Autism Through the Ages: A Mixed Methods Approach to Understanding How Age and Age of Diagnosis Affect Quality of Life

Time is of the essence: Age at autism diagnosis, sex assigned at birth, and psychopathology

LAY ABSTRACT

Previous research has shown that girls/women are diagnosed later than boys/men with autism. Individuals who are diagnosed later in life, especially girls/women, have greater anxious and depressive symptoms. Previous research has been limited due to narrow inclusionary criteria for enrollment in studies. The present study uses two samples-one clinic-based, large "real-world" sample and another research-based sample with strict criteria for autism diagnosis-to understand the relationships between diagnostic age, sex assigned at birth, and symptoms of anxiety/depression. In both samples, those who were diagnosed later had greater anxious/depressive symptoms, and anxiety was not predicted by sex. In the clinic-based but not research-based sample, those assigned female at birth were diagnosed later than those assigned male at birth. In the clinic-based sample only, individuals assigned female at birth and who were later diagnosed experienced greater symptoms of anxiety/depression compared to those assigned male who benefited from earlier diagnostic timing. Within the research-based sample, those assigned female at birth had greater depressive symptoms than those assigned male. These findings highlight the importance of timely identification of autism, especially for girls/women who are often diagnosed later. Community-based samples are needed to better understand real-world sex-based and diagnostic age-based disparities in mental health.

The adult experience of being diagnosed with autism spectrum disorder: A qualitative meta-synthesis

LAY ABSTRACT

There is little research looking at the experience of individuals diagnosed with autism spectrum disorder as adults. Adults diagnosed with autism spectrum disorder face different challenges than children, and more research is needed to better understand those challenges. For this review, autistic and non-autistic researchers looked at research on the experience of receiving a diagnosis of autism spectrum disorder as an adult. We looked for themes in people's experience leading up to diagnosis, going through the diagnostic process, and living their life after diagnosis. We analyzed 24 studies and found three overarching themes that captured thirty-two themes describing the experience of diagnosis. The three overarching themes expressed issues with identity and relationships before and after the diagnosis and identified that the diagnosis of autism spectrum disorder in adulthood impacted people's adaptation to and assimilation (i.e. the making sense of and internalizing the diagnosis) of autism spectrum disorder. While the diagnostic process itself was confusing and disappointing for many, it often led to a sense of relief and clarity regarding past experiences and had effects on identity and self-esteem. It created opportunities to connect with other autistic individuals and to access services, though appropriate supports were widely lacking. Recommendations are made that the impact of the diagnosis on people's identity and choices about telling others about their diagnosis, and whether and how people want to make adaptations, should be discussed and thought through in the process of diagnosis.

Autistic adults' experiences of financial wellbeing: Part II

LAY ABSTRACT

Money matters in people's lives. It helps to meet people's basic needs (food, clothes, shelter) and live the lives they want to. When people talk about 'financial wellbeing', they mean how much you feel in control over day-to-day finances and how much freedom you have to make choices to enjoy life. We don't know what autistic people think about these things. That's why we did our study. We spoke to 21 autistic adults (24-69 years) about how they felt about their financial situation. We deliberately spoke to people who had told us previously they felt 'financially well' or 'financially unwell' so we could hear a range of opinions. Autistic people told us financial wellbeing meant having enough money to pay for their basics needs, to have a safety net for unexpected bills and not having to worry about money now or in the future. But many felt that good financial wellbeing was not possible for them. They often did not have a stable income to cover day-to-day expenses. This limited the choices they could make. Despite these challenges, autistic people told us they worked hard to budget and save money when they could - because feeling financial insecure was just too stressful, especially when they could not rely on family or friends for support. It made them feel mentally unwell. Our study shows there are many factors that influence autistic people's financial wellbeing. We need more research to help us understand how autistic people can be supported to achieve financial security.

Gender, assigned sex at birth, and gender diversity: Windows into diagnostic timing disparities in autism

LAY ABSTRACT

Later autism diagnosis is associated with risk for mental health problems. Understanding factors related to later autism diagnosis may help reduce mental health risks for autistic people. One characteristic associated with later autism diagnosis is female sex. However, studies often do not distinguish sex assigned at birth and gender identity. Gender diversity may be more common in autistic relative to neurotypical people, and autism is more common in gender-diverse populations. We studied age at autism diagnosis by sex assigned at birth, gender identity, and gender diversity (gender-diverse vs cisgender) status, separately. We studied three separate autistic samples, each of which differed in how they were diagnosed and how they were recruited. The samples included 193 persons (8.0-18.0 years) from a research-recruited academic medical center sample; 1,550 people (1.3-25.4 years) from a clinic-based sample; and 244 people (18.2-30.0 years) from a community-enriched sample. We found significant differences in the clinic-based and community-enriched samples. People assigned female sex at birth were diagnosed with autism significantly later than people assigned male at birth. People of female gender were diagnosed significantly later than people of male gender. Gender-diverse people were diagnosed significantly later than cisgender people. Sex assigned at birth, gender identity, and gender diversity may each show unique relationships with age of autism diagnosis. Differences in how autistic people are diagnosed and recruited are important to consider in studies that examine sex assigned at birth or gender identity. More research into autism diagnosis in adulthood is needed.

Re-examining the association between the age of learning one is autistic and adult outcomes

LAY ABSTRACT

An interesting recent study found that people who learned they were autistic at a younger age felt more positive about their lives (i.e., had better quality of life) than those who learned at an older age. However, this study has some limitations: (a) the study only involved a fairly small group of university students, (b) whether 'learning one is autistic' referred to learning about one's diagnosis or receiving one's diagnosis was unclear, (c) the influence of other factors on the link between age of learning one is autistic and quality of life was not considered, and (d) the assessment of different areas of quality of life was limited. Addressing these limitations, we re-examined whether the age at which one learns they are autistic relates to quality of life in adulthood. Contrary to the previous study, we found the age at which one learns about their autism does not have a significantly independent impact on their quality of life as an adult. Rather, other factors (e.g., autistic traits, sex, and additional mental health conditions) may have a greater impact. Given our participant sample was larger and more diverse in age and education level compared to previous research, this finding is likely to be more applicable to autistic adults from different backgrounds. Importantly, however, we are not suggesting that individuals should be made aware of their diagnosis later than sooner. Getting a timely diagnosis remains crucial for autistic people and their families to access appropriate support.

Frozen in Time, a Focused Review of Autism Prevalence in Canadian Indigenous Communities

The unprecedented global continuous rise in autism prevalence is often referred to as a Pandemic while its parallel cost increase to society portrays a Tsunami. Autism data originates mostly from industrialized High-Income geopolitical regions in Europe, North America, and Asian regions. Although efforts to determine autism data from regions in Low and Mid-economies are ongoing, prevalence information from geographically remote and economically vulnerable communities within the privileged regions is largely undetermined, as is the case of the Canadian Indigenous communities, the First Nations, Inuit, and Métis highlighted in this focused review. The underlying theoretical approach adopted here is Transcultural Psychiatry with its emphasis on Context including sociopolitical circumstances, considered the gateway to understanding health, illness, and recovery in groups and individuals. Accordingly, the review includes a concise relevant government system description and history of the relations with Indigenous peoples to provide context to present indigenous relations to Canadian government agencies. Scores in these communities face a myriad of survival challenges encompassing meagre health resources and services. Establishing autism prevalence data in these communities are exceedingly difficult due to multiple factors. While prominent among them are their strong ties to traditional approaches to health, illness, and autism conceptualization, the crucial obstacle is Crown and Provincial government authorities' and agencies' historically rooted colonial response to the needs of families with autistic members. It embodies a posture of infantilization, an attitude that is "frozen in time" in the approach, practice, accommodations, and services for these families. The review provides the preferred autism terminology, information sources, article flow, and Future Directions, all found in the Introduction's first paragraphs.

Harsh Parenting and Trajectories of Emotional and Behavioural Difficulties in Autistic Children

Autistic children show higher rates of co-occurring emotional and behavioural difficulties compared to other children in the general population. However, the environmental factors which contribute to the development of emotional (internalising) and behavioural (externalising) difficulties in autistic individuals are poorly understood. This study sought to investigate the association between harsh parenting (smacking, shouting, telling off) and the trajectories of emotional and behavioural difficulties in autistic children from ages 3 to 7. A sample comprising of 349 autistic children participated from the UK's Millennium Cohort Study. Associations between harsh parenting and child emotional and behavioural difficulties were modelled using multilevel growth curve models. In autistic children, harsh parenting was associated with total emotional and behavioural difficulties and behavioural (but not emotional) problems concurrently. Moreover, harsh parenting was not associated with changes in emotional and behavioural difficulties over time. Harsh parenting may have an important role in externalising problems in young autistic children indicating the need for public health strategies which educate parents on its effects.

Toward Equity in Research on Intellectual and Developmental Disabilities

Lack of diversity in IDD research is typically conceptualized only in terms of (1) recruitment of samples that do not appropriately represent the sociodemographics of the population, or (2) the limited number of researchers from historically marginalized backgrounds. Critically, the field also suffers from over-reliance on perspectives and social systems of dominant culture-both in how disability is regarded and in relation to other dimensions of identity and culture. These lenses lead to research findings that reinforce, rather than reduce, social inequities. We propose a framework that minimizes reliance on diagnostic categories, shifts from deficit- to person-centered models, acknowledges people's multiple identities, and includes self-advocates and diverse communities as partners in the research enterprise. The systems change necessary to support this framework is described.

Autism, Discrimination and Masking: Disrupting a Recipe for Trauma

Outcomes of discrimination for autistic people include masking, social isolation and exclusion, trauma, and mental health problems. This discursive paper discusses the discrimination experienced by autistic people in health, education, employment, and media settings; and considers how to reduce the impact of discrimination. Addressing the impact of discrimination requires an improved understanding of the lived experience of the autistic person, the embedding of inclusive practices in communities, developing the person's life skills and supports, and enabling the person to work through their psychological trauma. Further research can aid in minimizing and preventing discrimination against people with autism.

The Intersection of Autism and Transgender and Nonbinary Identities: Community and Academic Dialogue on Research and Advocacy

Many transgender people are autistic. Community expressions of the autism transgender intersection abound. Some commentators have questioned the proportional overrepresentation of autism among gender-diverse people, suggesting these individuals may not be truly autistic or truly transgender. However, increasing evidence challenges assertions that deny the authenticity of co-occurring autistic and transgender identities. Specifically, research by authors of this article indicates autistic transgender people show neurophenotypes generally consistent with cisgender autistic people and implicit gender phenotypes consistent with nonautistic transgender people. This article features a dialogue between eight leading experts in the field of intersectional autism and gender diversity, including clinicians, researchers, community advocates, and experts who are themselves autistic transgender. Key topics of discussion included: how research findings on autism and gender diversity inform respectful and supportive responses to autistic transgender people; the benefits and harms of increased societal attention toward the autism transgender intersection; and research and advocacy priorities. The expert panel concluded the following: (1) it is important to respect transgender autistic people's wellness and resilience, while also acknowledging the pathologization and stigmatization they face; (2) autistic gender-diverse people are experts of their own identity and should be involved in all aspects of research and clinical care; (3) research is needed to understand the disparities autistic transgender people face; (4) attempts to restrict autistic transgender people's access to gender care are unsupported by existing research; (5) adult gender care may benefit from incorporating universal design principles and neurodiversity-affirming strategies to reduce barriers to care and improve clinician-client communication in treatment delivery and the informed consent process; (6) cross-cultural and cross-societal research will improve best care practices in diverse contexts; (7) research and advocacy must be inclusive across ethnoracial identities, including in leadership and perspectives represented; and (8) a life span developmental framework is needed for adult research in this field.

Mental Health Professionals' Experiences of Adapting Mental Health Interventions for Autistic Adults: A Systematic Review and Thematic Synthesis

Autistic adults experience high rates of metal health difficulties and face significant barriers to accessing appropriate mental health care. Empirical research and recent professional guidelines emphasise the importance of modifying standard mental health interventions to best meet the needs of autistic adults. This systematic review explored mental health professionals' experiences of adapting mental health interventions for autistic adults. A systematic search was conducted on CINAHL, PsychINFO, PubMed, Scopus, and Web of Science in July 2022. The findings from 13 identified studies were synthesised using thematic synthesis. Three major analytical themes were generated, the unique experience of adapting interventions for autistic clients, factors which facilitate successful adaptations, and challenges to adapting interventions. Each theme contained a number of subsequent sub-themes. Professionals view the process of adapting interventions to be a highly individualised process. A range of personal traits, professional experiences, and systemic, service-based issues were identified in facilitating or challenging this individualised process. Further research regarding adaptations with different intervention models and increased supportive resources are required to enable professionals to successfully adapt interventions for autistic adult clients.

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

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

"Peas in a pod": Oral History Reflections on Autistic Identity in Family and Community by Late-Diagnosed Adults

In this paper, we report on a participatory oral history study documenting the lives of late-diagnosed autistic adults in Australia. We interviewed 26 autistic adults about their life history and the impact of late diagnosis. All were diagnosed after the age of 35, growing up in an era when autism was not well known. Using reflexive thematic analysis, we uncovered a rich body of reflections on shared Autistic identity and identified three major themes within that data set: 'conceptualising the Autistic family', 'creating Autistic community', and 'contesting Autistic identity'. Overall, the study provides insights into the active creation of shared Autistic identity and the importance of Autistic community to these late-diagnosed autistic adults.

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

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

Barriers to healthcare and their relationship to well-being and social support for autistic adults during COVID-19

AIM

The present study aimed to investigate barriers to healthcare and their relationships to social and emotional well-being and intersectional inequalities for autistic adults during COVID-19 restrictions in the UK.

BACKGROUND

Autistic adults experience severe health inequalities and report more barriers to accessing health services compared to other both disabled and non-disabled populations. The COVID-19 pandemic has impacted many areas of society that may have increased vulnerability of autistic people to social and health inequalities, including delivery of healthcare from in-person to remote methods.

METHOD

One hundred twenty-eight autistic adults who lived in the UK took part in an online survey. Measures included the Barriers to Healthcare Checklist (Short Form) and PROMIS outcome measure bank to assess emotional well-being and social support. Participants rated their agreement with items, retrospectively considering three different points of the trajectory of COVID-19 restrictions: before COVID-19, during the first lockdown in spring 2020, and in the month prior to taking the survey during autumn 2020. They completed a follow-up survey six months later to continue to assess change as restrictions in the UK were eased.

FINDINGS

The average number of barriers to healthcare showed no significant change between all four time points. However, the nature of barriers to healthcare changed at the point of lockdown and persisted beyond the easing of COVID-19 restrictions. Barriers to healthcare were associated with some social and emotional well-being variables and demographic groups including gender, education and presence of additional disabilities. The findings may help to identify areas to target to improve access to both remote and in-person health systems for autistic people as modes of delivery continue to change over time.

Recent Developments in Autism Genetic Research: A Scientometric Review from 2018 to 2022

Genetic research in Autism Spectrum Disorder (ASD) has progressed tremendously in recent decades. Dozens of genetic loci and hundreds of alterations in the genetic sequence, expression, epigenetic transformation, and interactions with other physiological and environmental systems have been found to increase the likelihood of developing ASD. There is therefore a need to represent this wide-ranging yet voluminous body of literature in a systematic manner so that this information can be synthesised and understood at a macro level. Therefore, this study made use of scientometric methods, particularly document co-citation analysis (DCA), to systematically review literature on ASD genetic research from 2018 to 2022. A total of 14,818 articles were extracted from Scopus and analyzed with CiteSpace. An optimized DCA analysis revealed that recent literature on ASD genetic research can be broadly organised into 12 major clusters representing various sub-topics. These clusters are briefly described in the manuscript and potential applications of this study are discussed.

A capabilities approach to understanding and supporting autistic adulthood

There is little comprehensive research into autistic adulthood, and even less into the services and supports that are most likely to foster flourishing adult autistic lives. This limited research is partly because autism is largely conceived as a condition of childhood, but this focus of research has also resulted from the orthodox scientific approach to autism, which conceptualizes autistic experience almost entirely as a series of biologically derived functional deficits. Approaching autism in this way severely limits what is known about this neurodevelopmental difference, how research is conducted and the services and supports available. In this Review, we adopt an alternative research strategy: we apply Martha Nussbaum’s capabilities approach, which focuses on ten core elements of a thriving human life, to research on autistic adulthood. In doing so, we identify areas where autistic adults thrive and where they often struggle, and highlight issues to which researchers, clinicians and policymakers should respond. The resulting picture is far more complex than conventional accounts of autism imply. It also reveals the importance of engaging autistic adults directly in the research process to make progress towards genuinely knowing autism and supporting flourishing autistic lives.

The focus on functional deficits in conventional autism research constrains understanding of autistic lives. In this Review, Pellicano et al. appraise research on autistic adulthood through a capabilities lens to identify areas where autistic adults thrive, and where more research and services are needed to enhance their quality of life.

'They ask no questions and pass no criticism': A mixed-methods study exploring pet ownership in autism

Many autistic people cite a strong attachment to animals, and some studies suggest they may even show a bias towards animals over people. This mixed-methods study explored companion animal attachment in the adult autistic community. In a quantitative study with 735 people, we found that autistic adults were equally attached to their pets as neurotypicals but were less likely to own them, even though pet ownership corresponded with better mental health outcomes. Substituting pets for people also served as a compensatory mechanism for social contact in the autistic sample. In a second qualitative study, we explored the lived experiences of 16 autistic pet owners. The interpretive phenomenological analysis highlighted the benefits and the barriers to animal companionship. Together these mixed methods findings underline how pets improve the lives of their autistic owners. We conclude with specific recommendations for increasing animal companionship opportunities for autistic adults.