Clinical features, developmental course, and psychiatric comorbidity of adult autism spectrum disorders

Prevalence of autistic traits and their relationships with other psychopathological domains in young adults seeking psychiatric attention: a cluster analysis

BACKGROUND

Nearly two-thirds of individuals with a mental disorder start experiencing symptoms during adolescence or early adulthood, and the onset of a mental disorder during this critical life stage strongly predicts adverse socioeconomic and health outcomes. Subthreshold manifestations of autism spectrum disorders (ASDs), also called autistic traits (ATs), are known to be associated with a higher vulnerability to the development of other psychiatric disorders. This study aimed to assess the presence of ATs in a population of young adults seeking specialist assistance and to evaluate the study population across various psychopathological domains in order to determine their links with ATs.

METHODS

We recruited a sample of 263 adolescents and young adults referring to a specialized outpatient clinic, and we administered them several self-report questionnaires for the evaluation of various psychopathological domains. We conducted a cluster analysis based on the prevalence of ATs, empathy, and sensory sensitivity scores.

RESULTS

The cluster analysis identified three distinct groups in the sample: an AT cluster (22.43%), an intermediate cluster (45.25%), and a no-AT cluster (32.32%). Moreover, subjects with higher ATs exhibited greater symptomatology across multiple domains, including mood, anxiety, eating disorder severity, psychotic symptoms, and personality traits such as detachment and vulnerable narcissism.

CONCLUSIONS

This study highlights the importance of identifying ATs in young individuals struggling with mental health concerns. Additionally, our findings underscore the necessity of adopting a dimensional approach to psychopathology to better understand the complex interplay of symptoms and facilitate tailored interventions.

Extended-Release Lithium Treatment for Adolescents with Bipolar Disorder with or Without Comorbid Autism Spectrum Disorder: Protocol of a Longitudinal Prospective Naturalistic Study for the Assessment of Efficacy and Tolerability

Background: Lithium is the gold-standard treatment for Bipolar Disorder (BD) in both adults and adolescents, effectively managing mood episodes and reducing suicide risk. While its efficacy in neurotypical youth is well established, its use in adolescents with Autism Spectrum Disorder (ASD) and comorbid BD remains under-researched. Here, we present the protocol for a study aiming to evaluate the efficacy and tolerability of Extended-Release Lithium Salts in treating adolescents with BD and comorbid ASD compared to neurotypical BD patients. Methods: This longitudinal prospective naturalistic comparative study will enroll lithium-naïve adolescents aged 12-18 with BD, with or without comorbid ASD, from the Department of Child and Adolescent Psychiatry and Psychopharmacology. Participants will be followed for six months while receiving Extended-Release Lithium Salts treatment. Primary outcomes will include mood instability, suicidality, emotional dysregulation, and aggression, assessed through a range of clinical rating scales and diagnostic tools at baseline, three months, and six months. Secondary outcomes will focus on the safety and tolerability of Extended-Release Lithium Salts, with measures including side effect ratings, physical exams, and laboratory tests. Results: We hypothesize that Extended-Release Lithium Salts will demonstrate non-inferiority in treating BD symptoms in adolescents with comorbid ASD compared to those without ASD. Conclusions: This study is poised to fill a significant gap in the literature by providing critical data on the use of lithium for adolescents with BD and ASD. Findings will inform clinical practice and future research, potentially guiding more personalized treatment approaches for this complex and vulnerable population.

Disentangling negative and positive symptoms in schizophrenia and autism spectrum disorder

Autism spectrum disorder (ASD) and schizophrenia (SZ) share traits, especially in social skills and negative symptoms, and to a lesser degree positive symptoms. Differential diagnosis can be challenging and discerning expressive and experiential negative symptoms may provide knowledge with potential diagnostic and functional relevance that can guide treatment. Two exploratory factor analyses (EFA) were conducted to reveal the underlying dimensions of negative and positive symptoms using the Positive and Negative Syndrome Scale (PANSS), the Scale for the Assessment of Positive Symptoms & Negative Symptoms (SAPS/SANS) and the Autism Diagnostic Observation Schedule-Generic (ADOS-G). Three factors emerged from the negative symptom EFA (70.5 % variance): NF1) Expressive Negative; NF2) Experiential Negative; and NF3) Preoccupation, Absorption & Expressive Affective Flattening. Three positive factors emerged (68.6 % variance): PF1) Hallucinations-Delusions; PF2) Grandiosity; and PF3) Thought Disorder-ADOS positive Symptoms. SZ showed higher PF1 scores, and ASD had higher PF3 scores. No differences between groups were observed in the negative factors. Across groups, all negative factors were inversely associated with quality of life. Only NF1 and NF2 and PF1 were detrimentally related to social functioning. A discriminant function analysis using all factors classified correctly 84.4 % of participants, with PF1, NF1 followed by NF2 being the best predictors of diagnosis. Expressive negative followed by Experiential negative symptoms are of diagnostic value independent of and beyond SZ-related positive symptoms and are related with detrimental functioning. Findings confirm the need to distinctively target negative symptoms, and specific SZ-related and ASD-related positive symptoms, and especially the use of several assessment tools for diagnostic classification.

Cumulative comorbidity between neurodevelopmental, internalising, and externalising disorders in childhood: a network approach

Cumulative comorbidity of mental disorders is common, but the extent and patterns of comorbid psychopathology in childhood are not well established. The current study aimed to elucidate the emergent patterns of cumulative mental disorder comorbidity in children using network analysis of diagnoses recorded between birth and age 12 years. Participants were 90,269 children (mean age 12.7 years; 51.8% male) within the New South Wales Child Development Study (NSW-CDS)-a longitudinal record-linkage cohort study of Australian children born in NSW between 2002 and 2005. Binary indicators for eight types of mental disorder were derived from administrative health records. Patterns of conditional association between mental disorders were assessed utilising network analysis. Of 90,269 children, 2268 (2.5%) had at least one mental disorder by age 12 years; of the 2268 children who had at least one mental disorder by age 12 years, 461 (20.3%) were diagnosed with two or more different disorders out of the eight disorder types included in analyses. All disorders were either directly or indirectly interconnected, with childhood affective and emotional disorders and developmental disorders being most central to the network overall. Mental disorder nodes aggregated weakly (modularity = 0.185) into two communities, representative of internalising and externalising disorders, and neurodevelopmental and sleep disorders. Considerable sex differences in the structure of the mental disorder comorbidity networks were also observed. Developmental and childhood affective and emotional disorders appear to be key to mental disorder comorbidity in childhood, potentially reflecting that these disorders share symptoms in common with many other disorders.

Unpacking the overlap between Autism and ADHD in adults: A multi-method approach

The overlap between Autism and Attention-Deficit Hyperactivity Disorder (ADHD) is widely observed in clinical settings, with growing interest in their co-occurrence in neurodiversity research. Until relatively recently, however, concurrent diagnoses of Autism and ADHD were not possible. This has limited the scope for large-scale research on their cross-condition associations, further stymied by a dearth of open science practices in the neurodiversity field. Additionally, almost all previous research linking Autism and ADHD has focused on children and adolescents, despite them being lifelong conditions. Tackling these limitations in previous research, 5504 adults - including a nationally representative sample of the UK (Study 1; n = 504) and a large pre-registered study (Study 2; n = 5000) - completed well-established self-report measures of Autism and ADHD traits. A series of network analyses unpacked the associations between Autism and ADHD at the individual trait level. Low inter-item connectivity was consistently found between conditions, supporting the distinction between Autism and ADHD as separable constructs. Subjective social enjoyment and hyperactivity-impulsivity traits were most condition-specific to Autism and ADHD, respectively. Traits related to attention control showed the greatest Bridge Expected Influence across conditions, revealing a potential transdiagnostic process underlying the overlap between Autism and ADHD. To investigate this further at the cognitive level, participants completed a large, well-powered, and pre-registered study measuring the relative contributions of Autism and ADHD traits to attention control (Study 3; n = 500). We detected age- and sex-related effects, however, attention control did not account for the covariance between Autism and ADHD traits. We situate our findings and discuss future directions in the cognitive science of Autism, ADHD, and neurodiversity, noting how our open datasets may be used in future research.

Traits of narcissistic vulnerability in adults with autism spectrum disorders without intellectual disabilities

The relationship between Autism Spectrum Disorders (ASD) and Narcissistic Personality Disorder (NPD), considering the dimensions of narcissistic grandiosity and vulnerability, represents an important differential diagnosis and potential ground of comorbidity, since both conditions show high grades of pervasiveness, a life-long course, ego-syntonic traits, and difficulties in building up and sustaining interpersonal relationships Although the co-diagnosis rates, according to the categorical criteria in use, are limited (0%-6.4%), it is common to encounter diagnostic doubts in clinical practice. Here we investigated the dimensions of narcissistic vulnerability and grandiosity in a sample of 87 adults diagnosed with ASD without intellectual disabilities through the administration of the Pathological Narcissism Inventory-52 Items (PNI-52). The mean scores of our sample were compared with the normative distribution available in the literature, and we found that individuals with ASD scored significantly higher than neurotypical controls at the Total Score and at the Vulnerable Narcissism subscale, but not at the Grandiose Narcissism subscales. Demographic features did not influence these results. Vulnerable narcissism was significantly associated with the "Ritvo Autism and Asperger Diagnostic Scale - Revised" subscale Social Relatedness. These findings could potentially be indicative of a greater comorbidity rate between the two disorders with respect to the one reported to date, possibly because DSM-5 criteria are mainly focused on the grandiose dimension. Potential explanatory links between ASD phenomenology and vulnerable narcissism, such as the personality dimension of neuroticism, are discussed, together with the possible role of narcissistic vulnerability in mediating internalizing symptoms (e.g., anxiety, depression) in individuals with ASD.

Measuring the Autistic Women's Experience (AWE)

We developed a Dutch questionnaire called the Autistic Women's Experience (AWE) and compared its psychometric properties to the Autism Spectrum Quotient (AQ). Whilst attenuated gender differences on the AQ have been widely replicated, this instrument may not fully capture the unique experience of autistic women. The AWE was co-developed with autistic women to include items that reflect autistic women's experience. We investigated the AWE (49 items) and compared it with the AQ (50 items) in Dutch autistic individuals (N = 153, n = 85 women) and in the general population (N = 489, n = 246 women) aged 16+. Both the AQ and AWE had excellent internal consistency and were highly and equally predictive of autism in both women and men. Whilst there was a gender difference on the AQ among non-autistic people (men > women), there was no gender difference among autistic people, confirming all earlier studies. No gender differences were detected on the AWE overall scale, yet subtle gender differences were observed on the subscales. We conclude that the AQ is valid for both genders, but the AWE provides an additional useful perspective on the characteristics of autistic women. The AWE needs further validation in independent samples using techniques that allow for testing gender biases, as well as a confirmatory factor analysis in a larger sample.

Autism Spectrum Disorders in forensic psychiatric investigations-patterns of comorbidity and criminality

Background

There are contradictory research findings regarding whether individuals with Autism Spectrum Disorders (ASDs) are more or less likely to commit crimes. The aims of the current study were to: (1) Describe psychiatric and crime-related characteristics of a large group of offenders with ASD who had undergone a Forensic Psychiatric Investigation (FPI). (2) Identify clinical subgroups among this group of offenders. (3) Investigate associations between the identified clinical subgroups and (a) psychiatric comorbidity (b) types of crimes and (c) criminal responsibility.

Methods

The study cohort consists of all subjects (n = 831) who received an ASD-diagnosis at an FPI between 2002 and 2018 in Sweden. Descriptive and clinical, as well as crime related variables were obtained from the FPIs. Non-parametric (Pearson χ2, Fisher's exact and Mann-Whitney U-test) inferential statistics were used for analyses of between-group differences and effect sizes were reported. A Latent Class Analysis was used to identify homogeneous subgroups (or classes) from categorical characteristics.

Results

The cohort consisted of 708 men and 123 women, aged 18 to 74 yrs. Two-thirds (66.7%) of the cohort had at least one other psychiatric diagnosis, the most prevalent was substance use disorder (SUD). A severe mental disorder, equivalent to lack of criminal responsibility, was most often reported among offenders with a comorbid diagnosis of schizophrenia spectrum disorder. The most common type of crime was violent crime. Three person-oriented clinical subgroups were identified; (1) ASD with few other diagnoses; (2) ASD and very high levels of SUDs, plus moderate levels of other externalizing disorders and psychotic psychopathology and (3) ASD and moderate to high levels of personality disorders (other than ASPD) and SUDs.

Conclusion

Our results highlight the importance of all parts of the CJS to be prepared to handle offenders with ASD, often with high levels of additional psychiatric problems. Traditional approaches in treatment or other psychosocial interventions for ASD may need to be adapted to at least three general clinical profiles- one with mainly neurodevelopmental problems, one with a spectrum of externalizing problems and one with complex personality related difficulties.

Altered Relationship between Functional Connectivity and Fiber-Bundle Structure in High-Functioning Male Adults with Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a pervasive neurodevelopmental disorder characterized by abnormalities in structure and function of the brain. However, how ASD affects the relationship between fiber-bundle microstructures and functional connectivity (FC) remains unclear. Here, we analyzed structural and functional images of 26 high-functioning adult males with ASD, alongside 26 age-, gender-, and full-scale IQ-matched typically developing controls (TDCs) from the BNI dataset in the ABIDE database. We utilized fixel-based analysis to extract microstructural information from fiber tracts, which was then used to predict FC using a multilinear model. Our results revealed that the structure-function relationships in both ASD and TDC cohorts were strongly aligned in the primary cortex but decoupled in the high-order cortex, and the ASD patients exhibited reduced structure-function relationships throughout the cortex compared to the TDCs. Furthermore, we observed that the disrupted relationships in ASD were primarily driven by alterations in FC rather than fiber-bundle microstructures. The structure-function relationships in the left superior parietal cortex, right precentral and inferior temporal cortices, and bilateral insula could predict individual differences in clinical symptoms of ASD patients. These findings underscore the significance of altered relationships between fiber-bundle microstructures and FC in the etiology of ASD.

Autism spectrum disorders in adults and the autonomic nervous system: Heart rate variability markers in the diagnostic procedure

The diagnostic assessment of autism spectrum disorders (ASD) in adults is a challenging and time-consuming procedure. In order to address the lack of specialised health-care professionals and improve the waiting time, we aimed to identify specific electrocardiogram (ECG) derived Heart Rate Variability (HRV) parameters that could be used for diagnostic purposes. 152 patients were diagnosed based on a standardised clinical procedure and assigned to one of three groups: ASD (n = 56), any other psychiatric disorder (OD) (n = 72), and patients with no diagnosis (ND) (n = 24). Groups were compared using ANOVA. Discriminative power of biological parameters and the clinical assessment were compared using receiver operating characteristic curves (ROCs). Patients with ASD showed reduced parasympathetic and increased sympathetic activity compared to ND. The accuracy determined by the area under the curve (AUC) of the biological parameters for discrimination between ASD vs. pooled OD/ND was 0.736 (95% CI = 0.652-0.820), compared to .856 (95% CI = 0.795-0.917) for the extensive clinical assessment. Our results confirmed the dysregulation of the autonomic nervous system in ASD with reduced parasympathetic and increased sympathetic activity as compared to ND. The discriminative power of biological markers including HRV was considerable and could supplement less sophisticated clinical assessments.

Comorbidity of mental health and autism spectrum disorder: perception of practitioners in management of their challenging behaviour

The relationship between mental health problems, Autism Spectrum Disorder (ASD) and challenging behaviour among children and adolescents is complex and multifaceted. The study investigated practitioners' perception of comorbidity of mental health and ASD in the management of challenging behaviours among children and adolescents in Kenya. Target population was 3490 practitioners. Sample size was 1047, comprising of 38 assessment staff, 27 mental health workers 548 regular teachers, 294 teachers from special schools, and 140 teachers from special units for children with ASD. Stratified and purposive sampling techniques were used. Interviews and structured questionnaires were used. Test-retest yielded a coefficient of 0.78 while Cronbachs' reliability coefficient was 0.830. There was a positive significant correlation between perception of challenging behaviours and mental health problems (r = .415, p = .000). Challenging behaviour perceptions have a negative significant effect on behaviour management strategies, (β = -0.163, p = .000) implying that the choice of management strategies is dependent on the perceptions. Challenging behaviours accounts for 2.7% variance in the choice of the management strategies, R2 = .027, F(1,1045) = 28.471, p = .000.The practitioners' perception of mental health and comorbid ASD, showed that children with ASD, when enduring life stressors, can be at a higher risk of mental health difficulties than their peers There is need for multidisciplinary synergy in developing effective challenging behaviour programmes for children and adolescents with ASD.

Psychiatric Comorbidities in Children and Adolescents with High-Functioning Autism Spectrum Disorder: A Study on Prevalence, Distribution and Clinical Features in an Italian Sample

This study investigated the prevalence and distribution of psychiatric comorbidities in a group of 472 children and adolescents with ASD aged 3-18 years. We examined differences in age, sex, IQ, adaptive skills, and ASD symptom severity by comparing participants with ASD (ASD group) with participants with ASD and a psychiatric disorder (ASD/PSY group). Overall, 32.2% of participants had a comorbid psychiatric condition. Attention deficit/hyperactivity disorder (ADHD) was the most frequent diagnosis among preschoolers (20.4%); among school-age children, ADHD and anxiety/obsessive-compulsive disorders were the most frequent conditions (21% and 10.6%, respectively); finally, adolescents exhibit higher prevalence of anxiety/obsessive-compulsive disorders (21.8%). The ASD/PSY group showed a higher percentage of males, they were older and showed lower adaptive skills than the group with ASD; moreover, their mothers exhibited higher stress levels than mothers of participants in the ASD group. The comparison between age groups in participants within ASD/PSY group revealed that preschoolers had lower IQ than school-age children and adolescents, and worse adaptive skills, more repetitive behaviors, and restricted interests than adolescents. This study highlights the importance of an accurate diagnosis of psychiatric comorbidities in children and adolescents with ASD, also considering individual and family impairment.

Comorbidities in Youth with Bipolar Disorder: Clinical Features and Pharmacological Management

BACKGROUND

Bipolar Disorder (BD) is a highly comorbid condition, and rates of cooccurring disorders are even higher in youth. Comorbid disorders strongly affect clinical presentation, natural course, prognosis, and treatment.

METHODS

This review focuses on the clinical and treatment implications of the comorbidity between BD and Attention-Deficit/Hyperactivity Disorder, disruptive behavior disorders (Oppositional Defiant Disorder and/or Conduct Disorder), alcohol and substance use disorders, Autism Spectrum Disorder, anxiety disorders, Obsessive-Compulsive Disorder, and eating disorders.

RESULTS

These associations define specific conditions which are not simply a sum of different clinical pictures, but occur as distinct and complex combinations with specific developmental pathways over time and selective therapeutic requirements. Pharmacological treatments can improve these clinical pictures by addressing the comorbid conditions, though the same treatments may also worsen BD by inducing manic or depressive switches.

CONCLUSION

The timely identification of BD comorbidities may have relevant clinical implications in terms of symptomatology, course, treatment and outcome. Specific studies addressing the pharmacological management of BD and comorbidities are still scarce, and information is particularly lacking in children and adolescents; for this reason, the present review also included studies conducted on adult samples. Developmentally-sensitive controlled clinical trials are thus warranted to improve the prognosis of these highly complex patients, requiring timely and finely personalized therapies.

Choice behavior in autistic adults: What drives the extreme switching phenomenon?

BACKGROUND

Previous studies reported that autistic adolescents and adults tend to exhibit extensive choice switching in repeated experiential tasks. However, a recent meta-analysis showed that this switching effect was non-significant across studies. Furthermore, the relevant psychological mechanisms remain unclear. We examined the robustness of the extreme choice-switching phenomenon, and whether it is driven by a learning impairment, feedback-related aspects (e.g., avoiding losses), or alternatively a different information sampling strategy.

METHODS

We recruited an online sample of 114 US participants (57 autistic adults and 57 non-autistic). All participants performed the Iowa Gambling task, a four-option repeated choice task. Standard task blocks were followed by a trial block with no feedback.

RESULTS

The findings replicate the extreme choice switching phenomenon (Cohen's d = 0.48). Furthermore, the effect was found with no difference in average choice rates denoting no learning impairment, and was even observed in trial blocks with no feedback (d = 0.52). There was no evidence that the switching strategy of autistic individuals was more perseverative (i.e., that similar switching rates were used in subsequent trial blocks). When adding the current dataset to the meta-analysis, the choice switching phenomenon is significant across studies, d = 0.32.

CONCLUSIONS

The findings suggest that the increased choice switching phenomenon in autism may be robust and that it represents a distinct information sampling strategy and not poor implicit learning (or a bias in the sensitivity to losses). Such extended sampling may underlie some of the phenomena previously attributed to poor learning.

Abnormal Dynamic Functional Network Connectivity in Adults with Autism Spectrum Disorder

PURPOSE

This study sought to explore changes of brain dynamic functional network connectivity (dFNC) in adults with autism spectrum disorder (ASD) and investigate their relationship with clinical manifestations.

METHODS

Resting-state functional magnetic resonance imaging (rs-fMRI) data were acquired from 78 adult ASD patients from autism brain imaging data exchange datasets, and 65 age-matched healthy controls subjects from the local community. Independent component analysis was conducted to evaluate dFNC patterns on the basis of 13 independent components (ICs) within 11 resting-state networks (RSN), namely, auditory network (AUDN), basal ganglia network (BGN), language network (LN), sensorimotor network (SMN), precuneus network (PUCN), salience network (SN), visuospatial network (VSN), dorsal default mode network (dDMN), high visual network (hVIS), primary visual network (pVIS), ventral default mode network (vDMN). Fraction time, mean dwell time, number of transitions, and RSN connectivity were calculated for group comparisons. Correlation analyses were performed between abnormal metrics and autism diagnostic observation schedule (ADOS) scores.

RESULTS

Compared with controls, ASD patients had higher fraction time and mean dwell time in state 2 (P = 0.017, P = 0.014). Reduced dFNC was found in the SMN with PUCN, SMN with hVIS, and increased dFNC was observed in the dDMN with SN in state 2 in the ASD group. Fraction time and mean dwell time was positively correlated with stereotyped behavior scores of ADOS.

CONCLUSION

The findings demonstrated the importance of evaluating transient alterations in specific neural networks of adult ASD patients. The abnormal metrics and connectivity may be related to symptoms such as stereotyped behavior.

Pharmacotherapy for bipolar disorder in adults with high-functioning autism

INTRODUCTION

The association between high-functioning autism (HFA) and bipolar disorder (BD) in adult subjects has been confirmed by a growing number of studies. However, identifying and treating BD in this population is a clinical challenge and requires careful assessment and adequate knowledge of both disorders.

AREAS COVERED

This review aims to provide a clinical presentation of mood episodes in HFA individuals, and an update on the pharmacotherapy of BD in these individuals, sharing with the reader expert opinion on the current state of the art and future perspectives.

EXPERT OPINION

BD has an atypical clinical presentation in HFA subjects with the possibility of diagnostic and therapeutic mistakes. Despite the absence of controlled studies, the available evidence indicates mood stabilizers, especially lithium, as the first treatment option. HFA subjects are particularly vulnerable to pharmacological side effects, such as extrapyramidal and catatonic symptoms with antipsychotics, or activation syndrome with antidepressants. Accordingly, initial titration of these drugs should be slow and their use should be limited in time. Among antipsychotics, dopamine receptor antagonists with combined serotonergic activity are preferable. Further research is needed to improve the diagnostic process and to delineate the effectiveness of different drugs for BD in HFA subjects.

Memantine for autism spectrum disorder

BACKGROUND

Autism spectrum disorder (ASD; also known as autism) is a developmental disability that begins in childhood and is typically seen in around 1% to 2% of children. It is characterised by social communication difficulties and repetitive and restricted behaviours and routines that can have a negative impact on a child's quality of life, achievement at school, and social interactions with others. It has been hypothesised that memantine, which is traditionally used to treat dementia, may be effective in reducing the core symptoms of autism as well as some co-occurring symptoms such as hyperactivity and language difficulties. If memantine is being used to treat the core symptoms of autism, it is important to review the evidence of its effectiveness.

OBJECTIVES

To assess the effects of memantine on the core symptoms of autism, including, but not limited to, social communication and stereotypical behaviours.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, nine other databases and three trials registers up to February 2022. We also checked reference lists of key studies and checked with experts in the field for any additional papers. We searched for retractions of the included studies in MEDLINE, Embase, and the Retraction Watch Database. No retractions or corrections were found.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of any dose of memantine compared with placebo in autistic people. We also included RCTs in which only one group received memantine, but both groups received the same additional therapy (e.g. a behaviour intervention).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were core autism symptoms and adverse effects. Secondary outcomes were language, intelligence, memory, adaptive behaviour, hyperactivity, and irritability. We used GRADE to assess certainty of evidence.

MAIN RESULTS

We included three RCTs (two double-blind and one single-blind) with 204 participants that examined the short-term effect (immediately postintervention) of memantine in autistic people. Two studies took place in the USA and the other in Iran. All three studies focused on children and adolescents, with a mean age of 9.40 (standard deviation (SD) 2.26) years. Most participants were male (range across studies 73% to 87%). The diagnosis of ASD was based on the Diagnostic and Statistical Manual of Mental Disorders (4th edition; 4th edition, text revision; or 5th edition). To confirm the diagnosis, one study used the Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview-Revised (ADI-R); one used ADOS, ADI-R or the Autism Diagnostic Interview Screener; and one used the Gilliam Autism Rating Scale. Dosage of memantine was based on the child's weight and ranged from 3 mg to 15 mg per day.  Comparisons  Two studies examined memantine compared with placebo; in the other study, both groups had a behavioural intervention while only one group was given memantine.  Risk of bias All studies were rated at high risk of bias overall, as they were at high or unclear risk of bias across all but four domains in one study, and all but two domains in the other two studies. One study was funded by Forest Laboratories, LLC, (Jersey City, New Jersey), Allergan. The study sponsor was involved in the study design, data collection (via contracted clinical investigator sites), analysis and interpretation of data, and the decision to present these results. The other two studies reported no financial support or sponsorship; though in one of the two, the study medication was an in-kind contribution from Forest Pharmaceuticals. Primary outcomes There was no clear evidence of a difference between memantine and placebo with respect to severity of core symptoms of autism, although we are very uncertain about the evidence. The standardised mean difference in autism symptoms score in the intervention group versus the control group was -0.74 standard deviations (95% confidence interval (CI) -2.07 to 0.58; 2 studies, 181 participants; very low-certainty evidence; medium effect size); lower scores indicate less severe autistic symptoms. Two studies (144 participants) recorded adverse effects that the authors deemed related to the study and found there may be no difference between memantine and placebo (odds ratio (OR) 0.64, 95% CI 0.17 to 2.39; low-certainty evidence). Secondary outcomes There may be no difference between memantine and placebo on language (2 studies, 144 participants; low-certainty evidence); memory or adaptive behaviour (1 study, 23 participants; both low-certainty evidence); or hyperactivity or irritability (1 study, 121 participants; both low-certainty evidence).

AUTHORS' CONCLUSIONS

It is unclear whether memantine is an effective treatment for autistic children. None of the three included trials reported on the effectiveness of memantine in adults. Further studies using rigorous designs, larger samples, longer follow-up and clinically meaningful outcome measures that are important to autistic people and their families will strengthen our knowledge of the effects of memantine in autism.

Egocentric norm in health-based decision making of patients on the autistic spectrum

BACKGROUND

Individuals diagnosed with autism spectrum disorder (ASD) without intellectual disability (ID) may have advanced mental reasoning; however, symptomology may vary within the population. Possible symptomology includes communication problems, difficulty relating to people, things, and events, and sensory sensitivity. Current concepts in determining health behavior are not applicable to the ASD without ID population.

AIM

The aim of this analysis is to define the concept of egocentric norm in the context of health-based decisions of adults diagnosed with ASD without ID and to support improved nursing practice with this population.

DESIGN

The Walker and Avant approach was used. Model, borderline, and contrary cases are offered.

DATA SOURCE

Literature search yielded 47 peer reviewed papers that were included in the analysis.

REVIEW METHODS

Uses of the concept were reviewed, following the Walker and Avant approach.

RESULTS

Egocentric norm is defined as an individual's ability to perceive, adapt, and respond to information and potential consequences of personal health behavior based on self-evaluation and the immediate environment with limited regard to peer and family influence.

CONCLUSIONS

The new concept of egocentric norm may account for the unique dynamics presented by adults with ASD without ID, which may impact health behaviors and actions.

Population-Based Psychiatric Comorbidity in Children and Adolescents With Autism Spectrum Disorder: A Meta-Analysis

Psychiatric comorbidity in autism spectrum disorder (ASD) is a subject of critical scientific importance, affecting the quality of life, prognosis, and functional outcomes. The prevalence of psychiatric disorders vary considerably according to variables such as index subject characteristics, study setting, sampling frame, diagnostic methods used, as well as country of geographic origin. To date, most studies comprise clinical or treatment referral samples in tertiary care or subjects enrolled in clinical trials and genetic cohort collections. Such samples carry the potential for overestimation of both the frequency and severity of psychiatric comorbidity. A systematic literature search was performed using PubMed and Web of Science databases restricted to population-based study publications in the English between May 1, 2015, and May 31, 2020. A comprehensive keyword list was generated to investigate co-occurrence of psychiatric disorders in children and adolescents with ASD. A wide range of DSM-5 based disorders such as anxiety, mood, ADHD, intellectual disability/intellectual developmental disorder, eating/feeding, gender dysphoria and sleep-wake disorders were assessed. Initial search revealed a total of 1674 articles after removal of duplicates. Two independent researchers conducted a parallel-blinded screening process to identify the eligible studies based on titles and abstracts; 39 studies were analyzed in the current review. The main findings show prevalence estimates of 22.9% (95% CI: 17.7- 29.2) for intellectual disability; 26.2% (22-31) for attention-deficit hyperactivity disorder; 11.1% (8.6-14.1) for anxiety disorders; 19.7% (11.9-30.7) for sleep disorders; 7% (5.2- 9.3) for disruptive disorders; 2% (1.3- 3.1) for bipolar disorders; 2.7% (1.8- 4.2) for depression; 1.8% (0.4-8.7) for obsessive-compulsive disorder; and 0.6% (0.3-1.1) for psychosis. Psychiatric comorbidity in population-based studies is lower than in clinical and referred samples. However, our results also indicate that the frequency of psychiatric comorbidity in children and adolescents with ASD in the population context is considerable, without the influence of referral bias implicit in clinical and treatment samples. There is a need for better targeted diagnostic tools to detect psychiatric comorbidity in children and youth in future population-based studies, as an essential component in providing care as well as new insights into the nature and mechanisms of its underlying associations.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42021234464].

Autism spectrum disorder and personality disorders: Comorbidity and differential diagnosis

BACKGROUND

Differential diagnosis, comorbidities and overlaps with other psychiatric disorders are common among adults with autism spectrum disorder (ASD), but clinical assessments often omit screening for personality disorders (PD), which are especially common in individuals with high-functioning ASD where there is less need for support.

AIM

To summarize the research findings on PD in adults with ASD and without intellectual disability, focusing on comorbidity and differential diagnosis.

METHODS

PubMed searches were performed using the key words "Asperger's Syndrome", "Autism", "Personality", "Personality disorder" and "comorbidity" in order to identify relevant articles published in English. Grey literature was identified through searching Google Scholar. The literature reviews and reference sections of selected papers were also examined for additional potential studies. The search was restricted to studies published up to April 2020. This review is based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method.

RESULTS

The search found 22 studies carried out on ASD adults without intellectual disability that met the inclusion criteria: 16 evaluated personality profiles or PD in ASD (comorbidity), five compared ASD and PD (differential diagnosis) and one performed both tasks. There were significant differences in the methodological approaches, including the ASD diagnostic instruments and personality measures. Cluster A and cluster C PD are the most frequent co-occurring PD, but overlapping features should be considered. Data on differential diagnosis were only found with cluster A and cluster B PD.

CONCLUSION

ASD in high-functioning adults is associated with a distinct personality profile even if variability exists. Further studies are needed to explore the complex relationship between ASD and PD.

A preliminary study on abnormal brain function and autistic behavior in mice caused by dcf1 deletion

Autism is one of the urgent problems in neuroscience. Early research in our laboratory found that dcf1 gene-deficient mice exhibited autistic behavior. Reviewing the literature, we know that the caudate putamen (CPu) brain region is closely related to the occurrence of autism. In this study, we observed that the electrical signal in the abnormal brain region of adult mice was enhanced by using field potential detection for the corresponding brain region. We then used retrovirus markers to track neurons in the CPu brain region and found that there are neural projections in the hippocampus-CPu brain region. Therefore, we selected DREADDs (Designer receptors exclusively activated by designer drugs) to inhibit the abnormal brain region of the mouse and found, through behavioral testing, that this can inhibit the autistic behavior of mice. This research provides new evidence for the understanding of the cause of autism and has accumulated new basis for the treatment of autism. It has theoretical significance and potential application value for the understanding and treatment of autism.

Risk factors of violent offending in mentally ill prisoners with autism spectrum disorders

BACKGROUND

Results of research regarding a possible causal relation between autism spectrum disorders (ASDs) and violence are mixed. Several explanations have been proposed.

AIMS

To assess prevalence rates of comorbid disorders in a large sample of mentally ill offenders diagnosed with ASD. Offenders with and without comorbid mental disorders were compared on several characteristics. To better understand the relationship between ASD and violent criminal behavior, the predictive value of several proposed risk factors (comorbidity, negative social network/influenceability, and childhood trauma/victimization) on violent offending was investigated.

METHOD

Data of 394 male offenders with a diagnosis of ASD were included. Prevalence rates of comorbid mental disorders next to ASD were calculated, and characteristics were compared using chi-square or t-tests. The predictive value of the risk factors was assessed using a binary logistic regression (n = 357).

RESULTS

High rates of comorbidity were found (78.9%), specifically for substance use disorders (39.8%), schizophrenia spectrum disorders (31.7%), and neurodevelopmental disorder other than ASD (24.1%). Offenders with and without comorbidity differed significantly in their criminal and mental health care history. Both comorbidity (OR = 1.68; 95% CI 1.27-2.18) and a negative social network/influenceability (OR = 1.49; 95% CI 1.11-1.99) showed to be significant predictors of violent offending within this sample.

CONCLUSIONS

The highest rates of comorbid disorders found were disorders that have been previously linked to violent offending, and the risk of violent offending could be unrelated to ASD. However, the role of social functioning indicates a risk specific to the symptoms of ASD.

The comorbidity between autism spectrum disorder and post-traumatic stress disorder is mediated by brooding rumination

LAY ABSTRACT

Autism spectrum disorder is a neurodevelopmental condition characterized by social communication difficulties and restricted repetitive behaviors. Individuals with autism spectrum disorder are often diagnosed with other psychiatric conditions, including attention deficit hyperactivity disorder, anxiety, and depression. However, research on post-traumatic stress disorder among individuals with autism spectrum disorder is scarce. Nonetheless, studies have shown that those with autism spectrum disorder may face an increased risk of exposure to traumatic events. Separate lines of research in autism spectrum disorder and post-traumatic stress disorder have shown that the two may share several vulnerability factors. One of those is ruminative thinking, that is, one's tendency to re-hash thoughts and ideas, in a repetitive manner. This article examined the role of two rumination types as potential factors connecting autism spectrum disorder and post-traumatic stress disorder: brooding (continuously comparing one's current condition to one's desired condition) and reflection (an introspective effort to cognitively solve one's problems). A total of 34 adults with autism spectrum disorder (with no intellectual impairment) and 66 typically developing adults completed questionnaires assessing post-traumatic stress disorder symptoms and rumination. The results showed increased post-traumatic stress disorder symptoms in adults with autism spectrum disorder, compared to typically developing adults. Brooding rumination was also higher among those with autism spectrum disorder. Finally, brooding, but not reflection, served as a mechanism connecting autism spectrum disorder and post-traumatic stress disorder, that is, those with autism spectrum disorder showed increased brooding, which in turn predicted more post-traumatic stress disorder symptoms. This study has potential clinical implications. Rumination and cognitive inflexibility, which are common in autism spectrum disorder, could exacerbate post-traumatic symptoms among individuals with autism spectrum disorder who experience traumatic events. Interventions targeting brooding rumination and cognitive flexibility may assist in alleviating post-traumatic symptoms in individuals with autism spectrum disorder.

Autism - A Comprehensive Array of Prominent Signs and Symptoms

BACKGROUND

Autism Spectrum Disorder (ASD) is a multifaceted neurodevelopmental condition characterized by multiple psychological and physiological impairments in young children. According to the recent reports, 1 out of every 58 newly-born children is suffering from autism. The aetiology of the disorder is complex and poorly understood, hindering the adaptation of targeted and effective therapies. There are no well- established diagnostic biomarkers for autism. Hence the analysis of symptoms by the pediatricians plays a critical role in the early intervention.

METHODS

In the present report, we have emphasized 24 behavioral, psychological and clinical symptoms of autism.

RESULTS

Impaired social interaction, restrictive and narrow interests, anxiety, depression; aggressive, repetitive, rigid and self-injurious behavior, lack of consistency, short attention span, fear, shyness and phobias, hypersensitivity and rapid mood alterations, high level of food and toy selectivity; inability to establish friendships or follow the instructions; fascination by round spinning objects and eating non-food materials are common psychological characteristics of autism. Speech or hearing impairments, poor cognitive function, gastrointestinal problems, weak immunity, disturbed sleep and circadian rhythms, weak motor neuromuscular interaction, lower level of serotonin and neurotransmitters, headache and body pain are common physiological symptoms.

CONCLUSION

A variable qualitative and quantitative impact of this wide range of symptoms is perceived in each autistic individual, making him/her distinct, incomparable and exceptional. Selection and application of highly personalized medical and psychological therapies are therefore recommended for the management and treatment of autism.

The influence of autistic symptoms on social and non-social cognition and on real-life functioning in people with schizophrenia: Evidence from the Italian Network for Research on Psychoses multicenter study

Background

Autism spectrum disorders (ASDs) and schizophrenia spectrum disorders (SSDs), although conceptualized as separate entities, may share some clinical and neurobiological features. ASD symptoms may have a relevant role in determining a more severe clinical presentation of schizophrenic disorder but their relationships with cognitive aspects and functional outcomes of the disease remain to be addressed in large samples of individuals.

Aims

To investigate the clinical, cognitive, and functional correlates of ASD symptoms in a large sample of people diagnosed with schizophrenia.

Methods

The severity of ASD symptoms was measured with the PANSS Autism Severity Scale (PAUSS) in 921 individuals recruited for the Italian Network for Research on Psychoses multicenter study. Based on the PAUSS scores, three groups of subjects were compared on a wide array of cognitive and functional measures.

Results

Subjects with more severe ASD symptoms showed a poorer performance in the processing speed (p = 0.010), attention (p = 0.011), verbal memory (p = 0.035), and social cognition (p = 0.001) domains, and an overall lower global cognitive composite score (p = 0.010). Subjects with more severe ASD symptoms also showed poorer functional capacity (p = 0.004), real-world interpersonal relationships (p < 0.001), and participation in community-living activities (p < 0.001).

Conclusions

These findings strengthen the notion that ASD symptoms may have a relevant impact on different aspects of the disease, crucial to the life of people with schizophrenia. Prominent ASD symptoms may characterize a specific subpopulation of individuals with SSD.

Autism and Williams syndrome: Dissimilar socio-cognitive profiles with similar patterns of abnormal gene expression in the blood

LAY ABSTRACT

Autism spectrum disorders and Williams syndrome are complex cognitive conditions exhibiting quite opposite features in the social domain: whereas people with autism spectrum disorders are mostly hyposocial, subjects with Williams syndrome are usually reported as hypersocial. At the same time, autism spectrum disorders and Williams syndrome share some common underlying behavioral and cognitive deficits. It is not clear, however, which genes account for the attested differences (and similarities) in the socio-cognitive domain. In this article, we adopted a comparative molecular approach and looked for genes that might be differentially (or similarly) regulated in the blood of people with these conditions. We found a significant overlap between genes dysregulated in the blood of patients compared to neurotypical controls, with most of them being upregulated or, in some cases, downregulated. Still, genes with similar expression trends can exhibit quantitative differences between conditions, with most of them being more dysregulated in Williams syndrome than in autism spectrum disorders. Differentially expressed genes are involved in aspects of brain development and function (particularly dendritogenesis) and are expressed in brain areas (particularly the cerebellum, the thalamus, and the striatum) of relevance for the autism spectrum disorder and the Williams syndrome etiopathogenesis. Overall, these genes emerge as promising candidates for the similarities and differences between the autism spectrum disorder and the Williams syndrome socio-cognitive profiles.

Building Skills, Confidence, and Wellness: Psychosocial Effects of Soft Skills Training for Young Adults with Autism

Recognizing that social functioning and mental health are linked to social participation and employment outcomes, this pilot study examined the preliminary outcomes of an eight-session, work-related social skills training program designed for young adults with high-functioning autism (HFASD). Results indicate statistically significant improvements in social cognition, social function, and social confidence. Furthermore, participants (n = 26) reported statistically significant reductions in anxiety, and a trend toward lessening depressive symptoms. These results suggest that: (1) social skills training is suitable for individuals with HFASD and clinically-significant levels of anxiety and/or depression, and (2) bolstered social functioning may have broader, cyclical impacts on social confidence, psychological wellness, and social and vocational participation in this population.

Trajectories of co-occurring psychopathology symptoms in autism from late childhood to adulthood

Given high rates of co-occurring conditions in youth and adults with autism spectrum disorder (ASD), it is critical to examine the developmental trajectories of these symptoms of psychopathology. Using data from a cohort of participants (n = 194), most of whom were first assessed for ASD in very early childhood, we investigated the trajectories of co-occurring depressive, anxiety, and attention-deficit hyperactivity disorder (ADHD) symptoms from late childhood to adulthood. Additionally, childhood predictors and adult outcomes associated with these symptom trajectories were examined. Using group-based trajectory modeling, we found two distinct classes of individuals exhibiting each of these co-occurring symptom patterns: one class exhibited fairly low symptoms across time, and one class with elevated symptoms with varied fluctuation across time (ADHD symptoms starting high but decreasing, anxiety symptoms high and stable, and depressive symptoms fluctuating but peaking at clinically significant levels in young adulthood). All high trajectory classes were associated with age 9 adaptive skills; verbal IQ predicted higher anxiety and depressive symptom classes. After accounting for verbal IQ, all high symptom trajectory classes were negative predictors of objective adult outcomes. These findings call for wide-ranging considerations of the needs of individuals across ability levels, autism symptoms, and behavioral and emotional challenges.

Early maturation of the social brain: How brain development provides a platform for the acquisition of social-cognitive competence

Across the last century psychology has provided a lot of insight about social-cognitive competence. Recognizing facial expressions, joint attention, discrimination of cues and experiencing empathy are just a few examples of the social skills humans acquire from birth to adolescence. However, how very early brain maturation provides a platform to support the attainment of highly complex social behavior later in development remains poorly understood. Magnetic Resonance Imaging provides a safe means to investigate the typical and atypical maturation of regions of the brain responsible for social cognition in as early as the perinatal period. Here, we first review some technical challenges and advances of using functional magnetic resonance imaging on developing infants to then describe current knowledge on the development of diverse systems associated with social function. We will then explain how these characteristics might differ in infants with genetic or environmental risk factors, who are vulnerable to atypical neurodevelopment. Finally, given the rapid early development of systems necessary for social skills, we propose a new framework to investigate sensitive time windows of development when neural substrates might be more vulnerable to impairment due to a genetic or environmental insult.

Social Cognition in a Research Domain Criteria Perspective: A Bridge Between Schizophrenia and Autism Spectra Disorders

Schizophrenia and autism spectra disorders are currently conceptualized as distinct clinical categories. However, the relationship between these two nosological entities has been revisited in recent years due to the evidence that they share some important clinical and neurobiological features, putting into question the nature and the extent of their commonalities and differences. In this respect, some core symptoms that are present in both disorders, such as social cognitive deficits, could be a primary target of investigation. This review briefly summarizes the commonalities and overlapping features between schizophrenia and autism spectra disorders in social cognitive functions, considering this construct in a Research Domain Criteria perspective. The clinical manifestation of deficits in social cognition are similar in schizophrenia spectrum disorders and autism spectrum disorders, and brain areas that appear to be altered in relation to these impairments are largely shared; however, the results of various studies suggest that, in some cases, the qualitative nature of these alterations may be different in the two spectra. Moreover, relevant differences could be present at the level of brain networks and connections. More research is required in this field, regarding molecular and genetic aspects of both spectra, to better define the neurobiological mechanisms involved in social cognition deficits, with the objective of developing specific and targeted treatments.

Psychiatric comorbidities in Asperger syndrome are related with polygenic overlap and differ from other Autism subtypes

There is great phenotypic heterogeneity within autism spectrum disorders (ASD), which has led to question their classification into a single diagnostic category. The study of the common genetic variation in ASD has suggested a greater contribution of other psychiatric conditions in Asperger syndrome (AS) than in the rest of the DSM-IV ASD subtypes (Non_AS). Here, using available genetic data from previously performed genome-wide association studies (GWAS), we aimed to study the genetic overlap between five of the most related disorders (schizophrenia (SCZ), major depression disorder (MDD), attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorders (OCD) and anxiety (ANX)), and AS, comparing it with the overlap in Non_AS subtypes. A Spanish cohort of autism trios (N = 371) was exome sequenced as part of the Autism Sequencing Consortium (ASC) and 241 trios were extensively characterized to be diagnosed with AS following DSM-IV and Gillberg's criteria (N = 39) or not (N = 202). Following exome imputation, polygenic risk scores (PRS) were calculated for ASD, SCZ, ADHD, MDD, ANX, and OCD (from available summary data from Psychiatric Genomic Consortium (PGC) repository) in the Spanish trios' cohort. By using polygenic transmission disequilibrium test (pTDT), we reported that risk for SCZ (P_scz= 0.008, corrected-P_SCZ = 0.0409), ADHD (P_ADHD = 0.021, corrected-P_ADHD = 0.0301), and MDD (P_MDD = 0.039, corrected-P_MDD = 0.0501) is over-transmitted to children with AS but not to Non_AS. Indeed, agnostic clustering procedure with deviation values from pTDT tests suggested two differentiated clusters of subjects, one of which is significantly enriched in AS (P = 0.025). Subsequent analysis with S-Predixcan, a recently developed software to predict gene expression from genotype data, revealed a clear pattern of correlation between cortical gene expression in ADHD and AS (P < 0.001) and a similar strong correlation pattern between MDD and AS, but also extendable to another non-brain tissue such as lung (P < 0.001). Altogether, these results support the idea of AS being qualitatively distinct from Non_AS autism and consistently evidence the genetic overlap between AS and ADHD, MDD, or SCZ.

Developmental changes in attention to social information from childhood to adolescence in autism spectrum disorders: a comparative study

BACKGROUND

Elucidating developmental changes in the symptoms of autism spectrum disorder (ASD) is important to support individuals with ASD. However, no report has clarified the developmental changes in attention to social information for a broad age range. The aim of this study was to investigate the developmental changes in attention to social information from early childhood to adolescence in individuals with ASD and typically developed (TD) children.

METHODS

We recruited children with ASD (n = 83) and TD participants (n = 307) between 2 and 18 years of age. Using the all-in-one-eye-tracking system, Gazefinder, we measured the percentage fixation time allocated to areas of interest (AoIs) depicted in movies (the eyes and mouth in movies of a human face with/without mouth motion, upright and inverted biological motion in movies showing these stimuli simultaneously, people and geometry in preference paradigm movies showing these stimuli simultaneously, and objects with/without finger-pointing in a movie showing a woman pointing toward an object). We conducted a three-way analysis of variance, 2 (diagnosis: ASD and TD) by 2 (sex: male and female) by 3 (age group: 0-5, 6-11, and 12-18 years) and locally weighted the scatterplot smoothing (LOESS) regression curve on each AoI.

RESULTS

In the face stimuli, the percentage fixation time to the eye region for the TD group increased with age, whereas the one for the ASD group did not. In the ASD group, the LOESS curves of the gaze ratios at the eye region increased up to approximately 10 years of age and thereafter tended to decrease. For the percentage fixation time to the people region in the preference paradigm, the ASD group gazed more briefly at people than did the TD group.

LIMITATIONS

It is possible that due to the cross-sectional design, the degree of severity and of social interest might have differed according to the subjects' age.

CONCLUSIONS

There may be qualitative differences in abnormal eye contact in ASD between individuals in early childhood and those older than 10 years.

Structural white matter alterations in male adults with high functioning autism spectrum disorder and concurrent depressive symptoms; a diffusion tensor imaging study

BACKGROUND

Autism spectrum disorder (ASD), a prevalent developmental condition, is associated with comorbid mood disorders, most importantly depression. Here, we explored the underlying association between brain white matter microstructural integrity, assessed by diffusion tensor imaging (DTI), and depressive symptoms, in male adults with high-functioning ASD.

METHOD

To assess our main purpose, Autism Brain Imaging Data Exchange II dataset was used to acquire brain diffusion imaging from 26 adult male patients with ASD ranging from 18 to 62 years of age, and 26 age and gender-matched typically developed control subjects. Participants were evaluated for depressive symptoms manifestation by the Beck Depression Index (BDI). DWI images were preprocessed and analyzed for DTI scalers in the "ExploreDTI" toolbox. Adjusted linear regression models were used. Association between normalized BDI score and its interaction with diagnosis, as predictors, and measures of fractional anisotropy (FA) and mean diffusivity (MD) of regions of interest according to Mori atlas was assessed.

RESULT

Significant lower microstructural integrity of white matter was found in association with higher BDI scores in ASD group, mainly in regions of anterior limb of internal capsule (ALIC) and corona radiata. Also, a statistically significant positive interaction between BDI and ASD was seen in FA of left ALIC.

DISCUSSION

Considering similar regional brain white matter involvement with the imaging studies of depression in the typically developed population, we propose that these alterations of white matter tracts in depressive symptoms of adult ASD subjects might be, at least, similar to depression in typically developed population.

Risk of non-affective psychotic disorder or bipolar disorder in autism spectrum disorder: a longitudinal register-based study in the Netherlands

BACKGROUND

Individuals with autism spectrum disorder (ASD) appear to be at increased risk of non-affective psychotic disorder (NAPD) and bipolar disorder (BD). However, most previous studies examined the co-occurrence of ASD and NAPD or BD, ignoring possible diagnostic bias and selection bias. We used longitudinal data from Dutch psychiatric case registers to assess the risk of NAPD or BD among individuals with ASD, and compared the results to those obtained for the Dutch population in earlier studies.

METHODS

Individuals with ASD (n = 17 234) were followed up between 16 and 35 years of age. Kaplan-Meier estimates were used to calculate the risk of NAPD or BD. We conducted separate analyses to reduce possible bias, including an analysis among individuals diagnosed with ASD before age 16 years (n = 8337).

RESULTS

Of the individuals with ASD, 23.50% (95% confidence interval 21.87-25.22) were diagnosed with NAPD and 3.79% (3.06-4.69) with BD before age 35 years. The corresponding figures for the general population were 0.91% (0.63-1.28) and 0.13% (0.08-0.20). Risk estimates were substantially lower, but still higher than general population estimates, when we restricted our analyses to individuals diagnosed with ASD before age 16, with 1.87% (1.33-2.61) being diagnosed with NAPD and 0.57% (0.21-1.53) with BD before age 25 years. The corresponding figures for the general population were 0.63% (0.44-0.86) and 0.08% (0.05-0.12).

CONCLUSIONS

Individuals with ASD are at increased risk of NAPD or BD. This is likely not the result of diagnostic or selection bias.

Obsessive-compulsive Disorder with Comorbid Bipolar Disorders: Clinical Features and Treatment Implications

BACKGROUND

Obsessive-compulsive disorder (OCD) symptoms within the context of a bipolar disorder (BD) have been described since the 19th century. Interestingly, the existence of a relevant overlap between the aforementioned psychiatric syndromes has been confirmed by a number of recent epidemiological and family studies.

AIMS

The aim of the present paper is to review the clinical features and the therapeutic implications of the OCD-BD comorbidity.

DISCUSSION

In the last two decades, the frequent association between OCD and BD has been earning a growing interest given its relevant nosological and therapeutic implications. Usually patients suffering from OCD-BD comorbidity show a peculiar clinical course, characterized by a larger number of concomitant depressive episodes and episodic course. In these cases, the treatment with antidepressants is more likely to elicit hypomanic or manic switches, while mood stabilizers significantly improve the overall clinical picture. Moreover, OCD-BD patients are frequently comorbid with a number of other psychiatric disorders, in particular anxiety disorders, social phobia, and different substance abuses, such as alcohol, nicotine, caffeine and sedatives.

CONCLUSIONS

BD-OCD comorbidity needs further investigations in order to provide more solid evidences to give patients a more precise clinical diagnosis and a more targeted therapeutic approach.

A case of mistaken diagnoses: diagnostic and management challenges in a case of adult autism spectrum disorder

Autism spectrum disorder (ASD) is frequently identified in children but is often unrecognised in adults. ASD is characterised by difficulties in social interaction, communication and restricted interests, but other presentations are common, especially in adults. This report describes a 34-year-old man with a history of multiple psychiatric diagnoses including generalised anxiety disorder, major depressive disorder and panic disorder. He was diagnosed with ASD in his early 30s and engaged in a targeted treatment plan, including rationalisation of medications, supportive therapy and occupational therapy, which successfully facilitated discharge from mental health services. This case illustrates the atypical presentation of ASD in adults, which is diagnostically challenging. Such cases often present to community mental health services and may be misdiagnosed as treatment resistant cases of depressive, anxiety or personality disorders. Accurate diagnosis and targeted management is more likely to yield a successful outcome.

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.

Overview of genetic models of autism spectrum disorders

Autism spectrum disorders (ASDs) are a group of neurodevelopment disorders that are characterized by heterogenous cognitive deficits and genetic factors. As more ASD risk genes are identified, genetic animal models have been developed to parse out the underlying neurobiological mechanisms of ASD. In this review, we discuss a subset of genetic models of ASD, focusing on those that have been widely studied and strongly linked to ASD. We focus our discussion of these models in the context of the theories and potential mechanisms of ASD, including disruptions in cell growth and proliferation, spine dynamics, synaptic transmission, excitation/inhibition balance, intracellular signaling, neuroinflammation, and behavior. In addition to ASD pathophysiology, we examine the limitations and challenges that genetic models pose for the study of ASD biology. We end with a review of innovative techniques and concepts of ASD pathology that can be further applied to and studied using genetic ASD models.

Leisure participation and satisfaction in autistic adults and neurotypical adults

Leisure participation is important for well-being and has been attributed to improved quality of life for autistic individuals. Rigorous studies exploring the leisure participation of autistic adults are sparse. This study aimed to compare the type of leisure activity and frequency of participation between autistic adults and neurotypical adults as well as compare and identify factors associated with their leisure satisfaction. Data for 145 autistic and 104 neurotypical adults were obtained from time point one of the Australian Longitudinal Study of Adults with Autism. The primary outcome measure used was the Leisure Satisfaction Scale. Autistic adults were less satisfied with their leisure overall (mean = 3.29, standard deviation = 0.75) compared with neurotypical adults (mean = 3.69, standard deviation = 0.55). Multiple linear regression revealed being younger and reporting less depressive symptoms were significantly associated with higher leisure satisfaction in autistic but not neurotypical adults. Engagement in solitary leisure activities was comparable across participants, but socialising in person was predominated by neurotypical adults. Leisure activity preferences of autistic adults' and the frequency of their leisure participation are important factors for clinicians to understand when working with this population and tailoring well-being interventions.

The genetic architecture of schizophrenia, bipolar disorder, obsessive-compulsive disorder and autism spectrum disorder

Considerable evidence suggests that autism spectrum disorders (ASD), schizophrenia (SCZ), bipolar disorder (BD) and obsessive-compulsive disorder (OCD) share a common molecular aetiology, despite their unique clinical diagnostic criteria. The aim of this study was therefore to determine and characterise the common and unique molecular architecture of ASD, SCZ, BD and OCD. Gene lists were obtained from previously published studies for ASD, BD, SCZ and for OCD. Genes identified to be common to all disorders, or unique to one specific disorder, were included for enrichment analyses using the web-server tool Enrichr. Ten genes were identified to be commonly associated with the aetiology of ASD, SCZ, BD and OCD. Enrichment analyses determined that these genes are predominantly involved in the dopaminergic and serotonergic pathways, the voltage-gated calcium ion channel gene network, folate metabolism, regulation of the hippo signaling pathway, and the regulation of gene silencing and expression. In addition to well-characterised and previously described pathways, regulation of the hippo signaling pathway was commonly associated with ASD, SCZ, BD and OCD, implicating neural development and neuronal maintenance as key in neuropsychiatric disorders. In contrast, a large number of previously associated genes were shown to be disorder-specific. And unique disorder-specific pathways and biological processes were presented for ASD, BD, SCZ and OCD aetiology. Considering the current global incidence and prevalence rates of mental health disorders, focus should be placed on cross-disorder commonalities in order to realise actionable and translatable results to combat mental health disorders.

Comprehensive Description of Comorbidity for Autism Spectrum Disorder in a General Population

CONTEXT

Few published studies of autism spectrum disorder (ASD) and comorbidity are population based.

OBJECTIVE

To describe the comorbidity of ASD and disorders listed in the main classes of the International Classification of Diseases, Ninth Revision (ICD-9) in a general population.

DESIGN

Direct physician billing data for the city of Calgary, Alberta, Canada, for the treatment of any presenting concern in the Calgary Health Zone (n = 763,449) from 1994 to 2009 were extracted. Diagnosed ICD-9 disorders (independent variable) were grouped into 17 categories using ICD-9 diagnosis codes. ASD (dependent variable) was classified under ICD-9 Code 299. Individuals with and without independent disorder classes were counted by the presence or absence of any ASD. Odds ratios (ORs) and 95% confidence intervals of the association were calculated.

MAIN OUTCOME MEASURES

ORs of ASD comorbidities.

RESULTS

Annual rates of ASD increased 3.9-fold for males and 1.4-fold for females. Diagnosed disorders ranked by OR in the independent ICD-9 categories indicated that males with ASD had overall higher ORs (> 1.0) in 11 main ICD-9 classes, and females with ASD had higher ORs (> 1.0) in 12 main ICD-9 classes. Males with ASD had lower ORs in 4 main ICD-9 disease classes; females with ASD had lower ORs related only to the main class "complications of pregnancy and childbirth." Five main ICD-9 classes were not significant for males or females.

CONCLUSIONS

Patients with ASD have significant comorbidity of physical disorders. This finding may inform other areas of research and assessment in clinical management.

Psychiatric Co-occurring Symptoms and Disorders in Young, Middle-Aged, and Older Adults with Autism Spectrum Disorder

Although psychiatric problems are less prevalent in old age within the general population, it is largely unknown whether this extends to individuals with autism spectrum disorders (ASD). We examined psychiatric symptoms and disorders in young, middle-aged, and older adults with and without ASD (N_max = 344, age 19–79 years, IQ > 80). Albeit comparable to other psychiatric patients, levels of symptoms and psychological distress were high over the adult lifespan; 79 % met criteria for a psychiatric disorder at least once in their lives. Depression and anxiety were most common. However, older adults less often met criteria for any psychiatric diagnosis and, specifically, social phobia than younger adults. Hence, despite marked psychological distress, psychiatric problems are also less prevalent in older aged individuals with ASD.