Pre-school children with suspected autism spectrum disorders: do girls and boys have the same profiles?

Male and Female Toddlers with DSM-5 Autism Spectrum Disorder have Similar Developmental Profiles and Core Autism Symptoms

Compare developmental profiles and core ASD symptom manifestation between male and female toddlers with DSM-5 ASD. Retrospective record review of 500 toddlers (79% male) at time of ASD diagnosis. There were no differences in developmental functioning between males and females. When adjusting for multiple comparisons, sex differences were only noted for sensory seeking behavior occurring at a higher frequency in females. Overall, there were no significant differences in demographic characteristics, developmental functioning, or manifestation of core ASD symptoms between males versus female toddlers at the time of DSM-5 ASD diagnosis.

A systematic review of interventions for echolalia in autistic children

INTRODUCTION

Echolalia, the repetition of others' speech, is a common observation in autistic people. Research has established that echolalia is functional and meaningful for many; however, some clinicians and researchers continue to characterise it as pathological and in need of reduction. The aim of this systematic review was to understand the range and impact of interventions for echolalia in autistic children.

METHOD

A systematic search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 15 studies met predetermined inclusion criteria. Screening, data extraction and quality rating using the Scientific Merit Rating Scale (SMRS) were performed in duplicate.

RESULTS

Ten interventions across 15 papers were found. Results indicated that interventions generally decreased levels of echolalia. However, there were considerable inconsistencies in the definitions and conceptualisations of echolalia, administration, generalisation techniques and the measures used. The quality of the studies was very low.

CONCLUSION

Interventions for echolalia vary widely in terms of administration and measurement. There is limited consensus on the definition of echolalia among the reviewed studies, and no evidence that echolalia is recognised as functional or meaningful to the autistic children. Further, the lack of methodological rigour makes it difficult to draw clinical conclusions about the interventions.

WHAT THIS PAPER ADDS

What is already known Echolalia is the immediate or delayed repetition of others' speech and is a common observation in autistic children and in some older autistic people. While research and practice has established that echolalia is a functional and meaningful form of communication, particularly for those first developing spoken communication, some clinicians and researchers continue to characterise it as problematic and suggest that echolalia should be reduced or eliminated. What this study adds We systematically searched the literature about echolalia interventions to try to find out about the types of interventions that aim to reduce or eliminate echolalia. We found 15 studies on this topic. The way they defined echolalia was varied, and there was a range of interventions researched. None of the research papers recognised echolalia as functional or meaningful and the quality of the research was very low. What are the potential or actual clinical implications of this work? Clinicians, families and researchers should think carefully and critically about suggesting any programs or supports that aim to reduce echolalia as no recommendations can be drawn from the research we studied. Echolalia should be considered functional, and efforts made to understand the meaning and purpose of echolalic speech.

Sex Differences in the Developmental Trajectories of Autism Spectrum Disorder

Purpose of Review

Females and males are disproportionately diagnosed with autism, a sex difference that has historically represented this neurodevelopmental condition. The current review examines lifespan developmental trajectories of autism based on sex to elucidate behavioral phenotypic differences that may contribute to differential rates of diagnosis.

Recent Findings

We review sex differences in diagnostic criteria: social communication and restricted interests/repetitive behaviors (RRBs). Results suggest RRBs are more indicative of a diagnosis in males, whereas social differences are more indicative of a diagnosis in females. Factors contributing to a later diagnosis in females include social strengths (camouflaging) and diagnostic overshadowing.

Summary

Sex differences in diagnostic criteria may contribute to differential rates of identification in males and females. Sex differences are most pronounced when assessing naturalistic social communication instead of reliance on standardized measure. Numerous future directions are identified including increasing samples of sub-threshold autistic females and evaluating longitudinal sex differences.

Sex Differences in Neurodevelopmental Disorders: A Key Role for the Immune System

Sex differences are prominent defining features of neurodevelopmental disorders. Understanding the sex biases in these disorders can shed light on mechanisms leading to relative risk and resilience for the disorders, as well as more broadly advance our understanding of how sex differences may relate to brain development. The prevalence of neurodevelopmental disorders is increasing, and the two most common neurodevelopmental disorders, Autism Spectrum Disorder (ASD) and Attention-Deficit/Hyperactivity Disorder (ADHD) exhibit male-biases in prevalence rates and sex differences in symptomology. While the causes of neurodevelopmental disorders and their sex differences remain to be fully understood, increasing evidence suggests that the immune system plays a critical role in shaping development. In this chapter we discuss sex differences in prevalence and symptomology of ASD and ADHD, review sexual differentiation and immune regulation of neurodevelopment, and discuss findings from human and rodent studies of immune dysregulation and perinatal immune perturbation as they relate to potential mechanisms underlying neurodevelopmental disorders. This chapter will give an overview of how understanding sex differences in neuroimmune function in the context of neurodevelopmental disorders could lend insight into their etiologies and better treatment strategies.

Clinical and demographic differences by sex in autistic Venezuelan children: A cross-sectional study

BACKGROUND

Sex differences in symptom severity and adaptive function in children with ASD have been historically inconsistent and studies are predominantly from American- and European-residing populations. Alike, there is limited information on the complex interplay between sex, intelligence, adaptive function, and autism symptom severity; this is crucial to identify given their predictive value for health outcomes in autism AIM: This study aimed to identify sex differences in autism symptom severity and adaptive function in a sample of Venezuelan children.

METHOD

One-hundred-and-three Venezuelan children ages 3-7 completed a comprehensive assessment for symptom severity, adaptive functioning, and intelligence.

RESULTS

Sex differences were not present in any autism diagnostic domain or adaptive function.Symptom severity was not a significant predictor for adaptive function, which contrasts with studies sampling American children.

CONCLUSION

This study corroborates other findings based on non-American children, where symptom severity was not a function of adaptive function. Awareness of the interplay of culture, sex-related standards, and autism symptomatology will result in better identification and diagnosis of autism regardless of sex or cultural background. What this paper adds? This paper aids the current literature on sex difference on both autism symptom severity and adaptive function. It also provides a snapshot of the relationship between symptom severity, adaptive function, and other psychological variables that influence the outcome of children with ASD.

The Early Childhood Signs of Autism in Females: a Systematic Review

Compared to males, females are at a much greater likelihood of receiving a later diagnosis of autism, which impacts their opportunity to receive early support. To assist with early identification, this systematic literature review aimed to ascertain whether females differ from males in the early childhood signs of autism. The small number of heterogeneous studies made it difficult to draw conclusions, although it appears that females and males under 6 years of age are more similar than different in terms of their expression of autistic behaviours. Given the discrepant sex/gender ratio in autism, these findings highlight the importance of exploring whether there are different and/or specific, not yet identified, early signs of autism in females and males.

Sex Differences in Autism Spectrum Disorder: Diagnostic, Neurobiological, and Behavioral Features

Autism Spectrum Disorder (ASD) is a complex neurodevelopmental disorder with a worldwide prevalence of about 1%, characterized by impairments in social interaction, communication, repetitive patterns of behaviors, and can be associated with hyper- or hypo-reactivity of sensory stimulation and cognitive disability. ASD comorbid features include internalizing and externalizing symptoms such as anxiety, depression, hyperactivity, and attention problems. The precise etiology of ASD is still unknown and it is undoubted that the disorder is linked to some extent to both genetic and environmental factors. It is also well-documented and known that one of the most striking and consistent finding in ASD is the higher prevalence in males compared to females, with around 70% of ASD cases described being males. The present review looked into the most significant studies that attempted to investigate differences in ASD males and females thus trying to shade some light on the peculiar characteristics of this prevalence in terms of diagnosis, imaging, major autistic-like behavior and sex-dependent uniqueness. The study also discussed sex differences found in animal models of ASD, to provide a possible explanation of the neurological mechanisms underpinning the different presentation of autistic symptoms in males and females.

Symptoms of Autism Spectrum Disorders Measured by the Qualitative Checklist for Autism in Toddlers in a Large Sample of Polish Toddlers

This study aimed to assess some early symptoms of autism spectrum disorders (ASD) measured by a screening tool developed for an early detection of ASD. We investigated if the early symptoms were associated with toddlers’ age, gender or ASD familial risk status. We used the Polish version of the Quantitative Checklist for Autism in Toddlers (Q-CHAT) to assess 1024 children aged 16 to 36 months. The sample included four groups of participants: typically developing toddlers, toddlers with parent-reported ASD-specific concerns, toddlers at risk for autism due to having an older sibling with ASD, and toddlers with a developmental delay. We found that mean Q-CHAT scores were significantly higher in boys than in girls. We did not find any associations between Q-CHAT scores and age. We observed that toddlers with a familial risk for ASD and those with a developmental delay scored significantly higher than controls. We collated these results with previous studies that used the Q-CHAT and other instruments.

Big Data Approach to Characterize Restricted and Repetitive Behaviors in Autism

OBJECTIVE

Despite being a core diagnostic feature of autism spectrum disorder (ASD), demographic, developmental and clinical correlates of restricted and repetitive behaviors and interests (RRB) remain poorly characterized. This study aimed to utilize the largest available RRB data set to date to provide a comprehensive characterization of how distinct RRB domains vary according to a range of individual characteristics.

METHOD

Data were obtained from 17,581 children and adolescents with ASD (mean_age= 8.24 years, SD_age= 4.06) from the Simons Foundation Powering Autism Research for Knowledge cohort. Caregivers completed the Repetitive Behavior Scale-Revised questionnaire as a measure of repetitive motor behaviors, self-injurious behaviors, compulsions, insistence on sameness, and circumscribed interests RRB domains. Caregivers also provided information on children's cognitive functioning, language ability, and social and communication impairments.

RESULTS

Male sex was associated with higher severity of repetitive motor behaviors and restricted interests and with lower severity of compulsions and self-injurious behaviors; no sex differences were found for the insistence on sameness domain. Although repetitive motor behaviors showed a mostly linear (negative) association with age, other RRB domains showed more complex and nonlinear pattern of associations. Higher severity of social and communication impairments provided significant independent contribution in predicting higher severity of all RRB domains at the p < .001 level; however, these effects were small (d < 0.25). The strongest of these effects was observed for insistence on sameness (d = 0.24), followed by repetitive motor behaviors (d = 0.21), compulsions (d = 0.17), restricted interests (d = 0.14), and self-injurious behaviors (d = 0.12).

CONCLUSION

Findings reported here provide further evidence that RRB subdomains show a somewhat distinct pattern of associations with demographic, developmental, and clinical variables, with a key implication that separate consideration of these domains can help to facilitate efforts to understand diverse ASD etiology and to inform the design of effective interventions.

Presenting age and features of females diagnosed with autism spectrum disorder

AIM

Autism spectrum disorder (ASD) is reportedly more prevalent in males than in females. Hypotheses for this gender imbalance include differing presentations in females. The aim of this study was to identify gender-based ASD differences in age at presentation, clinical features, comorbidities and severity levels.

METHODS

A cross-sectional study was conducted at a Child Development Unit. Children diagnosed with ASD during a 6-month period were analysed.

RESULTS

A total of 195 children were analysed with a male-to-female ratio of 2.8:1. No difference was found between gender and age at diagnosis. Males were more likely to display deficits in imaginative play and use repeated or learned phrases. Females were more likely to present with proprioception and vestibular issues, fears reflecting sensory avoidance and ASD of lesser severity.

CONCLUSION

Our study supports the hypothesis that gender-based differences exist within ASD presenting features. These differences should be considered when assessing for ASD in females to avoid under recognition.

Sex Differences in Autism Spectrum Disorder: Focus on High Functioning Children and Adolescents

Autism Spectrum Disorder (ASD) has historically been studied, known, and diagnosed in males. Females tend to remain unidentified, especially those with average intelligence abilities. This sex/gender difference might be partially explained by biological risk factors, but it is probably also bound to methodological issues. The present study aims to examine phenotypic characteristics (cognitive, emotive, socio-communicative, and academic) of a group of 54 females with ASD matched to a group of 55 males with ASD (3-18 years), all without cognitive impairment. Results suggest that there are subtle, yet potentially meaningful, quantitative, and qualitative phenotypic differences between females and males that common screening tests are not always sensitive enough to recognize. Further studies to improve practice and course for the assessment of females, reducing sex/gender-based inequities in ASD care, are required.

Gender differences between adolescents with autism in emergency psychiatry

LAY ABSTRACT

Among adolescents seen for psychiatric emergency consultation, the percentage of adolescents with autism is increasing over the years. This applies even more to girls than to boys. We collected data of 1378 adolescents aged 12-18 years who were seen for urgent consultation by mobile psychiatric emergency services in the Netherlands. Among these, there were 64 autistic girls and 125 autistic boys. We wanted to know more about differences in problems between autistic and typical developing adolescents in crisis, both to prevent crisis and to improve services. The percentage of adolescents with autism increased over the years studied. Autistic adolescents experienced more severe impairment in functioning compared to typically developing adolescents. Compared to other adolescents, both boys and girls on the autism spectrum were diagnosed less frequently with mood disorders, behavioral disorders, relational problems, and abuse. Autistic girls had a higher suicide risk and suffered more often from anxiety disorders than autistic boys, while autistic boys had a longer history of problems. Outpatient care for children with autism should include easy access to specialized professionals who aim to reduce anxiety and help young people with autism to cope with the challenges of adolescence. Because possibly signs were missed during the emergency consultation, we recommend that as part of the routine procedure in crisis situations adolescents with autism are asked about mood and behavioral problems explicitly, as well as about negative life events.

Birth month and infant gross motor development: Results from the Japan Environment and Children's Study (JECS)

The association between birth month and neurodevelopmental or psychiatric disorders has been investigated in a number of previous studies; however, the results have been inconsistent. This study investigated the association between birth month and child gross motor development at 6 and 12 months of age in a large cohort of infants (n = 72,203) participating in the Japan Environment and Children’s Study (JECS). Gross motor development was assessed using the Ages and Stages Questionnaire (ASQ-3). At 6 months and 12 months, 20.7% and 14.2%, respectively, had ASQ-3 indications of gross motor problems. Birth month was strongly associated with gross motor development at both time points, particularly at 6 months. Summer-born infants had the worst outcomes at both 6 months and 12 months of age. This outcome applied to the ASQ-3 score itself and to the adjusted Relative Risk (aRR), with the highest aRRs (relative to January-born) among August-born (aRR 2.51; 95%CI 2.27–2.78 at 6 months), and June-born (aRR 1.84; 95%CI 1.63–2.09 at 12 months). Boys had better scores than girls both at 6 and 12 months of age. We speculate that seasonal factors—such as maternal vitamin D deficiency and influenza infection—affecting the fetus in early pregnancy might account for the findings.

Evaluation of sex differences in preschool children with and without autism spectrum disorder enrolled in the study to explore early development

BACKGROUND AND AIMS

Research in school-aged children, adolescents, and adults with autism spectrum disorder (ASD) has found sex-based differences in behavioral, developmental, and diagnostic outcomes. These findings have not been consistently replicated in preschool-aged children. We examined sex-based differences in a large sample of 2-5-year-old children with ASD symptoms in a multi-site community-based study.

METHODS AND PROCEDURES

Based on a comprehensive evaluation, children were classified as having ASD (n = 1480, 81.55 % male) or subthreshold ASD characteristics (n = 593, 70.15 % male). Outcomes were behavior problems, developmental abilities, performance on ASD screening and diagnostic tests, and parent-reported developmental conditions diagnosed before study enrollment.

OUTCOMES AND RESULTS

We found no statistically significant sex differences in behavioral functioning, developmental functioning, performance on an ASD screening test, and developmental conditions diagnosed before study enrollment among children with ASD or subthreshold ASD characteristics. Males in both study groups had more parent reported restricted interests and repetitive behaviors than females, but these differences were small in magnitude and not clinically meaningful.

CONCLUSIONS AND IMPLICATIONS

Preschool males and females who showed risk for ASD were more similar than different in the outcomes assessed in our study. Future research could examine sex-based differences in ASD phenotypes as children age.

Sex Differences in Autism Spectrum Disorder: Repetitive Behaviors and Adaptive Functioning

Sex differences in restricted and repetitive behaviors (RRBs) in individuals with Autism Spectrum Disorder (ASD) have been explored with mixed findings. We aimed to investigate sex differences in RRBs through a specific measure—i.e., the Repetitive Behavior Scale Revised (RBS-R)—in a sample of preschool-age and school-age children with ASD. Additionally, we evaluated if RRBs were differently related to adaptive functioning within the male and the female age groups. A sample of 210 ASD individuals (3–18 years; 145 males, 65 females) underwent an in-depth assessment including a cognitive, adaptive functioning evaluation (i.e., the Adaptive Behavior Assessment System, Second Edition (ABAS-II)) and RRBs assessment (i.e., RBS-R). No significant sex differences on the RBS-R total score or any RBS-R subscale emerged. Within the group of older participants, RRBs were negatively associated with all adaptive skill domains independently from sex and age. Our results suggest a lack of sex differences in RRBs in our sample. Additionally, our findings highlight the possible negative impact of RRBs on adaptive skills in older individuals with autism, emphasizing the need for autistic individuals of both sexes to undergo an early intervention targeting RRBs, in order to improve their adaptive skills.

Sex Differences in Autism Spectrum Disorder: An Investigation on Core Symptoms and Psychiatric Comorbidity in Preschoolers

Findings regarding sex differences in autism spectrum disorder (ASD), as far as core symptoms and psychiatric comorbidities (PC) are concerned, are inconsistent, inconclusive, or conflicting among studies. The lower prevalence of ASD in females than in males and the age and intelligence quotient (IQ) heterogeneity among samples made it difficult to investigate these differences. This case–control study tries to deepen the impact of sex differences on core symptoms of autism and PC in 214 preschoolers with ASD (mean age, 45.26) without impairment in non-verbal IQ (nvIQ ≥70). A total of 107 ASD females (mean age, 44.51 ± 13.79 months) were matched one by one with 107 males (mean age, 46.01 ± 13.42 months) for chronological age (±6 months) and nvIQ (±6 points). We used the Autism Diagnostic Observation Schedule 2 (ADOS-2) and the Child Behavior Checklist (CBCL) 1.5–5 to explore autism severity and PC. The results highlight that ASD females did not significantly differ from ASD males regarding the severity of autism. Statistically significant lower levels of emotionally reactive (p = 0.005, η² = 0.04), anxious-depressed (p = 0.001, η² = 0.05), internalizing problems (p = 0.04, η² = 0.02), and DSM-Oriented Scales anxiety problems (p = 0.02, η² = 0.04) in ASD females than in ASD males were also detected. Our findings of no difference in the autism severity and lower internalizing problems in females than males with ASD extend the knowledge of autism in females during preschool years. Compared to other similar studies on this topic, we can state that these results are not supported by differences in nvIQ between sexes nor by the presence of cognitive impairment. It confirms the need for clinicians to consider sex differences when describing autism psychopathology.

Brief Report: Predicting Sex Differences and Diagnosis from Early Parent Concerns

Autism spectrum disorder (ASD) research is largely based on males, and females with ASD are at risk for under-identification. Research recommends listening to parent concerns since these are often predictive of a child's eventual diagnosis. This study examined how patterns of parent concerns predicted sex differences and eventual child diagnosis (ASD or developmental delay [DD]). We performed a secondary analysis with n = 273 children ages 36-72 months. Results suggested males with ASD had a higher likelihood of repetitive behavior and speech and language concerns compared to females with ASD. Females with DD were significantly more likely to have problem-solving concerns; whereas, males with DD were significantly less likely to have social communication concerns compared to females with ASD.

Sex Differences in Social Participation of High School Students with Autism Spectrum Disorder

There is lack of consensus in the literature regarding sex differences in social outcomes for individuals on the autism spectrum. Furthermore, little research has focused on the social experiences of high school students with autism spectrum disorder (ASD) during the school day. Using a large racially/ethnically diverse sample of high school students with ASD receiving special education services (n = 547; 76 females, 471 males), we examined sex differences in social interactions of youth both during and after school. We also tested for sex differences in background and phenotypic characteristics including autism severity, IQ, adaptive behavior, and mental health. Results indicated few statistically significant differences between males and females in social interactions and phenotypic characteristics (including raw scores of autism symptom severity). However, analysis of standardized scores of autism symptoms suggested that symptom scores for females with ASD diverged more from same-sex peers in the normed sample than scores of males with ASD. Lack of sex difference in social participation for youth with ASD in this study stands in contrast to patterns of sex differences in the general population. Findings suggest that few differences between males and females with ASD, both in social participation and autism symptom severity, might result in females with ASD being more dissimilar to their same-sex peers than males with ASD. Implications of findings for understanding sex differences in ASD across the life course are discussed. LAY SUMMARY: The present study examined sex differences in social participation in a large, diverse sample of high school students with autism spectrum disorder (ASD). Males and females were very similar in their social interactions both at school and outside of school, based on reports by teachers and parents. Level of autism symptoms was also similar for males and females. However, standardized scores of autism symptoms, which take into account age and sex specific norms, suggested that females with ASD may have behaviors that are more divergent from their same-sex peers than males with ASD.

Evaluation of Chromosome Microarray Analysis in a Large Cohort of Females with Autism Spectrum Disorders: A Single Center Italian Study

Autism spectrum disorders (ASD) encompass a heterogeneous group of neurodevelopmental disorders resulting from the complex interaction between genetic and environmental factors. Thanks to the chromosome microarray analysis (CMA) in clinical practice, the accurate identification and characterization of submicroscopic deletions/duplications (copy number variants, CNVs) associated with ASD was made possible. However, the widely acknowledged excess of males on the autism spectrum reflects on a paucity of CMA studies specifically focused on females with ASD (f-ASD). In this framework, we aim to evaluate the frequency of causative CNVs in a single-center cohort of idiopathic f-ASD. Among the 90 f-ASD analyzed, we found 20 patients with one or two potentially pathogenic CNVs, including those previously associated with ASD (located at 16p13.2 16p11.2, 15q11.2, and 22q11.21 regions). An exploratory genotype/phenotype analysis revealed that the f-ASD with causative CNVs had statistically significantly lower restrictive and repetitive behaviors than those without CNVs or with non-causative CNVs. Future work should focus on further understanding of f-ASD genetic underpinnings, taking advantage of next-generation sequencing technologies, with the ultimate goal of contributing to precision medicine in ASD.

CE: From the CDC: Understanding Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a condition characterized by impaired social communication as well as restricted and repetitive behaviors. It is considered a neurodevelopmental disorder because it is associated with neurologic changes that may begin in prenatal or early postnatal life, alters the typical pattern of child development, and produces chronic signs and symptoms that usually manifest in early childhood and have potential long-term consequences. In past decades, autism was conceptualized as a strictly defined set of behaviors, usually accompanied by intellectual impairment. Today, it is recognized as a spectrum, ranging from mild to severe, in which behaviors vary substantially and the majority of children who fall on the spectrum have average to above average intellectual ability. Here, the authors discuss the risk factors for ASD, its epidemiology, common concurrent conditions, evaluation, diagnosis, treatments, and outcomes.

The effects of sex on prevalence and mechanisms underlying neurodevelopmental disorders

Neurodevelopmental disorders occur more frequently in boys than in girls and often differ in presentation between the sexes. The sex differences in prevalence and presentation of autism spectrum disorder, intellectual disability, communication disorders, specific learning disabilities, attention deficit/hyperactivity disorder, Tourette's syndrome, and epilepsy are discussed, as well as sex differences in the patterns of comorbidities between these disorders. Prominent theories have been proposed to explain sex biases. These include genetic factors, sex hormones, sociological factors, cognitive differences between the sexes, and environmental insult. Despite the large body of research reviewed in this chapter, many aspects of sex-related effects in neurodevelopmental disorders remain poorly understood.

Schooling for Pupils with Autism Spectrum Disorder: Parents' Perspectives

The current study, based on a survey of 1799 parents, explored parental perspectives of school absence in relation to approved grades, challenges, demands and obstacles in education for children with autism spectrum disorder. The results revealed a relatively high rate of school absenteeism for reasons other than illness. Girls had higher rates of absenteeism than boys for short durations of absence. Absenteeism was primarily caused by a lack of teacher competence regarding autism and inadequate adaptation of teaching. There were no significant differences between genders in approved grades, but the rate of failure to achieve approved grades was approximately 50%. The most common form of educational support was support from special needs teachers and adapted pedagogy.

ASD symptoms in toddlers and preschoolers: An examination of sex differences

Although considerable work has documented higher prevalence rates of autism spectrum disorder (ASD) in boys, fewer studies have focused on sex differences within samples of young children at-risk for ASD. This study examined sex differences in ASD symptom domains and ASD screening outcomes among toddlers (18-35 months) and preschoolers (36-72 months) with ASD-related concerns. Participants included 480 children between 18 and 72 months evaluated by university-based ASD specialty clinics. Results revealed significant sex differences in severity of social communication (SC) deficits across age groups. Within the toddler group, girls diagnosed with ASD displayed greater SC deficits according to standardized observation and clinician severity ratings. Within the preschool group, girls diagnosed with ASD were rated by parents as having more severe SC deficits, but these differences were not corroborated by standardized observations or clinician ratings. No sex differences emerged for severity of restricted repetitive behaviors (RRBs) for either age group. Across the entire referred sample, boys and girls did not differ in terms of scores on commonly used screening instruments. Importantly, results suggest that two of the most commonly used ASD screeners (i.e., Modified-Checklist for Autism in Toddlers-Revised with Follow-up and Social Communication Questionnaire ) may underidentify RRBs in toddler and preschool-aged girls as screening scores were only influenced by severity of SC deficits. Greater SC deficits in young girls with ASD along with its impact on screening status suggests greater attention be placed on the under-identification of ASD in girls as well as current screening measures' ability to tap into the topography of ASD symptoms across genders. Autism Res 2020, 13: 157-166. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: In this study, we found that young girls diagnosed with autism spectrum disorder tend to have greater social communication deficits than young boys and that these differences vary by age. Specifically, toddler-aged girls receive higher clinician ratings of social communication deficits when compared to boys, while preschool-aged girls receive higher parent ratings of social communication deficits. For girls, current screening tools seem to be more highly influenced by severity of social communication deficits than by restricted repetitive behaviors.

Gender Differences in Social Inclusion of Youth with Autism and Intellectual Disability

The aim of this study was to delve into the role of gender differences in social inclusion of children and youth with autism spectrum disorder (ASD) and intellectual disability (ID). A sample of 420 participants with ASD and ID aged between 4 and 21 years was evaluated using the ASD-KidsLife Scale. Females obtained lower scores in most of the items of social inclusion. These differences remained when the covariables of level of ID, support needs, and age were controlled. None of the items presented differential item functioning as a function of gender. Gender differences, as were found in social inclusion, are discussed and recommendations are given in order to provide equal opportunities to girls and boys with ASD.

Brief Report: Sex/Gender Differences in Symptomology and Camouflaging in Adults with Autism Spectrum Disorder

Autism spectrum disorder (ASD) is more prevalent in males than females. Previous research indicates females camouflage ASD symptoms more than males, potentially contributing to the difference in prevalence. This study investigated sex/gender differences in behavioral phenotypes in 17 males and 11 females with ASD, as well camouflaging in ASD, in an attempt to partially replicate findings from Lai et al. (Autism 21(6):690-702, 2017). Overall ASD symptoms were measured by the autism spectrum quotient (AQ). Mean AQ in females with ASD was higher than males with ASD, with the difference approaching statistical significance. Camouflaging was found to be more common in females with ASD, and not associated to social phobia. Furthermore, camouflaging correlated negatively with emotional expressivity in females, but not males, with ASD. These findings strengthen previous findings regarding camouflaging being more common in females and add to the literature on how camouflaging may be different in females versus males.

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

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

Exploring the female autism phenotype of repetitive behaviours and restricted interests (RBRIs): a systematic PRISMA review

Purpose

The purpose of this paper is to address the need for increased understanding, awareness and recognition of the autism female phenotype in terms of repetitive behaviours and restricted interests (RBRIs).

Design/methodology/approach

A systematic PRISMA review was conducted. The main aim of the present systematic review is to identify studies which have investigated RBRIs in females with autism spectrum disorder (ASD) or the differences in RBRIs between males and females with ASD.

Findings

In sum, 19 relevant articles were identified: 5 studies found no significant evidence to support the notion of sex differences in RRBIs in ASD; 1 study did not report any differences in RRBIs between males and females with ASD; 12 studies found evidence that males with ASD had significantly more RRBIs compared to females with ASD; and, lastly, 1 study found that girls with ASD have features of RRBIs which are exhibited more compared to boys with ASD.

Research limitations/implications

There is a real lack of in-depth knowledge and understanding of the female phenotype of ASD, and such lack of knowledge has a detrimental impact on the identification of autistic females and a lack of identification can have negative consequence. This is important to address in future research as it is well established that the earlier the diagnosis, the better the outcomes, due to the timely access to appropriate interventions.

Practical implications

The RBRIs exhibited in autistic females are not sufficiently captured by most currently diagnostic instruments. Clinicians are less likely to identify the RBRIs in females as they tend not to be the typical repetitive behaviours commonly associated with ASD. It has been recommended that clinicians consider “females as a whole” in terms of their clinical presentation and look for any indication of RBRIs, even repetitive interests which appear clinically innocuous.

Originality/value

There is relatively little research investigating RBRIs in autistic women and girls. There is a real need to highlight the importance of understanding and recognising how RBRIs can differ between males and females with ASD.

Autism Mental Status Examination (AMSE): A Valid Instrument in the Evaluation of Pre-school Children with Suspected Autism Spectrum Disorders?

In this study the Autism Mental Status Exam (AMSE) was validated towards ICD-10 Autism Spectrum Diagnoses (ASD) based on an interview with the Diagnostic Interview for Social and Communication Disorders (DISCO-11) with parent(s)/caregiver(s) in a group of 124 children referred for assessment to a clinical assessment unit for pre-school children. The results from the study indicates a Fair relation across the AMSE score and ICD-10 Autism Spectrum Disorder (ASD). AMSE mean score for children not fulfilling criteria for an ASD at the assessment was significantly lower compared to the AMSE mean score for children who acquired an ASD diagnosis in the study. In addition, Vineland-II Parent/caregiver rating questionnaire GAF standard scores showed a reversed correlation to the AMSE mean scores (i.e. higher AMSE mean scores were related to lower Vineland-II GAF standard scores and vice versa).

Gender Differences in Pragmatic Communication in School-Aged Children with Autism Spectrum Disorder (ASD)

Possible gender differences in manifestations of autism spectrum disorder (ASD) were examined using data on production of narratives. The Expression, Reception and Recall of Narrative Instrument (ERRNI; Bishop, Expression, Reception and Recall of Narrative Instrument, Harcourt assessment, London, 2004) was administered to a sample of matched 8-year-old intellectually able boys and girls with ASD (13M, 13F), who had been selected from a large, longitudinal study. In addition, transcripts of the narratives were analyzed in detail. Significant gender differences were found in narrative production. Girls included more salient story elements than boys. On detailed language analysis, girls were also shown to tell richer stories, including more descriptors of planning or intention. Overall, our findings suggest that subtle differences in social communication may exist between intellectually able boys and girls with ASD. If reliably identifiable in young children, such gender differences may contribute to differential diagnosis of ASD. In addition, such differences may pave the way for differential approaches to intervention when the target is effective communication in sophisticated discourse contexts.

Diagnosis of Autism Spectrum Disorder in Adolescents with Complex Clinical Presentations: A Montreal Case Series

Background:

Despite increased attention and recognition of autism spectrum disorders, many patients suffering from these disorders remain undiagnosed or are diagnosed late due to their subtle clinical presentation. The challenge for clinicians working in the field of mental health is not in screening and diagnosing young children showing typical signs of autism spectrum disorders, but rather in identifying patients at the high-functioning end of the spectrum whose intellectual abilities mask their social deficits.

Objective:

Because therapeutic interventions differ radically once the diagnosis of ASD has been made, it is important to understand the trajectory of those adolescents and identify clues that could help raise the diagnosis of ASD earlier.

Methods:

Records of eight adolescents with a late diagnosis of ASD were retrospectively reviewed to identify relevant clinical features that were overlooked in childhood and early adolescence.

Results:

The patients were previously misdiagnosed with multiple mental health disorders. These cases showed striking similarities in terms of developmental history, reasons for misdiagnosis, and the clinical picture at the time of ASD recognition. The cases were characterized by complex and fluctuating symptomatology, including depression, anxiety, behavioural problems, self-injurious behaviour and suicidal thoughts. Their Autism Spectrum Disorder (ASD) went previously undiagnosed due to the individual’s intelligence and learning abilities, which masked their social deficits and developmental irregularities. Signs of ASD were continuously present since childhood in all the eight cases. Once the developmental histories and the psychiatric evaluation of these adolescents were done by psychiatrists with appropriate knowledge of autism, the diagnosis of ASD was made.

Conclusion:

The ASD hypothesis should be raised in the presence of confusing symptoms that do not respond to usual treatment and are accompanied by an irregular developmental background. It is indeed a difficult diagnosis to make; however, the focused clinician can note subtle signs of ASD despite the intellectual learning of social codes. Family history, developmental irregularities, rigidity, difficulty in spontaneously understanding emotions, discomfort in groups and the need to be alone are significant indicators to recognize. Once the diagnosis has been considered, it must be confirmed or rejected by an experienced multidisciplinary team. The challenge for clinicians working in the field of mental health is not in screening and diagnosing young children showing typical signs of ASD, but rather in identifying patients who are at high-functioning end of the spectrum whose intellectual abilities mask their social deficits.

What About the Girls? Sex-Based Differences in Autistic Traits and Adaptive Skills

There is growing evidence of a camouflaging effect among females with autism spectrum disorder (ASD), particularly among those without intellectual disability, which may affect performance on gold-standard diagnostic measures. This study utilized an age- and IQ-matched sample of school-aged youth (n = 228) diagnosed with ASD to assess sex differences on the ADOS and ADI-R, parent-reported autistic traits, and adaptive skills. Although females and males were rated similarly on gold-standard diagnostic measures overall, females with higher IQs were less likely to meet criteria on the ADI-R. Females were also found to be significantly more impaired on parent reported autistic traits and adaptive skills. Overall, the findings suggest that some autistic females may be missed by current diagnostic procedures.

Sex differences in restricted repetitive behaviors and interests in children with autism spectrum disorder: An Autism Treatment Network study

Compared to the social communication domain, considerably less is known about the cause, development, and impact of restricted, repetitive behaviors interests and activities in children with autism spectrum disorder, including possible sex differences. This study examined sex differences in clinically identified (Autism Diagnostic Observation Schedule) restricted and repetitive behavior symptoms using the largest known sample (N = 1024) of age-matched and intelligence quotient-matched female and male children with autism spectrum disorder. More similarities than differences were observed; however, younger higher functioning and older lower functioning females presented reduced rates on the Autism Diagnostic Observation Schedule restricted and repetitive behavior subcategory unusually repetitive/excessive, stereotyped behaviors compared to similar males. These findings identify key restricted and repetitive behavior similarities and differences among young females and males with autism spectrum disorder and emphasize the need for a deeper understanding of the female autism phenotype.

Gender Differences and Similarities: Autism Symptomatology and Developmental Functioning in Young Children

A growing body of research suggests that symptoms of autism spectrum disorder (ASD) may present differently in males and females. This study examined gender differences in ASD symptoms and developmental functioning, using the Baby and Infant Screen for Children with aUtism Traits, Part 1 (BISCUIT-Part 1) and the Battelle Developmental Inventory, 2nd Edition (BDI-2), amongst children aged 17-37 months meeting ASD diagnostic criteria (n = 1317). No gender differences were found in regards to overall symptom severity or symptom domains on the BISCUIT-Part 1 when gender groups were matched by cognitive ability. Females with ASD had greater motor deficits and less communication impairment compared to their male counterparts as measured by the BDI-2. Secondary analyses examining item endorsement patterns were also conducted. Implications of the findings are discussed.

Profiling Autism Symptomatology: An Exploration of the Q-ASC Parental Report Scale in Capturing Sex Differences in Autism

The Questionnaire for Autism Spectrum Conditions (Q-ASC) was developed by Attwood et al. (2011) to identify gender-sensitive profiles of autism symptomatology; prioritise and adjust the direction of clinical interventions; and support positive psychosocial outcomes and prognosis into adulthood. The current research piloted the Q-ASC with parents of 238 children with a clinical diagnosis of ASD-Level 1 (without intellectual or language impairment). Data analysis revealed eight interpretable and reliable components of the Q-ASC using Principle components analysis. Comparisons across age and gender groups found statistically significant mean differences of parent-reported characteristics. The findings from this study aim to identify improvements in the Q-ASC towards the future assessment of the sensitivity and diversity of presentations of autism among female children and adolescents.

Increased psychiatric symptoms in university students with autism spectrum disorder are associated with reduced adaptive behavior

High variability in adaptive behavior in cognitively-able adults with autism spectrum disorder has been previously reported, and may be caused by the high prevalence of psychiatric comorbidity in this population. This study's goals were to examine self-reported psychiatric symptoms in students with ASD, and to identify their relative contribution to the variance in adaptive behaviors. The study population included 95 students: 55 diagnosed with ASD (4 females; age range 18-34) who participated in a university integration program (ASD group), and 40 regularly matriculated students (non-ASD group, 7 females; age range 20-36). The ASD group showed a lower adaptive skill level than the non-ASD group as measured by the Adaptive Behavior Assessment System (GAC-ABAS). Significantly higher scores for the ASD group were found for social anxiety, trait anxiety, obsessive-compulsive symptoms, and depression symptoms. The level of adaptive skills correlated negatively and significantly with the severity of social anxiety symptoms in both groups and with severity of obsessive-compulsive symptoms only in the ASD group. Additionally, in a regression model, significant contributions of having an ASD diagnosis and severity of social anxiety explained 41.7% of the variance in adaptive skills. Adequate evaluation and treatment, if needed, are recommended in this population.

Parental Perspectives on Psychiatric Comorbidity in Preschoolers With Autism Spectrum Disorders Receiving Publicly Funded Mental Health Services

An increased prevalence of psychiatric comorbidity (PC) in individuals with Autism Spectrum Disorders (ASD) is consistently reported. While several studies have examined PC in school-aged children, adolescents and adults with ASD, investigations on PC in preschoolers are less common. In this study, we explore the prevalence and the type of PC in a sample of 989 preschoolers with ASD through the DSM-Oriented Scales (DOS) of the Child Behavior Checklist (CBCL 1½-5) and their possible links with the core features of ASD and cognitive functioning. Results indicated that 37.8% of the sample had at least one PC in addition to ASD; these subjects displayed significantly higher Total score (p = 0.02) and Social Affect score (p = 0.003) on the ADOS-based calibrated severity scores (CSS), as well as lower (p ≤ 0.0001) performance IQ (pIQ) compared to ASD individuals without PC. As far as the specific DOS, Affective Problems (AP) were detected in 23.4% of the whole sample, ADHD Problems (ADHD) in 17.3%, Anxiety Problems (AXP) in 16.7%, and Oppositional Problems (OP) in 7.9%. These different comorbidities were isolated in 195 subjects (Mono-comorbid group: 19.7% of the whole sample), while 179 subjects (18.1% of the whole sample) had two or more types of PC (Multi-comorbid group). One-way ANOVA revealed that subjects with multi-comorbidity have statistically significant lower pIQ and higher Total score and Social Affect score on CSS-ADOS. Specific differences for each type of comorbidity and gender differences were also discussed. Taken together, results indicate a considerable presence of PC in preschoolers with ASD that should be accurately considered during the assessment and diagnosis process in order to plan a tailored intervention based not only on core symptoms of ASD, but also on comorbid psychiatric condition since preschool age.

Prevalence and Characteristics of Autism Spectrum Disorder Among Children Aged 8 Years - Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2012

Problem/Condition

Autism spectrum disorder (ASD).

Period Covered

2012.

Description of System

The Autism and Developmental Disabilities Monitoring (ADDM) Network is an active surveillance system that provides estimates of the prevalence and characteristics of ASD among children aged 8 years whose parents or guardians reside in 11 ADDM Network sites in the United States (Arkansas, Arizona, Colorado, Georgia, Maryland, Missouri, New Jersey, North Carolina, South Carolina, Utah, and Wisconsin). Surveillance to determine ASD case status is conducted in two phases. The first phase consists of screening and abstracting comprehensive evaluations performed by professional service providers in the community. Data sources identified for record review are categorized as either 1) education source type, including developmental evaluations to determine eligibility for special education services or 2) health care source type, including diagnostic and developmental evaluations. The second phase involves the review of all abstracted evaluations by trained clinicians to determine ASD surveillance case status. A child meets the surveillance case definition for ASD if one or more comprehensive evaluations of that child completed by a qualified professional describes behaviors that are consistent with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision diagnostic criteria for any of the following conditions: autistic disorder, pervasive developmental disorder–not otherwise specified (including atypical autism), or Asperger disorder. This report provides ASD prevalence estimates for children aged 8 years living in catchment areas of the ADDM Network sites in 2012, overall and stratified by sex, race/ethnicity, and the type of source records (education and health records versus health records only). In addition, this report describes the proportion of children with ASD with a score consistent with intellectual disability on a standardized intellectual ability test, the age at which the earliest known comprehensive evaluation was performed, the proportion of children with a previous ASD diagnosis, the specific type of ASD diagnosis, and any special education eligibility classification.

Results

For 2012, the combined estimated prevalence of ASD among the 11 ADDM Network sites was 14.5 per 1,000 (one in 69) children aged 8 years. Estimated prevalence was significantly higher among boys aged 8 years (23.4 per 1,000) than among girls aged 8 years (5.2 per 1,000). Estimated ASD prevalence was significantly higher among non-Hispanic white children aged 8 years (15.3 per 1,000) compared with non-Hispanic black children (13.1 per 1,000), and Hispanic (10.2 per 1,000) children aged 8 years. Estimated prevalence varied widely among the 11 ADDM Network sites, ranging from 8.2 per 1,000 children aged 8 years (in the area of the Maryland site where only health care records were reviewed) to 24.6 per 1,000 children aged 8 years (in New Jersey, where both education and health care records were reviewed). Estimated prevalence was higher in surveillance sites where education records and health records were reviewed compared with sites where health records only were reviewed (17.1 per 1,000 and 10.4 per 1,000 children aged 8 years, respectively; p<0.05). Among children identified with ASD by the ADDM Network, 82% had a previous ASD diagnosis or educational classification; this did not vary by sex or between non-Hispanic white and non-Hispanic black children. A lower percentage of Hispanic children (78%) had a previous ASD diagnosis or classification compared with non-Hispanic white children (82%) and with non-Hispanic black children (84%). The median age at earliest known comprehensive evaluation was 40 months, and 43% of children had received an earliest known comprehensive evaluation by age 36 months. The percentage of children with an earliest known comprehensive evaluation by age 36 months was similar for boys and girls, but was higher for non-Hispanic white children (45%) compared with non-Hispanic black children (40%) and Hispanic children (39%).

Interpretation

Overall estimated ASD prevalence was 14.5 per 1,000 children aged 8 years in the ADDM Network sites in 2012. The higher estimated prevalence among sites that reviewed both education and health records suggests the role of special education systems in providing comprehensive evaluations and services to children with developmental disabilities. Disparities by race/ethnicity in estimated ASD prevalence, particularly for Hispanic children, as well as disparities in the age of earliest comprehensive evaluation and presence of a previous ASD diagnosis or classification, suggest that access to treatment and services might be lacking or delayed for some children.

Public Health Action

The ADDM Network will continue to monitor the prevalence and characteristics of ASD among children aged 8 years living in selected sites across the United States. Recommendations from the ADDM Network include enhancing strategies to 1) lower the age of first evaluation of ASD by community providers in accordance with the Healthy People 2020 goal that children with ASD are evaluated by age 36 months and begin receiving community-based support and services by age 48 months; 2) reduce disparities by race/ethnicity in identified ASD prevalence, the age of first comprehensive evaluation, and presence of a previous ASD diagnosis or classification; and 3) assess the effect on ASD prevalence of the revised ASD diagnostic criteria published in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Adaptive trajectories and early risk factors in the autism spectrum: A 15-year prospective study

Little is known about long-term outcomes. We investigate the adaptive trajectories and their risk factors in ASD. Data were obtained from 281 children prospectively followed untill adulthood. The final sample consisted of 106 individuals. Vineland scores were collected at baseline (T1), 3 (T2), 10 (T3), and 15 (T4) years later. A group-based method was used to identify homogeneous patterns of adaptive skills trajectories. Results show that among the children initially categorized as autistic, 82.6% remained over the ADOS diagnostic threshold, 11.9% converted to atypical autism, and 5.4% fell under the ADOS threshold. Most atypical autism diagnoses were unstable. Most (81.7%) autistic participants had an ID at inclusion. At T1, 59.3% were nonverbal, but only 39% at T4. Most changes occurred between 4 and 8 years of age. Approximately 25% of participants exhibited a "high" growth trajectory, in which progress continues throughout adolescence, and 75% a "low" growth trajectory, characterized by greater autistic symptoms, intellectual disability, and lower language abilities reflected by high CARS scores, low apparent DQ, and speech difficulties, which mostly, but not always, predicted low trajectories. Our findings suggest that the adaptive prognosis of autism is mostly poor in this cohort, biased toward intellectual disability. However, changes in diagnostic, speech, and adaptive status are not uncommon, even for indivduals with low measured intelligence or apparent intellectual disability, and are sometimes difficult to predict. Autism Research 2018, 11: 1455-1467. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Most autism diagnoses given before 5 years of age are stable to adulthood, but one-fifth of individuals are no longer considered to be autistic, even in a cohort biased toward apparent intellectual disability. Conversely, atypical autism diagnoses are mostly unstable. One-third of children who are nonverbal at 5 years are verbal within 15 years, mostly before 8 years of age. Concerning adaptive behavior outcomes, only one-fourth of children exhibit a high-growth trajectory through at least 15 years.

Sex differences in restricted repetitive behaviors and interests in children with autism spectrum disorder: An Autism Treatment Network study

Compared to the social communication domain, considerably less is known about the cause, development, and impact of restricted, repetitive behaviors interests and activities in children with autism spectrum disorder, including possible sex differences. This study examined sex differences in clinically identified (Autism Diagnostic Observation Schedule) restricted and repetitive behavior symptoms using the largest known sample (N = 1024) of age-matched and intelligence quotient-matched female and male children with autism spectrum disorder. More similarities than differences were observed; however, younger higher functioning and older lower functioning females presented reduced rates on the Autism Diagnostic Observation Schedule restricted and repetitive behavior subcategory unusually repetitive/excessive, stereotyped behaviors compared to similar males. These findings identify key restricted and repetitive behavior similarities and differences among young females and males with autism spectrum disorder and emphasize the need for a deeper understanding of the female autism phenotype.

Evaluating Sex and Age Differences in ADI-R and ADOS Scores in a Large European Multi-site Sample of Individuals with Autism Spectrum Disorder

Research on sex-related differences in Autism Spectrum Disorder (ASD) has been impeded by small samples. We pooled 28 datasets from 18 sites across nine European countries to examine sex differences in the ASD phenotype on the ADI-R (376 females, 1763 males) and ADOS (233 females, 1187 males). On the ADI-R, early childhood restricted and repetitive behaviours were lower in females than males, alongside comparable levels of social interaction and communication difficulties in females and males. Current ADI-R and ADOS scores showed no sex differences for ASD severity. There were lower socio-communicative symptoms in older compared to younger individuals. This large European ASD sample adds to the literature on sex and age variations of ASD symptomatology.

Self-reported sex differences in high-functioning adults with autism: a meta-analysis

Background

Sex differences in autistic symptomatology are believed to contribute to the mis- and missed diagnosis of many girls and women with an autism spectrum condition (ASC). Whilst recent years have seen the emergence of clinical and empirical reports delineating the profile of young autistic girls, recognition of sex differences in symptomatology in adulthood is far more limited.

Methods

We chose here to focus on symptomatology as reported using a screening instrument, the Ritvo Autism Asperger Diagnostic Scale-Revised (RAADS-R). In a meta-analysis, we pooled and analysed RAADS-R data from a number of experimental groups. Analysis of variance (ANOVA) searched for the presence of main effects of Sex and Diagnosis and for interactions between these factors in our sample of autistic and non-autistic adults.

Results

In social relatedness and circumscribed interests, main effects of Diagnosis revealed that as expected, autistic adults reported significantly greater lifetime prevalence of symptoms in these domains; an effect of Sex, in circumscribed interests, also suggested that males generally reported more prevalent symptoms than females. An interaction of Sex and Diagnosis in language symptomatology revealed that a normative sex difference in language difficulties was attenuated in autism. An interaction of Sex and Diagnosis in the sensorimotor domain revealed the opposite picture: a lack of sex differences between typically developing men and women and a greater prevalence of sensorimotor symptoms in autistic women than autistic men.

Conclusions

We discuss the literature on childhood sex differences in relation to those which emerged in our adult sample. Where childhood sex differences fail to persist in adulthood, several interpretations exist, and we discuss, for example, an inherent sampling bias that may mean that only autistic women most similar to the male presentation are diagnosed. The finding that sensorimotor symptomatology is more highly reported by autistic women is a finding requiring objective confirmation, given its potential importance in diagnosis.

Electronic supplementary material

The online version of this article (10.1186/s13229-018-0216-6) contains supplementary material, which is available to authorized users.

Developmental neurogenetics and multimodal neuroimaging of sex differences in autism

Examining sex differences in the brain has been historically contentious but is nonetheless important for advancing mental health for both girls and boys. Unfortunately, females in biomedical research remain underrepresented in most mental health conditions including autism spectrum disorders (ASD), even though equal inclusion of females would improve treatment for girls and yield benefits to boys. This review examines sex differences in the relationship between neuroanatomy and neurogenetics of ASD. Recent findings reveal that girls diagnosed with ASD exhibit more intellectual and behavioral problems compared to their male counterparts, suggesting that girls may be less likely diagnosed in the absence of such problems or that they require a higher mutational load to meet the diagnostic criteria. Thus far, the female biased effect of chromosome 4, 5p15.33, 8p, 9p24.1, 11p12-13, 15q, and Xp22.3 and the male biased effect of 1p31.3, 5q12.3, 7q, 9q33.3, 11q13.4, 13q33.3, 16p11.2, 17q11-21, Xp22.33/Yp11.31, DRD1, NLGN3, MAOA, and SHANK1 deletion have been discovered in ASD. The SNPs of genes such as RYR2, UPP2, and the androgen receptor gene have been shown to have sex-biasing factors in both girls and boys diagnosed with ASD. These sex-related genetic factors may drive sex differences in the neuroanatomy of these girls and boys, including abnormal enlargement in temporal gray and white matter volumes, and atypical reduction in cerebellar gray matter volumes and corpus callosum fibers projecting to the anterior frontal cortex in ASD girls relative to boys. Such factors may also be responsible for the attenuation of brain sexual differentiation in adult men and women with ASD; however, much remains to be uncovered or replicated. Future research should leverage further the association between neuroanatomy and genetics in girls for an integrated and interdisciplinary understanding of ASD.

Young children who screen positive for autism: Stability, change and "comorbidity" over two years

BACKGROUND

Autism spectrum disorder (ASD) is a developmental disorder with a wide variety of clinical phenotypes and co-occurrences with other neurodevelopmental conditions. Symptoms may change over time.

AIMS

The aim of the present study was to prospectively follow 96 children, initially assessed for suspected ASD at an average age of 2.9 years.

METHODS AND PROCEDURES

All children had been identified with autistic symptoms in a general population child health screening program, and had been referred to the Child Neuropsychiatry Clinic in Gothenburg, Sweden for further assessment by a multi-professional team at Time 1 (T1). This assessment included a broad neurodevelopmental examination, structured interviews, a cognitive test and evaluations of the child́s adaptive and global functioning. Two years later, at Time 2 (T2), the children and their parents were invited for a follow-up assessment by the same team using the same methods.

OUTCOMES AND RESULTS

Of the 96 children, 76 had met and 20 had not met full criteria for ASD at T1. Of the same 96 children, 79 met full ASD criteria at T2. The vast majority of children with ASD also had other neurodevelopmental symptoms or diagnoses. Hyperactivity was observed in 42% of children with ASD at T2, and Intellectual Developmental Disorder in 30%. Borderline Intellectual Functioning was found in 25%, and severe speech and language disorder in 20%. The children who did not meet criteria for ASD at T2 had symptoms of or met criteria for other neurodevelopmental/neuropsychiatric disorders in combination with marked autistic traits. Changes in developmental profiles between T1 and T2 were common in this group of young children with ASD. The main effect of Cognitive level at T1 explained more than twice as much of the variance in Vineland scores as did the ASD subtype; children with IDD had significantly lower scores than children in the BIF and AIF group. Co-existence with other conditions was the rule.

CONCLUSIONS AND IMPLICATIONS

Reassessments covering the whole range of these conditions are necessary for an optimized intervention-adapted to the individual child's needs.

Gender comparisons in children with ASD entering early intervention

BACKGROUND

Males are diagnosed with Autism Spectrum Disorder (ASD) approximately four times as often as females. This has led to interest in recent years of potential under-diagnosis of females, as well as negative consequences for females with ASD due to under-identification. A number of potential explanations for gender bias in diagnosis are discussed including that females and males may present differently despite showing the same core symptoms. Previous research has shown inconsistent findings in comparisons between genders in young children with ASD for whom early intervention is vital. Thus, the aim of the present study was to investigate the social, communication, and cognitive functioning, as well as level of ASD symptoms, in a cohort of children who presented for early intervention to inform understanding of gender differences in this population, as well as to inform understanding of the mechanisms by which gender bias may occur.

METHOD

Participants included 254 children (42 females) aged 29-74 months who completed measures of cognition, communication skills, adaptive behaviour, and ASD symptoms on entry to early intervention.

RESULTS

Consistent with hypotheses, no significant gender differences were found both overall, and when split by functioning level. However, a similar ratio of males and females was found in both high- and low-functioning groups contrary to predictions.

CONCLUSIONS

These results are consistent with some of the previous research that suggests gender differences may not be apparent in clinical samples at this young age. We highlight a need for further research that may use universal screening or longitudinal methods to understand the trajectory of development for females with ASD specifically. Such research could better inform timely and tailored intervention from the preschool years onwards.

Empirically Identified Subgroups of Children Served in Part C Early Intervention Programs

OBJECTIVE

Early intervention (EI) programs under Part C of the Individuals with Disabilities Education Act serve a developmentally heterogeneous population of infants and toddlers with or at risk of developmental delays or disabilities. The aim of this study was to identify empirically distinct subgroups of children in EI so as to inform early prognosis and service planning.

METHODS

We applied mixture modeling to developmental assessment data from 1513 children who enrolled in a large, urban EI program between 2009 and 2013. The observed variables were children's EI-entry developmental quotients (DQs) in 5 domains (communication, cognitive, motor, adaptive, and personal-social) as assessed by the Battelle Developmental Inventory, Second Edition.

RESULTS

A 4-class model showed the best fit to the data, revealing subgroups with distinct developmental profiles. Children in the first subgroup showed a severe delay in communication with less severe delays in the other domains. Children in the second subgroup likewise showed a severe delay in communication, but with comparably severe delays in the cognitive and motor domains. Profiles for the third and fourth subgroups showed the same overall patterns as those for the first and second subgroups, respectively, but to a less severe degree. Developmental trajectories differed by subgroup.

CONCLUSION

Consideration of subgroups based on children's developmental assessment scores provides insight into underlying commonalities among children with different presenting diagnoses on entry into EI. The subgroups also have clinical relevance in terms of both practitioners' and parents' understanding of children's likely service needs and developmental trajectories.

Measurement properties of screening and diagnostic tools for autism spectrum adults of mean normal intelligence: A systematic review

BACKGROUND

The autism spectrum (AS) is a multifaceted neurodevelopmental variant associated with lifelong challenges. Despite the relevant importance of identifying AS in adults for epidemiological, public health, and quality of life issues, the measurement properties of the tools currently used to screen and diagnose adults without intellectual disabilities (ID) have not been assessed.

OBJECTIVES

This systematic review addresses the accuracy, reliability, and validity of the reported AS screening and diagnostic tools used in adults without ID.

METHODS

Electronic databases and bibliographies were searched, and identified papers evaluated against inclusion criteria. The PRISMA statement was used for reporting the review. We evaluated the quality of the papers using the COSMIN Checklist for psychometric data, and QUADAS-2 for diagnostic data. For the COSMIN assessment, evidence was considered to be strong when several methodologically good articles, or one excellent article, reported consistent evidence for or against a measurement property. For the QUADAS ratings, evidence was considered to be "satisfactory" if at least one study was rated with a low risk of bias and low concern about applicability.

RESULTS

We included 38 articles comprising 32 studies, five reviews, and one book chapter and assessed nine tools (three diagnostic and six screening, including eight of their short versions). Among screening tools, only AQ-50, AQ-S, and RAADS-R and RAADS-14 were found to provide satisfactory or intermediate values for their psychometric properties, supported by strong or moderate evidence. Nevertheless, risks of bias and concerns on the applicability of these tools limit the evidence on their diagnostic properties. We found that none of the gold standard diagnostic tools used for children had satisfactory measurement properties.

CONCLUSION

There is limited evidence for the measurement properties of the screening and diagnostic tools used for AS adults with a mean normal range of measured intelligence. This may lessen the validity of conclusions and public health decisions on an important fraction of the adult autistic population. This not only justifies further validation studies of screening and diagnostic tools for autistic adults, but also supports the parallel use of self-reported information and clinical expertise with these instruments during the diagnostic process.

Sex differences in frontal lobe connectivity in adults with autism spectrum conditions

Autism spectrum conditions (ASC) are more prevalent in males than females. The biological basis of this difference remains unclear. It has been postulated that one of the primary causes of ASC is a partial disconnection of the frontal lobe from higher-order association areas during development (that is, a frontal 'disconnection syndrome'). Therefore, in the current study we investigated whether frontal connectivity differs between males and females with ASC. We recruited 98 adults with a confirmed high-functioning ASC diagnosis (61 males: aged 18-41 years; 37 females: aged 18-37 years) and 115 neurotypical controls (61 males: aged 18-45 years; 54 females: aged 18-52 years). Current ASC symptoms were evaluated using the Autism Diagnostic Observation Schedule (ADOS). Diffusion tensor imaging was performed and fractional anisotropy (FA) maps were created. Mean FA values were determined for five frontal fiber bundles and two non-frontal fiber tracts. Between-group differences in mean tract FA, as well as sex-by-diagnosis interactions were assessed. Additional analyses including ADOS scores informed us on the influence of current ASC symptom severity on frontal connectivity. We found that males with ASC had higher scores of current symptom severity than females, and had significantly lower mean FA values for all but one tract compared to controls. No differences were found between females with or without ASC. Significant sex-by-diagnosis effects were limited to the frontal tracts. Taking current ASC symptom severity scores into account did not alter the findings, although the observed power for these analyses varied. We suggest these findings of frontal connectivity abnormalities in males with ASC, but not in females with ASC, have the potential to inform us on some of the sex differences reported in the behavioral phenotype of ASC.

‘I was just so different’: The experiences of women diagnosed with an autism spectrum disorder in adulthood in relation to gender and social relationships

Existing literature exploring autism spectrum disorders within female populations predominantly utilises quantitative methodology. A limited number of small-scale, qualitative studies have explored the experiences of adolescent girls with autism spectrum disorder, but adult women have remained largely unheard. This study aims to broaden the stories told within autobiographical literature and empower those within the wider community of women with autism spectrum disorder. In doing so, it seeks to extend existing conceptualisations of experience to include socially and culturally located factors. A qualitative methodology was adopted, utilising multi-stage narrative analysis. Seven semi-structured interviews with women who received a diagnosis in adulthood were conducted. Recruitment spanned community mental health services, an inpatient service and a community support group. From the women’s diverse experiences and stories emerged two broad categories related to gender identity and social relationships. The findings are discussed in relation to existing constructs of autism in women.