Risk factors for self-injurious behaviours among 222 young children with autistic disorders

Exploring sensory alterations and repetitive behaviors in children with autism spectrum disorder from the perspective of artificial neural networks

BACKGROUND

Restrictive repetitive behaviors (RRBs) and sensory processing disorders are core symptoms of autism spectrum disorder (ASD). Their relationship is reported, but existing data are conflicting as to whether they are related but distinct, or different aspects of the same phenomenon.

AIMS

This study investigates this relationship using artificial neural networks (ANN) analysis and an innovative data mining analysis known as Auto Contractive Map (Auto-CM), which allows to discover hidden trends and associations among complex networks of variables (e.g. biological systems).

METHODS AND PROCEDURES

The Short Sensory Profile and the Repetitive Behavior Scale-Revised were administered to 45 ASD children's caregivers (M 78 %; F 22 %; mean age 6 years). Questionnaires' scores, clinical and demographic data were collected and analyzed applying Auto-CM, and a connectivity map was drawn.

OUTCOMES AND RESULTS

The main associations shown by the resulting maps confirm the known relationship between RBBs and sensory abnormalities, and support the existence of sensory phenotypes, and important links between RRBs and sleep disturbance in ASD.

CONCLUSIONS AND IMPLICATIONS

Our study demonstrates the usefulness of ANNs application and its easy handling to research RBBs and sensory abnormalities in ASD, with the aim to achieve better individualized rehabilitation technique and improve early diagnosis.

PAPER'S CONTRIBUTION

Restricted, repetitive patterns of behaviors and interests and alteration of sensory elaboration are core symptoms of ASD; their impact on patients' quality of life is known. This study introduces two main novelties: 1) the simultaneous and comparative use of two parent questionnaires (SSP and RBS-R) utilized for RRBs and alteration of sensory profile; 2) the application of ANNs to this kind of research. ANNs are adaptive models particularly suited for solving non-linear problems. While they have been widely used in the medical field, they have not been applied yet to the analysis of RRBs and sensory abnormalities in general, much less in children with ASD. The application of Auto Contractive Map (Auto-CM), a fourth generation ANNs analysis, to a dataset previously explored using classical statistical models, confirmed and expanded the associations emerged between SSP and RBS-R subscales and demographic-clinical variables. In particular, the Low Energy subscale has proven to be the central hub of the system; interesting links have emerged between the subscale Self-Injurious Behaviors and the variable intellectual disability and between sleep disturbance and various RRBs. Expanding research in this area aims to guide and modulate an emerging targeted and personalized rehabilitation therapy.

Oral Health Care for Children and Youth With Developmental Disabilities: Clinical Report

Oral health is an essential component of overall health for all individuals. The oral health of children and youth with developmental disabilities (CYDD) involves unique characteristics and needs of which pediatricians and pediatric clinicians can be aware. Risk for oral disease in CYDD is multifactorial and includes underlying medical conditions, medications, and ability to participate in preventive oral health care and treatment, and lack of access to providers is common for this population despite being eligible for Medicaid. Pediatric clinicians are uniquely positioned to support the oral health needs of CYDD and their families through the medical home. This clinical report aims to inform pediatric clinicians about the unique oral health needs of CYDD. It provides guidance on assessing caries risk and periodontal status using structured screening instruments; understanding dental trauma, the role of diet and caries risk, trauma prevention, and malocclusion; and providing anticipatory guidance on oral hygiene that includes tooth brushing, use of fluoridated toothpaste, assessing community water fluoridation, advocating for a dental home by 1 year of age, and transition to adult dental care as part of adolescent health care. It also highlights special considerations for dental treatment rendered under sedation or general anesthesia that CYDD may need. Pediatric clinicians can help reduce risk of CYDD developing dental disease by understanding the unique needs of their patients and their barriers to accessing oral health care in their community, communicating with the child's dental home, and advocating for safe and accessible dental procedures.

Diagnostic overshadowing: self-injurious behaviour as a manifestation of pain in the head and neck

In the healthcare domain, diagnostic overshadowing is a concerning issue involving the erroneous attribution of physical symptoms to a patient's mental health, behavioural intricacies, or pre-existing disabilities. Individuals facing learning and communication challenges are particularly susceptible to this phenomenon, struggling to articulate or comprehend their experienced symptoms. Likewise, patients with autism spectrum disorder can have an escalated risk due to possible challenges in interpreting bodily cues. This article delves into the specialised care required for individuals with learning disabilities and/or autism, highlighting the pervasive risk of diagnostic overshadowing and the potential manifestation of pain as self-injurious behaviour in these patient groups. By underscoring the need to mitigate diagnostic overshadowing within dental practice, we advocate for reasonable adjustments in care delivery and comprehensive education of the dental team. Proficient tools for pain assessment and effective communication are emphasised to collectively improve the healthcare experience for these vulnerable patient cohorts.

Physical Aggression Toward Others and Self: Correlates in Autism, Attention-Deficit/Hyperactivity Disorder, and Population-Based Child Samples

Objective

This is the first study investigating physical aggression toward others and toward self (self-injurious behavior [SIB]) and its association with comorbid disorders and symptoms and demographics in large autism, ADHD, and population-based samples.

Method

The referred sample comprised 2,456 children (1,415 with autism, 739 with ADHD-combined, and 302 with ADHD-inattentive) aged 2 to 17 years. The population-based sample consisted of 665 children evaluated at baseline (6-12 years of age) and 259 reevaluated at follow-up (12-17 years). The Pediatric Behavior Scale was rated by mothers yielding scores on 2 dependent variables: physical aggression ("hits, bites, or throws things at people") and SIB ("bites or hits self, bangs head, or repeats other acts causing self-injury") and 9 independent variables (oppositional behavior, irritability, conduct problems, hyperactivity, impulsivity, autism, inattention, anxiety, and depression).

Results

Physical aggression was strongly linked with the autism and ADHD-combined groups (28% and 20% often a problem) but not the ADHD-inattentive or community group (<2%). SIB was primarily associated with autism (16% often a problem). Irritability, conduct problems, and younger age were significant concurrent predictors of physical aggression in most groups, and irritability predicted SIB in autism and ADHD-combined. IQ, sex, race, and parent occupation were not predictors.

Conclusion

Physical aggression is common in autism and ADHD-combined, whereas SIB is strongly linked with autism. The irritability component of oppositional defiant disorder and not oppositional behavior significantly predicted physical aggression and SIB. In addition to treating aggression directly, addressing irritability with the use of pharmacological, behavioral, and psychosocial interventions may also decrease aggression.

A review of the use of psychotropic medication to address challenging behaviour in neurodevelopmental disorders

Engagement in challenging behaviour (e.g., aggression, self-injury) is reported to occur in neurodevelopmental disorders such as intellectual disabilities (ID), autism spectrum disorder (ASD), and fragile X syndrome (FXS). Common interventions to address these behaviours include both behavioural and pharmacological approaches. Although psychotropic medications are commonly used to address challenging behaviour in ID, ASD, and FXS, demonstration of the effectiveness of treatment is limited. Furthermore, research examining interaction effects between psychotropic medication, challenging behaviour, and environmental events within specific neurodevelopmental disorders such as ID, ASD, and FXS is scarce. The purpose of this chapter is to provide an overview of challenging behaviour within ID, ASD, and FXS and of the effectiveness of psychotropic medication as an intervention for challenging behaviour within these neurodevelopmental disorders. Finally, research examining how psychotropic medication may impact the relationship between challenging behaviour and environmental events is reviewed.

Predicting self-injurious behavior at age three among infant siblings of children with autism

Existing research suggests that self-injurious behavior (SIB) is a relatively common interfering behavior that can occur across the lifespan of individuals with autism spectrum disorder (ASD). We previously reported that SIB or proto-injurious SIB at 12 months was related to increased risk of SIB at 24 months among a preschool sample of children with a high familial likelihood for ASD (Dimian et al., 2017). In the present study, we extend these findings, examine SIB occurrence, and associated potential risk factors at 36 months. The present sample included 149 infants with an older sibling with ASD (65.8% male) who completed assessments at ages 12, 24, and 36 months. Descriptive analyses and binary logistic regression models were utilized. SIB was more prevalent among those children who received a diagnosis of ASD. Logistic regression indicated that presence of SIB, stereotypy, hyper- and hypo- sensory responsivity, and lower intellectual functioning at age 12 months significantly predicted the occurrence of SIB at 36 months. These findings have implications for understanding developmental processes culminating in persistent SIB and may inform prevention programming.

Autism Spectrum Disorder in Children with an Early History of Paediatric Acquired Brain Injury

Autism spectrum disorder (ASD) is a neurodevelopmental condition that arises from a combination of both genetic and environmental risk factors. There is a lack of research investigating whether early acquired brain injury (ABI) may be a risk factor for ASD. The current study comprehensively reviewed all hospital records at The Brain Injury Service, Kids Rehab at the Children's Hospital at Westmead (Australia) from January 2000 to January 2020. Of the approximately 528 cases, 14 children with paediatric ABI were subsequently given an ASD diagnosis (2.7%). For this ASD sample, the mean age at the time of the ABI was 1.55 years, indicating a high prevalence of early ABI in this diagnostic group. The mean age of ASD diagnosis was, on average, 5 years later than the average ASD diagnosis in the general population. Furthermore, 100% of children had at least one medical comorbidity and 73% had three or more co-occurring DSM-5 diagnoses. Although based on a small data set, results highlight early paediatric ABI as a potential risk factor for ASD and the potential for a delayed ASD diagnosis following early ABI, with comorbidities possibly masking symptoms. This study was limited by its exploratory case series design and small sample size. Nonetheless, this study highlights the need for longitudinal investigation into the efficacy of early screening for ASD symptomatology in children who have sustained an early ABI to maximise potential intervention.

Developmental Regression Followed by Epilepsy and Aggression: A New Syndrome in Autism Spectrum Disorder?

Autism spectrum disorder (ASD) with regression (ASD-R) involves the loss of previously attained developmental milestones, typically during the first or second year of life. As children age, it is not uncommon for them to develop comorbid conditions such as aggressive behaviors or epilepsy, which can inhibit habilitation in language and social function. In this paper, we hypothesize that aggressive behaviors and epilepsy more commonly develop in patients with ASD-R than in those without a history of regression (ASD-NR). We conducted a retrospective review of non-syndromic patients with ASD over 12 years of age and compared the rates of epilepsy and aggression between ASD-R and ASD-NR patients. Patients with ASD-R, as compared to ASD-NR patients, demonstrated non-significantly higher rates of epilepsy (51.8% vs. 38.1%, p = 0.1335) and aggressive behaviors (73.2% vs. 57.1%, p = 0.0673) when evaluated separately. The rates for combined epilepsy and aggression, however, were statistically significant when comparing ASD-R versus ASD patients (44.5% vs. 23.8%, p = 0.0163). These results suggest that epilepsy with aggression is more common in ASD-R as compared to ASD-NR patients. When considering the impact of epilepsy and aggression on quality of life, these co-morbidities effectively cause a second regression in patients who experienced an earlier regression as toddlers. A larger, prospective trial is recommended to confirm these associations and further define the timeline in which these characteristics develop from early childhood to adolescence.

Heart Rate as a Predictor of Challenging Behaviours among Children with Autism from Wearable Sensors in Social Robot Interactions

Children with autism face challenges in various skills (e.g., communication and social) and they exhibit challenging behaviours. These challenging behaviours represent a challenge to their families, therapists, and caregivers, especially during therapy sessions. In this study, we have investigated several machine learning techniques and data modalities acquired using wearable sensors from children with autism during their interactions with social robots and toys in their potential to detect challenging behaviours. Each child wore a wearable device that collected data. Video annotations of the sessions were used to identify the occurrence of challenging behaviours. Extracted time features (i.e., mean, standard deviation, min, and max) in conjunction with four machine learning techniques were considered to detect challenging behaviors. The heart rate variability (HRV) changes have also been investigated in this study. The XGBoost algorithm has achieved the best performance (i.e., an accuracy of 99%). Additionally, physiological features outperformed the kinetic ones, with the heart rate being the main contributing feature in the prediction performance. One HRV parameter (i.e., RMSSD) was found to correlate with the occurrence of challenging behaviours. This work highlights the importance of developing the tools and methods to detect challenging behaviors among children with autism during aided sessions with social robots.

Validating the repetitive behavior scale-revised for children in China aged 9 to 16 with autism spectrum disorder

Restricted and repetitive behavior (RRB) is one of the two core diagnostic features used to determine the severity of autism spectrum disorder (ASD). The Repetitive Behavior Scale‑Revised (RBS-R) is widely used to measure the presence and severity of a variety of RRBs in individuals with ASD. Previous studies have implemented a factor analysis framework to examine the RBS-R, while there're still inconsistencies in the use of the measure. This study analyzed the validity and reliability of the RBS-R using data from 315 Chinese children aged 9-16 with ASD. The results showed that the original tested items were adaptable to the Chinese cultural environment when treating such disorders. A confirmatory factor analysis indicated that a 6-factor model was most suitable for evaluating RRB in this context. Consistent with previous studies, the 6-factor model was preferred because of its fit statistics in evaluating RRBs using data from Chinese children with ASD aged 9-16. It's necessary to implement the same structure (e.g. 6-factor model) of the RBS-R to enable efficient comparisons of results across studies. Validating the RBS-R cross different contexts and using longitudinal data are helpful to advance our knowledge of RRB.

Is language ability associated with behaviors of concern in autism? A systematic review

This review systematically synthesized evidence on the association between structural language ability and behaviors of concern (BoC) in autism. Four databases were searched for studies that included >10 autistic participants, measures of structural language (content and/or form of language) and BoC, and an analysis of their association. BoCs included self-injurious behavior (SIB), aggression, tantrums, and externalizing behavior. Methodological quality of studies were assessed using the Newcastle Ottawa Scale. Forty-five publications (n = 11,961) were included. Forty studies were cross-sectional and five were prospective cohort studies. Over 70% of the studies investigating expressive language and SIB (n = 10), aggression (n = 5), tantrums (n = 3), and externalizing behavior (n = 17) reported an inverse association, where lower expressive language ability was associated with increased BoC. Eleven out of sixteen studies of combined expressive and receptive language reported an inverse relationship with SIB or aggression. All outcomes were rated as moderate to very low certainty of evidence. This review highlights evidence showing an inverse association between expressive or combined language ability and SIB, and externalizing behavior in autism. However, further high-quality studies that use standardized, consistent measures of language and behavior and investigate longitudinal associations are needed. Early detection and support for reduced structural language difficulties have substantial potential to assist in reducing BoC.

Teacher- and parent-reported trajectories of maladaptive behaviors among individuals with autism and non-spectrum delays

People with autism spectrum disorder (ASD) and non-spectrum developmental delays frequently exhibit maladaptive behaviors throughout the lifespan, which can have pervasive effects on quality of life. Maladaptive behaviors have been shown to change over time as a function of various individual-level factors (e.g., cognitive ability), yet research is primarily limited to parent-reported measures. To expand upon this work, the present study aimed to examine trajectories of teacher- and parent-reported maladaptive behaviors (i.e., hyperactivity, irritability, social withdrawal) and to test whether individual-level predictors (e.g., autism features, verbal intelligence quotient) and school-related predictors (e.g., teacher type, student-adult ratio, personal aide, school type) impact these trajectories among 165 individuals with ASD or non-spectrum delays from ages 9 to 18. Multilevel models revealed that, according to both teacher and parent report, participants showed the greatest improvement in hyperactivity, less but still notable improvement in irritability, and stable levels of social withdrawal over time. Higher verbal ability and fewer ASD features, in addition to mainstream school placement, emerged as important individual- and school-related differences associated with fewer maladaptive behaviors over time. The multi-informant perspective and longitudinal design provide novel insight into the manifestations of these maladaptive behaviors across different contexts and across time. Findings highlight the consistency of teacher- and parent-reported trajectories over time and further emphasize the importance of targeting maladaptive behaviors using a multisystem intervention approach in both school and home contexts.

Autism spectrum disorder and dentoalveolar trauma: A systematic review and meta-analysis

OBJECTIVES

Patients with autism spectrum disorder (ASD) may be more predisposed to oral pathology, including dentoalveolar trauma. Our aim was to assess the risk of dentoalveolar trauma in patients with ASD.

MATERIALS AND METHODS

Meta-analysis methodology was used to compare the prevalence of dentoalveolar trauma in individuals with ASD compared to individuals without ASD. A literature search was carried out, with predefined inclusion and exclusion criteria, to identify controlled studies evaluating dentoalveolar trauma in individuals with ASD. Data were combined using the random-effects meta-analysis model.

RESULTS

Out of an initial 154 studies, 14 were selected for inclusion in the meta-analysis, resulting in a total of 1488 individuals with ASD. Meta-analysis results showed significant difference in the overall risk of dentoalveolar trauma between individuals with ASD versus a control group (RR = 1.45). Looking at specific types of dentoalveolar trauma, individuals with ASD were found to be more at risk for partial or total (avulsion) luxation injuries (RR = 3.02) than healthy individuals.

CONCLUSIONS

Individuals with ASD are more at risk for dentoalveolar trauma than those without ASD, especially for more severe dentoalveolar trauma such as luxation and avulsion injuries.

Gastrointestinal concerns in children with autism spectrum disorder: A qualitative study of family experiences

LAY ABSTRACT

Gastrointestinal problems are common in the autism spectrum disorder community and may affect both the person with autism spectrum disorder and their families. However, little research is available on the experiences of families who have a child with both autism spectrum disorder and gastrointestinal symptoms. We held one-on-one interviews with 12 parents of children who had both autism spectrum disorder and gastrointestinal symptoms. We analyzed the raw text responses from these interviews and identified four main themes. First, parents shared that their children had trouble verbally communicating when they were experiencing gastrointestinal symptoms (Theme 1). This led parents to use bodily signs, such as changes in the stool, and non-verbal behaviors, such as irritability, to recognize when their child was having gastrointestinal symptoms. Next, gastrointestinal issues affected both the child's well-being and their ability to attend class and extracurricular or social activities (Theme 2). The gastrointestinal issues also affected the family's routines, overall well-being, and their ability to go out and do activities together as a family (Theme 3). Finally, parents often had challenges receiving accessible and quality healthcare for their child's gastrointestinal problems (Theme 4). Together, these findings highlight the enormous burden that gastrointestinal symptoms have on the wellness of children with autism spectrum disorder and their families.

Sibling Influences on Trajectories of Maladaptive Behaviors in Autism

Siblings play an important role in the behavioral trajectories of individuals with autism spectrum disorder (ASD). While having siblings has been associated with positive outcomes in ASD, including stronger adaptive functioning, social and non-verbal communication, and theory of mind, little is known about the impact of siblings on more negative outcomes, such as maladaptive behaviors. To address this gap, the present longitudinal study tested sibling predictors of trajectories of maladaptive behaviors (e.g., teacher- and parent-reported hyperactivity, irritability, and social withdrawal) from childhood through early adulthood among individuals with ASD and non-spectrum delays. Multilevel models revealed that, while the mere presence of a sibling did not impact maladaptive behavior trajectories apart from teacher-reported hyperactivity, the diagnostic profile of the sibling (e.g., emotional/behavioral disorder, ASD, medical condition) emerged as an important predictor. Specifically, although findings varied across teacher and parent reports, more hyperactivity and irritability across time was identified when the sibling had diagnoses of an emotional/behavioral disorder, ASD, and/or a medical condition. Overall, this study provides novel insight into the broader family-level factors that influence the presentation of maladaptive behaviors across time and across contexts.

Auditory-motor mapping training: Testing an intonation-based spoken language treatment for minimally verbal children with autism spectrum disorder

We tested an intonation-based speech treatment for minimally verbal children with autism (auditory-motor mapping training, AMMT) against a nonintonation-based control treatment (speech repetition therapy, SRT). AMMT involves singing, rather than speaking, two-syllable words or phrases. In time with each sung syllable, therapist and child tap together on electronic drums tuned to the same pitches, thus coactivating shared auditory and motor neural representations of manual and vocal actions, and mimicking the "babbling and banging" stage of typical development. Fourteen children (three females), aged 5.0-10.8, with a mean Autism Diagnostic Observation Schedule-2 score of 22.9 (SD = 2.5) and a mean Kaufman Speech Praxis Test raw score of 12.9 (SD = 13.0) participated in this trial. The main outcome measure was percent syllables approximately correct. Four weeks post-treatment, AMMT resulted in a mean improvement of +12.1 (SE = 3.8) percentage points, compared to +2.8 (SE = 5.7) percentage points for SRT. This between-group difference was associated with a large effect size (Cohen's d = 0.82). Results suggest that simultaneous intonation and bimanual movements presented in a socially engaging milieu are effective factors in AMMT and can create an individualized, interactive music-making environment for spoken-language learning in minimally verbal children with autism.

Characteristics of children with autism and unspecified intellectual developmental disorder (intellectual disability) presenting with severe self-injurious behaviours

Objective: This study aims to delineate the characteristics of severe self-injurious behaviors (SIB) in a cohort of children with autism and unspecified intellectual developmental disorder (UIDD) (intellectual disability) and examine potential risk factors for developing SIB. Methods: A retrospective chart review studied characteristics of severe SIB in 30 children with autism spectrum disorder (ASD) and UIDD referred to a tertiary care center. Characteristics examined include genetic syndromes, brain MRI abnormalities, verbal ability, adaptive functioning, SIB frequency and severity, age of onset, number of psychopharmacological agents, irritability, hyperactivity, stereotypy, psychiatric and physical comorbidities, among others. Descriptive and bivariate analysis were applied to explore potential relationships between factors. Results: Children with severe SIB exhibit this behaviour with high frequency, inflicting moderate to severe injury. Most children in the study sample are non-verbal and have ASD (93.3%; n = 28) with psychiatric (96.7%; n = 29) and physical (90%; n = 27) comorbidities. Overall SIB improvement using the Clinical Global Impression, Improvement Score (CGI-I) was 3.0 (minimally improved). A minority were much or very much improved following appropriate intervention. Conclusions: The severity of SIB is much higher in this sample than previously noted in the literature. Severe SIB is associated with ADHD, early onset mood disorders, tics, avoidant restrictive food intake disorder and Obsessive-Compulsive Disorder.

Real-Time Social Robot’s Responses to Undesired Interactions Between Children and their Surroundings

Aggression in children is frequent during the early years of childhood. Among children with psychiatric disorders in general, and autism in particular, challenging behaviours and aggression rates are higher. These can take on different forms, such as hitting, kicking, and throwing objects. Social robots that are able to detect undesirable interactions within its surroundings can be used to target such behaviours. In this study, we evaluate the performance of five machine learning techniques in characterizing five possible undesired interactions between a child and a social robot. We examine the effects of adding different combinations of raw data and extracted features acquired from two sensors on the performance and speed of prediction. Additionally, we evaluate the performance of the best developed model with children. Machine learning algorithms experiments showed that XGBoost achieved the best performance across all metrics (e.g., accuracy of 90%) and provided fast predictions (i.e., 0.004 s) for the test samples. Experiments with features showed that acceleration data were the most contributing factor on the prediction compared to gyroscope data and that combined data of raw and extracted features provided a better overall performance. Testing the best model with data acquired from children performing interactions with toys produced a promising performance for the shake and throw behaviours. The findings of this work can be used by social robot developers to address undesirable interactions in their robotic designs.

A systematic review of risk for the development and persistence of self-injurious behavior in intellectual and developmental disabilities

Self-injurious behavior (SIB) by individuals with intellectual and developmental disabilities including autism (I/DD) is among the most clinically disturbing, socially costly, and scientifically challenging behavior disorders. Forty years of clinical research has produced a knowledge base supporting idiographic behavioral assessment and treatment approaches. Despite the treatment progress, from a public health and population perspective, we argue it is less clear that we have reduced the disorder's burden. The developmental course of the disorder is mostly unknown and empirically informed population-level models of risk are absent. In this review, we systematically examined the published scientific literature specific to risk for SIB in the I/DD population. We reviewed study methodology in detail intentionally informed by an epidemiological perspective with a set of questions intended to test the quality of the inferences about risk. Results are discussed in terms of conceptual, methodological, and translational issues with respect to what needs to be done to create credible and useful clinical models for SIB risk in the I/DD population.

Parenting Programs That Address Physical Abuse in Childhood for Families of Children With Developmental Disabilities in Mainland China: Systematic Review and Meta-Regression

Millions of children in China are diagnosed with developmental disabilities (DD), many of whom are subject to physical abuse. While a significant body of research suggests that parenting interventions can reduce the incidence and risk of such abuse, there is currently limited evidence of their effectiveness for this population or from non-English-speaking countries. This review involved searches in both English and Chinese databases to identify randomized controlled trials and quasi-experimental studies of parenting interventions for families of children with DD in mainland China. Multilevel meta-analyses were undertaken to examine the effectiveness of parenting programs. Subgroup analyses and meta-regression were conducted to investigate heterogeneity and identify potential moderators with a focus on intervention and delivery components. Risk of bias was assessed for each study. Thirty-one studies were included. The results showed that parenting interventions could reduce child emotional and behavioral problems (CEBP) and improve the parent-child relationship, although only one study directly measured the actual incidence of abuse. Programs for autism and epilepsy had stronger treatment effects. Teaching knowledge about CEBP, skills to improve parental mental health, and techniques to cultivate empathy were associated with program success; however, positive reinforcement was associated with more problems. The results also supported the delivery of programs with longer duration, a combination of group and individual sessions, efforts to build rapport, ongoing communication outside the programs, and delivery in hospitals or service agencies. Further research is needed, however, in addition to improvements in the quality of research and reporting.

An open-label prospective pilot trial of nucleus accumbens deep brain stimulation for children with autism spectrum disorder and severe, refractory self-injurious behavior: study protocol

BACKGROUND

Children and youth with autism spectrum disorder (ASD) may manifest self-injurious behaviors (SIB) that may become severe and refractory with limited pharmacologic or behavioral treatment options. Here, we present the protocol of a prospective, mixed-methods study to assess the safety and efficacy of deep brain stimulation (DBS) of the nucleus accumbens (NAcc) for children and youth with ASD and severe, refractory SIB.

METHODS

This is a prospective, single-center, single-cohort, open-label, non-randomized pilot trial of 6 patients. Participants will be recruited through specialized behavioral clinics with persistent severe and refractory SIB following standard and intensive interventions. Following NAcc-DBS, participants will be enrolled in the study for 12 months. The primary objectives of the study are safety and feasibility, assessed by rate of recruitment and identification of factors impacting adherence to follow-up and study protocol. Potential treatment efficacy will be assessed by changes in the Children's Yale-Brown Obsessive-Compulsive Scale in ASD (CYBOCS-ASD), the Behavior Problems Index (BPI), the Inventory of Statements about Self-Injury (ISAS) and the Repetitive Behavior Scale-Revised (RBS-R) questionnaires. Additional clinical outcomes will be assessed, including measures of participant and caregiver quality of life, actigraph measurements, and positron emission tomography (PET) changes following DBS.

DISCUSSION

This study will be the first to evaluate the effect of DBS of the NAcc on a pediatric population in a controlled, prospective trial. Secondary outcomes will improve the understanding of behavioral, neuro-imaging, and electrophysiologic changes in children with ASD and SIB treated with DBS. This trial will provide an estimated effect size of NAcc-DBS for severe refractory SIB in children with ASD in preparation for future comparative trials.

TRIAL REGISTRATION

Registration on ClinicalTrials.gov was completed on 12 June 2019 with the Identifier: NCT03982888 .

Update about "minimally verbal" children with autism spectrum disorder

OBJECTIVE

To review clinical and neurobiological features of minimally verbal children with autism spectrum disorder.

DATA SOURCE

We carried out a narrative review using the PubMed database. We considered the following search terms combined through the Boolean operator "AND": "autism spectrum disorder"; "minimally verbal."

DATA SYNTHESIS

To date, there is no shared definition of minimally verbal children with autism spectrum disorder. The heterogeneity in intellectual functioning and in linguistic abilities among these individuals suggests there is no single mechanism underlying their difficulties in learning to speak. However, the reasons why these children do not speak and the biological markers that can identify them are still unknown. Language impairment in these children can lead to several unfavorable consequences, including behavior problems (such as self-aggression, hetero-aggression, and property destruction), poorer daily living and social skills. Psychiatric comorbidities (including attention deficit/hyperactivity disorder, specific phobias, and compulsions) consist in a serious problem related to the lack of verbal language in individuals with autism spectrum disorder. Although in the literature there are very few evidence-based results, several findings suggest that an alternative and augmentative communication intervention, creating an extra-verbal communication channel, may be effective in these individuals.

CONCLUSIONS

The exact definition, clinical characteristics, associated disorders, etiology, and treatment of minimally verbal subjects with autism spectrum disorder must still be further studied and understood.

QABF - Polish adaptation and validation of the tool for assessing the functions of challenging behaviors

BACKGROUND

Autism spectrum disorders are a diagnostic unit predisposing the occurrence of challenging behaviors. Depending on their frequency and severity, behavioral problems may significantly limit the developmental possibilities of people with ASD, and also significantly affect family life and the therapeutic process. Aggressive, self-injury, destructive or stereotypic behaviors require intervention based on individualized support, the basis of which should be a functional assessment.

AIMS

The aim of the study was to develop and adapt the Polish version of the Question About Behavioral Function (QABF) questionnaire by Matson and Vollmer used to assess the functions of challenging behaviors.

METHOD

Data was obtained from 107 people with ASD. Material was analyzed relating to 168 problem behaviors manifested by these people. To determine the psychometric properties of the tool, reliability and validity analyses were carried out with confirmatory factor analysis using the maximum likelihood method. The Fornell and Larcker method (1981) was used to estimate the convergent and differential validity.

RESULT

The analysis confirmed the structure of 5-factor QABF. Composite reliability (CR) achieved values ​​at a level of 0.855 and higher. An AVE value of above 0.5 for all factors, while at the same time lower than the CR value, confirmed the convergent validity of the tool. The differential value was confirmed on the basis of the AVE and MSV values. The results obtained confirm that the analyzed tool is accurate and reliable.

CONCLUSION

QABF, in the Polish language version, is a reliable tool for assessing the behavioral functions of people with ASD. The limitations of the research are also discussed.

Mindful Parenting, Caregiver Distress, and Conduct Problems in Children With Autism

Children with autism may display an externalizing problem behavior, which are associated with increased parenting stress and depression in caregivers. Mindful parenting is defined as having a non-judgmental moment-to-moment awareness during caregiver-child interactions. The extant literature is mixed, with some reporting that associations between child problem behavior and parenting stress and depression vary by level of mindful parenting, while others have not found these relations. We sought to extend these explorations. Participants who were caregivers of 75 children with autism spectrum disorder (ASD) ages 5-10, in the Pacific Northwestern region of the United States. Child conduct problems, parenting stress and caregiver depression, and mindful parenting were measured using caregiver-reported measures. Child conduct problems, parenting stress, and caregiver depression, and mindful parenting were all significantly correlated. The association between child conduct problems and parenting stress was significant for caregivers with high and low levels of mindful parenting. In contrast, the association between child conduct problems and caregiver depression was significant only for caregivers with low levels of mindful parenting. Our results suggest that mindful parenting may be a promising protective factor for the well-being of caregivers of children with autism. Implications are discussed.

Short-term trajectories of restricted and repetitive behaviors in minimally verbal children with autism spectrum disorder

Very little is known about the 30% of children with Autism Spectrum Disorder (ASD) who remain minimally verbal when they enter school. Restricted and repetitive behaviors (RRBs) are well-characterized in younger, preschool, and toddler samples. However, the prevalence and impact of RRBs has not been characterized in older, minimally verbal children. The goal of this study was to characterize this core diagnostic feature in minimally verbal children with ASD ages 5-8 years over a 9-month period to better understand how these behaviors manifest in this crucially understudied population. RRBs were coded from caregiver-child interactions (CCX) at four timepoints. Upon entry into the study, children demonstrated an average of 17 RRBs during a 10-min CCX. The most common category was Verbal. RRBs remained constant over 6 months; however, a slight reduction was observed at the final timepoint. Compared to prior literature on younger samples, minimally verbal children with ASD demonstrated higher rates of RRBs and higher rates of verbal RRBs. Further work is required to understand the function and impact of RRBs in minimally verbal children. LAY ABSTRACT: Approximately one-third of children with autism spectrum disorder (ASD) remain minimally verbal at the time of school entry. In this study, we sought to characterize the presence of restricted and repetitive behaviors (RRBs) in school-aged children (5-8) who were minimally verbal. Compared to prior studies, minimally verbal children with ASD had higher frequencies of RRBs and demonstrated a different profile of behaviors, including more verbal RRBs.

A Modeling-Guided Case Study of Disordered Speech in Minimally Verbal Children With Autism Spectrum Disorder

Purpose Understanding what limits speech development in minimally verbal (MV) children with autism spectrum disorder (ASD) is important for providing highly effective targeted therapies. This preliminary investigation explores the extent to which developmental speech deficits predicted by Directions Into Velocities of Articulators (DIVA), a computational model of speech production, exemplify real phenotypes. Method Implementing a motor speech disorder in DIVA predicted that speech would become highly variable within and between tokens, while implementing a motor speech plus an auditory processing disorder predicted that DIVA's speech would become highly centralized (schwa-like). Acoustic analyses of DIVA's output predicted that acoustically measured phoneme distortion would be similar between the two cases, but that in the former case, speech would show more within- and between-token variability than in the latter case. We tested these predictions quantitatively on the speech of children with MV ASD. In Study 1, we tested the qualitative predictions using perceptual analysis methods. Speech pathologists blinded to the purpose of the study tallied the signs of childhood apraxia of speech that appeared in the speech of 38 MV children with ASD. K-means clustering was used to create two clusters from the group of 38, and analysis of variance was used to determine whether the clusters differed according to perceptual features corresponding to within- and between-token variability. In Study 2, we employed acoustic analyses on the speech of the child from each cluster who produced the largest number of analyzable tokens to test the predictions of differences in within-token variability, between-token variability, and vowel space area. Results Clusters produced by k-means analysis differed by perceptual features that corresponded to within-token variability. Nonsignificant differences between clusters were found for features corresponding to between-token variability. Subsequent acoustic analyses of the selected cases revealed that the speech of the child from the high-variability cluster showed significantly more quantitative within- and between-token variability than the speech of the child from the low-variability cluster. The vowel space of the child from the low-variability cluster was more centralized than that of typical children and that of the child from the high-variability cluster. Conclusions Results provide preliminary evidence that subphenotypes of children with MV ASD may exist, characterized by (a) comorbid motor speech disorder and (b) comorbid motor speech plus auditory processing disorder. The results motivate testable predictions about how these comorbidities affect speech. Supplemental Material https://doi.org/10.23641/asha.14384432.

Verbal Ability, Behavior Problems, and Mother-Child Relationship Quality in Autism Spectrum Disorder

This study examined differences in mother-child relationship quality and parent-rated child behavior problems based on child verbal status (i.e., minimally verbal versus verbal) in mothers and their adolescent and adult children with autism spectrum disorder (n = 219 dyads; child M_age = 25.38 years, SD = 10.22). Relationship quality was assessed via parent-reported maternal burden and mother-child closeness, and coded speech samples ascertaining maternal critical and positive remarks regarding the child. Groups did not differ in relationship quality. The verbal group was more likely to display disruptive and socially inappropriate behaviors, but otherwise the groups did not differ in behavior problems. Verbal status moderated the relationship between behavior problems and negative (maternal burden, critical remarks) but not positive (mother-child closeness, positive remarks) aspects of relationship quality.

Informing Developmental Milestone Achievement for Children With Autism: Machine Learning Approach

Background

Care for children with autism spectrum disorder (ASD) can be challenging for families and medical care systems. This is especially true in low- and- middle-income countries such as Bangladesh. To improve family–practitioner communication and developmental monitoring of children with ASD, mCARE (Mobile-Based Care for Children with Autism Spectrum Disorder Using Remote Experience Sampling Method) was developed. Within this study, mCARE was used to track child milestone achievement and family sociodemographic assets to inform mCARE feasibility/scalability and family asset–informed practitioner recommendations.

Objective

The objectives of this paper are threefold. First, it documents how mCARE can be used to monitor child milestone achievement. Second, it demonstrates how advanced machine learning models can inform our understanding of milestone achievement in children with ASD. Third, it describes family/child sociodemographic factors that are associated with earlier milestone achievement in children with ASD (across 5 machine learning models).

Methods

Using mCARE-collected data, this study assessed milestone achievement in 300 children with ASD from Bangladesh. In this study, we used 4 supervised machine learning algorithms (decision tree, logistic regression, K-nearest neighbor [KNN], and artificial neural network [ANN]) and 1 unsupervised machine learning algorithm (K-means clustering) to build models of milestone achievement based on family/child sociodemographic details. For analyses, the sample was randomly divided in half to train the machine learning models and then their accuracy was estimated based on the other half of the sample. Each model was specified for the following milestones: Brushes teeth, Asks to use the toilet, Urinates in the toilet or potty, and Buttons large buttons.

Results

This study aimed to find a suitable machine learning algorithm for milestone prediction/achievement for children with ASD using family/child sociodemographic characteristics. For Brushes teeth, the 3 supervised machine learning models met or exceeded an accuracy of 95% with logistic regression, KNN, and ANN as the most robust sociodemographic predictors. For Asks to use toilet, 84.00% accuracy was achieved with the KNN and ANN models. For these models, the family sociodemographic predictors of “family expenditure” and “parents’ age” accounted for most of the model variability. The last 2 parameters, Urinates in toilet or potty and Buttons large buttons, had an accuracy of 91.00% and 76.00%, respectively, in ANN. Overall, the ANN had a higher accuracy (above ~80% on average) among the other algorithms for all the parameters. Across the models and milestones, “family expenditure,” “family size/type,” “living places,” and “parent’s age and occupation” were the most influential family/child sociodemographic factors.

Conclusions

mCARE was successfully deployed in a low- and middle-income country (ie, Bangladesh), providing parents and care practitioners a mechanism to share detailed information on child milestones achievement. Using advanced modeling techniques this study demonstrates how family/child sociodemographic elements can inform child milestone achievement. Specifically, families with fewer sociodemographic resources reported later milestone attainment. Developmental science theories highlight how family/systems can directly influence child development and this study provides a clear link between family resources and child developmental progress. Clinical implications for this work could include supporting the larger family system to improve child milestone achievement.

Unsupervised Machine Learning for Identifying Challenging Behavior Profiles to Explore Cluster-Based Treatment Efficacy in Children With Autism Spectrum Disorder: Retrospective Data Analysis Study

Background

Challenging behaviors are prevalent among individuals with autism spectrum disorder; however, research exploring the impact of challenging behaviors on treatment response is lacking.

Objective

The purpose of this study was to identify types of autism spectrum disorder based on engagement in different challenging behaviors and evaluate differences in treatment response between groups.

Methods

Retrospective data on challenging behaviors and treatment progress for 854 children with autism spectrum disorder were analyzed. Participants were clustered based on 8 observed challenging behaviors using k means, and multiple linear regression was performed to test interactions between skill mastery and treatment hours, cluster assignment, and gender.

Results

Seven clusters were identified, which demonstrated a single dominant challenging behavior. For some clusters, significant differences in treatment response were found. Specifically, a cluster characterized by low levels of stereotypy was found to have significantly higher levels of skill mastery than clusters characterized by self-injurious behavior and aggression (P<.003).

Conclusions

These findings have implications on the treatment of individuals with autism spectrum disorder. Self-injurious behavior and aggression were prevalent among participants with the worst treatment response, thus interventions targeting these challenging behaviors may be worth prioritizing. Furthermore, the use of unsupervised machine learning models to identify types of autism spectrum disorder shows promise.

Relationship between Sensory Alterations and Repetitive Behaviours in Children with Autism Spectrum Disorders: A Parents' Questionnaire Based Study

The relationship between sensory profile and repetitive behaviours in autism spectrum disorder (ASD) has long been known. However, there is no consensus on the type of relationship that exists between them. This monocentric retrospective-prospective observational study aimed (a) to detect a clinical correlation between the severity of repetitive behaviours and the alterations of sensory profile in a sample of 50 children diagnosed with ASD; (b) to evaluate how different patterns of stereotypies and sensory alterations correlate with each other and with the main clinical-instrumental variables in the same sample. We enrolled 29 children in the retrospective phase of the study and 21 in the prospective phase. The Repetitive Behaviour Scale-Revised (RBS-R) and the Short Sensory Profile (SSP) were administered to the caregivers, and clinical-instrumental data were collected. SSP and RBS-R total scores directly correlated with a high significance rate. Among the subscales, the strongest correlations involved "Visual/Auditory Sensitivity", related to "Stereotyped Behaviour" and "Sameness Behaviour". "Under-Responsive/Seeks Sensation" related to "Stereotyped Behaviour". Sex and intellectual disability significantly influenced both the stereotypies and the sensory alterations of the examined population. In conclusion, this study provides new insights into the relationship between sensory alterations and repetitive behaviours in ASD children by using direct medical observation and parent observation.

Intentional Self Harm in Children with Autism

The study examined the demographic, socioeconomic, and clinical correlates of self injurious behaviors (SIBs) in a large clinical sample of children with autism spectrum disorder (ASD). A case record review of 1252 ASD children for whom complete information on socioeconomic background variables and presence/absence of SIBs was available were included. The overall prevalence of SIBs was 22.1% and the most prevalent SIBs were head banging (47%), followed by self hitting (27.8%). Several factors including age at diagnosis (t = 2.09, P = 0.037), education of mother (χ² = 14.48, P = 0.0001), presence of co-morbid medical condition (χ² = 4.22, P = 0.040), intellectual disability (χ² = 23.17, P = 0.0001), sensory processing abnormalities (χ² = 13.01, P = 0.0001), and severity of autism (χ² = 51.13, P = 0.0001) were found to be significantly associated with presence of SIBs. Logistic regression analysis revealed that severity of autism was the only significant predictor of SIBs. Intentional self harm is related with significant morbidity and needs early intervention.

Prevalence and Risk-Markers of Self-Harm in Autistic Children and Adults

Self-harm is purportedly common in autistic individuals, but under-researched, particularly in younger samples and those without intellectual disability. This study aimed to describe prevalence, profile and correlates of self-harm in autistic individuals without impairments in adaptive functioning. Parents of autistic participants (n = 83) completed questionnaires regarding the presence/topography of self-harm, demographic characteristics, autism severity, age of diagnosis, affect, activity levels and repetitive behaviour. 24.10% of participants engaged in self-harm. Self‐harm was associated with significantly higher levels of impulsivity, over-activity, negative affect, compulsive behaviour and insistence on sameness. Low mood and overactivity/impulsivity predicted the presence of self-harm, with the model correctly classifying 82.9% of cases. Findings highlight a role for impaired behavioural inhibition and low mood in the aetiological mechanisms underpinning self-harm in autism.

The Prevalence of Self-injurious Behaviour in Autism: A Meta-analytic Study

Self-injurious behaviour is purportedly common in autism, but prevalence rates have not yet been synthesised meta-analytically. In the present study, data from 14,379 participants in thirty-seven papers were analysed to generate a pooled prevalence estimate of self-injury in autism of 42% (confidence intervals 0.38-0.47). Hand-hitting topography was the most common form of self-injury (23%), self-cutting topography the least common (3%). Sub-group analyses revealed no association between study quality, participant intellectual disability or age and overall prevalence rate of self-injury. However, females obtained higher prevalence rates than males (p = .013) and hair pulling and self-scratching were associated with intellectual disability (p = .008 and p = .002, respectively). The results confirm very high rates of self-injury in autism and highlight within group risk-markers.

Simulation-based education for teaching aggression management skills to health care providers in the acute health care setting: a systematic review protocol

BACKGROUND

Clinical aggression episodes, that is aggression and externalising behaviours that create risk, in acute care hospitals are increasing. Acute care staff are often not confident or trained in the management of aggression. Various aggression management training formats have been described in practice including face to face training, written learning resources, web- and media-based training resources, and simulation training. The aim of this systematic review is to assess whether simulation-based training is effective in increasing de-escalation knowledge, skills, and behaviour of staff working in the acute care setting.

METHODS

We designed and registered a study protocol for a systematic review of studies evaluating simulation-based training for the management of patients with aggression. We will include randomised controlled trials, non-randomised controlled trials, quasi-experimental studies, and observational studies including health care professionals and trainees in acute health care settings. Comprehensive searches will be conducted in the following databases (from January 1980 onwards): PubMed, MEDLINE, PsycINFO, CINAHL, and the Cochrane Library. The reference lists of selected studies, trial registers, and leading journals will also be searched. Two reviewers will independently screen all citations, full-text articles, and abstract data. Potential discrepancies will be resolved through discussion. The primary outcomes will include patient outcomes (e.g. frequency of clinical aggression), quality of care (e.g. frequency of emergency situations, physical/chemical/mechanical restraint), and adverse effects (e.g. patient/family complaints, patient harms, staff harms). Secondary outcomes will include workplace resource use, health care provider-related outcomes, knowledge (de-escalation techniques), performance, attitudes, and satisfaction. The study methodological risk of bias will be appraised using appropriate tools. A narrative synthesis will be performed for included studies. If feasible, we will conduct random-effects meta-analysis of data. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g. participant characteristics, interventions, and follow-up).

DISCUSSION

This systematic review will identify, evaluate, and integrate the evidence on simulation-based training programmes for acute care health professionals on managing clinical aggression. The results of this study will inform the implementation of effective training strategies. Implications for future research will be discussed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42020151002.

Behavioral Approaches to Assessment and Early Intervention for Severe Problem Behavior in Intellectual and Developmental Disabilities

This article summarizes the literature on prevalence and establishment of severe problem behavior in individuals with intellectual and developmental disabilities, empirical support for applied behavior analysis, and evidence-based behavioral assessment and treatment procedures. Early intervention and prevention approaches and the role of the pediatrician with regard to surveillance, early intervention, and coordination of care are discussed.

Clinical and cost effectiveness of staff training in the delivery of Positive Behaviour Support (PBS) for adults with intellectual disabilities, autism spectrum disorder and challenging behaviour - randomised trial

BACKGROUND

Although Positive Behaviour Support (PBS) is a widely used intervention for ameliorating challenging behaviour (CB), evidence for its use in adults with intellectual disability (ID) and comorbid autism (ASD) is lacking. We report a planned subsidiary analysis of adults with both ASD and ID who participated in a randomised trial of PBS delivered by health professionals.

METHODS

The study was a multicentre, cluster randomised trial conducted in 23 community ID services in England, participants were randomly allocated to either the delivery of PBS (n = 11 clusters) or to treatment as usual (TAU; n = 12). One-hundred and thirteen participants (46% of all participants in the trial) had a diagnosis of ID, autism spectrum disorder and CB (ASD+); (47 allocated to the intervention arm, and 66 to the control). CB (primary outcome) was measured with the Aberrant Behaviour Checklist total score (ABC-CT). Secondary outcomes included mental health status, psychotropic medication use, health and social care costs and quality adjusted life years (QALYs) over 12 months.

RESULTS

There were no statistically significant differences in ABC-CT between ASD+ groups randomised to the two arms over 12 months (adjusted mean difference = - 2.10, 95% CI: - 11.3 7.13, p = 0.655) or other measures. The mean incremental cost of the intervention per participant was £628 (95% CI -£1004 to £2013). There was a difference of 0.039 (95% CI - 0.028 to 0.103) for QALYs and a cost per QALY gained of £16,080.

CONCLUSIONS

Results suggest lack of clinical effectiveness for PBS delivered by specialist ID clinical teams. Further evidence is needed from larger trials, and development of improved interventions.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01680276.

Temperament predicts challenging behavior in children with autism spectrum disorder at age 5

BACKGROUND

Challenging behaviors during early childhood have a significant impact on cognitive and social development. The present study aimed to identify the developmental predictors of these behaviors in preschool aged children with Autism Spectrum Disorder (ASD) at 2-year follow-up. We examined temperament, which has been identified as key to emotion regulation in typical development, as well as developmental level and ASD symptom severity, as potential predictors of parent-reported challenging behavior.

METHOD

Forty-three parents of preschool aged children with ASD from a previous study were invited to participate. Data from 26 children with ASD aged 4-6 years (M = 5, SD = .60) were available for follow-up analyses. Developmental level, ASD symptom severity, and temperamental difficulty at baseline were considered as potential predictors of frequency and severity of challenging behavior at follow-up.

RESULTS

Baseline negative affectivity was uniquely predictive of frequency of challenging behavior at follow-up. Although no individual variable was identified as a unique predictor of variance, the combined effects of temperament were predictive of the severity of challenging behavior at follow-up, contributing to 46 % of variance in scores.

CONCLUSIONS

These findings highlight the potential impact of emotion-regulation related aspects of temperament on later emerging challenging behavior in young children with ASD, suggesting opportunities for early intervention. Results also identified a role for developmental level in the severity of challenging behavior, but suggest that the effect may be metered by temperament.

A grounded theory study on work related stress in professionals who provide health & social care for people who exhibit behaviours that challenge

Providing direct health and social care services for people who exhibit behaviours that challenge can be a highly stressful occupation. Existing literature has suggested that there is a need to develop further theoretical understanding of how work related stress can be reduced in professions that consist of providing care for people who exhibit behaviours that challenge. The aim for this study was to use a Classic Grounded Theory approach to develop a theoretical framework to illustrate a common issue that could influence work related stress levels experienced when managing behaviours that challenge in health and social care settings. A series of focus groups and 1:1 semi-structured interviews were conducted to explore the articulated experiences of 47 health/social care professionals who provide care for people who exhibit behaviours that challenge. This led to the development of Therapeutic Engagement Stress Theory (TEST), which illustrates that the perceived capacity to therapeutically engage with people who exhibit behaviours that challenge is an issue that can influence the levels of stress experienced by health/social care professionals. TEST provides a framework that could be applied to identify specific factors that inhibit staff to successfully deliver caring interventions for people who exhibit behaviours that challenge, and also inform bespoke support mechanisms to reduce stress in health/social care professionals.

Influence of Reaction Time in the Emotional Response of a Companion Robot to a Child’s Aggressive Interaction

The quality of a companion robot’s reaction is important to make it acceptable to the users and to sustain interactions. Furthermore, the robot’s reaction can be used to train socially acceptable behaviors and to develop certain skills in both normally developing children and children with cognitive disabilities. In this study, we investigate the influence of reaction time in the emotional response of a robot when children display aggressive interactions toward it. Different interactions were considered, namely, pickup, shake, drop and throw. The robot produced responses as audible sounds, which were activated at three different reaction times, namely, 0.5 s, 1.0 s, and 1.5 s. The results for one of the tasks that involved shaking the robotic toys produced a significant difference between the timings tested. This could imply that producing a late response to an action (i.e. greater than 1.0 s) could negatively affect the children’s comprehension of the intended message. Furthermore, the response should be comprehensible to provide a clear message to the user. The results imply that the designers of companion robotic toys need to consider an appropriate timing and clear modality for their robots’ responses.

Associated Factors of Self-injury Among Adolescents with Autism Spectrum Disorder in a Community and Residential Treatment Setting

Self-injurious behavior (SIB) occurs in up to 50% of individuals with autism. As one of the most serious conditions in individuals with developmental disabilities, SIB affects the individual and his or her family in multiple contexts. A systematic analysis of factors most commonly associated with SIB could inform the development of individualized intervention strategies. The current study examined factors related to SIB in an analysis of client records of 145 children with autism in a comprehensive care center. Predictor variables included age, gender, the Adaptive Behavior Composite, sensory processing, aggression, stereotypies, irritability, adaptive skills, and medical conditions. Age, irritability, and the Adaptive Behavior Composite were found to significantly predict SIB.

Developing a Diagnostic Algorithm for the Music-Based Scale for Autism Diagnostics (MUSAD) Assessing Adults with Intellectual Disability

Initial studies have presented the Music-based Scale for Autism Diagnostics (MUSAD) as a promising DSM-5-based observational tool to identify autism spectrum disorder (ASD) in adults with intellectual disability (ID). The current study is the first to address its clinical utility in a new sample of 124 adults with ID (60.5% diagnosed with ASD). The derived diagnostic algorithm differentiated well between individuals with and without ASD (sensitivity 79%, specificity 74%, area under the curve = 0.81). Inter-rater reliability, assessed by the scorings of four independent experts in 22 consensus cases, was excellent (ICC = 0.92). Substantial correlations with scores from other ASD-specific measures indicated convergent validity. The MUSAD yields accurate and reliable scores, supporting comprehensive ASD diagnostics in adults with ID.

Pathobiology of Christianson syndrome: Linking disrupted endosomal-lysosomal function with intellectual disability and sensory impairments

Christianson syndrome (CS) is a recently described rare neurogenetic disorder presenting early in life with a broad range of neurological symptoms, including severe intellectual disability with nonverbal status, hyperactivity, epilepsy, and progressive ataxia due to cerebellar atrophy. CS is due to loss-of-function mutations in SLC9A6, encoding NHE6, a sodium-hydrogen exchanger involved in the regulation of early endosomal pH. Here we review what is currently known about the neuropathogenesis of CS, based on insights from experimental models, which to date have focused on mechanisms that affect the CNS, specifically the brain. In addition, parental reports of sensory disturbances in their children with CS, including an apparent insensitivity to pain, led us to explore sensory function and related neuropathology in Slc9a6 KO mice. We present new data showing sensory deficits in Slc9a6 KO mice, which had reduced behavioral responses to noxious thermal and mechanical stimuli (Hargreaves and Von Frey assays, respectively) compared to wild type (WT) littermates. Immunohistochemical and ultrastructural analysis of the spinal cord and peripheral nervous system revealed intracellular accumulation of the glycosphingolipid GM2 ganglioside in KO but not WT mice. This cellular storage phenotype was most abundant in neurons of lamina I-II of the dorsal horn, a major relay site in the processing of painful stimuli. Spinal cords of KO mice also exhibited changes in astroglial and microglial populations throughout the gray matter suggestive of a neuroinflammatory process. Our findings establish the Slc9a6 KO mouse as a relevant tool for studying the sensory deficits in CS, and highlight selective vulnerabilities in relevant cell populations that may contribute to this phenotype. How NHE6 loss of function leads to such a multifaceted neurological syndrome is still undefined, and it is likely that NHE6 is involved with many cellular processes critical to normal nervous system development and function. In addition, the sensory issues exhibited by Slc9a6 KO mice, in combination with our neuropathological findings, are consistent with NHE6 loss of function impacting the entire nervous system. Sensory dysfunction in intellectually disabled individuals is challenging to assess and may impair patient safety and quality of life. Further mechanistic studies of the neurological impairments underlying CS and other genetic intellectual disability disorders must also take into account mechanisms affecting broader nervous system function in order to understand the full range of associated disabilities.

Influence of the shape and mass of a small robot when thrown to a dummy human head

Social robots have shown some efficacy in assisting children with autism and are now being considered as assistive tools for therapy. The physical proximity of a small companion social robot could become a source of harm to children with autism during aggressive physical interactions. A child exhibiting challenging behaviors could throw a small robot that could harm another child’s head upon impact. In this paper, we investigate the effects of the mass and shape of objects thrown on impact at different velocities on the linear acceleration of a developed dummy head. This dummy head could be the head of another child or a caregiver in the room. A total of 27 main experiments were conducted based on Taguchi’s orthogonal array design. The data were then analyzed using ANOVA and then optimized based on the signal-to-noise ratio. Our results revealed that the two design factors considered (i.e. mass and shape) and the noise factor (i.e. impact velocities) affected the response. Finally, confirmation runs at the optimal identified shape and mass (i.e. mass of 0.3 kg and shape of either cube or wedge) showed an overall reduction in the resultant peak linear acceleration of the dummy head as compared to the other conditions. These results have implications on the design and manufacturing of small social robots whereby minimizing the mass of the robots can aid in mitigating the potential harm to the head due to impacts.

The Developmental Behaviour Checklist (DBC) Profile in Young Children on the Autism Spectrum: The Impact of Child and Family Factors

High levels of emotional/behavioural difficulties are frequently reported in children on the autism spectrum. However, given the diversity in profiles, there is a need to explore such behaviours in relation to individual factors. Parents of 130 children aged 4-5 on the autism spectrum completed measures of behaviour and adaptive behaviour. Hierarchical multiple regressions explored child and family characteristics in relation to children's emotional/behavioural presentation. Different aspects of the behavioural profile were associated with different factors, with child autism characteristics, medication use, and parent mental health making significant unique contributions to a range of behavioural subscales. Understanding individual profiles beyond total scores is therefore needed to truly understand the emotional and behavioural profile of specific subgroups.

Treatment of psychiatric comorbidities in patients with epilepsy and intellectual disabilities: Is there a role for the neurologist?

This paper will explore the nature of psychiatric co-morbidities in people with an intellectual disability (ID) who have epilepsy. The complexity of clinical presentations and associated co-morbidities require thorough assessment utilising both neurological and psychiatric skills. The neurologist plays a central role in the management of epilepsy in people with ID and therefore requires basic competencies in the assessment of neuropsychiatric co-morbidities. This is key to liaison with other specialist services to ensure individuals receive holistic person-centred care. This article is part of the Special Issue "Obstacles of Treatment of Psychiatric Comorbidities in Epilepsy".

Deliberate Self-Harm Among Chinese Children with Different Types and Severity of Disabilities

Background: The aims of this study were to determine the prevalence of deliberate self-harm (DSH) and to compare the risk of self-harm in Chinese children with different types and severity of disabilities. Methods: Participants were 1300 children aged 6–17 years in Beijing, China; 650 children with disabilities and 650 healthy peers matched on age, gender and residence district. Questionnaires were completed anonymously by parents or children if the age or disability made it necessary. The associations between the disability type, severity and DSH were examined using the Chi-square testing and logistic regression models. Results: Children with a single disability or multiple disabilities had statistically higher rates of DSH than children without disabilities (15.6% and 39.7% compared to 10.9%). The prevalence of DSH was associated with the severity of disability, being 36.2% among children with level 1 (the most severe) disability, 19.8% among children with level 2 disability, and 9.2% among children with level 3 + 4 disability. The multivariable odds ratio (OR) of DSH among children with any disability was statistically higher than that among children without a disability (OR = 2.40; 95% CI = 1.71, 3.36; p < 0.05). Children with multiple disabilities (OR = 6.89; 95% CI: 4.24–11.20) and level 1 severity of disability (OR = 6.11; 95% CI: 3.91–9.56) had the highest risk of DSH. Conclusions: This study clearly demonstrated associations between the severity and type of disability and DSH. This finding highlights the importance of DSH in children with disabilities, and underlines the importance of the prevention of DSH among a vulnerable pediatric population in China.