Continuity and Change in Cognition and Autism Severity from Toddlerhood to School Age

Autism Severity and its Relationship to Disability

Autism severity is currently defined and measured based exclusively on the severity levels of the two core symptom domains: social-communication and restricted or repetitive patterns of behaviors and interests. Autistic individuals, however, are often diagnosed with other medical, developmental, and psychological co-occurring conditions. These additional challenges such as intellectual disability, limited expressive and/or receptive language, and anxiety disorders, can have a tremendous impact on the day-to-day lives of autistic individuals, for both their adaptive functioning as well as their sense of wellbeing. Furthermore, the initial presentation of core symptoms and their likelihood of changing over time are influenced by the presence of such co-occurring conditions. In order to truly understand how a person's autism impacts their life, both core symptoms as well as other challenges should be considered. This approach was recently taken by The Lancet Commission on the future of care and clinical research in autism, which proposed the term "profound autism" for a subgroup of individuals presenting with high core symptom severity, co-occurring intellectual disability, and little or no language, who require extensive long-term care. Considering other individual factors such as daily living skills, specific support needs and environmental resources would also enhance the evaluation of disability in autistic individuals. As currently employed in the assessment of intellectual disability, a multidimensional approach to autism could provide a more comprehensive system for classification of impairment. At present, however, there is no formal way to designate the combined effect of these different aspects of autism on a person's life. A comprehensive outlook that acknowledges impairments, capabilities, co-occurring conditions, and environmental factors would be useful for identifying subgroups of individuals as well as for determining individual needs and strengths in clinical assessments. Lay Summary: The severity of a person's autism is currently defined based on the severity of their core autism symptoms: impaired social-communication and the presence of restricted or repetitive patterns of behaviors and interests. But autistic people often face additional challenges such as intellectual disability, epilepsy, and anxiety disorder, that considerably impact their everyday life, wellbeing, and the need for support. A more complete view of autism severity, one that includes core symptoms as well as additional challenges, could help identify meaningful sub-groups of autistic individuals and could be useful in clinical care. Appeared originally in Autism Res 2023; 16:685-696.

Trajectory research in children with an autism diagnosis: A scoping review

LAY ABSTRACT

The types of outcomes studied in children on the autism spectrum include clinical characteristics, such as social functioning, communication, language, or autism symptoms. Research that measures these outcomes at multiple timepoints is useful to improve our understanding of what to expect as children develop. In trajectory studies, researchers assess outcomes at three or more timepoints. This method has advantages over two-timepoint studies because it allows researchers to describe changes in the speed of development, such as accelerations, plateaus, or slowdowns. We identified and reviewed 103 published trajectory studies in children (to age 18 years) with an autism diagnosis. Importantly, we did not include studies of treatments or their effects, nor did we summarize the results of studies. Instead, this review summarizes the characteristics of the available published research, including the methods used, the many different outcomes that have been studied over time and the ages over which they have been studied. This summary may be of interest to autistic people and caregivers (parents) who want to know about the existence of research that provides answers about what to expect during an autistic child's development. We have recommended that future trajectory research efforts try to make up for the lack of studies from low- and middle-income countries; that more attention is given to the following outcomes that are meaningful to caregivers and autistic people; and to try to fill in the age gaps where more outcome-specific data are needed.

Using normalization process theory to inform practice: evaluation of a virtual autism training for clinicians

Background

There is growing demand for developmental and behavioral pediatric services including autism evaluation and care management. Clinician trainings have been found to result in an increase of knowledge and attitudes. This study utilizes Normalization Process theory (NPT) to evaluate a clinician training program and its effects on practice.

Methods

The year-long virtual training program about autism screening and care management included didactic portions and case presentations. Focus groups and interviews were conducted with primary care clinicians (n = 10) from community health centers (n = 6) across an urban area five months post-training. Transcripts were deductively coded using NPT to uncover barriers to implementation of autism screening and care, benefits of the training program, and areas for future training.

Results

Participants were motivated by the benefits of expanding and improving support for autistic patients but noted this effort requires effective collaboration within a complex network of care providers including clinicians, insurance agencies, and therapy providers. Although there were support that participants could provide to families there were still barriers including availability of behavior therapy and insufficient staffing. Overall, participants positively viewed the training and reported implementing new strategies into practice.

Conclusion

Despite the small sample size, application of NPT allowed for assessment of both training delivery and implementation of strategies, and identification of recommendations for future training and practice sustainability. Follow-up focus groups explored participants' practice five months post-program. Variations in participants' baseline experience and context at follow-up to enable application of skills should be considered when using NPT to evaluate clinician trainings.

The Selective Social Attention task in children with autism spectrum disorder: Results from the Autism Biomarkers Consortium for Clinical Trials (ABC-CT) feasibility study

The Selective Social Attention (SSA) task is a brief eye-tracking task involving experimental conditions varying along socio-communicative axes. Traditionally the SSA has been used to probe socially-specific attentional patterns in infants and toddlers who develop autism spectrum disorder (ASD). This current work extends these findings to preschool and school-age children. Children 4- to 12-years-old with ASD (N = 23) and a typically-developing comparison group (TD; N = 25) completed the SSA task as well as standardized clinical assessments. Linear mixed models examined group and condition effects on two outcome variables: percent of time spent looking at the scene relative to scene presentation time (%Valid), and percent of time looking at the face relative to time spent looking at the scene (%Face). Age and IQ were included as covariates. Outcome variables' relationships to clinical data were assessed via correlation analysis. The ASD group, compared to the TD group, looked less at the scene and focused less on the actress' face during the most socially-engaging experimental conditions. Additionally, within the ASD group, %Face negatively correlated with SRS total T-scores with a particularly strong negative correlation with the Autistic Mannerism subscale T-score. These results highlight the extensibility of the SSA to older children with ASD, including replication of between-group differences previously seen in infants and toddlers, as well as its ability to capture meaningful clinical variation within the autism spectrum across a wide developmental span inclusive of preschool and school-aged children. The properties suggest that the SSA may have broad potential as a biomarker for ASD.

A systematic review on speech-in-noise perception in autism

Individuals with autism spectrum disorder (ASD) exhibit atypical speech-in-noise (SiN) perception, but the scope of these impairments has not been clearly defined. We conducted a systematic review of the behavioural research on SiN perception in ASD, using a comprehensive search strategy across databases (Embase, Pubmed, Web of Science, APA PsycArticles, LLBA, clinicaltrials.gov and PsyArXiv). We withheld 20 studies that generally revealed intact speech perception in stationary noise, while impairments in speech discrimination were found in temporally modulated noise, concurrent speech, and audiovisual speech perception. An association with auditory temporal processing deficits, exacerbated by suboptimal language skills, is shown. Speech-in-speech perception might be further impaired due to deficient top-down processing of speech. Further research is needed to address remaining challenges and gaps in our understanding of these impairments, including the developmental aspects of SiN processing in ASD, and the impact of gender and social attentional orienting on this ability. Our findings have important implications for improving communication in ASD, both in daily interactions and in clinical and educational settings.

Development, delivery, and evaluation of a training program for the early identification of autism: Monitoring of Social Attention, Interaction, and Communication

Introduction

Early identification of Autistic children is an important precursor to diagnosis, and access to supports and services. Here we describe the training of the maternal and child health (MCH) workforce in the state of Victoria, Australia in the early identification of infants and toddlers with a high likelihood of autism.

Methods

In 2019, 1,428 MCH nurses completed early autism training held at venues across the state, with an additional 82 nurses completing online-only training. A training needs analysis enabled the research team to determine the workforce's current skill and knowledge levels, and to identify knowledge gaps, training needs and workplace barriers. The professional development program, known as Monitoring of Social Attention, Interaction, and Communication (MoSAIC), comprised: online pre-workshop modules; a face-to-face instructor-led workshop, which included the use of the Social Attention and Communication-Revised (SACS-R) tool; and online post-workshop modules, which included a recording of a face-to-face workshop with all accompanying resources. This was the first time that the MCH workforce received this training package. Attendees were asked to complete a training satisfaction survey immediately following the face-to-face instructor-led workshop and a follow-up survey regarding their autism knowledge and SACS-R implementation 4-6 weeks after the workshop.

Results

Over 90% (n = 325) of MCH nurses who completed the training satisfaction survey agreed or strongly agreed with statements that the training was clear and of high quality. Most nurses also reported that the training was well-presented and that they would recommend it to a colleague. In the 6 months following the training, a total of 82,581 SACS-R assessments were conducted by the MCH workforce, reflecting that MCH nurses had successfully integrated SACS-R assessments into their work practice after receiving the early autism identification training.

Discussion

This study demonstrated that training on the early identification of autism can be successfully designed, customized, and delivered to a large primary healthcare workforce for universal developmental surveillance of autism.

From neurodevelopmental to neurodegenerative disorders: Investigating symptoms of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) in patients with dementia

Dementia is characterized by a progressive cognitive decline that could be caused by several disorders. Autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) are two prevalent neurodevelopmental disorders that might overlap with dementia symptoms. Hence, this study aimed to evaluate the ASD and ADHD symptoms in dementia patients referred to a memory clinic in Iran. We recruited 65 dementia patients and instructed them to fill out the autism quotient (AQ) and the Conners' Adult ADHD Rating Scales (CAARS) questionnaires. Considering the cutoff points of AQ and CAARS questionnaires, 18.5% of participants were at higher risk of ASD, and 35.4% were at higher risk of ADHD. The results indicated that ADHD and ASD symptoms might be common comorbidities in patients with dementia which can increase the disease burden. Specialized ADHD and ASD screening tools in the elderly population with dementia are needed to prevent misdiagnoses due to symptom overlaps.

Autism severity and its relationship to disability

Autism severity is currently defined and measured based exclusively on the severity levels of the two core symptom domains: social-communication and restricted or repetitive patterns of behaviors and interests. Autistic individuals, however, are often diagnosed with other medical, developmental, and psychological co-occurring conditions. These additional challenges such as intellectual disability, limited expressive and/or receptive language, and anxiety disorders, can have a tremendous impact on the day-to-day lives of autistic individuals, for both their adaptive functioning as well as their sense of wellbeing. Furthermore, the initial presentation of core symptoms and their likelihood of changing over time are influenced by the presence of such co-occurring conditions. In order to truly understand how a person's autism impacts their life, both core symptoms as well as other challenges should be considered. This approach was recently taken byThe Lancet Commission on the future of care and clinical research in autism, which proposed the term "profound autism" for a subgroup of individuals presenting with high core symptom severity, co-occurring intellectual disability, and little or no language, who require extensive long-term care. Considering other individual factors such as daily living skills, specific support needs and environmental resources would also enhance the evaluation of disability in autistic individuals. As currently employed in the assessment of intellectual disability, a multidimensional approach to autism could provide a more comprehensive system for classification of impairment. At present, however, there is no formal way to designate the combined effect of these different aspects of autism on a person's life. A comprehensive outlook that acknowledges impairments, capabilities, co-occurring conditions, and environmental factors would be useful for identifying subgroups of individuals as well as for determining individual needs and strengths in clinical assessments.

Does the severity of autism symptoms change over time? A review of the evidence, impacts, and gaps in current knowledge

Studies evaluating change in autism symptom severity across the lifespan have yielded inconsistent results, making it difficult to assess the prevalence of meaningful change in autism symptom severity, and what characterizes it. Better understanding the ways in which autism symptoms change over time is crucial, with important implications for intervention. Synthesizing information across past studies, autism symptom severity change (especially decreases) appears common, though stability of symptoms is also frequent. Symptom severity change is characterized by variability in patterns of change between different individuals (between-person), variability in change within a person's trajectory across time (within-person), and variability in change patterns across symptom domains (i.e., social-communication, restricted/repetitive behaviors). Variability in severity change is likely impacted by differences in person-level characteristics (e.g., sex, IQ, sociodemographic factors) as well as developmental processes across time. Numerous methodological issues may impact our ability to understand how common change in symptom severity is, including varying measurement tools, analytic approaches, and change patterns between symptom domains across time. Potential implications of better understanding and characterizing symptom severity change include incorporation of severity change patterns and predictors of change into research on biomarkers, and consideration of such predictors as moderators or mediators of change in clinical practice.

Overall prognosis of preschool autism spectrum disorder diagnoses

BACKGROUND

Autism spectrum disorder is a neurodevelopmental disorder characterised by social communication difficulties, restricted interests and repetitive behaviours. The clinical pathway for children with a diagnosis of autism spectrum disorder is varied, and current research suggests some children may not continue to meet diagnostic criteria over time.

OBJECTIVES

The primary objective of this review was to synthesise the available evidence on the proportion of preschool children who have a diagnosis of autism spectrum disorder at baseline (diagnosed before six years of age) who continue to meet diagnostic criteria at follow-up one or more years later (up to 19 years of age).

SEARCH METHODS

We searched MEDLINE, Embase, PsycINFO, and eight other databases in October 2017 and ran top-up searches up to July 2021. We also searched reference lists of relevant systematic reviews.

SELECTION CRITERIA

Two review authors independently assessed prospective and retrospective follow-up studies that used the same measure and process within studies to diagnose autism spectrum disorder at baseline and follow-up. Studies were required to have at least one year of follow-up and contain at least 10 participants. Participants were all aged less than six years at baseline assessment and followed up before 19 years of age.

DATA COLLECTION AND ANALYSIS

We extracted data on study characteristics and the proportion of children diagnosed with autism spectrum disorder at baseline and follow-up. We also collected information on change in scores on measures that assess the dimensions of autism spectrum disorder (i.e. social communication and restricted interests and repetitive behaviours). Two review authors independently extracted data on study characteristics and assessed risk of bias using a modified quality in prognosis studies (QUIPS) tool. We conducted a random-effects meta-analysis or narrative synthesis, depending on the type of data available. We also conducted prognostic factor analyses to explore factors that may predict diagnostic outcome.

MAIN RESULTS

In total, 49 studies met our inclusion criteria and 42 of these (11,740 participants) had data that could be extracted. Of the 42 studies, 25 (60%) were conducted in North America, 13 (31%) were conducted in Europe and the UK, and four (10%) in Asia. Most (52%) studies were published before 2014. The mean age of the participants was 3.19 years (range 1.13 to 5.0 years) at baseline and 6.12 years (range 3.0 to 12.14 years) at follow-up. The mean length of follow-up was 2.86 years (range 1.0 to 12.41 years). The majority of the children were boys (81%), and just over half (60%) of the studies primarily included participants with intellectual disability (intelligence quotient < 70). The mean sample size was 272 (range 10 to 8564). Sixty-nine per cent of studies used one diagnostic assessment tool, 24% used two tools and 7% used three or more tools. Diagnosis was decided by a multidisciplinary team in 41% of studies. No data were available for the outcomes of social communication and restricted and repetitive behaviours and interests. Of the 42 studies with available data, we were able to synthesise data from 34 studies (69% of all included studies; n = 11,129) in a meta-analysis. In summary, 92% (95% confidence interval 89% to 95%) of participants continued to meet diagnostic criteria for autism spectrum disorder from baseline to follow-up one or more years later; however, the quality of the evidence was judged as low due to study limitations and inconsistency. The majority of the included studies (95%) were rated at high risk of bias. We were unable to explore the outcomes of change in social communication and restricted and repetitive behaviour and interests between baseline and follow-up as none of the included studies provided separate domain scores at baseline and follow-up. Details on conflict of interest were reported in 24 studies. Funding support was reported by 30 studies, 12 studies omitted details on funding sources and two studies reported no funding support. Declared funding sources were categorised as government, university or non-government organisation or charity groups. We considered it unlikely funding sources would have significantly influenced the outcomes, given the nature of prognosis studies.

AUTHORS' CONCLUSIONS

Overall, we found that nine out of 10 children who were diagnosed with autism spectrum disorder before six years of age continued to meet diagnostic criteria for autism spectrum disorder a year or more later, however the evidence was uncertain. Confidence in the evidence was rated low using GRADE, due to heterogeneity and risk of bias, and there were few studies that included children diagnosed using a current classification system, such as the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or the eleventh revision of the International Classification of Diseases (ICD-11). Future studies that are well-designed, prospective and specifically assess prognosis of autism spectrum disorder diagnoses are needed. These studies should also include contemporary diagnostic assessment methods across a broad range of participants and investigate a range of relevant prognostic factors.

Diagnostic Accuracy of the Social Attention and Communication Surveillance-Revised With Preschool Tool for Early Autism Detection in Very Young Children

Importance

Early identification of children on the autism spectrum is crucial to facilitate access to early supports and services for children and families. The need for improved early autism identification tools is highlighted by the lack of sufficient diagnostic accuracy in current tools.

Objectives

To examine the diagnostic accuracy of the Social Attention and Communication Surveillance-Revised (SACS-R) and SACS-Preschool (SACS-PR) tools when used with a large, community-based, convenience sample and identify the prevalence of autism in this sample.

Design, Setting, and Participants

This diagnostic accuracy study was conducted in Melbourne, Australia, training maternal and child health nurses who monitored 13 511 children aged 11 to 42 months using the SACS-R and SACS-PR during their routine consultations (June 1, 2013, to July 31, 2018). Children identified as being at high likelihood for autism (12-24 months of age: n = 327; 42 months of age: n = 168) and at low likelihood for autism plus concerns (42 months of age: n = 28) were referred by their maternal and child health nurse for diagnostic assessment by the study team. Data analysis was performed from April 13, 2020, to November 29, 2021.

Exposures

Children were monitored with SACS-R and SACS-PR at 12, 18, 24, and 42 months of age.

Main Outcomes and Measures

Diagnostic accuracy of the SACS-R and SACS-PR was determined by comparing children's likelihood for autism with their diagnostic outcome using clinical judgment based on standard autism assessments (Autism Diagnostic Observation Schedule-Second Edition and Autism Diagnostic Interview-Revised).

Results

A total of 13 511 children (female: 6494 [48.1%]; male: 7017 [51.9%]) were monitored at least once with the SACS-R at their 12-, 18-, and 24-month-old routine maternal and child health consultations (mean [SD] age, 12.3 [0.59] months at 12 months; 18.3 [0.74] months at 18 months; 24.6 [1.12] months at 24 months) and followed up at their 42-month maternal and child health consultation (mean [SD] age, 44.0 [2.74] months) with SACS-PR (8419 [62.3%]). At 12 to 24 months, SACS-R showed high diagnostic accuracy, with 83% positive predictive value (95% CI, 0.77-0.87) and 99% estimated negative predictive value (95% CI, 0.01-0.02). Specificity (99.6% [95% CI, 0.99-1.00]) was high, with modest sensitivity (62% [95% CI, 0.57-0.66]). When the SACS-PR 42-month assessment was added, estimated sensitivity increased to 96% (95% CI, 0.94-0.98). Autism prevalence was 2.0% (1 in 50) between 11 and 30 months of age and 3.3% (1 in 31) between 11 and 42 months of age.

Conclusions and Relevance

The SACS-R with SACS-PR (SACS-R+PR) had high diagnostic accuracy for the identification of autism in a community-based sample of infants, toddlers, and preschoolers, indicating the utility of early autism developmental surveillance from infancy to the preschool period rather than 1-time screening. Its greater accuracy compared with psychometrics of commonly used autism screening tools when used in community-based samples suggests that the SACS-R+PR can be used universally for the early identification of autism.

Identifying autism symptom severity trajectories across childhood

An individual's autism symptom severity level can change across childhood. The prevalence and direction of change, however, are still not well understood. Nor are the characteristics of children that experience change. Symptom severity trajectories were evaluated from early to middle childhood (approximately ages 3-11) for 182 autistic children. Symptom severity change was evaluated using individual change scores and the Reliable Change Index. Fifty-one percent of participants experienced symptom severity change: 27% of children decreased in severity, 24% increased and 49% were stable. Symptom severity decreases were more common during early childhood. Severity increases occurred at both early and middle childhood but increase in social affect severity was especially prominent during middle childhood. Most children experienced significant change during only one period and remained stable during the other. Girls decreased more and increased less in symptom severity than boys. Children that increased in severity decreased in adaptive functioning across childhood. Exploratory analyses indicated that a decrease in severity was associated with higher parental education level and older parental age at the time of the child's birth. Conversely, increase in autism severity was associated with lower parental education level and younger parental age at the child's birth. These findings extend recent observations that symptom severity change is more likely than previously appreciated. An understanding of the role of both biological and sociodemographic factors in determining a child's symptom trajectory may factor into future decisions on allocation and type of interventions distributed to young autistic children. LAY SUMMARY: We studied whether a child's autism severity changed from initial diagnosis until middle childhood (ages 3-11). We found that 27% of the children decreased in severity, 24% increased and the rest stayed the same. Symptom severity decreases were more common during early childhood while severity increases were more prominent during middle childhood. We also found that girls were more likely to decrease than boys. Whether a child decreased or increased is related, in part, to parental characteristics.

Experiences and Attitudes on Early Identification Practices of Autism: A Preliminary Survey of Pediatric Professionals in Ecuador

Early identification of children with autism is necessary to support their social and communicative skills and cognitive, verbal, and adaptive development. Researchers have identified several barriers to early diagnosis. Data collected in low- and middle-income contexts—where the vast majority of children in the world live—is scarce. In Ecuador, as in many other countries, estimates are lower compared to the global prevalence. Health authorities estimate a prevalence of 0.28% (0.18%–0.41%) in children aged five years old or less. Based on the hypothesis that, as in many parts of the world, children in Ecuador are not routinely screened and that this situation may result from poor recognition of this condition, our objective was to identify potential obstacles to case identification in pediatric settings. Several barriers, consistent with those identified in other countries, were reported by 153 participants on a survey, including lack of time, lack of resources to refer, fear of unnecessarily alarming families, and lack of information to guide families with concerns. The vast majority of participants are aware of the need for a screening tool for autism detection but report a lack of knowledge of its formal application. Most of the barriers reported in this study could be overcome by educational programs tailored to professional needs in order to support the well-being of children with autism and their families.

Distinct Patterns of Cognitive Outcome in Young Children With Autism Spectrum Disorder Receiving the Early Start Denver Model

Evidence-based, early intervention significantly improves developmental outcome in young children with autism. Nonetheless, there is high interindividual heterogeneity in developmental trajectories during the therapy. It is established that starting intervention as early as possible results in better developmental outcomes. But except for younger age at start, there is no clear consensus about behavioral characteristics that could provide a reliable individual prediction of a child's developmental outcome after receiving an early intervention. In this study, we analyze developmental trajectories of preschoolers with autism who received 2 years of intervention using the Early Start Denver Model (ESDM) approach in Geneva, Switzerland in an individual setting (n = 55, aged 28.7 ± 5.1 months with a range of 15-42). Our aim was to identify early predictors of response to intervention. We applied a cluster analysis to distinguish between 3 groups based on their cognitive level at intake, and rates of cognitive change over the course of intervention. The first group of children only had a mild cognitive delay at intake and nearly no cognitive delay by the end of intervention (Higher Cognitive at baseline: HC). The children in the two other groups all presented with severe cognitive delay at baseline. However, they had two very different patterns of response to intervention. The majority significantly improved developmental scores over the course of intervention (Optimal Responders: OptR) whereas a minority of children showed only modest improvement (Minimal Responders: MinR). Further analyses showed that children who ended up having an optimal 2-year intervention outcome (OptR) were characterized by higher adaptive functioning at baseline combined with rapid developmental improvement during the first 6 months of intervention. Inversely, less significant progress by the sixth month of intervention was associated with a less optimal response to treatment (MinR).

CLEAR Autism Diagnostic Evaluation (CADE): Evaluation of Reliability and Validity

Recent surveillance efforts indicate that 1 in 54 American children meet the criteria for Autism Spectrum Disorder (ASD), making it the fastest growing neurodevelopmental disorder in the U.S. Despite evidence that ASD can be reliably diagnosed as early as 24 months, the median age at ASD diagnosis in 2016 in the U.S. was 51 months. The CLEAR Autism Diagnostic Evaluation (CADE; Willard & Kroncke, 2019), was developed in response to the need to improve, shorten, and standardize the clinical ASD evaluation process. The CADE is a 33-item rating scale designed to be completed by caregivers and clinicians. The current study was conducted to examine the reliability and validity of the CADE using a sample of 191 individuals who received a private evaluation for ASD. Using the client's evaluation records, clinicians completed the CADE items. The coefficient alpha was .94, which indicates that the items form a scale that has high internal consistency. The CADE total scores were highly correlated with ADOS scores, with r values ranging from .52-.86, and discriminated between those participants with a diagnosis of ASD and those without (p < .001). Receiver operator characteristic (ROC) curve analyses indicated excellent diagnostic accuracy of the CADE total score (ROC area under the curve = .998). Results suggest that the CADE can be used as an efficient and accurate means of evaluating ASD. Limitations and implications for use of the CADE are discussed.

Effect of Brief Training to Identify Autism Spectrum Disorder During Toddler Well-Child Care Visits

OBJECTIVE

To examine the effect of a brief Enhanced training using the information-motivation-behavior (IMB) change model on improving providers' surveillance rates and accuracy of autism spectrum disorder (ASD) detection.

METHOD

Toddlers (n = 5,672) were screened for ASD during their pediatric well-child visits. Pediatric providers (n = 120) were randomized to receive Enhanced (incorporating components of the IMB model) or Control training. Providers indicated whether they had an ASD concern at each well-child visit. Toddlers who were positive on any screener and/or whose provider indicated ASD concern were invited for a diagnostic evaluation. Differences in provider-indicated ASD concerns before and after training were evaluated using log-linear analyses.

RESULTS

The Enhanced training did not have a significant effect on provider-endorsed ASD concerns (p = 0.615) or accuracy of endorsing concerns (p = 0.619). Providers in the Control training showed a significant reduction in indicating whether or not they had concerns after the training (from 71.9% to 64.3%), which did not occur in the Enhanced group. The Enhanced training led to more frequent endorsements of language (χ2 = 8.772, p = 0.003) and restricted and repetitive behavior (χ2 = 7.918, p = 0.005) concerns for children seen after training.

CONCLUSION

Provider training had limited impact on ASD surveillance, indicating the importance of using formal screening instruments that rely on parent report during well-child visits to complement developmental surveillance. Future research should examine whether providers who indicate specific concerns are more likely to accurately refer children for ASD evaluations.

Systematic Intervention for Children with Autism Spectrum Disorder and Integration in Regular School Classes: A Naturalistic Study

Objective of the present study was the assessment of the effect of a systematic community intervention offered at an early age to 32 children with autism spectrum disorder (ASD), 2 to 5 year after completion of treatment while attending public school classes. The intervention had been offered at a community Day Centre and lasted 3 years. On assessment all children showed clinical improvement and significant results on Childhood Autism Rating Scale (CARS) and Vineland Adaptive Scales and 13 scored below criteria for autism on Autism Diagnostic Observation Scale-2 (ADOS-2). Most performed adequately at school whilst 12 required academic assistance. No major disruptive behavior difficulties were reported.

Changes in Knowledge on the Signs of Autism in Young Children (11-30 Months) among Female Community Health Volunteers in Nepal

Nepalese Female Community Health Volunteers' (FCHVs) knowledge on social attention and communication development and the early signs of autism was evaluated before, immediately after, and 12-months following training on typical and atypical social-communicative development in infants/toddlers, early signs of autism, and monitoring of key "markers" of autism using Social Attention and Communication Surveillance. FCHVs (N = 60) significantly improved their knowledge about autism and reported increased perceived confidence in monitoring and referring young children at high likelihood of autism following training, which was sustained one year later. FCHVs also reported a positive impact of training on their work. These findings indicate the effectiveness of training in improving FCHVs' knowledge and perceived confidence to monitor and refer young children at high likelihood of autism.

Trajectories of Autism Symptom Severity Change During Early Childhood

Autism symptom severity change was evaluated during early childhood in 125 children diagnosed with autism spectrum disorder (ASD). Children were assessed at approximately 3 and 6 years of age for autism symptom severity, IQ and adaptive functioning. Each child was assigned a change score, representing the difference between ADOS Calibrated Severity Scores (CSS) at the two ages. A Decreased Severity Group (28.8%) decreased by 2 or more points; a Stable Severity Group (54.4%) changed by 1 point or less; and an Increased Severity Group (16.8%) increased by 2 or more points. Girls tended to decrease in severity more than boys and increase in severity less than boys. There was no clear relationship between intervention history and membership in the groups.

Cognitive, Language, and Behavioral Outcomes in Children With Autism Spectrum Disorders Exposed to Early Comprehensive Treatment Models: A Meta-Analysis and Meta-Regression

Background: Early comprehensive treatment models (CTMs) have been developed as effective treatments for children with autism spectrum disorder (ASD). Numerous studies have suggested that CTMs can improve short-term outcomes, but little is known about precise outcome information in childhood. The current meta-analysis reviewed studies reporting broader outcomes in children with ASD who had ever participated in a CTM and examined the predictors of developmental gains. Methods: We searched eight databases up to June 13, 2019, for relevant trials and natural experiments. Longitudinal studies were selected if they investigated the outcomes of CTMs. Two meta-analyses were undertaken to provide a summary estimate of change in treatment outcomes and to evaluate the effect of CTMs; one used the standardized mean change between the pretest and posttest, and the other was a classical meta-analysis. Stratified and random-effects meta-regression analyses were performed to search for outcome differences among studies. Results: Eighteen intervention studies (involving 495 children with ASD) met all the inclusion criteria: 12 used early intensive behavioral intervention (EIBI), and two used the Early Start Denver Model (ESDM). Outcomes were categorized into three parts: cognitive, language and behavioral (e.g., adaptive functioning and symptomatology). Overall, most children with ASD who had ever participated in an early CTM made gains in many areas of functioning, especially in terms of symptom- and language-related outcomes. Stratified analyses indicated that the ESDM displayed the largest effect on IQ improvement (ES = 1.37, 95% CI: 0.95 to 1.80), while EIBI was more effective for symptom reduction (ES = -1.27, 95% CI: -1.96 to -0.58). Further, meta-regression suggested that interventions with parent involvement, higher intensity, and longer treatment hours yielded greater improvements in IQ and social adaptive functioning, respectively. Conclusion: The results demonstrate a positive association between CTMs and better prognosis in childhood, especially regarding symptoms, and language. However, most extant research involves small, non-randomized studies, preventing definitive conclusions from being drawn. Clearly, the outcomes of children with ASD are still far from normal, especially with respect to adaptive functioning, and the four mediating variables pertaining to treatment elements can affect their gains, including approach, implementer, intensity, and total treatment hours. Systematic Review Registration: [www.crd.york.ac.uk/PROSPERO], identifier [CRD42019146859].

A Multistate Trial of an Early Surveillance Program for Autism Within General Practices in Australia

Background: The early detection of developmental conditions such as autism is vital to ensure children can access appropriate and timely evidence-based supports, services, and interventions. Children who have undetected developmental conditions early in life are more likely to develop later health, developmental, learning, and behavioral issues, which in turn can have a cumulative effect over the life course. Methods: The current protocol describes a multi-site, cluster randomized control trial comparing a developmental surveillance pathway for autism to usual care, using opportunistic visits to general practitioners (GPs). Units of randomization are GP clinics across two Australian states (New South Wales and Victoria), with thirty clinics within each state, each of which will aim to recruit approximately forty children aged between ~18- and 24-months, for a total of ~2,400 participants. Children will be randomized to two clusters; namely, an autism surveillance pathway (ASP) or surveillance as usual (SaU). The screening process for the ASP arm involves primary and secondary screenings for developmental concerns for autism, using both parent and GP reports and observations. Children in both arms who show signs of developmental concerns for autism will be offered a full developmental assessment by the research team at 24 months of age to determine the efficacy of developmental surveillance in successfully identifying children with autism. Trial Registration: The trial is registered with ANZCTR (ACTRN12619001200178) and reporting of the trial results will be according to recommendations in the CONSORT Statement.

A Comparison of Children Born Preterm and Full-Term on the Autism Spectrum in a Prospective Community Sample

Introduction: Previous research suggests children diagnosed with autism spectrum disorder (ASD or “autism”) born extremely and very preterm face substantially delayed development than their peers born full-term. Further, children born preterm are proposed to show a unique behavioral phenotype, which may overlap with characteristics of autism, making it difficult to disentangle their clinical presentation. To clarify the presentation of autism in children born preterm, this study examined differences in key indicators of child development (expressive language, receptive language, fine motor, and visual reception) and characteristics of autism (social affect and repetitive, restricted behaviors).

Materials and Methods: One fifty-eight children (136 full-term, twenty-two preterm) diagnosed with autism, aged 22–34 months, were identified prospectively using the Social Attention and Communication Surveillance tools during community-based, developmental surveillance checks in the second year of life. Those identified at “high likelihood” of an autism diagnosis were administered the Mullen Scales of Early Learning and the Autism Diagnostic Observation Schedule.

Results: The children born preterm and full-term did not differ significantly in their fine motor, visual reception, expressive language, or receptive language skills. No significant differences in social affect and repetitive and restrictive behavior traits were found.

Discussion: The findings of this study differs from previous research where children diagnosed with autism born very or extremely preterm were developmentally delayed and had greater autistic traits than their term-born peers. These null findings may relate to the large proportion of children born moderate to late preterm in this sample. This study was unique in its use of a community-based, prospectively identified sample of children diagnosed with autism at an early age. It may be that children in these groups differ from clinic- and hospital-based samples, that potential differences emerge later in development, or that within the autism spectrum, children born preterm and full-term develop similarly. It was concluded that within the current sample, at 2 years of age, children diagnosed with autism born preterm are similar to their peers born full-term. Thus, when clinicians identify characteristics of autism in children born preterm, it is important to refer the child for a diagnostic assessment for autism.

A Pilot Investigation of the Social Attention and Communication Surveillance (SACS) Tool for the Early Identification of Autism in Tianjin, China (SACS-C)

Introduction: Autism spectrum disorder (ASD) comprises difficulties in social communication and restrictive and repetitive behaviors. Despite an increased global prevalence, little remains known about early detection and diagnosis of autism in Mainland China. Our aim was to conduct a pilot investigation of the implementation of an Australian tool, Social Attention and Communication Surveillance (SACS), in Tianjin, China (SACS-C) by trained professionals to identify autism early compared to the Checklist for Autism in Toddlers-23 (CHAT-23) completed by parents and professionals. Materials and Methods: A total of 10,514 children were monitored across 61 Community Health Service Centres in six Tianjin districts on the SACS-C at 12, 18, and 24 months of age following a half-day training of 225 child health practitioners. Children deemed at "high likelihood" for autism on either the SACS, CHAT-23, or both, were referred for developmental assessments at the Tianjin Women and Children's Health Centre (TWCHC). Results: A total of 87 children (0.8%) were identified at "high likelihood" on the SACS-C, of whom 57 (66%) were assessed for autism; 24 children were subsequently diagnosed with autism (42.1%), and the remaining 33 (57.9%) were diagnosed with developmental and/or language delays. The SACS-C had a positive predictive value (PPV) of 42.1%, a negative predictive value (NPV) of 99.8%, and sensitivity and specificity of 53.3 and 99.7%, respectively. Only 21 children were identified at "high risk" for autism on the CHAT-23 (0.2%), over four times fewer children than the SACS-C, with 14 children assessed for autism (66%); nine were diagnosed with autism (64.3%) and the remaining five children were diagnosed with developmental and/or language delays. The CHAT-23 had an overall PPV of 64.3%, NPV of 99.6%, sensitivity of 27.3%, and specificity of 99.9%. Conclusion: This was the first large-scale study identifying autism in 12-24-month-old children in China. We ascertained the feasibility of training community health practitioners to monitor infants and toddlers for the early signs of autism, and determined the effectiveness of their use of SACS-C which had a better balance between accuracy and sensitivity in detecting autism in contrast to the CHAT-23 which missed the majority of children with autism (72.7%) vs. the SACS-C (46.7%). Given the emphasis on identifying as many children with autism as possible in Mainland China, SACS-C was identified as the tool of choice by the TWCHC. However, more work is needed to improve the psychometric properties in using the SACS-C in Mainland China so that it is comparable to its use in Australia.

Identifying Areas of Overlap and Distinction in Early Lexical Profiles of Children with Autism Spectrum Disorder, Late Talkers, and Typical Talkers

This study compares the lexical composition of 118 children with autism spectrum disorder (ASD) aged 12 to 84 months with 4626 vocabulary-matched typically developing toddlers with and without language delay, aged 8 to 30 months. Children with ASD and late talkers showed a weaker noun bias. Additionally, differences were identified in the proportion of nouns and verbs, and in the semantic categories of animals, toys, household items and vehicles. Most differences appear to reflect the extent of the age differences between the groups. However, children with ASD produced fewer high-social verbs than typical talkers and late talkers, a difference that might be associated with ASD features. In sum, our findings identified areas of overlap and distinction across the developing lexical profiles.

Towards a Multivariate Biomarker-Based Diagnosis of Autism Spectrum Disorder: Review and Discussion of Recent Advancements

An ever-evolving understanding of autism spectrum disorder (ASD) pathophysiology necessitates that diagnostic standards also evolve from being observation-based to include quantifiable clinical measurements. The multisystem nature of ASD motivates the use of multivariate methods of statistical analysis over common univariate approaches for discovering clinical biomarkers relevant to this goal. In addition to characterization of important behavioral patterns for improving current diagnostic instruments, multivariate analyses to date have allowed for thorough investigation of neuroimaging-based, genetic, and metabolic abnormalities in individuals with ASD. This review highlights current research using multivariate statistical analyses to quantify the value of these behavioral and physiological markers for ASD diagnosis. A detailed discussion of a blood-based diagnostic test for ASD using specific metabolite concentrations is also provided. The advancement of ASD biomarker research promises to provide earlier and more accurate diagnoses of the disorder.

Study protocol for an evaluation of ASDetect - a Mobile application for the early detection of autism

Background

Autism Spectrum Conditions (ASC) can be reliably diagnosed by 24 months of age. However, despite the well-known benefits of early intervention, there is still a research-practice gap in the timely identification of ASC, particularly in low-resourced settings. The Social Attention and Communication Surveillance (SACS) tool, which assesses behavioural markers of autism between 12 to 24 months of age, has been implemented in Maternal and Child Health (MCH) settings, with excellent psychometric properties. ASDetect is a free mobile application based on the SACS, which is designed to meet the need for an effective, evidence-based tool for parents, to learn about children’s early social-communication development and assess their child’s ‘likelihood’ for ASC.

Study aims

The primary aim of this study is to evaluate the psychometric properties of ASDetect in the early detection of children with ASC. A secondary aim is to assess ASDetect’s acceptability and parental user experience with the application.

Methods

Families are recruited to download the application and participate in the study via social media, health professionals (e.g., MCH nurses, paediatricians) and word of mouth. All participating caregivers complete a demographic questionnaire, survey regarding their user experience, and the Social Responsiveness Scale-2 (SRS-2), an autism screening questionnaire; they are also invited to participate in focus groups. Children identified at ‘high likelihood’ for ASC based on the ASDetect results, the SRS-2 or parental and/or professional concerns undergo a formal, gold-standard, diagnostic assessment. Receiver Operating Characteristic analyses will be used to assess psychometric properties of ASDetect. Thematic analyses will be used to explore themes arising in the focus groups to provide insights regarding user experiences with the app. Multiple regression analyses will be carried out to determine the extent to which demographic factors, parental stress and beliefs on health surveillance and child results on ASDetect are associated with the parental user-experience of the application.

Discussion

With a strong evidence-base and global access, ASDetect has the potential to empower parents by providing them with knowledge of their child’s social-communication development, validating and reassuring any parental concerns, and supporting them in communicating with other health professionals, ultimately enhancing child and family outcomes and well-being.

Gender Differences During Toddlerhood in Autism Spectrum Disorder: A Prospective Community-Based Longitudinal Follow-Up Study

Relatively few studies have examined gender differences in infants and toddlers, and most focus on clinically referred samples or high-risk infant cohorts. The current study aimed to examine gender differences in early autism manifestations and cognitive development in a community-ascertained sample. In total, 46 males and 21 females with ASD were seen at approximately 24 and 48 months of age. No significant gender differences were observed on overall cognitive ability, verbal skills, non-verbal skills, overall autism severity, or restricted repetitive behaviours. However, females were found to exhibit more social communication impairments than males. These findings may indicate that female toddlers with less severe or different, social communication impairments may be more likely to be missed during routine surveillance during toddlerhood.

School Age Outcomes of Children with Autism Spectrum Disorder Who Received Community-Based Early Interventions

This study followed children with Autism Spectrum Disorder (ASD) from early intervention into their early schooling years, when they were aged between 6 and 9 years, on autism symptom severity and cognitive functioning. The children, matched at pre-intervention, were compared on type of community provided service: 31 were in receipt of community-based group Early Start Denver Model and 28 had received other community provisions for ASD. Irrespective of groups, cognitive functioning was found to have significantly improved by school age compared to pre-intervention. Autism symptom severity increased during the same developmental period, seemingly driven by an increase in restricted and repetitive behaviours over time. In contrast, both groups displayed improved social affect by school age.

Adaptive Behaviour and Cognitive Skills: Stability and Change from 7 Months to 7 Years in Siblings at High Familial Risk of Autism Spectrum Disorder

Cognitive and adaptive behaviour abilities early in life provide important clinical prognostic information. We examined stability of such skills in children at high familial risk for ASD who either met diagnostic criteria for ASD at age 7 years (HR-ASD, n = 15) or did not (HR-non-ASD, n = 24) and low-risk control children (LR, n = 37), prospectively studied from infancy. For both HR groups, cognitive skills were consistently lower across time than those of LR children. HR-ASD children showed increasing difficulties in adaptive behaviour over time compared to LR children, while the HR-non-ASD children showed no such difficulties. This pattern of change may inform our understanding of developmental profiles of HR siblings beyond core ASD symptoms.

Early childhood behavioral features that discriminate autism from other developmental problems in Japan

PROBLEM

The criteria for early detection of autism spectrum disorder (ASD) and its discrimination from other developmental problems (ODP) are not clear. The Social Attention and Communication Study, which identified methods for early identification of ASD in community settings, was modified to the Japanese situation, and we examined its discriminant validity.

METHODS

This study followed a cohort of newborns in one town for 4 years. Structured behavioral assessments were added to the standardized health examination and performed five times during toddlerhood. Of the 264 children included in the statistical analysis, four were diagnosed with ASD, and four were diagnosed with ODP.

FINDINGS

A canonical discrimination analysis indicated two significant functions. Canonical 1, which involved disturbances of "eye contact" at 27 months and "concept comprehension" at 38 months, characterized both ASD and ODP. Canonical 2, which involved disturbances of "response name call" at 15 months, "showing" at 27 months, and negative loading of vocabulary development at 20 months, discriminated between ASD and ODP. The canonical plot showed good separation, but a few cases were misclassified.

CONCLUSIONS

Evaluations of early behavioral signs by public health nurses during general toddler examinations could be useful and convenient.

Autism spectrum disorder

Autism spectrum disorder is a term used to describe a constellation of early-appearing social communication deficits and repetitive sensory-motor behaviours associated with a strong genetic component as well as other causes. The outlook for many individuals with autism spectrum disorder today is brighter than it was 50 years ago; more people with the condition are able to speak, read, and live in the community rather than in institutions, and some will be largely free from symptoms of the disorder by adulthood. Nevertheless, most individuals will not work full-time or live independently. Genetics and neuroscience have identified intriguing patterns of risk, but without much practical benefit yet. Considerable work is still needed to understand how and when behavioural and medical treatments can be effective, and for which children, including those with substantial comorbidities. It is also important to implement what we already know and develop services for adults with autism spectrum disorder. Clinicians can make a difference by providing timely and individualised help to families navigating referrals and access to community support systems, by providing accurate information despite often unfiltered media input, and by anticipating transitions such as family changes and school entry and leaving.

Children with borderline intellectual functioning and autism spectrum disorder: developmental trajectories from 4 to 11 years of age

BACKGROUND

Studies on autism have tended to focus either on those with intellectual disability (ie, those with intellectual quotient [IQ] under 70) or on the group that is referred to as "high-functioning", that is, those with borderline, average or above average IQ. The literature on cognition and daily functioning in autism spectrum disorder combined specifically with borderline intellectual functioning (IQ 70-84) is limited.

METHODS

From a representative group of 208 preschool children diagnosed with autism spectrum disorder, those 50 children in the group with borderline intellectual functioning at ages 4.5-6.5 years were targeted for follow-up at a median age of 10 years. A new cognitive test was carried out in 30 children. Parents were interviewed with a semi-structured interview together with the Vineland Adaptive Behavior Scales (n=41) and the Autism-Tics, attention-deficit/hyperactivity disorder (AD/HD) and other comorbidities inventory (A-TAC) (n=36).

RESULTS

Most children of interviewed parents presented problems within several developmental areas. According to A-TAC and the clinical interview, there were high rates of attention deficits and difficulties with regulating activity level and impulsivity. Vineland Adaptive Behavior Scales composite scores showed that at school age, a majority of the children had declined since the previous assessment at ages between 4.5 and 6.5 years. Almost half the tested group had shifted in their IQ level, to below 70 or above 84.

CONCLUSION

None of the children assessed was without developmental/neuropsychiatric problems at school-age follow-up. The results support the need for comprehensive follow-up of educational, medical and developmental/neuropsychiatric needs, including a retesting of cognitive functions. There is also a need for continuing parent/family follow-up and support.