co-occurring intellectual disabilities), but wave was not associated with health status. Associations were with age OR = 1.18 (1.04, 1.33), co-occurring intellectual disabilities OR = 1.56 (1.00, 2.44), and household income OR = 0.61 (0.40, 0.94) at $30,001-$50,000, OR = 0.44 (0.27, 0.72) at $50,001-$70,000, and OR = 0.34 (0.20, 0.56) at $70,001+. Sex, ethnicity/race, and parental/guardian relationship status were not associated with health status. Conclusion: There was little change in general health status longitudinally across the transitional period, but the proportion with excellent/very good health was low at each wave. Transitional planning should consider co-occurring intellectual disabilities, and the wider socioeconomic context in which children/youth with autism are raised. Lack of other longitudinal studies indicates a need for replication.

Understanding the substance use of autistic adolescents and adults: a mixed-methods approach

BACKGROUND

Autistic individuals might be more likely to misuse substances than non-autistic individuals. Better understanding of these patterns can help clinicians identify strategies to reduce substance use, protecting physical and mental health. The aim of this study was to compare the experiences of substance use between autistic and non-autistic adolescents and adults.

METHODS

This study is a mixed-methods study, including both quantitative (closed-ended questions) and qualitative (one open-ended question) online assessments. Data were collected as part of a larger study, the Autism and Physical Health Survey, in which we administered an anonymised, online questionnaire to autistic and non-autistic individuals aged 16-90 years. In the present study, we investigated data on substance use or misuse, using two overlapping but separate samples from the survey (one sample with complete quantitative responses and one sample with complete qualitative responses). Binary measures of substance use were investigated using unadjusted and adjusted binomial logistic regression models. Content analysis was used to compare experiences of autistic and non-autistic adolescents and adults. We used Fisher's exact tests to assess differences in frequency of reporting particular qualitative themes and subthemes.

FINDINGS

Survey recruitment was done between Feb 7, 2018, and Aug 26, 2019. At the end of the recruitment, 3657 individuals had accessed the survey. After excluding duplicates as well as participants with missing or incomplete responses, we had data from 2386 participants (1183 autistic and 1203 non-autistic participants; 1571 female and 815 male participants) for the quantitative analyses and data from 919 participants (429 autistic and 490 non-autistic participants; 569 female and 350 male participants) in the qualitative analyses. The samples for the quantitative and qualitative analyses were predominantly composed of female individuals, White individuals, UK residents, and those without intellectual disability. Autistic individuals were less likely than non-autistic individuals to report consuming alcohol regularly (16·0% of autistic individuals vs 22·2% of non-autistic individuals; adjusted model: odds ratio [OR] 0·69, 95% CI 0·55-0·86; p=0·0022) or binge-drinking (3·8% vs 8·2%; adjusted model: OR 0·38, 0·26-0·56; p<0·0001). Autistic male participants were less likely than non-autistic male participants to report ever having smoked (50·8% of autistic male participants vs 64·6% of non-autistic male participants; adjusted OR 0·50; 0·32-0·76; p=0·0022) or ever using drugs (35·4% vs 52·7%; adjusted OR 0·53; 0·35-0·80; p=0·0022). Regarding our qualitative analyses, among participants who reported a specific motivation for drug use, compared with non-autistic individuals, autistic individuals were nearly nine times more likely to report using recreational substances to manage behaviour (OR 8·89, 2·05-81·12; p=0·0017) and more likely to report using recreational substances to manage mental health symptoms (OR 3·08, 1·18-9·08; p=0·032). Autistic individuals were also more likely to report vulnerability associated with substance use (OR 4·16, 1·90-10·05; p=0·00027), including childhood use of drugs and being forced or tricked into using drugs.

INTERPRETATION

Autistic individuals might be less likely than non-autistic individuals to report engaging in substance misuse. They also report using drugs to self-medicate. Clinicians should be aware of vulnerability linked to substance use among autistic patients and should work cooperatively with patients to effectively manage autistic and comorbid symptoms.

FUNDING

Autism Research Trust, Rosetrees Trust, Cambridge and Peterborough NHS Foundation Trust.

An investigation of the diet, exercise, sleep, BMI, and health outcomes of autistic adults

BACKGROUND

Studies of autistic children suggest that restricted eating, reduced physical activity, and sleep disorders are common; however, no studies attempt to broadly describe the diet, exercise, and sleep patterns of autistic adults or consider relationships between lifestyle behaviors and the widely reported increased risks of obesity and chronic conditions. To address this, the authors developed the largest study of lifestyle patterns of autistic adults and assessed their relationships to body mass index, health outcomes, and family history.

METHODS

We administered an anonymized, online survey to n = 2386 adults (n = 1183 autistic) aged 16-90 years of age. We employed Fisher's exact tests and binomial logistic regression to describe diet, exercise, and sleep patterns; mediation of seizure disorders on sleep; body mass index (BMI); relationships of lifestyle factors to BMI, cardiovascular conditions, and diabetic conditions; and sex differences among autistic adults.

RESULTS

Autistic adults, and particularly autistic females, exhibit unhealthy diet, exercise, and sleep patterns; they are also more likely to be underweight or obese. Limited sleep duration and high rates of sleep disturbances cannot be accounted for by epilepsy or seizure disorders. Lifestyle factors are positively related to higher risk of cardiovascular conditions among autistic males, even more than family history.

LIMITATIONS

Our sample may not be representative of all autistic and non-autistic people, as it primarily comprised individuals who are white, female, have a high school education or higher, and reside in the UK. Our sampling methods may also exclude some individuals on the autism spectrum, and particularly those with moderate to severe intellectual disability. This is a cross-sectional sample that can test for relationships between factors (e.g., lifestyle factors and health outcomes) but cannot assess the direction of these relationships.

CONCLUSIONS

Autistic adults are less likely to meet minimal health recommendations for diet, exercise, and sleep-and these unhealthy behaviors may relate to excess risk of cardiovascular conditions. Although the present study can only provide preliminary, correlational evidence, our findings suggest that diet, exercise, and sleep should be considered and further investigated as key targets for reducing the now widely reported and dramatically increased risks of health comorbidity and premature death among autistic individuals compared to others. Physicians should work cooperatively with patients to provide health education and develop individualized strategies for how to better manage challenges with diet, exercise, and sleep.

Autism and mood disorders

Individuals with autism experience substantially higher rates of mood problems compared to the general population, which contribute to reduced quality of life and increased mortality through suicide. Here, we reviewed evidence for the clinical presentation, aetiology and therapeutic approaches for mood problems in autism. We identified a lack of validated tools for accurately identifying mood problems in individuals with autism, who may present with 'atypical' features (e.g. severe irritability). Risk factors for mood problems in autism appear to be largely overlapping with those identified in the general population, including shared genetic, environmental, cognitive, physiological/neurobiological mechanisms. However, these mechanisms are exacerbated directly/indirectly by lived experiences of autism, including increased vulnerability for chronic stress - often related to social-communication difficulties(/bullying) and sensory sensitivities. Lastly, current therapeutic approaches are based on recommendations for primary mood disorders, with little reference to the neurobiological/cognitive differences associated with autism. Thus, we recommend: 1) the development and validation of (objective) tools to identify mood problems in autism and measure therapeutic efficacy; 2) an interactive approach to investigating aetiologies in large-scale longitudinal studies, integrating different levels of analysis (e.g. cognitive, neurobiological) and lived experience; 3) testing potential treatments through high-quality (e.g. sufficiently powered, blinded) clinical trials, specifically for individuals with autism.

Increased prevalence of non-communicable physical health conditions among autistic adults

LAY ABSTRACT

Previous research indicates autistic individuals die at a younger age than others and that this is possibly due in part to chronic physical health conditions. The present study used an anonymous, online survey to determine how common certain physical health conditions are among autistic adults, compared with non-autistic adults. We found autistic adults are more likely to develop heart conditions, lung conditions, and diabetes than non-autistic adults. Autistic females may be at higher risk of developing certain conditions (including respiratory conditions, asthma, and prediabetes) than autistic males. Finally, autistic individuals have increased health risks even when considering lifestyle factors (such as smoking, alcohol, and body mass index). This is still a relatively small study, and future research needs to confirm these findings and identify why these risks exist.

Facial Expression Processing Across the Autism-Psychosis Spectra: A Review of Neural Findings and Associations With Adverse Childhood Events

Autism spectrum disorder (ASD) and primary psychosis are classified as distinct neurodevelopmental disorders, yet they display overlapping epidemiological, environmental, and genetic components as well as endophenotypic similarities. For instance, both disorders are characterized by impairments in facial expression processing, a crucial skill for effective social communication, and both disorders display an increased prevalence of adverse childhood events (ACE). This narrative review provides a brief summary of findings from neuroimaging studies investigating facial expression processing in ASD and primary psychosis with a focus on the commonalities and differences between these disorders. Individuals with ASD and primary psychosis activate the same brain regions as healthy controls during facial expression processing, albeit to a different extent. Overall, both groups display altered activation in the fusiform gyrus and amygdala as well as altered connectivity among the broader face processing network, probably indicating reduced facial expression processing abilities. Furthermore, delayed or reduced N170 responses have been reported in ASD and primary psychosis, but the significance of these findings is questioned, and alternative frequency-tagging electroencephalography (EEG) measures are currently explored to capture facial expression processing impairments more selectively. Face perception is an innate process, but it is also guided by visual learning and social experiences. Extreme environmental factors, such as adverse childhood events, can disrupt normative development and alter facial expression processing. ACE are hypothesized to induce altered neural facial expression processing, in particular a hyperactive amygdala response toward negative expressions. Future studies should account for the comorbidity among ASD, primary psychosis, and ACE when assessing facial expression processing in these clinical groups, as it may explain some of the inconsistencies and confound reported in the field.

Adverse Childhood Experiences and Family Resilience Among Children with Autism Spectrum Disorder and Attention-Deficit/Hyperactivity Disorder

OBJECTIVES

The purpose of the present study was to (1) examine the differences in adverse childhood experiences (ACEs) among children with autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), and comorbid ASD/ADHD and healthy neurodevelopmental controls; (2) explore the levels of family resilience across diagnostic categories; (3) identify the differences in family resilience by the number of ACEs; and (4) explore the interaction between ACEs and the diagnostic category on family resilience.

METHOD

Participants were 2083 children between the ages of 6 and 17 years (M = 12.23, SD = 3.36) from the 2016 National Survey of Children's Health. The majority of the sample were male (68.7%) and white (78.6%).

RESULTS

Overall, youth diagnosed with solely ADHD had the highest number of ACEs (Madj = 1.94). In addition, individuals who endorsed exposure to 1 ACE reported higher levels of family resilience in comparison to those who reported 0 ACEs or 2 or more ACEs. Family resilience did not differ between youth who experienced 2 or more ACEs and youth who experienced 0 ACEs. Youth diagnosed with comorbid ASD/ADHD had the lowest levels of family resilience. Interestingly, family resilience did not differ between ADHD and neurotypical youth.

CONCLUSION

Youth diagnosed with ADHD seem to be at the highest risk for ACEs. Those with comorbid ASD/ADHD report the lowest levels of family resilience when controlling for exposure to ACEs. Families of youth with ASD had lower levels of family resilience than those of neurotypical youth when controlling for exposure to ACEs, whereas families of youth with solely ADHD displayed similar levels of family resilience in comparison to neurotypical youth and their families. Results have implications for prevention and intervention with ASD and/or ADHD youth and their families.

Age at identification, prevalence and general health of children with autism: observational study of a whole country population

OBJECTIVES

Reported childhood prevalence of autism varies considerably between studies and over time, and general health status has been little investigated. We aimed to investigate contemporary prevalence of reported autism by age, and general health status of children/young people with and without autism.

DESIGN

Secondary analysis of Scotland's Census, 2011 data. Cross-sectional study.

SETTING

General population of Scotland.

PARTICIPANTS

All children (n=916 331) and young people (n=632 488) in Scotland.

MAIN OUTCOME MEASURES

Number (%) of children/young people reported to have autism and their general health status; prevalence of autism; prevalence of poor health (fair, bad and very bad health); odds ratios (95% confidence intervals) of autism predicting poor health, adjusted for age and gender and OR for age and gender in predicting poor health within the population with reported autism.

RESULTS

Autism was reported for 17 348/916 331 (1.9%) children aged 0-15, and 7715/632 488 (1.2%) young people aged 16-24. The rate increased to age 11 in boys and age 10 in girls, reflecting age at diagnosis. Prevalence was 2.8% at age 10 (4.4% for boys; 1.1% for girls), and 2.9% at age 11 (4.5% for boys; 1.1% for girls). 22.0% of children and 25.5% of young people with autism reported poor health, compared with 2.0% and 4.4% without autism. Autism had OR=11.3 (11.0 to 11.7) in predicting poor health. Autistic females had poorer health than autistic males, OR=1.6 (1.5 to 1.8).

CONCLUSION

Accurate information on the proportion of autistic children and their health status is essential plan appropriate prevention and intervention measures and provide resources for those who may put demand on services designed for autistic people.

Autism Spectrum Disorder and the Experience of Traumatic Events: Review of the Current Literature to Inform Modifications to a Treatment Model for Children with Autism

Children with autism incur trauma and have increased vulnerabilities for experiencing trauma. This paper summarizes the current literature in the study of trauma in typically developing children and those with autism. A treatment model for children with autism, drawing on components from cognitive behavior therapy (CBT), trauma-focused CBT, and CBT to teach emotion regulation and treat anxiety in children with autism is suggested. Components include: (a) Functional Behavior Assessment; (b) behavior plans and behavioral skills training; (c) teaching emotion regulation; (d) exposure therapy; (e) cognitive restructuring; (f) parent and child support between sessions; (g) safety plan; and (h) programming for generalization and maintenance. Future research should establish evidence-based treatment of trauma in this population by evaluating the modified treatment package.

Adverse childhood experiences in children with autism spectrum disorder

PURPOSE OF REVIEW

Recent years have shown an uptick in studies assessing bullying and other adverse childhood experiences (ACEs) in children with autism spectrum disorder (ASD). This article reviews extant findings, and points to gaps in the literature.

RECENT FINDINGS

Children with ASD are bullied by peers at a rate three to four times that of nondisabled peers with negative impacts on academic functioning and mental health symptoms, including increased risk for suicidality. Children with ASD are also at enhanced risk for other ACES, particularly parental divorce and income insufficiency, and as observed in the general population, children with ASD who experience an increased number of ACES are at elevated risk for comorbid psychiatric and medical health problems. Children with ASD with an elevated number of ACES also experience a delay in ASD diagnosis and treatment initiation. There is no evidence of increased risk of child maltreatment within the ASD population.

SUMMARY

As bullying and other adverse experiences are common and associated with deleterious outcomes in children with ASD, there is a need for additional research on intervention strategies to prevent and mitigate the impact of these experiences. Ongoing work on the assessment of trauma experiences and PTSD symptoms in children on the spectrum is also needed.

Brief Report: Examining the Association of Autism and Adverse Childhood Experiences in the National Survey of Children's Health: The Important Role of Income and Co-occurring Mental Health Conditions

Adverse childhood experiences (ACEs) are risk factors for mental and physical illness and more likely to occur for children with autism spectrum disorder (ASD). The present study aimed to clarify the contribution of poverty, intellectual disability and mental health conditions to this disparity. Data on child and family characteristics, mental health conditions and ACEs were analyzed in 67,067 youth from the 2011-2012 National Survey of Children's Health. In an income-stratified sample, the association of ASD and ACEs was greater for lower income children and significantly diminished after controlling for child mental health conditions, but not intellectual disability. Findings suggest that the association of ACEs and ASD is moderated by family income and contingent on co-occurring mental health conditions.

Anxiety Disorders and Obsessive-Compulsive Disorder in Individuals with Autism Spectrum Disorder

PURPOSE OF REVIEW

This review aims to synthesize the most recent research on anxiety disorders and obsessive-compulsive disorder (OCD) in individuals with autism spectrum disorder (ASD) and discuss the relationship between these conditions and challenges for assessment. Furthermore, implications for treatment and future directions are discussed.

RECENT FINDINGS

Research suggests that anxiety disorders and OCD are highly prevalent in individuals with ASD. However, the significant overlap of ASD features with anxiety and OCD symptomology makes differential diagnosis of these disorders particularly challenging. Though several treatments for anxiety have been adapted for youth with ASD (e.g., cognitive behavior therapy), pharmacological treatments and treatments for adults are still marked undeveloped. Despite the high prevalence of anxiety disorders and OCD in ASD and some recent advances in assessment and treatment, research is needed to clarify the multifaceted relationship of these conditions and develop tailored assessment and treatment approaches appropriate for a full range of individuals with ASD.