Future directions for research in autism spectrum disorders

Exploring Emotion Control and Alexithymia in Autistic Adults: An Ecological Momentary Assessment Study

Difficulties in controlling emotions - a proxy for emotion dysregulation (ED)-and difficulties in expressing feelings in words-'absence of emotion labelling' or alexithymia-co-exist in autism and contribute to elevated levels of impulsive and suicidal behaviour. To date, studies linking the two phenomena have relied on retrospective self-reported measures, lacking support for generalizability to real-life situations. The present study investigated in vivo emotion labelling and its impact on emotion control in 29 autistic adults without intellectual disability (ASC) and 28 neurotypical (NT) individuals of similar age, sex, and educational level. Participants were trained in an Ecological Momentary Assessment (EMA) to label their emotions, the arousal dimension, and their emotion control via smartphone over a one-week period. Findings showed that the ASC group experienced more instances of 'having an emotion that I cannot name' and, when they were able to label their emotions, they reported higher rates of negative and conflicting (simultaneously positive and negative) emotions. In both groups, the absence of emotion labelling, and intense negative emotions were associated with impaired emotion control. However, the association between lack of emotional awareness-'I have no emotion'-and impaired emotion control was only evident in ASC individuals. Our study highlights a nuanced facet of emotional processing in the ASC population. Further research is needed to gain a deeper understanding of the complex relationship between ED and alexithymia in autism.

Mental health counseling is rated as most helpful by autistic adults: Service perspectives in adulthood

LAY ABSTRACT

The number of autistic adults is growing, but there are fewer services to support them in adulthood. Many autistic adults need some support services to lead successful adult lives. We know a lot about the services autistic adults use and some of the problems with using these services, but we do not know which services are most helpful to them and how the services they use relate to how they interact with their communities. Forty autistic adults took part in a study about service use and community participation. They completed surveys, interviews, and carried a global positioning system tracker. They answered questions about which services are most helpful in adulthood, things that make it hard to use services, and what services they needed. Most participants used two services in the past 2 years, most frequently mental health and employment services. Adults who were currently seeing a mental health counselor were more likely to be working full-time and visit more locations in the community compared to those who were not seeing a counselor. Mental health services were reported as the most helpful service they received as adults, followed by employment services. We often focus on the importance of employment services after high school, but our findings show a need for both mental health and employment services for autistic adults.

The effects of service dogs for children with autism spectrum disorder and their caregivers: a cross-sectional study

Introduction

Service dogs are an increasingly popular complementary intervention for children with autism spectrum disorder. However, despite increasing demand, there remains a lack of empirical research on their potential benefits. The purpose of this study was to evaluate the effects of service dogs on children with autism and their caregivers.

Methods

A total of N = 75 families of children with autism were recruited from a non-profit service dog provider in the US, including n = 39 families previously placed with a service dog and n = 36 families engaging in usual care while on the waitlist. Caregivers completed an online survey containing both self- and proxy-report standardized measures of child, caregiver, and family functioning. Linear regressions modeled the relationship between service dog presence and survey outcomes, controlling for relevant child and caregiver covariates.

Results

Results indicated that having a service dog was associated with significantly better child sleep behaviors, including better sleep initiation and duration and less sleep anxiety/co-sleeping with medium effect sizes. However, service dog presence was not significantly related to child withdrawal, negative emotionality, emotional self-control, hyperactivity, irritability, and lethargy with small effect sizes. For caregivers, having a service dog was not significantly related to standardized measures of caregiver strain, sleep disturbance, depression, or the impact of the child's condition on family functioning with small effect sizes. Supplemental matched case-control analyses confirmed these findings.

Discussion

In conclusion, service dogs were found to positively impact sleep behaviors among children with autism, but may not uniformly relate to other areas of child and caregiver wellbeing. Prospective longitudinal designs, larger sample sizes able to detect small effects, and studies that measure sleep using objective methods are needed to build on these findings.

Sex differences in autistic adults: A preliminary study showing differences in mentalizing, but not in narrative coherence

Studying autism might be a complex endeavor due to its clinical heterogeneity. Little is currently known about potential sex differences in autistic adults, especially regarding mentalizing and narrative coherence. In this study, male and female participants told a personal story about one of their most positive and most negative life events and performed two mentalizing tasks. One of these mentalizing tasks was a recently developed Picture and Verbal Sequencing task that has shown cerebellar recruitment, and which requires mentalizing in a sequential context (i.e., participants chronologically ordered scenarios that required true and false belief mentalizing). Our preliminary comparison shows that males were faster and more accurate on the Picture Sequencing task compared to female participants when ordering sequences involving false beliefs, but not true beliefs. No sex differences were found for the other mentalizing and narrative tasks. These results highlight the importance of looking at sex differences in autistic adults and provide a possible explanation for sex-related differences in daily life mentalizing functions, which suggest a need for more sensitive diagnosis and tailored support.

Impaired sequence generation: a preliminary comparison between high functioning autistic and neurotypical adults

Earlier research demonstrated robust cerebellar involvement in sequencing, including high-level social information sequencing that requires mental state attributions, termed mentalizing. Earlier research also found cerebellar deficiencies in autism spectrum disorders (ASD) which are characterized by social difficulties. However, studies on high-level social sequencing functionality by persons with ASD are almost non-existent. In this study, we, therefore, perform a comparison between behavioral performances of high-functioning ASD and neurotypical participants on the Picture and Verbal Sequencing Tasks. In these tasks, participants are requested to put separate events (depicted in cartoon-like pictures or behavioral sentences, respectively) in their correct chronological order. To do so, some of these events require understanding of high-level social beliefs, of social routines (i.e., scripts), or nonsocial mechanical functionality. As expected, on the Picture Sequencing task, we observed longer response times for persons with ASD (in comparison with neurotypical controls) when ordering sequences requiring an understanding of social beliefs and social scripts, but not when ordering nonsocial mechanical events. This confirms our hypotheses that social sequence processing is impaired in ASD. The verbal version of this task did not reveal differences between groups. Our results are the first step toward new theoretical insights for social impairments of persons with ASD. They highlight the importance of taking into account sequence processing, and indirectly the cerebellum when investigating ASD difficulties.

A narrative sequencing and mentalizing training for adults with autism: A pilot study

Adults diagnosed with autism experience difficulties with understanding the mental states of others, or themselves (mentalizing) and with adequately sequencing personal stories (narrative coherence). Given that the posterior cerebellum is implicated in both skills, as well as in the etiology of autism, we developed a narrative sequencing and mentalizing training for autistic adults. Participants with an official autism diagnosis were randomly assigned to a Training group (n = 17) or a waiting-list Control group (n = 15). The Training group took part in six weekly sessions in groups of three participants lasting each about 60 min. During training, participants had to (re)tell stories from the perspective of the original storyteller and answer questions that required mentalizing. We found significant improvements in mentalizing about others’ beliefs and in narrative coherence for the Training group compared to the Control group immediately after the training compared to before the training. Almost all participants from the Training group expressed beneficial effects of the training on their mood and half of the participants reported positive effects on their self-confidence in social situations. All participants recommended the current training to others. Results are discussed in light of cerebellar theories on sequencing of social actions during mentalizing. Further improvements to the program are suggested. Our results highlight the potential clinical utility of adopting a neuroscience-informed approach to developing novel therapeutic interventions for autistic populations.

Characterizing difficulties with emotion regulation in toddlers with autism spectrum disorder

Background

Difficulties with emotion regulation (ER) underlie emotional/behavioral challenges and co-occurring psychiatric symptoms in autism spectrum disorder (ASD), yet very little is known about the early development of emotion dysregulation. The present study aimed to identify differences in positive and negative emotional reactivity and regulation strategies in toddlers with and without ASD.

Method

Nine tasks from the Laboratory Temperament Assessment Battery (Lab-TAB) were completed with 37 toddlers with and without ASD (22-28 months). Video-recordings of these tasks were coded by research assistants using a behavioral coding scheme tapping facial, bodily, and vocal affect and the frequency of ER strategies. Mixed model analyses were performed to examine the mean affect and total regulation strategies across each task and t-tests were conducted to assess the types of ER strategies utilized.

Results

Toddlers with ASD showed significantly less positive affect and greater frustration compared to non-ASD toddlers; reactivity was comparable between the groups for fear. Both groups used ER strategies in a similar pattern across tasks, with the exception that toddlers with ASD more often engaged in distraction to regulate. Effects of age and developmental level are discussed.

Conclusions

Toddlers with ASD were robustly characterized by greater frustration and lower joy despite frequent and age appropriate attempts to regulate their emotions. This study provides preliminary evidence that observable indicators of emotion dysregulation are present by two years of age. Clinical implications and future research directions are discussed.

A white paper on a neurodevelopmental framework for drug discovery in autism and other neurodevelopmental disorders

In the last decade there has been a revolution in terms of genetic findings in neurodevelopmental disorders (NDDs), with many discoveries critical for understanding their aetiology and pathophysiology. Clinical trials in single-gene disorders such as fragile X syndrome highlight the challenges of investigating new drug targets in NDDs. Incorporating a developmental perspective into the process of drug development for NDDs could help to overcome some of the current difficulties in identifying and testing new treatments. This paper provides a summary of the proceedings of the 'New Frontiers Meeting' on neurodevelopmental disorders organised by the European College of Neuropsychopharmacology in conjunction with the Innovative Medicines Initiative-sponsored AIMS-2-TRIALS consortium. It brought together experts in developmental genetics, autism, NDDs, and clinical trials from academia and industry, regulators, patient and family associations, and other stakeholders. The meeting sought to provide a platform for focused communication on scientific insights, challenges, and methodologies that might be applicable to the development of CNS treatments from a neurodevelopmental perspective. Multidisciplinary translational consortia to develop basic and clinical research in parallel could be pivotal to advance knowledge in the field. Although implementation of clinical trials for NDDs in paediatric populations is widely acknowledged as essential, safety concerns should guide each aspect of their design. Industry and academia should join forces to improve knowledge of the biology of brain development, identify the optimal timing of interventions, and translate these findings into new drugs, allowing for the needs of users and families, with support from regulatory agencies.

Systematic Review of Disparities and Differences in the Access and Use of Allied Health Services Amongst Children with Autism Spectrum Disorders

Individuals with autism spectrum disorder (ASD) often benefit from allied health services such as occupational therapy, speech and language pathology, and applied behavioral analysis. While there is consistent evidence of disparities in access and use of medical services (e.g. dentistry), no such systematic review has examined disparities and differences in allied health use amongst children with ASD. In this systematic review, we examine disparities and differences in service access and use for children with ASD. Our findings suggest that children who are older, have less severe ASD symptoms, are from minority groups, and those from particular geographic regions are less likely to receive allied health services. Limitations and future directions are discussed.

"Less stress": a pilot study on a cognitive behavioral treatment program for anxiety in children with autism spectrum disorders

Background:

Comorbid anxiety disorders are prevalent in children with autism spectrum disorders (ASD), but only a minority receives adequate treatment for anxiety. Cognitive behavioral therapy (CBT) has been shown to be effective in treating anxiety disorders. The objectives of the present pilot study were to test the feasibility of the CBT program “Less stress” for comorbid anxiety disorders in children with ASD and explore whether an improvement in diagnostic outcomes for anxiety disorders and symptoms of anxiety was found after treatment.

Methods:

Participants were ten children diagnosed with ASD and anxiety disorders (eight boys, mean age = 9.5 years, range 8 - 12 years). The “Less Stress” program includes three months of weekly treatment sessions followed by three monthly booster sessions. Five therapists participated. A standardized semi-structured diagnostic interview with the mothers was used to assess comorbid disorders. Child anxiety symptoms were measured with the Revised Child Anxiety and Depression Scale (RCADS).

Results:

The therapists found the manual easy to use but adaptations were necessary, particularly shorter sessions due to frequent (n = 7) comorbid Attention-Deficit/Hyperactivity Disorder. The participants found the program useful and the parents noted that they had learned methods they could continue using after the end of the program.

Eight of ten children completed the treatment. Seven of the eight completers benefited from the program. Five of those seven children were free from all anxiety disorders, while two had fewer anxiety disorders. On a group level, a significant mean reduction of anxiety symptoms (RCADS) was found after treatment.

Conclusion:

The therapists found the “Less stress” program to be a feasible intervention in a sample of children with ASD and comorbid anxiety. The significant reduction of anxiety after treatment is promising, but a replication in a larger and more rigorous study is needed to investigate the effectiveness of the intervention.

Anxiety and Depression Reduction as Distal Outcomes of a College Transition Readiness Program for Adults with Autism

Young adults with autism spectrum disorder (ASD) experience increased rates of anxiety and depression which can impact academic success. The Stepped Transition in Education Program for Students with ASD (STEPS) applies cognitive-behavioral principles to help young adults with ASD improve their adjustment to postsecondary education. We aimed to determine if STEPS had an effect on anxiety and depression. Treatment-seeking adults with ASD (n = 32; Mage = 19.74) were randomized to STEPS or transition as usual (TAU; i.e., waitlist control group). STEPS participants evinced significantly greater declines in depressive symptoms from pre-treatment to post-treatment compared to the waitlist. Anxiety symptoms did not significantly change. Results suggest that transition support for young people with ASD may improve mental health.

Fractionating autism based on neuroanatomical normative modeling

Autism is a complex neurodevelopmental condition with substantial phenotypic, biological, and etiologic heterogeneity. It remains a challenge to identify biomarkers to stratify autism into replicable cognitive or biological subtypes. Here, we aim to introduce a novel methodological framework for parsing neuroanatomical subtypes within a large cohort of individuals with autism. We used cortical thickness (CT) in a large and well-characterized sample of 316 participants with autism (88 female, age mean: 17.2 ± 5.7) and 206 with neurotypical development (79 female, age mean: 17.5 ± 6.1) aged 6-31 years across six sites from the EU-AIMS multi-center Longitudinal European Autism Project. Five biologically based putative subtypes were derived using normative modeling of CT and spectral clustering. Three of these clusters showed relatively widespread decreased CT and two showed relatively increased CT. These subtypes showed morphometric differences from one another, providing a potential explanation for inconsistent case-control findings in autism, and loaded differentially and more strongly onto symptoms and polygenic risk, indicating a dilution of clinical effects across heterogeneous cohorts. Our results provide an important step towards parsing the heterogeneous neurobiology of autism.

Four Actionable Bottlenecks and Potential Solutions to Translating Psychiatric Genetics Research: An Expert Review

BACKGROUND

Psychiatric genetics has had limited success in translational efforts. A thorough understanding of the present state of translation in this field will be useful in the facilitation and assessment of future translational progress.

PURPOSE

A narrative literature review was conducted. Combinations of 3 groups of terms were searched in EBSCOhost, Google Scholar, and PubMed. The review occurred in multiple steps, including abstract collection, inclusion/exclusion criteria review, coding, and analysis of included papers.

RESULTS

One hundred and fourteen articles were analyzed for the narrative review. Across those, 4 bottlenecks were noted that, if addressed, may provide insights and help improve and increase translation in the field of psychiatric genetics. These 4 bottlenecks are emphasizing linear translational frameworks, relying on molecular genomic findings, prioritizing certain psychiatric disorders, and publishing more reviews than experiments.

CONCLUSIONS

These entwined bottlenecks are examined with one another. Awareness of these bottlenecks can inform stakeholders who work to translate and/or utilize psychiatric genetic information. Potential solutions include utilizing nonlinear translational frameworks as well as a wider array of psychiatric genetic information (e.g., family history and gene-environment interplay) in this area of research, expanding which psychiatric disorders are considered for translation, and when possible, conducting original research. Researchers are urged to consider how their research is translational in the context of the frameworks, genetic information, and psychiatric disorders discussed in this review. At a broader level, these efforts should be supported with translational efforts in funding and policy shifts.

Informative Feature-Guided Siamese Network for Early Diagnosis of Autism

Autism, or autism spectrum disorder (ASD), is a complex developmental disability, and usually diagnosed with observations at around 3-4 years old based on behaviors. Studies have indicated that the early treatment, especially during early brain development in the first two years of life, can significantly improve the symptoms, therefore, it is important to identify ASD as early as possible. Most previous works employed imaging-based biomarkers for the early diagnosis of ASD. However, they only focused on extracting features from the intensity images, ignoring the more informative guidance from segmentation and parcellation maps. Moreover, since the number of autistic subjects is always much smaller than that of normal subjects, this class-imbalance issue makes the ASD diagnosis more challenging. In this work, we propose an end-to-end informative feature-guided Siamese network for the early ASD diagnosis. Specifically, besides T1w and T2w images, the discriminative features from segmentation and parcellation maps are also employed to train the model. To alleviate the class-imbalance issue, the Siamese network is utilized to effectively learn what makes the pair of inputs belong to the same class or different classes. Furthermore, the subject-specific attention module is incorporated to identify the ASD-related regions in an end-to-end fully automatic learning manner. Both ablation study and comparisons demonstrate the effectiveness of the proposed method, achieving an overall accuracy of 85.4%, sensitivity of 80.8%, and specificity of 86.7%.

Effects of Dog Assisted Therapy for Adults with Autism Spectrum Disorder: An Exploratory Randomized Controlled Trial

Effective treatments of highly prevalent stress-related outcomes such as depression and anxiety are understudied in adults with autism spectrum disorder (ASD). A randomized controlled trial with baseline, post-intervention, and 10-week follow-up, that explores the effects of animal assisted therapy (AAT) was conducted. In total, 53 adults with ASD with normal to high intelligence were randomized in an intervention (N = 27) versus waiting list control group (N = 26). The remarkable adherence to the therapy program by study participants and the program's clinically relevant effects indicate that AAT with dogs can be used to reduce perceived stress and symptoms of agoraphobia, and to improve social awareness and communication in adults with ASD with normal to high intelligence.

Brief Report: What Happens After School? Exploring Post-school Outcomes for a Group of Autistic and Non-autistic Australian Youth

Young autistic Australians are less likely to attend higher education and have lower employment rates than non-autistic Australians (in: Australian Bureau of Statistics, Survey of disability, ageing and carers Australia: Summary of Findings 2018. Australian Bureau of Statistics, Canberra, 2019a). Few studies have examined post-school outcomes among this population. Using data from the first phase of a national longitudinal study including autistic (n = 79) and non-autistic (n = 107) 17-25-year olds, we found young autistic adults were (a) less likely to be employed, (b) more likely to attend technical and further education (TAFE) than university, (c) more likely to enrol in higher education on a part-time basis and (d) less likely to be engaged in both higher education and employment, than their non-autistic peers. Findings highlight a need to understand post-school trajectories of young autistic adults.

De novo duplication on Chromosome 19 observed in nuclear family displaying neurodevelopmental disorders

Pleiotropy and variable expressivity have been cited to explain the seemingly distinct neurodevelopmental disorders due to a common genetic etiology within the same family. Here we present a family with a de novo 1-Mb duplication involving 18 genes on Chromosome 19. Within the family there are multiple cases of neurodevelopmental disorders including autism spectrum disorder, attention deficit/hyperactivity disorder, intellectual disability, and psychiatric disease in individuals carrying this copy-number variant (CNV). Quantitative polymerase chain reaction (PCR) confirmed the CNV was de novo in the mother and inherited by both sons. Whole-exome sequencing did not uncover further genetic risk factors segregating within the family. Transcriptome analysis of peripheral blood demonstrated a ∼1.5-fold increase in RNA transcript abundance in 12 of the 15 detected genes within the CNV region for individuals carrying the CNV compared with their noncarrier relatives. Examination of transcript abundance across the rest of the transcriptome identified 407 differentially expressed genes (P-value < 0.05; adjusted P-value < 0.1) mapping to immune response, response to endoplasmic reticulum stress, and regulation of epithelial cell proliferation pathways. 16S microbiome profiling demonstrated compositional difference in the gut bacteria between the half-brothers. These results raise the possibility that the observed CNV may contribute to the varied phenotypic characteristics in family members through alterations in gene expression and/or dysbiosis of the gut microbiome. More broadly, there is growing evidence that different neurodevelopmental and psychiatric disorders can share the same genetic variant, which lays a framework for later neurodevelopmental and psychiatric manifestations.

Process Evaluation of Animal-Assisted Therapy: Feasibility and Relevance of a Dog-Assisted Therapy Program in Adults with Autism Spectrum Disorder

Simple Summary

An explorative study on the effects of animal-assisted therapy showed reduced stress and improved social communication in adults with autism spectrum disorder (ASD). To examine whether this intervention is suitable for a broader scope of application in clinical practice, we conducted a process evaluation alongside the effect study. The aim of this process evaluation was to gain insight into the quality of the study, the relevance and feasibility of the intervention, and the barriers and facilitators to the implementation of the intervention. Questionnaires, semi-structured interviews, and treatment reports were used to analyze process data in 27 participants who were randomized into the intervention condition and in three therapists. Both the participants and therapists evaluated the animal-assisted therapy program as satisfying, feasible, and relevant for adults with ASD. They reported the following arguments for their positive appraisal of the therapy: the therapy helped improve self-insight, joy, relaxation, and physical contact. The participants’ attitudes, personal skills for generalization, and severity of contextual problems were named as potential barriers to the feasibility of the therapy program. Females and dog owners were over-represented in this study, and therefore, generalization of the previously established effects should be made with caution. However, given the intervention’s effects and the positive evaluation of the program by the participants and therapists alike, animal-assisted therapy can be considered a valuable addition to treatment possibilities for reducing stress and improving social communication in adults with autism spectrum disorder.

Abstract

(1) Background: Randomized controlled trials (RCTs) are considered the gold standard for evaluating a treatment. However, the results of an RCT may remain meaningless for clinical practice in cases of poor intervention feasibility or fidelity (the extent to which the protocol was executed), or when health care professionals or patients experience the intervention as irrelevant or unpleasant. Feasibility and relevance of psychosocial interventions are highly understudied in adults with autism spectrum disorder (ASD). In order to put the effects revealed in an RCT on an animal-assisted therapy (AAT) program in adults with autism spectrum disorder (ASD) into the context of clinical practice and to formulate guidelines for potential improvements and further implementation of the therapy, the aim of this process evaluation was to gain insight into the relevance and feasibility of the intervention and barriers and facilitators to its implementation. (2) Methods: Data were collected from 27 participants with ASD and three therapists using questionnaires, semi-structured interviews, and treatment reports. Reach, adherence, program fidelity, and program appraisal were evaluated, and barriers and facilitators to recruitment and implementation of the AAT program were explored. (3) Results: The participants were satisfied with the program and evaluated it as feasible and relevant for adults with ASD. The participants documented improving self-insight, joy, relaxation, and physical contact with a therapy dog as the reason of their positive appraisal of the therapy. Documented aspects that may influence feasibility and appraised relevance were the participants’ therapy attitude, skills for generalization, and severity of contextual problems (e.g., problems at work, relationship problems). Regarding the sample quality, females and dog owners were slightly over-represented in the RCT. (4) Discussion: Considering the positive evaluation of the intervention and its positive effects revealed in the RCT, the AAT program can be added to the treatment repertoire to reduce stress and improve social communication in adults with ASD. More research in larger samples is needed for better understanding the generalization of the intervention effects, especially in male patients and those who do not have a dog at home.

Bridging the species gap in translational research for neurodevelopmental disorders

The prevalence and societal impact of neurodevelopmental disorders (NDDs) continue to increase despite years of research in both patient populations and animal models. There remains an urgent need for translational efforts between clinical and preclinical research to (i) identify and evaluate putative causes of NDD, (ii) determine their underlying neurobiological mechanisms, (iii) develop and test novel therapeutic approaches, and (iv) translate basic research into safe and effective clinical practices. Given the complexity behind potential causes and behaviors affected by NDDs, modeling these uniquely human brain disorders in animals will require that we capitalize on unique advantages of a diverse array of species. While much NDD research has been conducted in more traditional animal models such as the mouse, ultimately, we may benefit from creating animal models with species that have a more sophisticated social behavior repertoire such as the rat (Rattus norvegicus) or species that more closely related to humans, such as the rhesus macaque (Macaca mulatta). Here, we highlight the rat and rhesus macaque models for their role in previous psychological research discoveries, current efforts to understand the neurobiology of NDDs, and focus on the convergence of behavior outcome measures that parallel features of human NDDs.

Alexithymia - Not autism - is associated with frequency of social interactions in adults

OBJECTIVE

While much is known about the quality of social behavior among neurotypical individuals and those with autism spectrum disorder (ASD), little work has evaluated quantity of social interactions. This study used ecological momentary assessment (EMA) to quantify in vivo daily patterns of social interaction in adults as a function of demographic and clinical factors.

METHOD

Adults with and without ASD (N_ASD = 23, N_Neurotypical = 52) were trained in an EMA protocol to report their social interactions via smartphone over one week. Participants completed measures of IQ, ASD symptom severity and alexithymia symptom severity.

RESULTS

Cyclical multilevel models were used to account for nesting of observations. Results suggest a daily cyclical pattern of social interaction that was robust to ASD and alexithymia symptoms. Adults with ASD did not have fewer social interactions than neurotypical peers; however, severity of alexithymia symptoms predicted fewer social interactions regardless of ASD status.

CONCLUSIONS

These findings suggest that alexithymia, not ASD severity, may drive social isolation and highlight the need to reevaluate previously accepted notions regarding differences in social behavior utilizing modern methods.

Quantifying the Optimal Structure of the Autism Phenotype: A Comprehensive Comparison of Dimensional, Categorical, and Hybrid Models

OBJECTIVE

The two primary-seemingly contradictory-strategies for classifying child psychiatric syndromes are categorical and dimensional; conceptual ambiguities appear to be greatest for polythetic syndromes such as autism spectrum disorder (ASD). Recently, a compelling alternative has emerged that integrates both categorical and dimensional approaches (ie, a hybrid model), thanks to the increasing sophistication of analytic procedures. This study aimed to quantify the optimal phenotypic structure of ASD by comprehensively comparing categorical, dimensional, and hybrid models.

METHOD

The sample comprised 3,825 youth, who were consecutive referrals to a university developmental disabilities or child psychiatric outpatient clinic. Caregivers completed the Child and Adolescent Symptom Inventory-4R (CASI-4R), which includes an ASD symptom rating scale. A series of latent class analyses, exploratory and confirmatory factor analyses, and factor mixture analyses was conducted. Replication analyses were conducted in an independent sample (N = 2,503) of children referred for outpatient evaluation.

RESULTS

Based on comparison of 44 different models, results indicated that the ASD symptom phenotype is best conceptualized as multidimensional versus a categorical or categorical-dimensional hybrid construct. ASD symptoms were best characterized as falling along three dimensions (ie, social interaction, communication, and repetitive behavior) on the CASI-4R.

CONCLUSION

Findings reveal an optimal structure with which to characterize the ASD phenotype using a single, parent-report measure, supporting the presence of multiple correlated symptom dimensions that traverse formal diagnostic boundaries and quantify the heterogeneity of ASD. These findings inform understanding of how neurodevelopmental disorders can extend beyond discrete categories of development and represent continuously distributed traits across the range of human behaviors.

"Older Adults with ASD: The Consequences of Aging." Insights from a series of special interest group meetings held at the International Society for Autism Research 2016-2017

A special interest group (SIG) entitled "Older Adults with ASD: The Consequences of Aging" was held at the International Society for Autism Research (INSAR) annual meetings in 2016 and 2017. The SIG and subsequent meetings brought together, for the first time, international delegates who were members of the autistic community, researchers, practitioners and service providers. Based on aging autism research that is already underway in UK, Europe, Australia and North America, discussions focussed on conceptualising the parameters of aging when referring to autism, and the measures that are appropriate to use with older adults when considering diagnostic assessment, cognitive factors and quality of life in older age. Thus, the aim of this SIG was to progress the research agenda on current and future directions for autism research in the context of aging. A global issue on how to define 'aging' when referring to ASD was at the forefront of discussions. The 'aging' concept can in principle refer to all developmental transitions. However, in this paper we focus on the cognitive and physical changes that take place from mid-life onwards. Accordingly, it was agreed that aging and ASD research should focus on adults over the age of 50 years, given the high rates of co-occurring physical and mental health concerns and increased risk of premature death in some individuals. Moreover, very little is known about the cognitive change, care needs and outcomes of autistic adults beyond this age. Discussions on the topics of diagnostic and cognitive assessments, and of quality of life and well-being were explored through shared knowledge about which measures are currently being used and which background questions should be asked to obtain comprehensive and informative developmental and medical histories. Accordingly, a survey was completed by SIG delegates who were representatives of international research groups across four continents, and who are currently conducting studies with older autistic adults. Considerable overlap was identified across different research groups in measures of both autism and quality of life, which pointed to combining data and shared learnings as the logical next step. Regarding the background questions that were asked, the different research groups covered similar topics but the groups differed in the way these questions were formulated when working with autistic adults across a range of cognitive abilities. It became clear that continued input from individuals on the autism spectrum is important to ensure that questionnaires used in ongoing and future are accessible and understandable for people across the whole autistic spectrum, including those with limited verbal abilities.

Autism aging

Many people perceive autism spectrum disorder (ASD) as a childhood disorder, yet ASD is a lifelong condition. Although little is known about the mental and physical health issues of aging individuals with ASD, there are increasing numbers of older adults being diagnosed with ASD. Although there has been a recent "call to action" (to address lack of knowledge and the dearth of services and programs for aging individuals with autism, the authors think it is also important for those who are involved in educational programs related to gerontology and geriatrics settings to be aware of "autism aging." This term conceptualizes the demographics, person and contextual factors, and intellectual awareness of the trends and patterns of ASD as a life course challenge and opportunity for well-being and quality of life. The purposes of this article are to (1) provide a general overview of autism issues and to examine several dimensions of ASD in the context of the emergent and relevant scholarship in the adult and aging domain, (2) propose how to address the "gap" in the literature on autism and aging in terms of a conceptual model and by improving the methodology, and (3) to discuss the implications of these dimensions for educators in gerontology and geriatrics, and for those professionals who work in clinical and health care services. It is the goal of the authors to have this article represent a general introduction to ASD and to be a part of the foundation for educational awareness for educators in gerontology and geriatrics.

Dissecting the Heterogeneous Cortical Anatomy of Autism Spectrum Disorder Using Normative Models

BACKGROUND

The neuroanatomical basis of autism spectrum disorder (ASD) has remained elusive, mostly owing to high biological and clinical heterogeneity among diagnosed individuals. Despite considerable effort toward understanding ASD using neuroimaging biomarkers, heterogeneity remains a barrier, partly because studies mostly employ case-control approaches, which assume that the clinical group is homogeneous.

METHODS

Here, we used an innovative normative modeling approach to parse biological heterogeneity in ASD. We aimed to dissect the neuroanatomy of ASD by mapping the deviations from a typical pattern of neuroanatomical development at the level of the individual and to show the necessity to look beyond the case-control paradigm to understand the neurobiology of ASD. We first estimated a vertexwise normative model of cortical thickness development using Gaussian process regression, then mapped the deviation of each participant from the typical pattern. For this, we employed a heterogeneous cross-sectional sample of 206 typically developing individuals (127 males) and 321 individuals with ASD (232 males) (6-31 years of age).

RESULTS

We found few case-control differences, but the ASD cohort showed highly individualized patterns of deviations in cortical thickness that were widespread across the brain. These deviations correlated with severity of repetitive behaviors and social communicative symptoms, although only repetitive behaviors survived corrections for multiple testing.

CONCLUSIONS

Our results 1) reinforce the notion that individuals with ASD show distinct, highly individualized trajectories of brain development and 2) show that by focusing on common effects (i.e., the "average ASD participant"), the case-control approach disguises considerable interindividual variation crucial for precision medicine.

Caregiver Daily Reporting of Symptoms in Autism Spectrum Disorder: Observational Study Using Web and Mobile Apps

BACKGROUND

Currently, no medications are approved to treat core symptoms of autism spectrum disorder (ASD). One barrier to ASD medication development is the lack of validated outcome measures able to detect symptom change. Current ASD interventions are often evaluated using retrospective caregiver reports that describe general clinical presentation but often require recall of specific behaviors weeks after they occur, potentially reducing accuracy of the ratings. My JAKE, a mobile and Web-based mobile health (mHealth) app that is part of the Janssen Autism Knowledge Engine-a dynamically updated clinical research system-was designed to help caregivers of individuals with ASD to continuously log symptoms, record treatments, and track progress, to mitigate difficulties associated with retrospective reporting.

OBJECTIVE

My JAKE was deployed in an exploratory, noninterventional clinical trial to evaluate its utility and acceptability to monitor clinical outcomes in ASD. Hypotheses regarding relationships among daily tracking of symptoms, behavior, and retrospective caregiver reports were tested.

METHODS

Caregivers of individuals with ASD aged 6 years to adults (N=144) used the My JAKE app to make daily reports on their child's sleep quality, affect, and other self-selected specific behaviors across the 8- to 10-week observational study. The results were compared with commonly used paper-and-pencil scales acquired over a concurrent period at regular 4-week intervals.

RESULTS

Caregiver reporting of behaviors in real time was successfully captured by My JAKE. On average, caregivers made reports 2-3 days per week across the study period. Caregivers were positive about their use of the system, with over 50% indicating that they would like to use My JAKE to track behavior outside of a clinical trial. More positive average daily reporting of overall type of day was correlated with 4 weekly reports of lower caregiver burden made at 4-week intervals (r=-0.27, P=.006, n=88) and with ASD symptoms (r=-0.42, P<.001, n=112).

CONCLUSIONS

My JAKE reporting aligned with retrospective Web-based or paper-and-pencil scales. Use of mHealth apps, such as My JAKE, has the potential to increase the validity and accuracy of caregiver-reported outcomes and could be a useful way of identifying early changes in response to intervention. Such systems may also assist caregivers in tracking symptoms and behavior outside of a clinical trial, help with personalized goal setting, and monitoring of progress, which could collectively improve understanding of and quality of life for individuals with ASD and their families.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02668991; https://clinicaltrials.gov/ct2/show/NCT02668991.

Volume-Based Analysis of 6-Month-Old Infant Brain MRI for Autism Biomarker Identification and Early Diagnosis

Autism spectrum disorder (ASD) is mainly diagnosed by the observation of core behavioral symptoms. Due to the absence of early biomarkers to detect infants either with or at-risk of ASD during the first postnatal year of life, diagnosis must rely on behavioral observations long after birth. As a result, the window of opportunity for effective intervention may have passed when the disorder is detected. Therefore, it is clinically urgent to identify imaging-based biomarkers for early diagnosis and intervention. In this paper, for the first time, we proposed a volume-based analysis of infant subjects with risk of ASD at very early age, i.e., as early as at 6 months of age. A critical part of volume-based analysis is to accurately segment 6-month-old infant brain MRI scans into different regions of interest, e.g., white matter, gray matter, and cerebrospinal fluid. This is actually very challenging since the tissue contrast at 6-month-old is extremely low, caused by inherent ongoing myelination and maturation. To address this challenge, we propose an anatomy-guided, densely-connected network for accurate tissue segmentation. Based on tissue segmentations, we further perform brain parcellation and statistical analysis to identify those significantly different regions between autistic and normal subjects. Experimental results on National Database for Autism Research (NDAR) show the advantages of our proposed method in terms of both segmentation accuracy and diagnosis accuracy over state-of-the-art results.

Anatomy-guided joint tissue segmentation and topological correction for 6-month infant brain MRI with risk of autism

Tissue segmentation of infant brain MRIs with risk of autism is critically important for characterizing early brain development and identifying biomarkers. However, it is challenging due to low tissue contrast caused by inherent ongoing myelination and maturation. In particular, at around 6 months of age, the voxel intensities in both gray matter and white matter are within similar ranges, thus leading to the lowest image contrast in the first postnatal year. Previous studies typically employed intensity images and tentatively estimated tissue probabilities to train a sequence of classifiers for tissue segmentation. However, the important prior knowledge of brain anatomy is largely ignored during the segmentation. Consequently, the segmentation accuracy is still limited and topological errors frequently exist, which will significantly degrade the performance of subsequent analyses. Although topological errors could be partially handled by retrospective topological correction methods, their results may still be anatomically incorrect. To address these challenges, in this article, we propose an anatomy-guided joint tissue segmentation and topological correction framework for isointense infant MRI. Particularly, we adopt a signed distance map with respect to the outer cortical surface as anatomical prior knowledge, and incorporate such prior information into the proposed framework to guide segmentation in ambiguous regions. Experimental results on the subjects acquired from National Database for Autism Research demonstrate the effectiveness to topological errors and also some levels of robustness to motion. Comparisons with the state-of-the-art methods further demonstrate the advantages of the proposed method in terms of both segmentation accuracy and topological correctness.

A preliminary evaluation of metacognitive beliefs in high functioning children with autism spectrum disorder

Purpose

Metacognitive beliefs and processes have been found to perpetuate anxiety and depression in youth and adults. However, the presence of metacognitive beliefs in children with autism spectrum disorder is somewhat unclear and has received limited research attention to date. The purpose of this paper is to explore metacognitive beliefs in children with autism and associations with anxiety and depression.

Design/methodology/approach

In total, 23 high functioning participants (17 male and 6 female) between the ages of 8 and 12 (M=10.38) diagnosed on the autism spectrum completed the study. Participants completed the Revised Children’s Scale of Anxiety and Depression and the Metacognitions Questionnaire for Children.

Findings

Correlation analyses revealed that positive and negative metacognitive beliefs were found, as hypothesised, to be prevalent in this sample.

Originality/value

Despite methodological limitations, this is one of the first research evaluations to provide evidence for metacognitive beliefs in high functioning children with autism and comorbid anxiety or low mood.

Co-occurring psychiatric conditions in autism spectrum disorder

Individuals with autism spectrum disorder (ASD) are at increased risk for experiencing one or more co-occurring psychiatric conditions. When present, these conditions are associated with additional impairment and distress. It is therefore crucial that clinicians and researchers adequately understand and address these challenges. However, due to symptom overlap, diagnostic overshadowing, and ambiguous symptom presentation in ASD, the assessment of co-occurring conditions in ASD is complex and challenging. Likewise, individual difference factors, such as age, intellectual functioning, and gender, may influence the presentation of co-occurring symptoms. Relatedly, a transdiagnostic framework may offer utility in assessing and treating co-occurring conditions. However, with the exception of anxiety disorders, treatment research for co-occurring psychiatric conditions in ASD is relatively limited. Therefore, the present paper aims to summarize and review available research on the most common co-occurring psychiatric disorders in ASD, with a focus on estimated population-based prevalence rates, diagnostic challenges, the influence of individual differences, and assessment guidelines. The utility of a transdiagnostic framework for conceptualizing co-occurring disorders in ASD is discussed, and the state of treatment research for co-occurring disorders is summarized. This study concludes with a summary of the extant literature, as well as recommendations for future research.

Maternal Immune Activation and Autism Spectrum Disorder: From Rodents to Nonhuman and Human Primates

A subset of women who are exposed to infection during pregnancy have an increased risk of giving birth to a child who will later be diagnosed with a neurodevelopmental or neuropsychiatric disorder. Although epidemiology studies have primarily focused on the association between maternal infection and an increased risk of offspring schizophrenia, mounting evidence indicates that maternal infection may also increase the risk of autism spectrum disorder. A number of factors, including genetic susceptibility, the intensity and timing of the infection, and exposure to additional aversive postnatal events, may influence the extent to which maternal infection alters fetal brain development and which disease phenotype (autism spectrum disorder, schizophrenia, other neurodevelopmental disorders) is expressed. Preclinical animal models provide a test bed to systematically evaluate the effects of maternal infection on fetal brain development, determine the relevance to human central nervous system disorders, and to evaluate novel preventive and therapeutic strategies. Maternal immune activation models in mice, rats, and nonhuman primates suggest that the maternal immune response is the critical link between exposure to infection during pregnancy and subsequent changes in brain and behavioral development of offspring. However, differences in the type, severity, and timing of prenatal immune challenge paired with inconsistencies in behavioral phenotyping approaches have hindered the translation of preclinical results to human studies. Here we highlight the promises and limitations of the maternal immune activation model as a preclinical tool to study prenatal risk factors for autism spectrum disorder, and suggest specific changes to improve reproducibility and maximize translational potential.

National Database for Autism Research (NDAR): Big Data Opportunities for Health Services Research and Health Technology Assessment

The National Database for Autism Research (NDAR) is a US National Institutes of Health (NIH)-funded research data repository created by integrating heterogeneous datasets through data sharing agreements between autism researchers and the NIH. To date, NDAR is considered the largest neuroscience and genomic data repository for autism research. In addition to biomedical data, NDAR contains a large collection of clinical and behavioral assessments and health outcomes from novel interventions. Importantly, NDAR has a global unique patient identifier that can be linked to aggregated individual-level data for hypothesis generation and testing, and for replicating research findings. As such, NDAR promotes collaboration and maximizes public investment in the original data collection. As screening and diagnostic technologies as well as interventions for children with autism are expensive, health services research (HSR) and health technology assessment (HTA) are needed to generate more evidence to facilitate implementation when warranted. This article describes NDAR and explains its value to health services researchers and decision scientists interested in autism and other mental health conditions. We provide a description of the scope and structure of NDAR and illustrate how data are likely to grow over time and become available for HSR and HTA.