Depression in Youth with Autism Spectrum Disorder

Stability and Validity of Self-Reported Depression and Anxiety in Autistic Youth

The aim of this study was to assess test-retest reliability and diagnostic validity of self-report instruments of depression and anxiety in autistic youth. Participants were 55 autistic youth aged 8-17 years presenting with depressive or anxiety symptoms. They were interviewed with the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS-PL) and completed the Children's Depression Inventory, Second Edition - Self Report Short (CDI 2:SR[S]) and the Revised Child Anxiety and Depression Scale (RCADS) twice, separated by a two-week interval. Test-retest reliability was measured with intraclass correlation coefficients (ICCs), and diagnostic validity was assessed using receiver operating characteristic (ROC) curves with the summary ratings on the K-SADS-PL as the criterion. The effect of participant characteristics was analyzed through a moderation analysis. Generalized anxiety (GAD) and social anxiety disorder (SOC) were the two most prevalent disorders in the sample. Test-retest reliability for most of the subscales was good (ICC = 0.74 - 0.87), with the exception of the RCADS obsessive-compulsive disorder (OCD) and GAD. The Adaptive Behavior conceptual score was a significant moderator of the reliability of the CDI 2:SR[S]. The ROC analysis suggested the RCADS SOC and the CDI 2:SR[S] to be good screening tools with inadequate specificity when appropriately sensitive cutoff scores are used. Optimal cutoff scores in this sample were lower than originally published. The findings suggest that autistic youth can provide stable reports of anxiety and depressive symptoms over time. Diagnostic validity varied according to the construct and instrument.

Potential mechanisms underlying the association between feeding and eating disorders and autism

There is a reliable association between autism and Feeding and Eating Disorders. Concerningly, where these two conditions co-occur, clinical outcomes of Feeding and Eating Disorders are significantly worse, and treatment less effective, than when the Feeding and Eating Disorders occur in neurotypical individuals. Problematically, the reason for the association between autism and Feeding and Eating Disorders is poorly understood, which constrains advances in clinical care. This paper outlines several possible mechanisms that may underlie the observed association and suggests ways in which they may be empirically tested. Mechanisms are split into those producing an artefactual association, and those reflecting a genuine link between conditions. Artefactual associations may be due to conceptual overlap in both diagnostic criteria and measurement, Feeding and Eating Disorders causing transient autistic traits, or the association being non-specific in nature. A genuine association between autism and Feeding and Eating Disorders may be due to common causal factors, autism directly or indirectly causing Feeding and Eating Disorders, and Feeding and Eating Disorders being a female manifestation of autism.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Feasibility and preliminary efficacy of behavioral activation for treatment of depression in autistic adolescents

LAY ABSTRACT

Depression is common among autistic youth and has a significant negative impact on quality of life and day-to-day functioning. Despite great need for efficacious treatments, there are currently limited research-supported interventions for depression symptoms in autistic young people. This study tested a novel, behavior-based approach or psychotherapy for treatment of depression symptoms in autistic adolescents without intellectual disability (i.e. Behavioral Activation for Autistic Adolescents, BA-A) with 15 youth (11-16 years old). BA-A is an individually delivered 12-session therapy that was developed for and to meet the needs of autistic youth with depression. Results found that autistic youth and their caregivers were able to participate in BA-A therapy sessions, and clinicians were able to deliver BA-A in accordance with the treatment manual. Notably, results demonstrated that autistic youth depression symptoms significantly improved after participating in BA-A. Furthermore, anxiety symptoms and social skills significantly improved following BA-A.

Accelerated Theta Burst Transcranial Magnetic Stimulation for Refractory Depression in Autism Spectrum Disorder

PURPOSE

Major depressive disorder (MDD) disproportionately affects those living with autism spectrum disorder (ASD) and is associated with significant impairment and treatment recidivism.

METHODS

We studied the use of accelerated theta burst stimulation (ATBS) for the treatment of refractory MDD in ASD (3 treatments daily x 10 days). This prospective open-label 12-week trial included 10 subjects with a mean age of 21.5 years, randomized to receive unilateral or bilateral stimulation of the dorsolateral prefrontal cortex.

RESULTS

One participant dropped out of the study due to intolerability. In both treatment arms, depressive symptoms, scored on the Hamilton Depression Rating Scale scores, diminished substantially. At 12 weeks post-treatment, full remission was sustained in 5 subjects and partial remission in 3 subjects. Treatment with ATBS, regardless of the site of stimulation, was associated with a significant, substantial, and sustained improvement in depressive symptomatology via the primary outcome measure, the Hamilton Depression Rating Scale. Additional secondary measures, including self-report depression scales, fluid cognition, and sleep quality, also showed significant improvement. No serious adverse events occurred during the study. Mild transient headaches were infrequently reported, which are expected side effects of ATBS.

CONCLUSION

Overall, ATBS treatment was highly effective and well-tolerated in individuals with ASD and co-occurring MDD. The findings support the need for a larger, sham-controlled randomized controlled trial to further evaluate efficacy of ATBS in this population.

Resolving heterogeneity in dynamics of synchronization stability within the salience network in autism spectrum disorder

BACKGROUND

Heterogeneity in resting-state functional connectivity (FC) are one of the characteristics of autism spectrum disorder (ASD). Traditional resting-state FC primarily focuses on linear correlations, ignoring the nonlinear properties involved in synchronization between networks or brain regions.

METHODS

In the present study, the cross-recurrence quantification analysis, a nonlinear method based on dynamical systems, was utilized to quantify the synchronization stability between brain regions within the salience network (SN) of ASD. Using the resting-state functional magnetic resonance imaging data of 207 children (ASD/typically-developing controls (TC): 105/102) in Autism Brain Imaging Data Exchange database, we analyzed the laminarity and trapping time differences of the synchronization stability between the ASD subtype derived by a K-means clustering analysis and the TC group, and examined the relationship between synchronization stability and the severity of clinical symptoms of the ASD subtypes.

RESULTS

Based on the synchronization stability within the SN of ASD, we identified two subtypes that showed opposite changes in synchronization stability relative to the TC group. In addition, the synchronization stability of ASD subtypes 1 and 2 can predict the social interaction and communication impairments, respectively.

CONCLUSIONS

These findings reveal that ASD subgroups with different patterns of synchronization stability within the SN appear distinct clinical symptoms, and highlight the importance of exploring the potential neural mechanism of ASD from a nonlinear perspective.

Perspectives on Employer-Initiated Terminations Among Young Adults on the Autism Spectrum

Job instability is high among autistic adults, with employer-initiated terminations a common reason for job loss. The current study used qualitative methods to code reasons that autistic adults identified for their employer-initiated termination. From 315 autistic individuals ages 18-35 who completed an online survey, 93 (29.5%) reported having been terminated from a job. These individuals were asked about the reasons for their termination and responses were coded into thematic categories. Common reasons included work performance, social difficulties, attendance, and mental health challenges. Adults were more likely to attribute terminations to internal causes (related to the individual) than to external causes (environment-related). A good fit between workplace, individual preferences, skills, and abilities is likely key to promoting job continuity for autistic adults.

Discordance Between Psychiatric Diagnoses and Medication Use in Children and Adults With Autism Presenting in Crisis

Autistic individuals experience high rates of behavioral crises that present to healthcare providers for medication management. Co-occurring psychiatric conditions and psychotropic medication use are common among this patient population. Particularly for those with limited expressive language, evaluating for the presence of psychiatric and medical conditions that could contribute to distress is a critical component of crisis management. A records review study was completed on 126 autistic individuals for whom medical decision-making support was requested from The Huntsman Mental Health Institute Neurobehavior Consultation Service. Crisis manifestations and historical information were provided by the parent or caregiver through an online questionnaire. Nearly all individuals presented with behavioral (96.8%) and emotional (96.8%) symptoms; 97.6% received at least one co-occurring psychiatric diagnosis. Additionally, 75.4% of parents or caregivers endorsed the presence of a medical condition that they believed could be contributing to the crisis presentation. Most individuals (92.1%) were prescribed at least one psychotropic medication; 69.8% were taking an antipsychotic, suggesting a history of treatment resistance. The alignment between psychotropic medications and psychiatric diagnoses was evaluated in the context of prior studies and reviews on psychiatric management in autistic and neurotypical populations. Several individuals were taking a combination of medications that included both indicated and contraindicated medications for the psychiatric disorder diagnosed, likely contributing to treatment resistance. Identifying discordance between psychotropic medication use and psychiatric conditions present offers an opportunity to pursue better treatment outcomes for autistic individuals, particularly for those experiencing treatment-resistant agitation.

Differential Diagnosis of Autism and Other Neurodevelopmental Disorders

This article discusses the diagnostic criteria for autism spectrum disorder (ASD), as well as other neurodevelopmental disorders that may be confused with or co-occur with ASD. Practitioners involved in diagnostic assessment of ASD must be well versed in the features that differentiate ASD from other conditions and be familiar with how co-occurring conditions may manifest in the context of ASD. ASD symptoms present differently across development, underscoring the need for training about typical developmental expectations for youth. Periodic reevaluations throughout development are also important because support needs for individuals with autism change over time.

The importance of social relationships in depression in autistic adolescents: a narrative-review

Objective

The impact of social relationships on autistic adolescents has been recently studied. However, the link between social relationships and depression in autistic adolescents seem underrepresented in the scientific literature. Especially no specific assessment tool has been developed to evaluate depression in autistic adolescents. The aim of this narrative review is to raise the impact of social relationships on depression in autistic adolescents. We aim to propose lines of thought on the creation of a sensitive tool for identifying depression in this population.

Methods

We conducted two types of searches for articles and reviews on PubMed, Embase, and Cochrane. First, regarding social relationships, we searched the following terms: [("adolesc*" OR "youth") AND ("ASD" OR "autis*") AND ("social communication" OR "peer relationship") AND ("depress*")]. Secondly, regarding assessment tool, we searched the following terms: [("tool" OR "assess*") AND ("depress*") AND ("ASD" OR "Autis*)"].

Results

Social impact, verbal skills, and good social motivation are risk factors of depression in autistic adolescents. Social impairment during childhood is related to peer victimization and is a risk factor for depression. There is no specific tool to measure depression in autistic adolescents.

Conclusion

No specific tool based on social relationships was developed to evaluate depression in autistic adolescents. Depression in autistic adolescents needs to be assessed considering the social and pragmatic specificities of autism. Social communication and difficulties in peer relationships may be evaluated in specific assessment tools based on social relationships for depression in autistic adolescents.

Brief Report: Exploratory Evaluation of Clinical Features Associated with Suicidal Ideation in Youth with Autism Spectrum Disorder

There has been a heightened awareness of an increased risk of suicidality among individuals with autism spectrum disorder (ASD) due to high rates of suicidal ideation (SI) in this population (11-66%). The current study investigated the rate of parent-endorsed SI and associated clinical features in 48 youths with ASD (Age; M: 12.97 years, SD: 2.33). SI was endorsed in 18.75% of participants. Youth with SI exhibited significantly higher levels of affective problems, externalizing problems, feelings of humiliation and rejection, and symptoms related to perfectionism. Results indicate that co-occurring mental health problems are associated with suicidal ideation and provide relevant targets for psychotherapeutic intervention. This preliminary study in a modest sample suggests the value of further research in larger samples to replicate and generalize these findings.

Neurocognitive Test Performance and Concussion-Like Symptom Reporting Among Adolescent Athletes With Self-Reported Autism on Preseason Assessments

OBJECTIVE

To examine baseline neurocognitive functioning and symptom reporting among adolescents with self-reported autism.

METHOD

Participants in this cross-sectional, observational study were 60,751 adolescents who completed preseason testing. There were 425 students (0.7%) who self-reported an autism spectrum disorder (ASD) diagnosis. Cognitive functioning was measured by Immediate Post-Concussion Assessment and Cognitive Testing and symptom ratings were obtained from the Post-Concussion Symptom Scale.

RESULTS

Groups differed significantly across all neurocognitive composites (p values <.002); effect size magnitudes for most differences were small, though among boys a noteworthy difference on visual memory and among girls differences on verbal memory and visual motor speed composites were noted. Among boys, the ASD group endorsed 21 of the 22 symptoms at a greater rate. Among girls, the ASD group endorsed 11 of the 22 symptoms at a greater rate. Some examples of symptoms that were endorsed at a higher rate among adolescents with self-reported autism were sensitivity to noise (girls: odds ratio, OR = 4.38; boys: OR = 4.99), numbness or tingling (girls: OR = 3.67; boys: OR = 3.25), difficulty remembering (girls: OR = 2.01; boys: OR = 2.49), difficulty concentrating (girls: OR = 1.82; boys: OR = 2.40), sensitivity to light (girls: OR = 1.82; boys: OR = 1.76), sadness (girls: OR = 1.72; boys: OR = 2.56), nervousness (girls: OR = 1.80; boys: OR = 2.27), and feeling more emotional (girls: OR = 1.79; boys: OR = 2.84).

CONCLUSION

Students with self-reported autism participating in organized sports likely experience a low degree of functional impairment, on average. If they sustain a concussion, their clinical management should be more intensive to maximize the likelihood of swift and favorable recovery.

Differences between subclinical attention-deficit/hyperactivity and autistic traits in default mode, salience, and frontoparietal network connectivities in young adult Japanese

Attention-deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are associated with attentional impairments, with both commonalities and differences in the nature of their attention deficits. This study aimed to investigate the neural correlates of ADHD and ASD traits in healthy individuals, focusing on the functional connectivity (FC) of attention-related large-scale brain networks (LSBNs). The participants were 61 healthy individuals (30 men; age, 21.9 ± 1.9 years). The Adult ADHD Self-Report Scale (ASRS) and Autism Spectrum Quotient (AQ) were administered as indicators of ADHD and ASD traits, respectively. Performance in the continuous performance test (CPT) was used as a behavioural measure of sustained attentional function. Functional magnetic resonance imaging scans were performed during the resting state (Rest) and auditory oddball task (Odd). Considering the critical role in attention processing, we focused our analyses on the default mode (DMN), frontoparietal (FPN), and salience (SN) networks. Region of interest (ROI)-to-ROI analyses (false discovery rate < 0.05) were performed to determine relationships between psychological measures with within-network FC (DMN, FPN, and SN) as well as with between-network FC (DMN-FPN, DMN-SN, and FPN-SN). ASRS scores, but not AQ scores, were correlated with less frequent commission errors and shorter reaction times in the CPT. During Odd, significant positive correlations with ASRS were demonstrated in multiple FCs within DMN, while significant positive correlations with AQ were demonstrated in multiple FCs within FPN. AQs were negatively correlated with FPN-SN FCs. During Rest, AQs were negatively and positively correlated with one FC within the SN and multiple FCs between the DMN and SN, respectively. These findings of the ROI-to-ROI analysis were only partially replicated in a split-half replication analysis, a replication analysis with open-access data sets, and a replication analysis with a structure-based atlas. The better CPT performance by individuals with subclinical ADHD traits suggests positive effects of these traits on sustained attention. Differential associations between LSBN FCs and ASD/ADHD traits corroborate the notion of differences in sustained and selective attention between clinical ADHD and ASD.

Assessing suicidal thoughts and behaviors and nonsuicidal self-injury in autistic and non-autistic early adolescents using the Columbia Suicide Severity Rating Scale

LAY ABSTRACT

Autistic adolescents are more likely to experience suicidal thoughts and behaviors and nonsuicidal self-injury than non-autistic adolescents, per caregiver- and self-report on single-item questionnaires. Comprehensive, clinician-rated measures of suicide risk have not been used to measure suicidal thoughts and behaviors and nonsuicidal self-injury in autistic youth despite greater parent-child rating discrepancies among autistic youth than their non-autistic peers. The Columbia Suicide Severity Rating Scale is a widely used, clinician-rated measure of suicide risk that has not been tested with autistic youth. In this study, the Columbia Suicide Severity Rating Scale was employed to assess suicidal thoughts and behaviors and nonsuicidal self-injury in a community sample of 239 early adolescents (10:0-13:9 years old), of whom 138 youth were autistic and 101 were not autistic. Multiple analyses examined diagnostic (autistic vs non-autistic) and sex-based (male vs female) differences in suicidal thoughts and behaviors and nonsuicidal self-injury, as well as youth consistency in reporting across self- and clinician-rated measures. Findings show that a greater proportion of autistic youth reported lifetime suicidal thoughts and nonsuicidal self-injury than non-autistic youth; however, there were no sex-based differences. The majority of non-autistic youth were consistent in reporting suicidal thoughts on self- and clinician-rated measures; however, nearly one in five autistic youth disclosed suicidal thoughts on a self-report measure but not to a psychiatrist on the Columbia Suicide Severity Rating Scale. Findings suggest that autism diagnostic status, but not sex, confers significant risk for suicidal thoughts and behaviors and nonsuicidal self-injury in early adolescents and that the Columbia Suicide Severity Rating Scale may be a useful measure of suicide risk for some autistic youth, but it may not detect all autistic youth experiencing suicidal thoughts.

Exploring the association between social skills struggles and social communication difficulties and depression in youth with autism spectrum disorder

Autism spectrum disorder is characterized by social communication difficulties and social skills abilities that are significantly differ from neurotypical populations as well as restricted and repetitive behaviors and interests. Furthermore, many autistic youth experience co-occurring conditions, with one of the most common being depression. This depression is suggested to be, in part, the result of the relative social isolation experienced by autistic youth. Therefore, it is important to examine social functioning differences in autistic youth and their association with depression. There has been limited research investigating the association between social communication difficulties and depression, or the association between social skills struggles and depression, and no research investigating both of these in the same population. We found that social communicative symptoms of autism (as measured by the Autism Diagnostic Observation Schedule) were not associated with depression scores (as measured by the Revised Checklist for Anxiety and Depression) after controlling for age, sex, and IQ. In contrast, we did find a significant association between social skills struggles (as measured by the Adaptive Behavior Assessment System-2) and depression in the same sample. Higher social skills struggles were associated with higher depression scores after controlling for age, sex, and IQ. Reasons for the potential discrepancy between these findings are discussed, and clinical implications of these findings are explored.

Lower Completion of Depression Screening and Higher Positivity Among Autistic Adolescents Across a Large Pediatric Primary Care Network

OBJECTIVE

To examine rates of depression screening and positivity among autistic adolescents where electronic depression screening is administered universally; to compare rates between autistic and nonautistic youth; and to explore sociodemographic and clinical factors associated with screening completion and results.

METHODS

We conducted a retrospective cohort study comparing 12-17-year-old autistic and nonautistic adolescents presenting for well-child care in a large pediatric primary care network between November 2017 and January 2019 (N = 60,181). Sociodemographic and clinical data, including PHQ-9-M completion status and results, were extracted digitally from the electronic health record and compared between autistic and nonautistic youth. Logistic regression explored the relationship between sociodemographic and clinical factors and screen completion and results, stratified by autism diagnosis.

RESULTS

Autistic adolescents were significantly less likely to have a completed depression screen compared to nonautistic adolescents [67.0% vs 78.9%, odds ratio (OR) = 0.54, P < .01]. Among those with a completed screen, a higher percentage of autistic youths screened positive for depression (39.1% vs 22.8%; OR = 2.18, P < .01,) and suicidal ideation/behavior (13.4% vs 6.8%; OR = 2.13, P < .01). Factors associated with screening completion and positivity differed between autistic and nonautistic groups.

CONCLUSIONS

Autistic adolescents were less likely to have a completed depression screen when presenting for well-child care. However, when screened, they were more likely to endorse depression and suicide risk. This suggests disparities in depression screening and risk among autistic youth compared to nonautistic youth. Additional research should evaluate the source of these disparities, explore barriers to screening, and examine longitudinal outcomes of positive results among this population.

Extracurricular Activity Participation Among Autistic Children and Adolescents: Buffer for Internalizing Conditions and Foundation for Friendship?

PURPOSE

Internalizing conditions, such as anxiety and depression, and difficulties with developing and maintaining friendships are common among autistic children and adolescents. Participation in extracurricular activities may buffer against these challenges as they provide naturalistic opportunities to bring peers with shared interests and skills together. As such, the purpose of the current study was to examine associations between sport and club participation and (1) friendship success and (2) co-occurring anxiety and depression in a large sample of autistic youth.

METHODS

Secondary analysis was performed using data from the 2018-2019 National Survey of Children's Health. Participants were 562 autistic children (ages 6-11 years) and 818 autistic adolescents (ages 12-17 years). Within each age group, a series of binary logistic regression analyses were conducted.

RESULTS

Club participation was not associated with friendship or internalizing conditions. However, participation in sports was positively associated with friendship success among both children (OR = 2.07, p = .006) and adolescents (OR = 2.35, p = .001). Results also found that adolescents who participated in sports were 34% less likely to have diagnosis of depression (p = .048).

CONCLUSION

Findings suggest that participation in sports may play a meaningful role in protecting against depression during adolescence and serve as a context for friendship development across childhood and adolescence. Future research should address barriers to extracurricular activity participation and identify the specific components of sports that are most beneficial to autistic youth to inform activity offerings and the development of interventions targeting friendship formation and mental health outcomes.

Mental health challenges faced by autistic people

Mental health challenges impede the well-being of autistic people. This Review outlines contributing neurodevelopmental and physical health conditions, rates and developmental trajectories of mental health challenges experienced by autistic people, as well as unique clinical presentations. A framework is proposed to consider four contributing themes to aid personalized formulation: social-contextual determinants, adverse life experiences, autistic cognitive features, and shared genetic and early environmental predispositions. Current evidence-based and clinical-knowledge-informed intervention guidance and ongoing development of support are highlighted for specific mental health areas. Tailored mental health support for autistic people should be neurodivergence-informed, which is fundamentally humanistic and compatible with the prevailing bio-psycho-social frameworks. The personalized formulation should be holistic, considering physical health and transdiagnostic neurodevelopmental factors, intellectual and communication abilities, and contextual-experiential determinants and their interplay with autistic cognition and biology, alongside resilience. Supporting family well-being is integral. Mutual empathic understanding is fundamental to creating societies in which people across neurotypes are all empowered to thrive.

Patterns in Medication Use for Treatment of Depression in Autistic Spectrum Disorder

INTRODUCTION

Depression impacts many individuals with autism spectrum disorder (ASD), carrying increased risk of functional impairment, hospitalization, and suicide. Prescribing medication to target depression in patients with ASD occurs despite limited available systematic data describing medication management of depression in this population.

PURPOSE

The purpose of this study is to discover prescribing patterns for individuals with MDD and ASD during this time period (2004-2012) to inform current and future prescribing practices with historical data.

METHOD

Drawing from a large clinical database describing the prescribing practices in patients with ASD, we identified 166 individuals with ASD (mean age 14.5 ± 8.3 years old) who received medication targeting symptoms of depression. We report prescribing rates for specific drugs, drug treatment duration, and reasons for drug discontinuation when applicable.

RESULTS

Sertraline, mirtazapine, and fluoxetine were the three most commonly prescribed medications to treat comorbid depression for this patient population. Among 241 drug starts, 123 (49%) drug treatments were continued at the final reviewed follow-up visit (average treatment duration of ± 0.72 years). The most common reason for discontinuation across all medications prescribed was loss of or lack of effectiveness.

CONCLUSION

This study raises concern that standard of care pharmacological treatments for depression in individuals with ASD may be less effective than in neurotypical populations. There remains a need to develop effective interventions for depression specifically tailored to the needs of individuals with ASD.

Vasopressin as Possible Treatment Option in Autism Spectrum Disorder

Autism spectrum disorder (ASD) is rather common, presenting with prevalent early problems in social communication and accompanied by repetitive behavior. As vasopressin was implicated not only in salt-water homeostasis and stress-axis regulation, but also in social behavior, its role in the development of ASD might be suggested. In this review, we summarized a wide range of problems associated with ASD to which vasopressin might contribute, from social skills to communication, motor function problems, autonomous nervous system alterations as well as sleep disturbances, and altered sensory information processing. Beside functional connections between vasopressin and ASD, we draw attention to the anatomical background, highlighting several brain areas, including the paraventricular nucleus of the hypothalamus, medial preoptic area, lateral septum, bed nucleus of stria terminalis, amygdala, hippocampus, olfactory bulb and even the cerebellum, either producing vasopressin or containing vasopressinergic receptors (presumably V1a). Sex differences in the vasopressinergic system might underline the male prevalence of ASD. Moreover, vasopressin might contribute to the effectiveness of available off-label therapies as well as serve as a possible target for intervention. In this sense, vasopressin, but paradoxically also V1a receptor antagonist, were found to be effective in some clinical trials. We concluded that although vasopressin might be an effective candidate for ASD treatment, we might assume that only a subgroup (e.g., with stress-axis disturbances), a certain sex (most probably males) and a certain brain area (targeting by means of virus vectors) would benefit from this therapy.

Addressing the autism mental health crisis: the potential of phenomenology in neurodiversity-affirming clinical practices

The neurodiversity movement has introduced a new era for autism research. Yet, the neurodiversity paradigm and the autism clinic remain largely unconnected. With the present work, we aim to contribute to filling this lacuna by putting forward phenomenology as a foundation for developing neurodiversity-affirming clinical interventions for autism. In the first part of this paper, we highlight that autistic people face a severe mental health crisis. We argue that approaches focused on reducing autistic 'symptoms' are unlikely to solve the problem, as autistic mental health is positively correlated with autism acceptance and perceived quality of support provided, not necessarily with lack of 'symptomatologic severity'. Therefore, the development and dissemination of neurodiversity-affirming clinical interventions is key for addressing the autism mental health crisis. However, therapists and researchers exploring such neurodiversity-affirming practices are faced with two significant challenges. First, they lack concrete methodological principles regarding the incorporation of neurodiversity into clinical work. Second, they need to find ways to acknowledge rightful calls to respect the 'autistic self' within the clinic, while also challenging certain beliefs and behaviors of autistic clients in a manner that is sine qua non for therapy, irrespective of neurotype. In the second part of the paper, we introduce phenomenological psychology as a potential resource for engaging with these challenges in neurodiversity-affirming approaches to psychotherapy. In this vein, we put forward specific directions for adapting cognitive behavioral and interpersonal psychotherapy for autism.

Predicting Self-Esteem and Depressive Symptoms from Social Skills Among Youth Referred for an Autism Evaluation

Social skills are associated with depression and self-esteem in autistic youth. Minimal comparisons between youth and parent-reported social skills to clinically relevant samples limit existing studies. This study compared the relationships between parent and youth-reported social skills, self-esteem, and depressive symptoms between autistic youth and youth referred for but not given an autism diagnosis. Regression analyses of cross-sectional data revealed that youth-reported social skills statistically predicted self-esteem, parent-reported social skills statistically predicted depressive symptoms, and self-esteem statistically predicted depressive symptoms. All relationships were weaker in the autistic group, except parent-reported social skills and depressive symptoms, which was stronger. Results indicate that poor social skills are associated with mental health outcomes among youth referred for autism diagnosis, but that autism-related factors may influence these relationships. Implications for future research and clinical practice are discussed.

Psychometric validation of concerning behavior scale in Iranian children and young people with autism spectrum disorder

Introduction

Assessment of Concerning Behavior (ACB) was introduced by Tarver et al. (2021) to evaluate mental health and problematic/risky behaviors in children and young people with autism spectrum disorder (ASD).

Methods

This study examined the psychometric validation of the Assessment of Concerning Behavior (ACB) in an Iranian sample of parents of children and young people with ASD. Confirmatory factor analysis was conducted to examine the structure of ACB in a sample of 303 parents.

Results

The data supported the two factor structure, all factor loadings were significant and scale structure was confirmed similar to the original scale. The results supported the two-factor structure for ACB that included internalizing and externalizing problems scales. The two factors of ACB are positively correlated with Aberrant Behavior Checklist scores which showed that the validity of two factors is satisfactory. The reliability of the two subscales was reasonable as well.

Conclusion

The study suggests that the ACB could be an operational tool to assess the mental health and problematic/risky behaviors in Iranian children and young people with ASD.

Behavioral and Social Activation in Autism and Associations with Youth Depressive Symptoms from Youth and Caregiver Perspectives

Autistic youth are more likely to experience depression than their non-autistic peers, yet research on risk and protective factors to depression in this population is limited. Behavioral activation (i.e., prioritizing and engaging in meaningful activities), including social activities, is an important mechanism in the pathway to depression in non-autistic youth that is understudied in autism. Ratings of youth depressive symptoms and behavioral and social activation at one timepoint from 100 autistic youth without intellectual disability and 100 of their caregivers were analyzed. The study aims were to examine caregiver and youth ratings of youth internalizing symptoms and behavioral and social activation, inter-rater reliability on study variables, and associations between depressive symptoms and behavioral and social activation in autistic youth by rater. Results revealed significant differences in youth and caregiver ratings on all variables and inter-rater reliability ranged from poor to moderate. Across both raters, more severe anxiety symptoms and lower behavioral activation were associated with more severe depressive symptoms; social activation, specifically the number of friends youth have, was significant in caregiver ratings only. Findings can be leveraged to enhance risk stratification and intervention efforts for autistic youth experiencing depression.

The Emotion Regulation Checklist with Young Autistic Children: Data Set for Comparative Use in Intervention Studies

PURPOSE

Comparative data of autism-sensitive standardized measures of emotion regulation and lability, describing percentage change over time for populations of young autistic children, are currently publicly unavailable. We propose publication of such data as a support for future therapeutic intervention studies.

METHODS

We generate and present data of the Emotion Regulation Checklist (and subscales) for a comparative array of percentage change over time (10 months) for autistic children not receiving psychological or behavioral therapies (N = 98, ages 4-8).

RESULTS

Comparative data summaries are presented here, and the full data set is presented as Online Resource 1.

CONCLUSION

We propose that this autism-sensitive measure, now with autism-specific comparative data to provide a comparison group in studies of therapeutic intervention, is well placed to assess co-occurring affective, regulatory, and behavioral factors of personal development for autistic children.

Case report: Treatment-resistant depression, multiple trauma exposure and suicidality in an adolescent female with previously undiagnosed Autism Spectrum Disorder

High rates of co-occurring depression are commonly reported in youth with Autism Spectrum Disorder (ASD), especially in individuals without intellectual disability (ID). Depression in ASD undermines adaptive behavior and is associated with a higher risk of suicidality. Females with ASD may be particularly vulnerable due to their greater use of camouflaging strategies. Indeed, in comparison to males, ASD is underdiagnosed in females, despite higher rates of internalizing symptoms and suicidality. Trauma exposure may also play a role in the development of depressive symptoms in this population. Moreover, evidence for effective treatments of depression in autistic youth are lacking, with ASD individuals frequently experiencing low efficacy and side effects. We present the case of an adolescent female with previously undiagnosed ASD without ID, admitted for active suicidal plans and a treatment-resistant depression (TRD), occurred after a COVID-19 lockdown in the context of cumulative exposure to stressful life events. Comprehensive clinical assessments performed at intake confirmed severe depression with suicidality. Intensive psychotherapy and different changes in medications were carried out (SSRI, SNRI, SNRI + NaSSA, SNRI + aripiprazole), all of which were ineffective, with persistent suicidal thoughts, often requiring intensive individual monitoring. The patient was finally successfully treated with lithium augmentation of fluoxetine, with no side effects. During hospitalization she was also evaluated by an ASD specialized center, where a diagnosis of ASD was made according to the Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview-Revised (ADI-R) scores, as well as to clinical judgment of a senior psychiatrist. The present case report shows that clinicians should not overlook undiagnosed autism as a possible cause of TRD, especially in females without ID, where higher rates of under diagnosis may be in part related to their greater use of camouflage. It also suggests that ASD underdiagnosis and resulting unmet needs may be involved in vulnerability to stressful experiences, depression, and suicidality. Furthermore, it shows the complexity of providing care to TRD in youth with autism, suggesting that an augmentation therapy with lithium, a commonly recommended therapeutic strategy for refractory depression in typically developing samples, may also be effective in this population.

Cerebellar network changes in depressed patients with and without autism spectrum disorder: A case-control study

Pathophysiological difference of depression in patients with and without autistic spectrum disorder (ASD) has not been investigated previously. Therefore, we sought to determine whether there were differences between non-ASD and ASD groups on resting-state functional magnetic resonance imaging (rs-fMRI) in patients with depression. We performed 3T MRI under resting state in 8 patients with depression and ASD and 12 patients with depression but without ASD. The ASD group showed increased functional connectivity in the cerebellar network of the left posterior inferior temporal gyrus and anterior cerebellar lobes compared to the non-ASD group in an analysis of covariance. Adding antipsychotics, antidepressants, benzodiazepines, nonbenzodiazepines, anxiolytics, hypnotics, or age as covariates showed a similar increase in functional connectivity. Thus, this study found that depressive patients with ASD had increased functional connectivity in the cerebellar network. Our findings suggest that fMRI may be able to evaluate differences in depressed patients with and without ASD.

Longitudinal associations between early childhood irritability and adolescent depression symptoms in autistic children are mediated by peer relationships but not educational engagement

In the general population, irritability is associated with later depression. Despite irritability being more prevalent in autistic children, the long-term sequelae are not well explored. We tested whether irritability in early childhood predicted depression symptoms in autistic adolescents, and whether associations could be explained by difficulties in peer relationships and lower educational engagement. Analyses tested the longitudinal associations between early childhood irritability (ages 3-5) and adolescent depression symptoms (age 14) in a prospective inception cohort of autistic children (N = 390), followed from early in development shortly after they received a clinical diagnosis. Mediators were measured in mid-childhood (age 10) by a combination of measures, from which latent factors for peer relationships and educational engagement were estimated. Results showed early childhood irritability was positively associated with adolescent depression symptoms, and this association remained when adjusting for baseline depression. A significant indirect pathway through peer relationships was found, which accounted for around 13% of the association between early childhood irritability and adolescent depression, suggesting peer problems may partially mediate the association between irritability and later depression. No mediation effects were found for education engagement. Results highlight the importance of early screening and intervention for co-occurring irritability and peer problems in young autistic children.

Extracellular Vesicles in Mental Disorders: A State-of-art Review

Extracellular vesicles (EVs) are nanoscale particles with various physiological functions including mediating cellular communication in the central nervous system (CNS), which indicates a linkage between these particles and mental disorders such as schizophrenia, bipolar disorder, major depressive disorder, etc. To date, known characteristics of mental disorders are mainly neuroinflammation and dysfunctions of homeostasis in the CNS, and EVs are proven to be able to regulate these pathological processes. In addition, studies have found that some cargo of EVs, especially miRNAs, were significantly up- or down-regulated in patients with mental disorders. For many years, interest has been generated in exploring new diagnostic and therapeutic methods for mental disorders, but scale assessment and routine drug intervention are still the first-line applications so far. Therefore, underlying the downstream functions of EVs and their cargo may help uncover the pathogenetic mechanisms of mental disorders as well as provide novel biomarkers and therapeutic candidates. This review aims to address the connection between EVs and mental disorders, and discuss the current strategies that focus on EVs-related psychiatric detection and therapy.

Practitioner Review: Attention-deficit hyperactivity disorder and autism spectrum disorder - the importance of depression

Young people with neurodevelopmental disorders, such as attention-deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD), show high rates of mental health problems, of which depression is one of the most common. Given that depression in ASD and ADHD is linked with a range of poor outcomes, knowledge of how clinicians should assess, identify and treat depression in the context of these neurodevelopmental disorders is much needed. Here, we give an overview of the latest research on depression in young people with ADHD and ASD, including possible mechanisms underlying the link between ADHD/ASD and depression, as well as the presentation, assessment and treatment of depression in these neurodevelopmental disorders. We discuss the implications for clinicians and make recommendations for critical future research in this area.

Anxiety in Autism Spectrum Disorder: Clinical Characteristics and the Role of the Family

BACKGROUND

Anxiety Disorder (AD) is among the most common psychiatric comorbidity in children and adolescents with Autism Spectrum Disorder (ASD). Likewise, parental psychological distress (PPD) was linked to anxiety symptoms in children and adolescents with ASD. The aim of this study was to characterise, in a sample of children and adolescents with ASD, anxiety symptoms, the functional impairment associated and the presence of PPD.

METHODS

Participants were divided into three groups based on their diagnosis: children and adolescents with a diagnosis of ASD + AD, others with a diagnosis of AD but without a diagnosis of ASD, and others with a diagnosis of ASD but without a diagnosis of AD.

RESULTS

Group ASD + AD showed lower global functioning than Group ASD and Group AD. Generalised Anxiety Disorder, Separation Anxiety Disorder and Specific Phobias were more frequent in Group ASD + AD. Our findings also showed higher depressive symptoms in Group ASD + AD, both in the child and parent reports. Finally, parents of the Group ASD + AD revealed higher levels of PPD.

CONCLUSIONS

Our findings suggest that early assessment of AD with functional impairment associated with the role of PPD could define individualised treatments and consequently mean a better prognosis in children and adolescents with ASD and AD.

Associations between co-occurring conditions and age of autism diagnosis: Implications for mental health training and adult autism research

Adult autism studies are increasingly comprised of later-diagnosed adults, yet little is known about how these adults compare to those diagnosed earlier in life. The present study examines medical and psychiatric conditions endorsed by autistic adults and documents differences between those diagnosed with ASD in childhood versus adulthood, as well as across age groups and sex at birth. 4657 legally independent adults (ages 18-85, M = 33.4 years) with professional ASD diagnoses who completed a medical questionnaire were drawn from the Simons Powering Autism Research Knowledge (SPARK) study. Chi square analyses, t-tests, and logistic regressions were used to compare medical and psychiatric conditions between age groups, sex at birth and adults diagnosed in childhood (before age 21) versus adulthood (at or after 21 years). Overall number of conditions endorsed as being diagnosed by a professional was high, with an average of 1.69 (SD = 2.01) medical or developmental and 2.98 (SD = 2.29) psychiatric conditions reported across the sample. Females were more likely to endorse psychiatric conditions (OR = 1.68). Adult-diagnosed adults were more likely to endorse psychiatric conditions (OR = 2.71) and reported more lifetime psychiatric diagnoses (M = 3.15, SD = 2.23) than their childhood-diagnosed counterparts (M = 2.81, SD = 2.33). These findings underscore the need for research to better understand and treat co-occurring psychiatric conditions in autistic adults and report and consider the age of diagnosis in adult autism samples. Moreover, results suggest it is imperative that mental health professionals receive autism training to promote accurate differential diagnosis and equitable access to mental health care for autistic adults with co-occurring psychiatric conditions.

Psychosocial Functioning and the Educational Experiences of Students with ASD during the COVID-19 Pandemic in Poland

Due to their individual developmental and learning needs, adolescents with autism spectrum disorder (ASD) benefit from a variety of educational, medical, and therapeutic services. During the COVID-19 pandemic, these services were discontinued or significantly reduced, which may have resulted in increased difficulties in coping with various areas of life. The purpose of this study was to explore how the pandemic affected the psychosocial and educational functioning of students with ASD. A qualitative, problem-focused interview method was used. The obtained material was subjected to interpretive phenomenological analysis. The study involved 10 secondary school students diagnosed with ASD. The assessment of the effects of the pandemic on the functioning of people with ASD is inconclusive. The respondents noted both negative and positive effects of lockdown. On the positive side, they were able to spend time with their family, isolate themselves from difficult social relationships and feel better. Among the negative effects, adolescents point to difficulties in emotional functioning—increased levels of stress and anxiety, as well as increased feelings of loneliness and difficulties with online education. The study showed the varied experiences of young people with autism during the pandemic, highlighting the significant need to support some of them in terms of their emotional, social and educational functioning.

Signalling pathways in autism spectrum disorder: mechanisms and therapeutic implications

Autism spectrum disorder (ASD) is a prevalent and complex neurodevelopmental disorder which has strong genetic basis. Despite the rapidly rising incidence of autism, little is known about its aetiology, risk factors, and disease progression. There are currently neither validated biomarkers for diagnostic screening nor specific medication for autism. Over the last two decades, there have been remarkable advances in genetics, with hundreds of genes identified and validated as being associated with a high risk for autism. The convergence of neuroscience methods is becoming more widely recognized for its significance in elucidating the pathological mechanisms of autism. Efforts have been devoted to exploring the behavioural functions, key pathological mechanisms and potential treatments of autism. Here, as we highlight in this review, emerging evidence shows that signal transduction molecular events are involved in pathological processes such as transcription, translation, synaptic transmission, epigenetics and immunoinflammatory responses. This involvement has important implications for the discovery of precise molecular targets for autism. Moreover, we review recent insights into the mechanisms and clinical implications of signal transduction in autism from molecular, cellular, neural circuit, and neurobehavioural aspects. Finally, the challenges and future perspectives are discussed with regard to novel strategies predicated on the biological features of autism.

Brief Report: Risk and Protective Factors Associated with Depressive Symptoms among Autistic Adults

Autistic individuals are at risk for developing depression though the risk and protective factors for co-occurring depression in autistic individuals are not yet fully characterized. In this retrospective medical chart review study, we explored factors associated with self-reported depressive symptoms (Patient Health Questionnaire-9) in autistic adults (N = 58). For autistic adults, engagement in one or more activities (recreational, educational and/or vocational) was associated with less severe depressive symptoms (Mann-Whitney U test, p = 0.006); and reported family history of depression/anxiety was associated with increased likelihood of suicidal ideation (Chi-square test, p = 0.027). Promotion of community-based activities and family support systems may be an integral part of creating effective treatment plans for depressive symptoms in autistic adults.

Associations between sleep problems and domains relevant to daytime functioning and clinical symptomatology in autism: A meta-analysis

Autistic individuals experience significantly higher rates of sleep problems compared to the general population, which negatively impacts various aspects of daytime functioning. The strength of associations across domains of functioning has not yet been summarized across studies. The present meta-analysis examined the strength of associations between sleep problems and various domains of daytime functioning in autistic individuals. Searches were conducted in EMBASE, PubMed, Web of Science, and Google Scholar through May 2020. Inclusion criteria were: an index of sleep disturbance in individuals diagnosed with autism spectrum disorder (ASD); data collected prior to any sleep-related intervention; statistical data indicating relations between sleep problems and outcomes relevant to behavior, cognition, and physical or mental health. Exclusion criteria were: statistics characterizing the relationship between sleep disturbance and outcome variables that partialled out covariates; studies examining correlations between different measures of sleep disturbance. Participants totaled 15,074 from 49 published articles and 51 samples, yielding 209 effect sizes. Sleep problems were significantly associated with more clinical symptomatology and worse daytime functioning. Subgroup analyses demonstrated that sleep problems were most strongly associated with internalizing and externalizing symptoms and executive functioning, followed by core autism symptoms, family factors, and adaptive functioning. Findings highlight the far-reaching consequences of sleep problems on daytime functioning for autistic individuals and support the continued prioritization of sleep as a target for intervention through integrated care models to improve wellbeing. LAY SUMMARY: Autistic individuals experience higher rates of sleep problems, such as difficulty falling asleep and staying asleep, compared to the general population. We quantitatively summarized the literature about how sleep problems are related to different aspects of daytime functioning to identify areas that may be most affected by sleep. Sleep problems were related to all areas assessed, with the strongest associations for mood and anxiety symptoms. We recommend prioritizing sleep health in autistic individuals to improve wellbeing and quality of life.

Neuroticism Drives Associations Between Repetitive Behaviors and Depression in Autistic Adults

Depression is more prevalent among autistic adults than neurotypical adults, yet risk factors are incompletely understood in this population. Some research groups have focused on relationships between negative repetitive thinking and depression in the autistic population, which may explain elevated prevalence rates in line with general population findings on rumination and internalizing disorders. Little is known about associations between depression and more prototypical repetitive cognitions and/or behaviors characteristic of autism (i.e., insistence on sameness [IS] and repetitive sensorimotor [RSM] behaviors). Therefore, the present study aimed to examine associations between IS, RSM behaviors, and depressive symptoms in 762 autistic adults, and whether observed effects are confounded by additional factors (e.g., demographic factors, trait neuroticism). To test if greater IS scores were associated with greater depressive symptoms on the BDI-II, a Bayesian linear regression was conducted with BDI-II scores (dependent variable) regressed on age, gender, educational level, RSM scores, and IS scores (independent variables). To test the effects of neuroticism on observed relationships, a second regression was conducted that included all predictors from the baseline model and neuroticism. Standardized regression coefficients were tested against an interval null hypothesis of [-0.1, 0.1] to assess for practical significance. Results indicated that IS exhibited a moderate positive relationship with depressive symptoms, while RSM behaviors provided only a slight increase in predictive ability. However in the second model, neuroticism exhibited a strong positive relationship with depressive symptoms, completely attenuating the effect of IS. Associations between RSM behaviors and depressive symptoms did not meet our criteria for practical significance, particularly when neuroticism was added to the model. Neither RSM nor IS moderated the effect of neuroticism on depression. The findings from this study add to the literature on risk factors in the pathway to depression in autism, and suggest opportunities for clinical translation to screening and intervention efforts. Screening for IS in autistic individuals is a common diagnostic practice in clinical and research settings that may be leveraged to also identify those at higher risk for depression, and increasing flexibility in daily life may promote emotional regulation and distress tolerance.

Diagnostic- and sex-based differences in depression symptoms in autistic and neurotypical early adolescents

LAY ABSTRACT

Depression is more common in autistic adolescents than their neurotypical peers, but the effects of diagnosis and sex on the severity and types of depressive symptoms remain unclear. The study explored diagnostic- and sex-based differences in depressive symptoms in 212 autistic and neurotypical early adolescents. Results show that autism spectrum disorder and female may pose elevated risks, and depressive symptoms related to interpersonal problems and negative self-esteem are more frequent in autism spectrum disorder. Autistic males and females endorsed similar severity and type of depressive symptoms, but unique differences emerged when compared to sex-matched neurotypical peers. Exploratory analyses in a clinical subsample of early adolescents with elevated depressive symptoms (Children's Depression Inventory, Second Edition, Total T-score ⩾60) revealed more endorsement of beliefs of worthlessness in autistic early adolescents. Findings suggest initial intervention targets for treating depression in autistic early adolescents.

Ventrolateral prefrontal hemodynamic responses in autism spectrum disorder with and without depression

In clinical settings, autism spectrum disorder (ASD) with comorbid depression is often difficult to diagnose, and should be considered in treatment. However, to our knowledge, no functional imaging study has examined the difference between ASD adolescents with and without comorbid depression. We aimed to compare the characteristics and prefrontal brain function of ASD with and without depression in order to identify a biological marker that can be used to detect the difference. Twenty-eight drug-naïve adolescents with ASD (14 ASD with and 14 ASD without depression) and 14 age- and gender-matched adolescents with typical development were evaluated using several variables. These included intelligence quotient, autism quotient, depression severity using the Beck Depression Inventory 2nd edition (BDI-II), and level of social functioning using the Social Adaptation Self-evaluation Scale (SASS). In addition, frontotemporal hemodynamic responses during a verbal fluency task (VFT) were measured using functional near-infrared spectroscopy (fNIRS). The ASD group, including both of the ASD with and ASD without depression groups, showed smaller hemodynamic responses than the typical development group in portions of the left dorsolateral prefrontal cortex (DLPFC), bilateral ventrolateral prefrontal cortex (VLPFC) and anterior part of the temporal cortex (aTC) during the VFT. Moreover, the smaller hemodynamic responses in the right VLPFC during the VFT in the ASD group were associated with the worse BDI-II and SASS scores. Furthermore, the ASD with depression group showed smaller hemodynamic responses in the right VLPFC during the VFT than the ASD without depression group in a direct comparison. Adolescents with ASD showed reduced activation in broad frontotemporal regions during a cognitive task compared with those with typical development. More specifically, the right VLPFC activation reflected the level of self-estimated depression and social functioning in the ASD subjects, and could be used to discriminate between ASD adolescents with and without depression.

Drug development for Autism Spectrum Disorder (ASD): Progress, challenges, and future directions

In 2017, facing lack of progress and failures encountered in targeted drug development for Autism Spectrum Disorder (ASD) and related neurodevelopmental disorders, the ISCTM with the ECNP created the ASD Working Group charged to identify barriers to progress and recommending research strategies for the field to gain traction. Working Group international academic, regulatory and industry representatives held multiple in-person meetings, teleconferences, and subgroup communications to gather a wide range of perspectives on lessons learned from extant studies, current challenges, and paths for fundamental advances in ASD therapeutics. This overview delineates the barriers identified, and outlines major goals for next generation biomedical intervention development in ASD. Current challenges for ASD research are many: heterogeneity, lack of validated biomarkers, need for improved endpoints, prioritizing molecular targets, comorbidities, and more. The Working Group emphasized cautious but unwavering optimism for therapeutic progress for ASD core features given advances in the basic neuroscience of ASD and related disorders. Leveraging genetic data, intermediate phenotypes, digital phenotyping, big database discovery, refined endpoints, and earlier intervention, the prospects for breakthrough treatments are substantial. Recommendations include new priorities for expanded research funding to overcome challenges in translational clinical ASD therapeutic research.

Selective Mutism and Its Relations to Social Anxiety Disorder and Autism Spectrum Disorder

In current classification systems, selective mutism (SM) is included in the broad anxiety disorders category. Indeed, there is abundant evidence showing that anxiety, and social anxiety in particular, is a prominent feature of SM. In this article, we point out that autism spectrum problems in addition to anxiety problems are sometimes also implicated in SM. To build our case, we summarize evidence showing that SM, social anxiety disorder (SAD), and autism spectrum disorder (ASD) are allied clinical conditions and share communalities in the realm of social difficulties. Following this, we address the role of a prototypical class of ASD symptoms, restricted and repetitive behaviors and interests (RRBIs), which are hypothesized to play a special role in the preservation and exacerbation of social difficulties. We then substantiate our point that SM is sometimes more than an anxiety disorder by addressing its special link with ASD in more detail. Finally, we close by noting that the possible involvement of ASD in SM has a number of consequences for clinical practice with regard to its classification, assessment, and treatment of children with SM and highlight a number of directions for future research.

Prevalence and profile of depressive mixed state in patients with autism spectrum disorder

PURPOSE

The present study aimed to clarify prevalence and profile of depressive mixed state (DMX) in depressed individuals with autism spectrum disorder (ASD).

PATIENTS AND METHODS

The Quick Inventory of Depressive Symptomatology Self-Report Japanese version (QIDS-SR-J) and global assessment of functioning (GAF) were administered to 182 consecutive patients (36 ASD and 146 non-ASD subjects) with a major depressive episode (MDE). DMX was categorically diagnosed according to the criteria for mixed depression (MD) by Benazzi and mixed features (MF) specifier by DSM-5. Severity of DMX was assessed by the self-administered 12-item questionnaire for DMX (DMX-12). Clinical backgrounds and incidence/severity of DMX were compared between the ASD and non-ASD groups.

RESULTS

ASD patients showed higher prevalence of MD than non-ASD patients (36.1% versus 18.5%). Mood lability, distractibility, impulsivity, aggression, irritability, dysphoria and risk-taking behavior as mixed symptoms were more prevalent in ASD patients than those in non-ASD patients, together with higher scores of total DMX-12 and its disruptive emotion/behavior cluster. Multiple regression analysis revealed significant contribution of ASD to the disruptive emotion/behavior symptoms.

CONCLUSION

Careful monitoring and management of potential DMX are warranted in depressed ASD individuals.

Could You Give Me the Blue Brick? LEGO®-Based Therapy as a Social Development Program for Children with Autism Spectrum Disorder: A Systematic Review

LEGO®-based therapy is a social skills development program aimed at children with autism spectrum disorder (ASD). A systematic review of the literature was conducted using PRISMA guidelines. PubMed, Scopus and Web of Science bibliographic databases were searched from their date of inception to August 2020. The review included 19 studies. Studies were classified according to experimental designs (e.g., Randomized Control Trial, Non-Randomized Studies of Interventions and case report and series) and a narrative synthesis of each was provided, along with a critical discussion of the strengths and weaknesses of the available literature on the topic. Although LEGO®-based therapy appears a promising treatment for social interaction in ASD, the findings of LEGO®-based therapy studies should be interpreted and generalized with caution, due to the low quality of the studies and the small sample sizes.

Computer-aided autism diagnosis based on visual attention models using eye tracking

An advantage of using eye tracking for diagnosis is that it is non-invasive and can be performed in individuals with different functional levels and ages. Computer/aided diagnosis using eye tracking data is commonly based on eye fixation points in some regions of interest (ROI) in an image. However, besides the need for every ROI demarcation in each image or video frame used in the experiment, the diversity of visual features contained in each ROI may compromise the characterization of visual attention in each group (case or control) and consequent diagnosis accuracy. Although some approaches use eye tracking signals for aiding diagnosis, it is still a challenge to identify frames of interest when videos are used as stimuli and to select relevant characteristics extracted from the videos. This is mainly observed in applications for autism spectrum disorder (ASD) diagnosis. To address these issues, the present paper proposes: (1) a computational method, integrating concepts of Visual Attention Model, Image Processing and Artificial Intelligence techniques for learning a model for each group (case and control) using eye tracking data, and (2) a supervised classifier that, using the learned models, performs the diagnosis. Although this approach is not disorder-specific, it was tested in the context of ASD diagnosis, obtaining an average of precision, recall and specificity of 90%, 69% and 93%, respectively.

Empathy and Prosocial Behavior in Siblings of Children with Autism Spectrum Disorder: a Systematic Review

Siblings of children with ASD have, as a group, more autistic traits than typically developing individuals. A high prevalence of autistic traits may (or may not) include lower scores on measures of empathy and prosocial behavior compared with typically developing individuals. The purpose of this study was to conduct a systematic review of studies of empathy and prosocial behavior in siblings of individuals with ASD. We conducted a comprehensive literature search of studies published until March 2020. We identified 16 studies with a total of 1066 siblings that met inclusion criteria. Based on the review, we conclude that the current literature suggests that siblings of individuals with ASD exhibit normative empathic abilities and prosocial behavior.

An investigation to choose the proper therapy technique in the management of autism spectrum disorder

Aim: Autism spectrum disorder is a class of neurological disorders that affect the development of brain functions. This study aims to evaluate, compare and rank the therapy techniques used in the management of autism spectrum disorder using multicriteria decision-making approaches. Materials & methods: Fuzzy PROMETHEE and fuzzy TOPSIS approaches were used. Fuzzy PROMETHEE utilizes a pair-wise comparison of alternatives under the fuzzy environment while fuzzy TOPSIS utilizes geometric distance from the positive ideal solution under the fuzzy environment for the evaluation of the effectiveness of the alternatives.The techniques selected for evaluation are applied behavioral analysis, cognitive behavioral therapy, speech therapy and pharmacological therapy such as Risperidone and Aripiprazole. Criteria used in this study include efficacy, cost and side effects, and their weights are assigned based on specific patient conditions. Results: The results indicate that applied behavioral analysis, cognitive behavioral therapy and speech therapy are the most preferred techniques, followed by Aripiprazole and Risperidone. Conclusion: More criteria could be considered and the weights could be assigned according to the patient profile.

Reduced Brain Activation in Response to Social Cognition Tasks in Autism Spectrum Disorder with and without Depression

PURPOSE

In clinical settings, diagnosing comorbid depression in individuals with autism spectrum disorder (ASD) is often difficult. Neuroimaging studies have reported reduced activation of frontal and temporal regions during emotional face recognition task (EFRT) in ASD and depression. However, to the best of our knowledge, no study has examined differences in frontotemporal activation during EFRT between ASD with and without comorbid depression. We aimed to compare the frontotemporal hemodynamic responses to the EFRT in ASD with and without depression and to find clues to help in discriminating the characteristics between them.

PATIENTS AND METHODS

In 24 drug-naïve young adults with ASD (12 with depression [ASD-Dep(+)] and 12 without depression [ASD-Dep(-)]) and 12 with typical development (TD), frontotemporal hemodynamic responses during an EFRT were measured using functional near-infrared spectroscopy (fNIRS).

RESULTS

The ASD groups showed reduced activation during EFRT than the TD group in the right ventrolateral prefrontal cortex (VLPFC). Moreover, the ASD-Dep(+) group showed reduced activation during EFRT than the ASD-Dep(-) group in the right anterior temporal cortex (aTC), and reduced activation than the TD group in the left VLPFC.

CONCLUSION

The observed results might reflect reduced regional activation in ASD and ASD with comorbid depression.