Autism: from research to practice

Are the diagnostic rates of autistic females increasing? An examination of state-wide trends

BACKGROUND

Autism has been considered a 'male-dominant' condition. However, recent research suggests that autistic females are underdiagnosed, misdiagnosed, and later diagnosed. Females may also have different and more nuanced behavioral profiles. To examine diagnosis rates of females, we used 20 years of state-wide data to characterize historical trends in the diagnosis of autism in females to determine whether the proportion of females diagnosed with autism has changed over time.

METHODS

Data were drawn from 10,247 participants (males = 8,319, females = 1928) who received an autism diagnosis between 2000 and 2021 from state-wide autism centers associated with the University of North Carolina TEACCH Autism Program.

RESULTS

The rates of females diagnosed with autism increased at a greater rate compared with males. Age of diagnosis remained consistently higher for females. Late diagnosis (defined as 13+) increased over time across both males and females, however, was more commonly associated with females, particularly those with co-occurring intellectual disability.

CONCLUSIONS

Our results indicate that the proportion of females diagnosed with autism has increased steadily over a 20-year period, which likely reflects greater societal knowledge of how autism may manifest differentially in females.

Are minimally verbal autistic children's modality and form of communication associated with parent responsivity?

Prior work examined how minimally verbal (MV) children with autism used their gestural communication during social interactions. However, interactions are exchanges between social partners. Examining parent-child social interactions is critically important given the influence of parent responsivity on children's communicative development. Specifically, parent responses that are semantically contingent to the child's communication plays an important role in further shaping children's language learning. This study examines whether MV autistic children's (N = 47; 48-95 months; 10 females) modality and form of communication are associated with parent responsivity during an in-home parent-child interaction (PCI). The PCI was collected using natural language sampling methods and coded for child modality and form of communication and parent responses. Findings from Kruskal-Wallis H tests revealed that there was no significant difference in parent semantically contingent responses based on child communication modality (spoken language, gesture, gesture-speech combinations, and AAC) and form of communication (precise vs. imprecise). Findings highlight the importance of examining multiple modalities and forms of communication in MV children with autism to obtain a more comprehensive understanding of their communication abilities; and underscore the inclusion of interactionist models of communication to examine children's input on parent responses in further shaping language learning experiences.

Robust diagnostic classification via Q-learning

Machine learning (ML) models have demonstrated the power of utilizing clinical instruments to provide tools for domain experts in gaining additional insights toward complex clinical diagnoses. In this context these tools desire two additional properties: interpretability, being able to audit and understand the decision function, and robustness, being able to assign the correct label in spite of missing or noisy inputs. This work formulates diagnostic classification as a decision-making process and utilizes Q-learning to build classifiers that meet the aforementioned desired criteria. As an exemplary task, we simulate the process of differentiating Autism Spectrum Disorder from Attention Deficit-Hyperactivity Disorder in verbal school aged children. This application highlights how reinforcement learning frameworks can be utilized to train more robust classifiers by jointly learning to maximize diagnostic accuracy while minimizing the amount of information required.

Communicating Without Words: School-Based RCT Social Intervention in Minimally Verbal Peer Dyads with ASD

Despite their social withdrawal, school-age children with autism spectrum disorder who are minimally verbal (MVASD; i.e., use a limited repertoire of communicative spoken words) have received few interventions supporting peer engagement. This study examined efficacy of a novel ecological randomized controlled trial-school-based peer social intervention-designed to increase social engagement (via available communication channels) in school-age peer dyads with MVASD. Fifty-four children with MVASD (8-16 years) in 9 Israeli special education schools were randomly assigned to conversation intervention, collaboration intervention, or waitlisted treatment-as-usual (control) group (n = 18 per group). Manualized conversation and collaboration interventions each included 60 lessons (15 weeks × 4), implemented by teachers at school and supervised by researchers. Pretest-posttest improvement in spontaneous peer interaction was measured via 3 data sources/methods: teacher-reported social behavior (Vineland: Socialization domain) and direct observations of children's spontaneous free play (Modified-Classroom Observation Schedule to Measure Intentional Communication) and free conversation (Social Conversation Scale). Allocation group was masked from reporters/coders. As secondary outcomes, children's progress was measured in executive functions (BRIEF Inventory), and communication (Vineland). Significant pre-post improvement emerged for both intervention groups' spontaneous free conversation and for the collaboration group's spontaneous free play. Teacher reports, although mixed, indicated that the conversation group's socialization skills improved, but communication did not. Children in the conversation group also improved their metacognitive executive skills (e.g., planning, monitoring, organization). Strengthening this high-risk school-age population's ability to interact more spontaneously with peers through conversation and collaboration intervention holds promise for reducing social withdrawal in MVASD.

Diagnosis and treatment of ASD in women in secure and forensic hospitals

Purpose

The purpose of this paper is to explore the experience and possibilities for misdiagnosis of women with ASD in secure and forensic hospitals, via the medium of a lived experience case study. To consider the clinical value of the patient perspective of and insight into their disorder. The case study is supplemented by relevant associations to the MHA Code of Practice, the CQC report, Monitoring the Mental Health Act (MHA) 2016–2017, published on 27 February 2018 and current research findings in the fields of service provision, quality of care and treatment of female patients with a diagnosis of ASD.

Design/methodology/approach

A review and commentary of the author’s lived experience of a formal diagnostic assessment for ASD as a female patient in a secure and forensic hospital. In reviewing aspects of the author’s clinical assessment, the author has made contextual reference to the MHA Code of Practice, the CQC report, Monitoring the MHA 2016–2017, published on 27 February 2018, and current research findings. The account focuses on aspects of the author’s recent experience assessment and treatment for ASD which the author believes may be of use in informing clinical practice.

Findings

Open-ended exploration of a lived experience account/case study of a diagnostic assessment of an adult female patient for ASD, demonstrating the possible ambiguity of responses to questionnaire-based assessment tools and other deficiencies inherent to the assessment process and care and treatment of adult female ASD sufferers in secure and forensic hospitals.

Research limitations/implications

The author uses the lived experience as a patient to review and provide commentary on the clinical assessment for ASD. This review is, therefore, informed by an authentic patient perspective and not clinical perspectives. This paper highlights the need for further research into the diagnostic assessment of females for ASD in a secure and forensic hospitals.

Practical implications

First, to encourage practitioners to extend their range of thinking to be more inclusive of the patient perspective when performing a diagnostic assessment. Second, to increase practitioner awareness of the deficiencies in the current service provision for adult female patients diagnosed with ASD in secure and forensic hospitals.

Social implications

To improve patient experience of diagnostic assessment for ASD and the quality of the assessment and patient outcomes in secure and forensic hospitals.

Originality/value

The paper is original in concept in that it considers the inclusion of patient experience/views in assessment and formulation and links them to wider social policy and practice guidance. The case study is an authentic patient account informed by the author’s experience of secure and forensic psychiatric hospitals. The value of the paper may be determined by the extent to which the paper encourages practitioners to consider the patient perspective and experience of the diagnostic assessment and how this and subsequent care and treatment may affect the adult female patient in secure and forensic hospitals.

Community readiness assessment for disseminating evidence-based physical activity programs to older adults in Changsha, China: a case for Enhance®Fitness

Physical activity (PA) has declined in China due to urbanization in the past two decades. Evidence-based programs are good approaches to promote PA, but are limited in China. Adopting existing programs can be a viable option. Prior to that, readiness assessment is needed. This study aimed to assess community readiness levels for disseminating evidence-based PA programs to older adults in Changsha, China. In-person interviews were conducted with 33 participants of five districts in Changsha to assess the community readiness level in five dimensions: community knowledge of efforts, community climate, community knowledge about the issue, leadership and resources. Data was transcribed, reviewed and compared with an anchored rating scale to provide a stage of readiness score ranging from 1 (no awareness) to 9 (high level of community ownership). Participants included 14 community staff, 13 older adults, four community leaders and three health professionals. The top three barriers to disseminating PA programs were lack of appropriate locations, funding and instructors. The top three resources were availability of indoor space, chairs and loudspeakers. Community leadership was the highest-rated readiness dimension (3.3 out of 9) followed by community climate (3.2), community knowledge of efforts (3.1) and resources (2.8); knowledge about the issue scored the lowest (2.7). The overall community stage readiness score of Changsha was 3.0 out of 9. The stage of readiness for communities in Changsha, China is 'vague awareness'. Developing strategies to improve community readiness levels may increase evidence-based PA program dissemination in Changsha, China.

Autism spectrum disorder in adults: diagnosis, management, and health services development

Autism spectrum disorder (ASD) is a common neurodevelopmental disorder characterized by pervasive difficulties since early childhood across reciprocal social communication and restricted, repetitive interests and behaviors. Although early ASD research focused primarily on children, there is increasing recognition that ASD is a lifelong neurodevelopmental disorder. However, although health and education services for children with ASD are relatively well established, service provision for adults with ASD is in its infancy. There is a lack of health services research for adults with ASD, including identification of comorbid health difficulties, rigorous treatment trials (pharmacological and psychological), development of new pharmacotherapies, investigation of transition and aging across the lifespan, and consideration of sex differences and the views of people with ASD. This article reviews available evidence regarding the etiology, legislation, diagnosis, management, and service provision for adults with ASD and considers what is needed to support adults with ASD as they age. We conclude that health services research for adults with ASD is urgently warranted. In particular, research is required to better understand the needs of adults with ASD, including health, aging, service development, transition, treatment options across the lifespan, sex, and the views of people with ASD. Additionally, the outcomes of recent international legislative efforts to raise awareness of ASD and service provision for adults with ASD are to be determined. Future research is required to identify high-quality, evidence-based, and cost-effective models of care. Furthermore, future health services research is also required at the beginning and end of adulthood, including improved transition from youth to adult health care and increased understanding of aging and health in older adults with ASD.

European clinical network: autism spectrum disorder assessments and patient characterisation

The United Nations and World Health Organisation have identified autism spectrum disorder (ASD) as an important public health issue across global mental health services. Although a range of tools exist to identify and quantify ASD symptoms, there is a lack of information about which ASD measures are used in different services worldwide. This paper presents data from a large survey of measures used for patient characterisation in major ASD research and clinical centres across Europe collected between June 2013 and January 2014. The objective was to map the use of different instruments used to characterise ASD, comorbid psychopathology and cognitive and adaptive ability for patient diagnostic and characterisation purposes across Europe. Sixty-six clinical research sites diagnosing 14,844 patients per year contributed data. The majority of sites use the well-established Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview (ADI) instruments, though the proportion of sites in Western Europe using the ADI was almost double the rate in Eastern Europe. Approximately half the sites also used the Social Communication Questionnaire (SCQ) and Social Responsiveness Scale (SRS), although use of the SRS was over three times higher in Western Europe compared with Eastern Europe. The use of free/open access measures was lower than commercially available tools across all regions. There are clinical and scientific benefits in encouraging further convergence of clinical characterisation measures across ASD research and clinical centres in Europe to facilitate large-scale data sharing and collaboration, including clinical trials of novel medications and psychological interventions.

The role of behavior in translational models for psychopathology: functionality and dysfunctional behaviors

The history of science has frequently included a problem-based impetus toward research that can be translated expeditiously into solutions. A current problem is that psychopathologies, typically chronic, contribute hugely to the economic and social burden of medical care, especially in the United States. For behavioral neuroscientists a psychopathology-aimed translational research emphasis particularly involves animal models to facilitate the experimental and invasive work necessary to an understanding of the biology of normal and aberrant behavior. When the etiology of a particular psychopathology is unknown, and there are no specific biomarkers, behavioral parallels between the focal disorder and its putative models become crucial elements in assessing model validity. Evaluation of these parallels is frequently neglected, reflecting in part the lack of a systematic conceptualization of the organization of behavior and how this may be conserved across species. Recent work specifically attempting to bridge this gap suggests that analysis of behaviors that are functional - adaptive in crucial situations such as danger or social contexts - can facilitate an understanding of the parallels between behaviors of human and nonhuman species, including the dysfunctional behaviors of psycho pathologies. As research with animal models comes to provide a more systematic analysis of particular behaviors and their adaptive functions, cross-talk between model and focal psychopathology may be advantageous to understanding both.

Toward developmental models of psychiatric disorders in zebrafish

Psychiatric disorders are a diverse set of diseases that affect all aspects of mental function including social interaction, thinking, feeling, and mood. Although psychiatric disorders place a large economic burden on society, the drugs available to treat them are often palliative with variable efficacy and intolerable side-effects. The development of novel drugs has been hindered by a lack of knowledge about the etiology of these diseases. It is thus necessary to further investigate psychiatric disorders using a combination of human molecular genetics, gene-by-environment studies, in vitro pharmacological and biochemistry experiments, animal models, and investigation of the non-biological basis of these diseases, such as environmental effects. Many psychiatric disorders, including autism spectrum disorder, attention-deficit/hyperactivity disorder, mental retardation, and schizophrenia can be triggered by alterations to neural development. The zebrafish is a popular model for developmental biology that is increasingly used to study human disease. Recent work has extended this approach to examine psychiatric disorders as well. However, since psychiatric disorders affect complex mental functions that might be human specific, it is not possible to fully model them in fish. In this review, I will propose that the suitability of zebrafish for developmental studies, and the genetic tools available to manipulate them, provide a powerful model to study the roles of genes that are linked to psychiatric disorders during neural development. The relative speed and ease of conducting experiments in zebrafish can be used to address two areas of future research: the contribution of environmental factors to disease onset, and screening for novel therapeutic compounds.

Heparan sulfate deficiency in autistic postmortem brain tissue from the subventricular zone of the lateral ventricles

Abnormal cellular growth and organization have been characterized in postmortem tissue from brains of autistic individuals, suggestive of pathology in a critical neurogenic niche, the subventricular zone (SVZ) of the brain lateral ventricles (LV). We examined cellular organization, cell proliferation, and constituents of the extracellular matrix such as N-sulfated heparan sulfate (HS) and laminin (LAM) in postmortem brain tissue from the LV-SVZ of young to elderly individuals with autism (n=4) and age-matched typically developing (TD) individuals (n=4) using immunofluorescence techniques. Strong and systematic reductions in HS immunofluorescence were observed in the LV-SVZ of the TD individuals with increasing age. For young through mature, but not elderly, autistic pair members, HS was reduced compared to their matched TDs. Cellular proliferation (Ki67+) was higher in the autistic individual of the youngest age-matched pair. These preliminary data suggesting that HS may be reduced in young to mature autistic individuals are in agreement with previous findings from the BTBR T+tf/J mouse, an animal model of autism; from mice with genetic modifications reducing HS; and with genetic variants in HS-related genes in autism. They suggest that aberrant extracellular matrix glycosaminoglycan function localized to the subventricular zone of the lateral ventricles may be a biomarker for autism, and potentially involved in the etiology of the disorder.

Autism and exergaming: effects on repetitive behaviors and cognition

Autism is a neurodevelopmental disorder that leads to impairment in social skills and delay in language development, and results in repetitive behaviors and restricted interests that impede academic and social involvement. Physical exercise has been shown to decrease repetitive behaviors in autistic children and improve cognitive function across the life-span. Exergaming combines physical and mental exercise simultaneously by linking physical activity movements to video game control and may yield better compliance with exercise. In this investigation, two pilot studies explored the potential behavioral and cognitive benefits of exergaming. In Pilot I, twelve children with autism spectrum disorders completed a control task and an acute bout of Dance Dance Revolution (DDR); in Pilot II, ten additional youths completed an acute bout of cyber cycling. Repetitive behaviors and executive function were measured before and after each activity. Repetitive behaviors significantly decreased, while performance on Digits Backwards improved following the exergaming conditions compared with the control condition. Additional research is needed to replicate these findings, and to explore the application of exergaming for the management of behavioral disturbance and to increase cognitive control in children on the autism spectrum.

Impaired plasma phospholipids and relative amounts of essential polyunsaturated fatty acids in autistic patients from Saudi Arabia

Backgrounds

Autism is a developmental disorder characterized by social and emotional deficits, language impairments and stereotyped behaviors that manifest in early postnatal life. This study aims to compare the relative concentrations of essential fatty acids (Linoleic and α- linolenic), their long chain polyunsaturated fatty acids and phospholipids in plasma of autistic patients from Saudi Arabia with age-matching controls.

Methods

25 autistic children aged 3-15 years and 16 healthy children as control group were included in this study. Relative concentration of essential fatty acids/long chain polyunsaturated fatty acids and omega-3/omega-6 fatty acid series together with phosphatidylethanolamine, phosphatidylserine and phosphatidylcholine were measured in plasma of both groups.

Results

Remarkable alteration of essential fatty acids/long chain polyunsaturated fatty acids, omeg-3/omega-6 and significant lower levels of phospholipids were reported. Reciever Operating characteristics (ROC) analysis of the measured parameters revealed a satisfactory level of sensitivity and specificity.

Conclusion

Essential fatty acids/long chain polyunsaturated fatty acids and omeg-3/omega-6 ratios, phosphatidylethanolamine, phosphatidylserine and phosphatidylcholine could be used as potential biomarkers that point to specific mechanisms in the development of autism and may help tailor treatment or prevention strategies.