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 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.

Exploring the Perspectives of Parents of Individuals with Autism from Low-Resourced Communities to Inform Family Navigator Programs

Family navigator programs (i.e., programs to train family navigators) are becoming increasingly common among families of children with autism. Family navigators (i.e., individuals who help families access evaluations and/or services) may be parents of children with autism themselves or health professionals. Extant research has shown that family navigators can help families receive timely diagnostic evaluations and initial services. Yet, the development of family navigator programs is unclear; by exploring the input of families of children with autism, such programs can be responsive to family needs. In this study, we extend the extent literature by exploring the lived experiences of 12 parents of autistic children from low-resourced communities to inform the development of a family navigator program. Findings demonstrated that navigator programs need to prepare navigators to address barriers such as limited knowledge and difficulty accepting an autism diagnosis. Navigator programs should teach navigators to use strategies with families including educating families about services and connecting families with peer support. Program content should reflect direct services, government services, and advocacy strategies. Notably, for true improvements to service access for all autistic children, systemic changes are also needed in the service delivery systems. Implications are discussed.

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.

The role of adverse childhood experiences in obesity among adolescents with autism spectrum disorder: National survey of Children's health 2018-2019

BACKGROUND

Adolescents with autism spectrum disorder (ASD) are at an increased risk of overweight/obesity and adverse childhood experiences (ACEs).

OBJECTIVE

This study examined whether ACEs increased the odds of overweight/obesity in adolescents with ASD.

METHODS

This cross-sectional study used National Survey of Children's Health (NSCH) 2018-2019 data (N = 31,533 children ages 10-17 years, including n = 480 children with mild ASD and n = 423 children with moderate/severe ASD with normal or overweight/obese BMI). Parent-reported body mass index (BMI) was coded as overweight/obesity vs. normal weight. The independent variable was the count of nine ACEs. Binary logistic regression was conducted, controlling for social ecological factors.

RESULTS

The odds of overweight/obesity in adolescents with ASD with 1-2 ACEs (OR 1.3, CI 1.1-1.4) and 3+ ACEs (OR 1.6, CI 1.3-2.0) were higher than those with 0 ACEs; odds increased with higher counts of ACEs. Household income level was the most significant sociodemographic influence on odds of obesity in adolescents with ASD (0-99 % Federal Poverty Level: OR 1.9, CI 1.6-2.3). Adolescents with moderate/severe ASD (OR 1.7, CI 1.2-2.5) and mild ASD (OR 1.6, CI 1.0-2.4) had higher odds of overweight/obesity after accounting for ACEs, race/ethnicity, sex, household income, and physical activity.

CONCLUSION

Findings indicated ACEs are associated with ASD, which calls for integration of ACEs information within trauma-informed care practices for obesity prevention and intervention for adolescents with ASD. Persistent disparities of overweight/obesity exist by race/ethnicity, sex, and household income within this population, which indicates the need for tailoring trauma-informed approaches to the unique needs of this population.

Prevalence of Autism Spectrum Disorder and Co-Morbidities in Children and Adolescents: A Systematic Literature Review

Objective

Individuals with autism spectrum disorder often present somatic and/or psychiatric co-morbid disorders. The DSM-5 allows for consideration of additional diagnoses besides ASD and may have impacted the prevalence of co-morbidities as well as being limited in capturing the true differences in prevalence observed between males and females. We describe the prevalence of ASD and frequently observed co-morbidities in children and adolescents (<18 years) in the United States and five European countries.

Methods

Two systematic literature reviews were conducted in PubMed and Embase for the period 2014-2019 and focusing on the prevalence of ASD and nine co-morbidities of interest based on their frequency and/or severity: Attention Deficit Hyperactivity Disorder (ADHD), anxiety, depressive disorders, epilepsy, intellectual disability (ID), sleep disorders, sight/hearing impairment/loss, and gastro-intestinal syndromes (GI).

Results

Thirteen studies on prevalence of ASD and 33 on prevalence of co-morbidities were included. Prevalence of ASD was 1.70 and 1.85% in U.S children aged 4 and 8 years respectively, while prevalence in Europe ranged between 0.38 and 1.55%. Additionally, current evidence is supportive of a global increase in ASD prevalence over the past years. Substantial heterogeneity in prevalence of co-morbidities was observed: ADHD (0.00-86.00%), anxiety (0.00-82.20%), depressive disorders (0.00-74.80%), epilepsy (2.80-77.50%), ID (0.00-91.70%), sleep disorders (2.08-72.50%), sight/hearing impairment/loss (0.00-14.90%/0.00-4.90%), and GI syndromes (0.00-67.80%). Studies were heterogeneous in terms of design and method to estimate prevalence. Gender appears to represent a risk factor for co-morbid ADHD (higher in males) and epilepsy/seizure (higher in females) while age is also associated with ADHD and anxiety (increasing until adolescence).

Conclusion

Our results provide a descriptive review of the prevalence of ASD and its co-morbidities in children and adolescents. These insights can be valuable for clinicians and parents/guardians of autistic children. Prevalence of ASD has increased over time while co-morbidities bring additional heterogeneity to the clinical presentation, which further advocates for personalized approaches to treatment and support. Having a clear understanding of the prevalence of ASD and its co-morbidities is important to raise awareness among stakeholders.Appeared originally in Front Psychiatry 2021; 12:744709.

The Family-Check-Up® Autism Implementation Research (FAIR) Study: protocol for a study evaluating the effectiveness and implementation of a family-centered intervention within a Canadian autism service setting

Introduction

Prevalence rates of emotional and behavior problems (EBP) in autistic children and youth are high (40-70%), and often cause severe and chronic impairment. Furthermore, autistic children are also more likely to experience family "social-ecological" adversity compared to neurotypically developing peers, including social isolation, child maltreatment, caregiver mental illness, and socioeconomic risk. These family stressors increase the risk of co-occurring EBP among autistic children and can often impede access to evidence-based care, thus amplifying long-term health inequities for autistic children and their caregivers. In the current autism services landscape, there are few scalable, evidence-based programs that adequately address these needs. The Family Check-Up (FCU®) is a brief, strength-based, and tailored family-centered intervention that supports positive parenting and explicitly assesses the social determinants of child and family mental health within an ecological framework. Studies have demonstrated long-term positive child and caregiver outcomes in other populations, but the FCU® has not been evaluated in families of autistic children and youth. Therefore, we aimed to evaluate FCU® implementation within an established, publicly funded Autism Program in Ontario, Canada, with delivery by autism therapists, to demonstrate sustainable effectiveness within real-world settings.

Methods

In this study, we outline the protocol for a hybrid implementation-effectiveness approach with two key components: (1) A parallel-arm randomized controlled trial of N = 80 autistic children/youth (ages 6-17 years) and high levels of EBP and their caregivers. Primary and secondary outcomes include child EBP, and caregiver well-being and parenting. (2) A mixed methods implementation study, to describe facilitators and barriers to implementation of the FCU® within an autism service setting.

Discussion

Scalable, ecologically focused family-centered interventions offer promise as key components of a public health framework aimed at reducing mental health inequities among autistic children, youth, and their caregivers. Results of this study will inform further program refinement and scale-up.

Developmental Neuroendocrinology of Early-Life Stress: Impact on Child Development and Behavior

Our internal balance, or homeostasis, is threatened or perceived as threatened by stressful stimuli, the stressors. The stress system is a highly conserved system that adjusts homeostasis to the resting state. Through the concurrent activation of the hypothalamic-pituitary-adrenal axis and the locus coeruleus/norepinephrine-autonomic nervous systems, the stress system provides the appropriate physical and behavioral responses, collectively termed as "stress response", to restore homeostasis. If the stress response is prolonged, excessive or even inadequate, several acute or chronic stress-related pathologic conditions may develop in childhood, adolescence and adult life. On the other hand, earlylife exposure to stressors has been recognized as a major contributing factor underlying the pathogenesis of non-communicable disorders, including neurodevelopmental disorders. Accumulating evidence suggests that early-life stress has been associated with an increased risk for attention deficit hyperactivity disorder and autism spectrum disorder in the offspring, although findings are still controversial. Nevertheless, at the molecular level, early-life stressors alter the chemical structure of cytosines located in the regulatory regions of genes, mostly through the addition of methyl groups. These epigenetic modifications result in the suppression of gene expression without changing the DNA sequence. In addition to DNA methylation, several lines of evidence support the role of non-coding RNAs in the evolving field of epigenetics. In this review article, we present the anatomical and functional components of the stress system, discuss the proper, in terms of quality and quantity, stress response, and provide an update on the impact of early-life stress on child development and behavior.

Adverse childhood experiences in children with fetal alcohol spectrum disorders and their effects on behavior

BACKGROUND

Children with fetal alcohol spectrum disorders (FASD) have high rates of adverse childhood experiences (ACEs). ACEs are associated with a wide range of health outcomes including difficulty with behavior regulation, an important intervention target. However, the effect of ACEs on different areas of behavior has not been well characterized in children with disabilities. This study describes ACEs in children with FASD and how they impact behavior problems.

METHODS

A convenience sample of 87 caregivers of children (aged 3 to 12) with FASD participating in an intervention study reported on their children's ACEs using the ACEs Questionnaire and behavior problems on the Eyberg Child Behavior Inventory (ECBI). A theorized three-factor structure of the ECBI (Oppositional Behavior, Attention Problems, and Conduct Problems) was investigated. Data were analyzed using Pearson correlations and linear regression.

RESULTS

On average, caregivers endorsed 3.10 (SD = 2.99) ACEs experienced by their children. The two most frequently endorsed ACE risk factors were having lived with a household member with a mental health disorder, followed by having lived with a household member with a substance use disorder. Higher total ACEs score significantly predicted a greater overall frequency of child behavior (intensity scale), but not whether the caregiver perceived the behavior to be a problem (problem scale) on the ECBI. No other variable significantly predicted the frequency of children's disruptive behavior. Exploratory regressions indicated that a higher ACEs score significantly predicted greater Conduct Problems. Total ACEs score was not associated with Attention Problems or Oppositional Behavior.

DISCUSSION

Children with FASD are at risk for ACEs, and those with higher ACEs had a greater frequency of problem behavior on the ECBI, especially conduct problems. Findings emphasize the need for trauma-informed clinical care for children with FASD and increased accessibility of care. Future research should examine potential mechanisms that underlie the relationship between ACEs and behavior problems to optimally inform interventions.

Resilience and Coping Strategies in Adults with Autism Spectrum Disorder

Individuals with Autism spectrum disorder (ASD) are prone to stress and anxiety affecting their mental health. Although developing coping and resilience are key to cope with stressors of life, limited research exists. We aimed to explore stakeholders' experiences related to the coping and resilience of adults with ASD. We interviewed 22 participants, including 13 adults with ASD, five parents, and four service provides of adults with ASD from various Canadian provinces. Using thematic analysis, three themes emerged including: (a) societal expectations and conformity, (b) adjusting daily routines, and (c) learning overtime. This study highlights the importance of coping and informs the development of services to help enhance resilience among adults with ASD.

Expert consensus regarding indicators of a traumatic reaction in autistic youth: a Delphi survey

OBJECTIVE

It has been suggested that the sequelae of trauma are under-recognized in youth on the autism spectrum. We aimed to generate expert consensus regarding important trauma indicators, including but not limited to traumatic stress symptoms, in autistic youth.

METHODS

We recruited 72 experts in autism and/or childhood trauma. Via a 2-round Delphi survey, experts commented on and rated the importance of 48 potential indicators, drawn from PTSD criteria and a broader literature on traumatic sequelae in autism. A revised list of 51 indicators, 18 clinical guidelines developed from expert comments, and summaries of expert qualifications and ratings from Round 1 were submitted to a second round (n = 66; 92% retention) of expert review and rating.

RESULTS

Twenty-two indicators reached consensus (>75% round 2 endorsement). Many, but not all, reflected PTSD criteria, including intrusions (e.g., trauma re-enactments in perseverative play/speech), avoidance of trauma-reminders, and negative alterations in mood/cognition (e.g., diminished interest in activities) and in arousal/reactivity (e.g., exaggerated startle). Experts also identified increased reliance on others, adaptive and language regressions, self-injurious behavior, and non-suicidal self-injury as important indicators. Consensus guidelines emphasized the need for tailored measures, developmentally informed criteria, and multiple informants to increase diagnostic accuracy.

CONCLUSIONS

Expert consensus emphasizes and informs a need for tailored diagnostic guidelines and measures to more sensitively assess traumatic reactions in autistic youth.

Maternal risk factors vary between subpopulations of children with autism spectrum disorder

Previous work identified three subgroups of children with ASD based upon co-occurring conditions (COCs) diagnosed during the first 5 years of life. This work examines prenatal risk factors, given by maternal medical claims, for each of the three subgroups: children with a High-Prevalence of COCs, children with mainly developmental delay and seizures (DD/Seizure COCs), and children with a Low-Prevalence of COCs. While some risk factors are shared by all three subgroups, the majority of the factors identified for each subgroup were unique; infections, anti-inflammatory and other complex medications were associated with the High-Prevalence COCs group; immune deregulatory conditions such as asthma and joint disorders were associated with the DD/Seizure COCs group; and overall pregnancy complications were associated with the Low-Prevalence COCs group. Thus, we have found that the previously identified subgroups of children with ASD have distinct associated prenatal risk factors. As such, this work supports subgrouping children with ASD based upon COCs, which may provide a framework for elucidating some of the heterogeneity associated with ASD.

Evolving Our Understanding: Housing Instability as an ACE for Young Children

We investigated the conceptualization and impact of adverse childhood experiences (ACEs) in a sample of 231 children ages 3-5 living in poverty and experiencing homelessness, focusing specifically on caregiver well-being and housing instability. Data was collected using the Neurodevelopmental Ecological Screening Tool (NEST), which screens for developmental risk and resilience across three domains (neurodevelopmental, caregiver, and environment). We used structural equation modelling (SEM) to test the association between domains and ACE scores and assessed the impact on neurodevelopmental constructs. Fifty-five percent of the sample had high ACE scores (> 3), which were associated with lower attention, social skills, and emotional regulation. ACEs were strongly associated with 0.17 standard deviation units of higher levels of caregiver distress (p < .001), which was also associated with 0.26 standard deviation units of lower levels of child neurodevelopmental functioning (p = .001). For each unit increase in housing instability, there was a three-fourths increase in ACE (0.78 ACE at p = .004); four or more moves were associated with the worst neurodevelopmental outcomes (53% of the sample). We must use an ecological, developmental lens to understand how early adversity impacts children, at what age, and in what context. Housing stability plays a critical role in developmental well-being and should be accounted for in conceptualizations of child ACE scales. Caregiver and child relationships are reciprocal, and so the impacts of ACEs are also bidirectional. Our policies and practices at individual, community, and systemic levels should account for these dynamics to improve child well-being.

Anxiety in children and youth with autism spectrum disorder and the association with amygdala subnuclei structure

Autism spectrum disorder (ASD) is clinically characterized by social and communication difficulties as well as repetitive behaviors. Many children with ASD also suffer from anxiety, which has been associated with alterations in amygdala structure. In this work, the association between amygdala subnuclei volumes and anxiety was assessed in a cohort of 234 participants (mean age = 11.0 years, SD = 3.9, 95 children with ASD, 139 children were non-autistic). Children underwent magnetic resonance imaging. Amygdala subnuclei volumes were extracted automatically. Anxiety was assessed using the Screen for Child Anxiety Related Disorders, the Child Behavior Checklist, and the Strength and Difficulties Questionnaire. Children with ASD had higher anxiety scores relative to non-autistic children on all anxiety measures (all, p < 0.05). Anxiety levels were significantly predicted in children with ASD by right basal (right: B = 0.235, p = 0.002) and paralaminar (PL) (B = −0.99, p = 0.009) volumes. Basal nuclei receive multisensory information from cortical and subcortical areas and have extensive projections within the limbic system while the PL nuclei are involved in emotional processing. Alterations in basal and PL nuclei in children with ASD and the association with anxiety may reflect morphological changes related to in the neurocircuitry of anxiety in ASD.

Lay abstract

Autism spectrum disorder (ASD) is clinically characterized by social communication difficulties as well as restricted and repetitive patterns of behavior. In addition, children with ASD are more likely to experience anxiety compared with their peers who do not have ASD. Recent studies suggest that atypical amygdala structure, a brain region involved in emotions, may be related to anxiety in children with ASD. However, the amygdala is a complex structure composed of heterogeneous subnuclei, and few studies to date have focused on how amygdala subnuclei relate to in anxiety in this population. The current sample consisted of 95 children with ASD and 139 non-autistic children, who underwent magnetic resonance imaging (MRI) and assessments for anxiety. The amygdala volumes were automatically segmented. Results indicated that children with ASD had elevated anxiety scores relative to peers without ASD. Larger basal volumes predicted greater anxiety in children with ASD, and this association was not seen in non-autistic children. Findings converge with previous literature suggesting ASD children suffer from higher levels of anxiety than non-autistic children, which may have important implications in treatment and interventions. Our results suggest that volumetric estimation of amygdala’s subregions in MRI may reveal specific anxiety-related associations in children with ASD.

Profiles and predictors of thriving in children on the autism spectrum

BACKGROUND

Thriving is defined as the growth of attributes that mark a flourishing, healthy individual and include Competence, Confidence, Connectedness, Character, Caring and Contribution to self, family, community and civil society. Thriving has been linked to positive youth outcomes in neurotypical children and adolescents but has rarely been explored for individuals on the autism spectrum.

METHOD

This study explored the profiles and predictors of parent-reported thriving in 111 school children on the autism spectrum, aged 6 to 14 years.

RESULTS

Parents rated children as having relative strengths in the Caring and Connectedness dimensions and relative challenges in the Competence dimension. Stronger thriving outcomes were consistently predicted by stronger socialization scores; however, the other predictors of outcome differed by dimensions.

CONCLUSION

The current findings provide insight into the individual and contextual factors that predict thriving in children on the autism spectrum. As research into thriving is in its infancy, more work is needed to understand how child, family and contextual factors relate to thriving in individuals on the autism spectrum to foster positive outcomes.

A Qualitative Study of Self and Caregiver Perspectives on How Autistic Individuals Cope With Trauma

Background

Coping can moderate the relationship between trauma exposure and trauma symptoms. There are many conceptualisations of coping in the general population, but limited research has considered how autistic individuals cope, despite their above-average rates of traumatic exposure.

Objectives

To describe the range of coping strategies autistic individuals use following traumatic events.

Methods

Fourteen autistic adults and 15 caregivers of autistic individuals, recruited via stratified purposive sampling, completed semi-structured interviews. Participants were asked to describe how they/their child attempted to cope with events they perceived as traumatic. Using an existing theoretical framework and reflexive thematic analysis, coping strategies were identified, described, and organized into themes.

Results

Coping strategies used by autistic individuals could be organized into 3 main themes: (1) Engaging with Trauma, (2) Disengaging from Trauma, and (3) Self-Regulatory Coping. After the three main themes were developed, a fourth integrative theme, Diagnostic Overshadowing, was created to capture participants' reports of the overlap or confusion between coping and autism-related behaviors.

Conclusions

Autistic individuals use many strategies to cope with trauma, many of which are traditionally recognized as coping, but some of which may be less easily recognized given their overlap with autism-related behaviors. Findings highlight considerations for conceptualizing coping in autism, including factors influencing how individuals cope with trauma, and how aspects of autism may shape or overlap with coping behavior. Research building on these findings may inform a more nuanced understanding of how autistic people respond to adversity, and how to support coping strategies that promote recovery from trauma.

Investigating the relationships between resilience, autism-related quantitative traits, and mental health outcomes among adults during the COVID-19 pandemic

Resilience is a dynamic process through which people adjust to adversity and buffer anxiety and depression. The COVID-19 global pandemic has introduced a shared source of adversity for people across the world, with detrimental implications for mental health. Despite the pronounced vulnerability of autistic adults to anxiety and depression during the COVID-19 pandemic, relationships among autism-related quantitative traits, resilience, and mental health outcomes have not been examined. As such, we aimed to describe the relationships between these traits in a sample enriched in autism spectrum-related quantitative traits during the COVID-19 pandemic. We also aimed to investigate the impact of demographic and social factors on these relationships. Across three independent samples of adults, we assessed resilience factors, autism-related quantitative traits, anxiety symptoms, and depression symptoms during the COVID-19 pandemic. One sample (recruited via the Autism Spectrum Program of Excellence, n = 201) was enriched for autism traits while the other two (recruited via Amazon Mechanical Turk, n = 624 and Facebook, n = 929) drew from the general population. We found resilience factors and quantitative autism-related traits to be inversely related, regardless of the resilience measure used. Additionally, we found that resilience factors moderate the relationship between autism-related quantitative traits and depression symptoms such that resilience appears to be protective. Across the neurodiversity spectrum, resilience factors may be targets to improve mental health outcomes. This approach may be especially important during the ongoing COVID-19 pandemic and in its aftermath.

Prevalence of Adverse Childhood Experiences in Students with Emotional and Behavioral Disorders in Special Education Schools from a Multi-Informant Perspective

Adverse childhood experiences (ACEs) are associated with an increased risk of developing severe emotional and behavioral problems; however, little research is published on ACEs for students with emotional and behavioral disorders (EBD) in special education (SE) schools. We therefore systematically explored the prevalence, type and timing of ACEs in these students from five urban SE schools in the Netherlands (M_age = 11.58 years; 85.1% boys) from a multi-informant perspective, using students’ self-reports (n = 169), parent reports (n = 95) and school files (n = 172). Almost all students experienced at least one ACE (96.4% self-reports, 89.5% parent reports, 95.4% school files), and more than half experienced four or more ACEs (74.5% self-reports, 62.7% parent reports, 59.9% school files). A large majority of students experienced maltreatment, which often co-occurred with household challenges and community stressors. Additionally, 45.9% of the students experienced their first ACE before the age of 4. Students with EBD in SE who live in poverty or in single-parent households were more likely to report multiple ACEs. Knowledge of the prevalence of ACEs may help understand the severe problems and poor long-term outcomes of students with EBD in SE.

Anxiety and Trauma-Related Disorders in Children on the Autism Spectrum

PURPOSE OF REVIEW

To summarize recent findings regarding anxiety and trauma-related disorders in children diagnosed with autism spectrum disorder (autism), focusing on the distinct ways in which these conditions may be expressed, as well as advances in evidence-based assessment and treatment.

RECENT FINDINGS

Current findings suggest both anxiety and trauma-related disorders may be more prevalent, yet more complicated to address in autistic relative to non-autistic children. Overlapping symptoms and distinct manifestations of these disorders pose challenges for the accurate identification, assessment, and treatment of anxiety and trauma-related disorders in autistic children. Emerging evidence recommends adapting traditional assessment and treatment approaches to better meet the needs of autistic children. Recent research suggests autism-centered conceptualizations, which accommodate complexity in how anxiety and trauma-related disorders are experienced and expressed by autistic people, are needed to enhance the psychiatric care of this population.

Exploring potential sources of childhood trauma: A qualitative study with autistic adults and caregivers

The stressors autistic individuals encounter and experience as traumatic may vary from non-autistics. We conducted a qualitative study to identify potential sources of trauma for autistic individuals and evaluate correspondence with a standard measure. We enrolled autistic adults (N = 14) and caregivers (N= 15) with varied adversities, levels of functioning, and socio-demographics. Participants completed standard measures of autism, traumatic exposures and stress, and qualitative interviews, which were submitted to thematic analysis. A wide range of experiences were described as traumatic. Whereas some reflected traditional traumas (e.g. maltreatment) and forms of social marginalization, others reflected conflicts between autistic characteristics and the environment (e.g. sensory trauma). All adults and caregivers described sources of trauma in interviews not captured by standardized measures. Varied stressful experiences, many not detected by a standardized measure, may have a traumatic effect on autistic individuals. Whereas some reflect commonly recognized trauma sources, others may reflect particular vulnerabilities for autistic individuals. Results have implications for assessing traumatic events and understanding their contribution to mental health inequities in the autistic population.

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.

Exposure to family stressful life events in autistic children: Longitudinal associations with mental health and the moderating role of cognitive flexibility

Mental health problems are prevalent in autistic youth, but the underpinning mechanisms are not well explored. In neurotypical youth, stressful life events are an established risk factor for mental health problems. This study tested longitudinal bidirectional associations between family-level stressful life events and mental health problems and whether these were moderated by cognitive flexibility, in a cohort of autistic children (N = 247). Family-stressful life events, assessed using the parent-reported Family Inventory of Life Events and Changes, and mental health problems, assessed using the teacher-reported Child Behavior Checklist Internalizing and Externalizing Symptoms subscales, were measured at multiple points between 7 and 11 years. Analyses showed no significant pathways from internalizing or externalizing symptoms to family-stressful life events or from family-stressful life events to internalizing or externalizing symptoms. There was some evidence of moderation by cognitive flexibility; the family-stressful life events to internalizing symptoms pathway was non-significant in the group with typical shifting ability but significant in the group with clinically significant shifting problems. Information about family-level stressful life event exposure and cognitive flexibility may be helpful in identifying autistic youth who may be at higher risk of developing mental health problems. Established risk factors for mental health problems in neurotypical populations are relevant for understanding mental health in autistic youth.

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.

Early adversity and positive parenting: Association with cognitive outcomes in children with autism spectrum disorder

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by impairments in social communication and repetitive behaviors. Children with ASD are statistically more likely to experience early adversity; however, little is known about the types of early adversity that place these children at risk, the role of parenting as a protective factor, and how this early life stress impacts cognitive outcomes. We assessed early adversity in 302 children (ASD = 98) aged 6-16 years old, using parent-based report. To identify protective factors, we assessed parenting styles using parent surveys. Executive functions were assessed in the children using the WISC-V. Children with ASD had an increased incidence of familial stressors compared to the typically developing (TD) group. Positive parenting was associated with a significant decrease in the incidence of familial adverse events for both children with ASD and TD children. Examining the relationship between adversity and cognitive outcomes, in young children (6-11 years) with ASD, environmental stressors were associated with cognitive impairments. Findings suggest children with ASD may be at higher risk for familial adversity than their TD peers. However, all children benefit from positive parenting styles, which may mitigate the adverse effects of family-based early life stress. LAY SUMMARY: Some key features of Autism Spectrum Disorder (ASD) include difficulties with communication and social impairments. This means that children with ASD may be more likely to experience early adversity (stressful social interactions which take place during childhood) than children without ASD. Research in typically developing (TD) children has shown that experiencing more stressful events in childhood can cause changes in the brain, which can potentially impact the child's memory, reasoning, and decision-making skills later in life. However, there is evidence to suggest that having a nurturing relationship with a parent can offset some of the negative impacts of childhood adversity. In our study, we found that children with ASD are more likely to experience family-related stress compared to TD children. Having a positive relationship with a parent, however, was linked to experiencing this type of stress less often for all children, regardless of whether they were diagnosed with ASD. We also found that stressors related to environmental factors like financial instability were associated with lower cognitive abilities in children with ASD under 12 years of age. Understanding how these factors interact and differ in children with ASD can help to build stronger families and help children with ASD to thrive throughout their development.

TF-CBT Informed Teletherapy for Children with Autism and their Families

A diagnosis of autism spectrum disorder (ASD) often puts a child in a vulnerable position. While the research of the effects of trauma on children diagnosed with ASD is limited, we know children diagnosed with ASD presenting with a comorbid diagnosis of post-traumatic stress disorder (PTSD) have an increased risk of suicidal thoughts and behaviors. TF-CBT is an empirically validated treatment for trauma; in this paper, we provide adaptions for using this treatment with children diagnosed with ASD and using this method for teletherapy. These adaptions include recognizing trauma behaviors and ASD behaviors, the use of repetition and the need for flexibility from the therapist, and addressing safety with ASD behaviors while working from a teletherapy platform.

The association of adverse life events and parental mental health with emotional and behavioral outcomes in young adults with autism spectrum disorder

People with autism spectrum disorder (ASD) are at increased risk of developing co-occurring mental health difficulties across the lifespan. Exposure to adverse life events and parental mental health difficulties are known risk factors for developing a range of mental health difficulties. This study investigates the association of adverse life events, parental stress and mental health with emotional and behavioral problems in young adults with ASD. One hundred and fifteen young adults with ASD derived from a population-based longitudinal study were assessed at three time-points (12-, 16-, and 23-year) on questionnaire measures of emotional and behavioral problems. Parent-reported exposure to adverse life events and parental stress/mental health were measured at age 23. We used structural equation modeling to investigate the stability of emotional and behavioral problems over time, and the association between adverse life events and parental stress and mental health and emotional and behavioral outcomes at 23-year. Our results indicate that exposure to adverse life events was significantly associated with increased emotional and behavioral problems in young adults with ASD, while controlling for symptoms in childhood and adolescence. Higher reported parental stress and mental health difficulties were associated with a higher frequency of behavioral, but not emotional problems, and did not mediate the impact of adverse life events. These results suggest that child and adolescent emotional and behavioral problems, exposure to life events and parent stress and mental health are independently associated, to differing degrees, with emotional or behavioral outcomes in early adulthood. LAY SUMMARY: People with autism experience high rates of mental health difficulties throughout childhood and into adult life. Adverse life events and parental stress and mental health may contribute to poor mental health in adulthood. We used data at three time points (12-, 16-, and 23-year) to understand how these factors relate to symptoms at 23-year. We found that emotional and behavioral problems in childhood, adverse life events and parent mental health were all associated with increased emotional and behavioral problems in adulthood.

Ethical issues in participatory arts methods for young people with adverse childhood experiences

Context

Participatory arts‐based methods such as photovoice, drama and music have increasingly been used to engage young people who are exposed to psychosocial risks. These methods have the potential to empower youth and provide them with an accessible and welcoming environment to express and manage difficult feelings and experiences. These effects are, however, dependent on the way these methods are implemented and how potential ethical concerns are handled.

Objective

Using the current literature on arts‐based health research as a foundation, this paper examines ethical issues emerging from participatory arts methods with young people with traumatic experiences.

Results

We present a typology covering relevant issues such as power, accessibility, communication, trust and ownership, across the domains of partnership working, project entry, participation and dissemination. Drawing on our extensive clinical and research experiences, existing research and novel in‐practice examples, we offer guidance for ethical dilemmas that might arise at different phases of research.

Conclusion

Adequate anticipation and consideration of ethical issues, together with the involvement of young people, will help ensure that arts methods are implemented in research and practice with young people in a fair, meaningful and empowering way.

Patient or Public Contribution

The issues reviewed are largely based on the authors' experience conducting participatory research. Each of the projects referenced has its own systems for PPI including, variously, consultations with advisory groups, coproduction, youth ambassadors and mentor schemes. One of the coauthors, Josita Kavitha Thirumalai, is a young person trained in peer support and has provided extensive input across all stages.

Psychological effects of the 2017 California wildfires on children and youth with disabilities

The psychological effects of disasters on children with disabilities are understudied, despite evidence towards increased risk for complications after other types of trauma exposure. This study investigated the experience of children and youth with disabilities exposed to the 2017 Northern California wildfires, with a particular focus on psychological reactions. In-depth interviews were conducted with parents of 14 children and youth with disabilities one year post-disaster. Thematic analysis was used to analyze the interviews. Parents described the wildfires as traumatic events for both themselves and their children. Children and youth exhibited stress, grief, and other emotional and behavioral reactions during evacuation, in the immediate aftermath, and one year post-disaster. Navigating disability-related needs, such as accessible housing, contributed to parent stress post-disaster. School and community-based mental health efforts are described, along with a call for increased attention to disaster-related reactions in children with developmental disabilities. Suggestions for improving preparedness and response efforts that better support children with disabilities and their families post-disaster are given.

Needs assessment in unmet healthcare and family support services: A survey of caregivers of children and youth with autism spectrum disorder in Delaware

The study aimed to collect data from families of children and youth with Autism Spectrum Disorder (ASD) in the state of Delaware, USA to understand their ongoing needs and challenges in accessing child healthcare and family support services. We analyzed responses from 263 caregivers of children and youth with ASD from 3 to 24 years using a statewide needs assessment survey. Over 50% caregivers indicated having unmet needs relative to both child/youth healthcare services and family support services. Between 24 and 38% caregivers expressed unmet needs for healthcare services such as social skills training, speech-language therapy, behavioral intervention, and occupational therapy for their child and 20-24% expressed needs for family support services such as respite care, parent/sibling support groups, counseling, and babysitting support. Additionally, number of prior early interventions received, limitations in accessing healthcare services, and unmet needs for family support services significantly predicted child/youth unmet healthcare needs. Greater ASD severity and difficulties accessing child/youth healthcare services predicted participant's functional dependence on caregivers for activities of daily living. Together, these findings call for designing holistic, family-centered interventions that address needs of both children and youth with ASD and their families. LAY SUMMARY: A statewide needs assessment survey of caregivers of children and youth with ASD revealed that 50% responders had unmet needs relative to both child/youth healthcare services and family support services. Number of prior services received, limitations in accessing healthcare, and unmet needs for family support are linked to child/youth unmet healthcare needs. Severity of autism and difficulties accessing child/youth healthcare are associated with participant's functional dependence. Together, these findings call for placing the family at the heart of the service system in ASD.

Prevalence of Autism Spectrum Disorder and Co-morbidities in Children and Adolescents: A Systematic Literature Review

Objective: Individuals with autism spectrum disorder often present somatic and/or psychiatric co-morbid disorders. The DSM-5 allows for consideration of additional diagnoses besides ASD and may have impacted the prevalence of co-morbidities as well as being limited in capturing the true differences in prevalence observed between males and females. We describe the prevalence of ASD and frequently observed co-morbidities in children and adolescents (<18 years) in the United States and five European countries. Methods: Two systematic literature reviews were conducted in PubMed and Embase for the period 2014-2019 and focusing on the prevalence of ASD and nine co-morbidities of interest based on their frequency and/or severity: Attention Deficit Hyperactivity Disorder (ADHD), anxiety, depressive disorders, epilepsy, intellectual disability (ID), sleep disorders, sight/hearing impairment/loss, and gastro-intestinal syndromes (GI). Results: Thirteen studies on prevalence of ASD and 33 on prevalence of co-morbidities were included. Prevalence of ASD was 1.70 and 1.85% in US children aged 4 and 8 years respectively, while prevalence in Europe ranged between 0.38 and 1.55%. Additionally, current evidence is supportive of a global increase in ASD prevalence over the past years. Substantial heterogeneity in prevalence of co-morbidities was observed: ADHD (0.00-86.00%), anxiety (0.00-82.20%), depressive disorders (0.00-74.80%), epilepsy (2.80-77.50%), ID (0.00-91.70%), sleep disorders (2.08-72.50%), sight/hearing impairment/loss (0.00-14.90%/0.00-4.90%), and GI syndromes (0.00-67.80%). Studies were heterogeneous in terms of design and method to estimate prevalence. Gender appears to represent a risk factor for co-morbid ADHD (higher in males) and epilepsy/seizure (higher in females) while age is also associated with ADHD and anxiety (increasing until adolescence). Conclusion: Our results provide a descriptive review of the prevalence of ASD and its co-morbidities in children and adolescents. These insights can be valuable for clinicians and parents/guardians of autistic children. Prevalence of ASD has increased over time while co-morbidities bring additional heterogeneity to the clinical presentation, which further advocates for personalized approaches to treatment and support. Having a clear understanding of the prevalence of ASD and its co-morbidities is important to raise awareness among stakeholders.

Children and Adolescents with Disabilities and Exposure to Disasters, Terrorism, and the COVID-19 Pandemic: a Scoping Review

PURPOSE OF REVIEW

This paper reviews the empirical literature on exposures to disaster or terrorism and their impacts on the health and well-being of children with disabilities and their families since the last published update in 2017. We also review the literature on studies examining the mental health and functioning of children with disabilities during the COVID-19 pandemic.

RECENT FINDINGS

Few studies have examined the effects of disaster or terrorism on children with disabilities. Research shows that children with disabilities and their families have higher levels of disaster exposure, lower levels of disaster preparedness, and less recovery support due to longstanding discriminatory practices. Similarly, many reports of the COVID-19 pandemic have documented its negative and disproportionate impacts on children with disabilities and their families. In the setting of climate change, environmental disasters are expected to increase in frequency and severity. Future studies identifying mitigating factors to disasters, including COVID-19; increasing preparedness on an individual, community, and global level; and evaluating post-disaster trauma-informed treatment practices are imperative to support the health and well-being of children with disabilities and their families.

The Role of Diagnostic Instruments in Dual and Differential Diagnosis in Autism Spectrum Disorder Across the Lifespan

The heterogeneity inherent in autism spectrum disorder (ASD) makes the identification and diagnosis of ASD complex. We survey a large number of diagnostic tools, including screeners and tools designed for in-depth assessment. We also discuss the challenges presented by overlapping symptomatology between ASD and other disorders and the need to determine whether a diagnosis of ASD or another diagnosis best explains the individual's symptoms. We conclude with a call to action for the next steps necessary for meeting the diagnostic challenges presented here to improve the diagnostic process and to help understand each individual's particular ASD profile.

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.

The Role of Diagnostic Instruments in Dual and Differential Diagnosis in Autism Spectrum Disorder Across the Lifespan

The heterogeneity inherent in autism spectrum disorder (ASD) makes the identification and diagnosis of ASD complex. We survey a large number of diagnostic tools, including screeners and tools designed for in-depth assessment. We also discuss the challenges presented by overlapping symptomatology between ASD and other disorders and the need to determine whether a diagnosis of ASD or another diagnosis best explains the individual's symptoms. We conclude with a call to action for the next steps necessary for meeting the diagnostic challenges presented here to improve the diagnostic process and to help understand each individual's particular ASD profile.

Genomic influences on self-reported childhood maltreatment

Childhood maltreatment is highly prevalent and serves as a risk factor for mental and physical disorders. Self-reported childhood maltreatment appears heritable, but the specific genetic influences on this phenotype are largely unknown. The aims of this study were to (1) identify genetic variation associated with self-reported childhood maltreatment, (2) estimate SNP-based heritability (h2snp), (3) assess predictive value of polygenic risk scores (PRS) for childhood maltreatment, and (4) quantify genetic overlap of childhood maltreatment with mental and physical health-related phenotypes, and condition the top hits from our analyses when such overlap is present. Genome-wide association analysis for childhood maltreatment was undertaken, using a discovery sample from the UK Biobank (UKBB) (n = 124,000) and a replication sample from the Psychiatric Genomics Consortium-posttraumatic stress disorder group (PGC-PTSD) (n = 26,290). h2snp for childhood maltreatment and genetic correlations with mental/physical health traits were calculated using linkage disequilibrium score regression. PRS was calculated using PRSice and mtCOJO was used to perform conditional analysis. Two genome-wide significant loci associated with childhood maltreatment (rs142346759, p = 4.35 × 10-8, FOXP1; rs10262462, p = 3.24 × 10-8, FOXP2) were identified in the discovery dataset but were not replicated in PGC-PTSD. h2snp for childhood maltreatment was ~6% and the PRS derived from the UKBB was significantly predictive of childhood maltreatment in PGC-PTSD (r2 = 0.0025; p = 1.8 × 10-15). The most significant genetic correlation of childhood maltreatment was with depressive symptoms (rg = 0.70, p = 4.65 × 10-40), although we show evidence that our top hits may be specific to childhood maltreatment. This is the first large-scale genetic study to identify specific variants associated with self-reported childhood maltreatment. Speculatively, FOXP genes might influence externalizing traits and so be relevant to childhood maltreatment. Alternatively, these variants may be associated with a greater likelihood of reporting maltreatment. A clearer understanding of the genetic relationships of childhood maltreatment, including particular abuse subtypes, with a range of phenotypes, may ultimately be useful in in developing targeted treatment and prevention strategies.

Relationship between childhood socioeconomic position and adverse childhood experiences (ACEs): a systematic review

BACKGROUND

'Adverse childhood experiences' (ACEs) are associated with increased risk of negative outcomes in later life: ACEs have consequently become a policy priority in many countries. Despite ACEs being highly socially patterned, there has been very little discussion in the political discourse regarding the role of childhood socioeconomic position (SEP) in understanding and addressing them. The aim here was to undertake a systematic review of the literature on the relationship between childhood SEP and ACEs.

METHODS

MEDLINE, PsycINFO, ProQuest and Cochrane Library databases were searched. Inclusion criteria were: (1) measurement of SEP in childhood; (2) measurement of multiple ACEs; (3) ACEs were the outcome; and (4) statistical quantification of the relationship between childhood SEP and ACEs. Search terms included ACEs, SEP and synonyms; a second search additionally included 'maltreatment'. Overall study quality/risk of bias was calculated using a modified version of the Hamilton Tool.

RESULTS

In the ACEs-based search, only 6 out of 2825 screened papers were eligible for qualitative synthesis. The second search (including maltreatment) increased numbers to: 4562 papers screened and 35 included for synthesis. Eighteen papers were deemed 'high' quality, five 'medium' and the rest 'low'. Meaningful statistical associations were observed between childhood SEP and ACEs/maltreatment in the vast majority of studies, including all except one of those deemed to be high quality.

CONCLUSION

Lower childhood SEP is associated with a greater risk of ACEs/maltreatment. With UK child poverty levels predicted to increase markedly, any policy approach that ignores the socioeconomic context to ACEs is therefore flawed.

PROSPERO REGISTRATION NUMBER

CRD42017064781.

Update on the effectiveness of psychotherapy for anxiety disorders in children and adolescents with ASD

A growing body of research has examined the efficacy of varying formats (individual, group, linear, modular) of cognitive-behavioral therapy (CBT) as a treatment for anxiety disorders in children and youth with autism spectrum disorders (ASD). The present review utilized Chambless and Hollon's (1998) criteria for efficacious treatments to: (1) critically review the current evidence base for the efficacy of CBT for anxiety disorders in ASD; and (2) provide recommendations for future research. Findings identify two probably efficacious CBT programs (one group and one individual program) and five possibly efficacious programs, but no well-established programs. Similarities and differences in the components of these programs, which range from unmodified to specifically developed for ASD populations, are highlighted. In addition, the steps required to demonstrate well-established efficacy, and ultimately effectiveness, are discussed alongside other recommendations for refined future research.

Screening and treatment of trauma-related symptoms in youth with autism spectrum disorder among community providers in the United States

Using a cross-sectional survey of 673 multidisciplinary autism spectrum disorder providers recruited from five different sites in the United States, we examined the frequency with which community-based providers inquire about, screen, and treat trauma-related symptoms in their patients/students and assessed their perceptions regarding the need for and barriers to providing these services. Univariate and bivariate frequencies of self-reported trauma service provision, training needs, and barriers were estimated. Multivariable logistic regressions identified provider and patient-related factors associated with trauma-related symptoms screening and treatment. Over 50% of providers reported some screening and treatment of trauma-related symptoms in youth with autism spectrum disorder. Over 70% informally inquired about trauma-related symptoms; only 10% universally screened. Screening and treatment varied by provider discipline, setting, amount of interaction, and years of experience with autism spectrum disorder, as well as by patient/student sex, ethnicity, and socioeconomic status. Most providers agreed that trauma screening is a needed service impeded by inadequate provider training in trauma identification and treatment. The findings indicate that community providers in the United States of varied disciplines are assessing and treating trauma-related symptoms in youth with autism spectrum disorder, and that evidence-based approaches are needed to inform and maximize these efforts.

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.

Anxiety and Mood Disorder in Children With Autism Spectrum Disorder and ADHD

OBJECTIVES

Autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) frequently co-occur. Understanding the endophenotype of children with both ASD and ADHD may impact clinical management. In this study, we compare the comorbidity of anxiety and mood disorders in children with ASD, with and without ADHD.

METHODS

We performed a cross-sectional study of children with ASD who were enrolled in the Interactive Autism Network, an Internet-mediated, parent-report, autism research registry. Children ages 6 to 17 years with a parent-reported, professional, and questionnaire-verified diagnosis of ASD were included. Data were extracted regarding parent-reported diagnosis and/or treatment of ADHD, anxiety disorder, and mood disorder. ASD severity was measured by using Social Responsiveness Scale total raw scores.

RESULTS

There were 3319 children who met inclusion criteria. Of these, 1503 (45.3%) had ADHD. Comorbid ADHD increased with age (P < .001) and was associated with increased ASD severity (P < .001). A generalized linear model revealed that children with ASD and ADHD had an increased risk of anxiety disorder (adjusted relative risk 2.20; 95% confidence interval 1.97-2.46) and mood disorder (adjusted relative risk 2.72; 95% confidence interval 2.28-3.24) compared with children with ASD alone. Increasing age was the most significant contributor to the presence of anxiety disorder and mood disorder.

CONCLUSIONS

Co-occurrence of ADHD is common in children with ASD. Children with both ASD and ADHD have an increased risk of anxiety and mood disorders. Physicians who care for children with ASD should be aware of the coexistence of these treatable conditions.