Practitioner review: Diagnosis of autism spectrum disorder in 2- and 3-year-old children

Prenatal Exposure to Source-Specific Fine Particulate Matter and Autism Spectrum Disorder

In this study, associations between prenatal exposure to fine particulate matter (PM2.5) from 9 sources and development of autism spectrum disorder (ASD) were assessed in a population-based retrospective pregnancy cohort in southern California. The cohort included 318,750 mother-child singleton pairs. ASD cases (N = 4559) were identified by ICD codes. Source-specific PM2.5 concentrations were estimated from a chemical transport model with a 4 × 4 km2 resolution and assigned to maternal pregnancy residential addresses. Cox proportional hazard models were used to estimate the hazard ratios (HR) of ASD development for each individual source. We also adjusted for total PM2.5 mass and in a separate model for all other sources simultaneously. Increased ASD risk was observed with on-road gasoline (HR [CI]: 1.18 [1.13, 1.24]), off-road gasoline (1.15 [1.12, 1.19]), off-road diesel (1.08 [1.05, 1.10]), food cooking (1.05 [1.02, 1.08]), aircraft (1.04 [1.01, 1.06]), and natural gas combustion (1.09 [1.06, 1.11]), each scaled to standard deviation increases in concentration. On-road gasoline and off-road gasoline were robust for other pollutant groups. PM2.5 emitted from different sources may have different impacts on ASD. The results also identify PM source mixtures for toxicological investigations that may provide evidence for future public health policies.

Decomposing the variance: The unique and shared associations of fine and ultrafine particulate matter exposed during pregnancy with child autism spectrum disorder

While fine particulate matter (PM2.5) has been associated with autism spectrum disorder (ASD), few studies focused on ultrafine particles (PM0.1). Given that fine and ultrafine particles can be highly correlated due to shared emission sources, challenges remain to distinguish their health effects. In a retrospective cohort of 318,371 mother-child pairs (4549 ASD cases before age 5) in Southern California, pregnancy average PM2.5 and PM0.1 were estimated using a California-based chemical transport model and assigned to residential addresses. The correlation between PM2.5 and PM0.1 was 0.87. We applied a two-step variance decomposition approach: first, decomposing PM2.5 and PM0.1 into the shared and unique variances using ordinary least squares linear regression (OLS) and Deming regression considering errors in both exposures; then assessing associations between decomposed PM2.5 and PM0.1 and ASD using Cox proportional hazard models adjusted for covariates. Prenatal PM2.5 and PM0.1 each was associated with increased ASD risk. OLS decomposition showed that associations were driven mainly by their shared variance, not by their unique variance. Results from Deming regression considering assumptions of measurement errors were consistent with those from OLS. This decomposition approach has potential to disentangle health effects of correlated exposures, such as PM2.5 and PM0.1 from common emissions sources.

Mechanistic perspective on the actions of vitamin a in autism spectrum disorder etiology

Vitamin A (VA) has many functions in the body, some of which are key for the development and functioning of the nervous system, while some others might indirectly influence neural function. Both hypovitaminosis and hypervitaminosis A can lead to clinical manifestations of concern for individuals and for general global health. Scientific evidence on the link between VA and autism spectrum disorder (ASD) is growing, with some clinical studies and accumulating results obtained from basic research using cellular and animal models. Remarkably, it has been shown that VA deficiency can exacerbate autistic symptomatology. In turn, VA supplementation has been shown to be able to improve autistic symptomatology in selected groups of individuals with ASD. However, it is important to recognize that ASD is a highly heterogeneous condition. Therefore, it is important to clarify how and when VA supplementation can be of benefit for affected individuals. Here we delve into the relationship between VA and ASD, discussing clinical observations and mechanistic insights obtained from research on selected autistic syndromes and laboratory models to advance in defining how the VA signaling pathway can be exploited for treatment of ASD.

Abnormality of Early White Matter Development in Tuberous Sclerosis Complex and Autism Spectrum Disorder: Longitudinal Analysis of Diffusion Tensor Imaging Measures

Background: Abnormalities in white matter development may influence development of autism spectrum disorder in tuberous sclerosis complex (TSC). Our goals for this study were as follows: (1) use data from a longitudinal neuroimaging study of tuberous sclerosis complex (TACERN) to develop optimized linear mixed effects models for analyzing longitudinal, repeated diffusion tensor imaging metrics (fractional anisotropy, mean diffusivity) pertaining to select white matter tracts, in relation to positive Autism Diagnostic Observation Schedule-Second Edition classification at 36 months, and (2) perform an exploratory analysis using optimized models applied to all white matter tracts from these data. Methods: Eligible participants (3-12 months) underwent brain magnetic resonance imaging (MRI) at repeated time points from ages 3 to 36 months. Positive Autism Diagnostic Observation Schedule-Second Edition classification at 36 months was used. Linear mixed effects models were fine-tuned separately for fractional anisotropy values (using fractional anisotropy corpus callosum as test outcome) and mean diffusivity values (using mean diffusivity right posterior limb internal capsule as test outcome). Fixed effects included participant age, within-participant longitudinal age, and autism spectrum disorder diagnosis. Results: Analysis included data from n = 78. After selecting separate optimal models for fractional anisotropy and mean diffusivity values, we applied these models to fractional anisotropy and mean diffusivity of all 27 white matter tracts. Fractional anisotropy corpus callosum was related to positive Autism Diagnostic Observation Schedule-Second Edition classification (coefficient = 0.0093, P = .0612), and mean diffusivity right inferior cerebellar peduncle was related to positive Autism Diagnostic Observation Schedule-Second Edition classification (coefficient = -0.00002071, P = .0445), though these findings were not statistically significant after multiple comparisons correction. Conclusion: These optimized linear mixed effects models possibly implicate corpus callosum and cerebellar pathology in development of autism spectrum disorder in tuberous sclerosis complex, but future studies are needed to replicate these findings and explore contributors of heterogeneity in these models.

Differential Diagnosis of Autism and Other Neurodevelopmental Disorders

This article discusses the diagnostic criteria for autism spectrum disorder (ASD), as well as other neurodevelopmental disorders that may be confused with or co-occur with ASD. Practitioners involved in diagnostic assessment of ASD must be well versed in the features that differentiate ASD from other conditions and be familiar with how co-occurring conditions may manifest in the context of ASD. ASD symptoms present differently across development, underscoring the need for training about typical developmental expectations for youth. Periodic reevaluations throughout development are also important because support needs for individuals with autism change over time.

Assessment of Autism Spectrum Disorder

Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by challenges in social interaction and communication and the presence of restricted interests and repetitive behaviors. The importance of early detection of ASD and subsequent early intervention is well documented. Efforts have been made over the years to clarify ASD diagnostic criteria and develop predictive, accurate screening tools and evidence-based, standardized diagnostic instruments to aid in the identification of ASD. In this article, we review the most recent changes in ASD diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, summarize evidence-based instruments for ASD screening and diagnostic evaluations as well as the assessment of co-occurring conditions in ASD, the impact of COVID-19 on ASD assessment, and directions for future research in the field of ASD assessment.

Diagnosis and treatment challenges of autism spectrum disorder at a reference hospital in Douala, Cameroon

BACKGROUND

Autism spectrum disorder (ASD) is a neurodevelopmental disability associated with deficiency in social interaction, unusual development of social communication, and restricted or repetitive behaviors, interests and activities. This study aimed to describe management of pediatric ASD in Cameroon, a resource-constrained Central Africa country.

METHODS

A retrospective study was conducted between December 2021 and May 2022 at the Pediatrics department of a reference hospital in the town of Douala. Data of interest of children with ASD were collected through eligible medical records and telephone discussions with their parents/guardians.

RESULTS

Medical records of 145 children with ASD aged 2-15 years were included in the study, giving a hospital ASD prevalence of 3.7%. Time delay between parental concerns and hospital management was specified in 69 (47.58%) children, and among them 38 (55.07%) had a mean delay ± SD was less than five months. Children were mainly males (76%) and aged 4-5 years (37.93%), with mean age ± SD of 44.4 ± 22.2 months old. The main consultation reason was delayed language development (100%). Mean time delay between parental concerns and the first medical consultation was 18 months (range 1-60 month). Attention deficit hyperactivity disorder were found in 68.18% of children aged ≥ 6 years old. Neuropsychology (66.2%) was the most frequently used intervention. Some children were treated using traditional medicine.

CONCLUSIONS

Management of pediatric ASD is strongly influenced by socioeconomic and cultural context. It is crucial to implement behavioral change campaigns in community, organize training sessions to medical staff on diagnosis and treatment of ASD, and provide specialized centers with skilled staff and equipped material.

Theory of Mind Predicts Social Interaction in Children with Autism Spectrum Disorder: A Two-Year Follow-Up Study

This two-year follow-up study examined the predictive relationships of theory of mind (ToM) to social interaction by reciprocal social behaviors (RSBs) and social functioning (SF) in 106 children with ASD. The results of the path analysis showed that the earlier ToM predicted children's current component RSBs (B = 3.53, SE = 1.86, p = 0.039) and the current SF (B = 1.79-1.87, SE = 0.03-0.34, p < 0.001). The aloof and passive social interaction styles predicted fewer turn-taking of RSBs (B =  - 48.77 to - 111.17, p < 0.001) and fewer components of RSBs (B =  - 36.30 to - 81.41, p < 0.001). This finding provides empirical evidence that ToM predicts social interaction in children with ASD.

Prenatal air pollution, maternal immune activation, and autism spectrum disorder

BACKGROUND

Autism Spectrum Disorder (ASD) risk is highly heritable, with potential additional non-genetic factors, such as prenatal exposure to ambient particulate matter with aerodynamic diameter < 2.5 µm (PM2.5) and maternal immune activation (MIA) conditions. Because these exposures may share common biological effect pathways, we hypothesized that synergistic associations of prenatal air pollution and MIA-related conditions would increase ASD risk in children.

OBJECTIVES

This study examined interactions between MIA-related conditions and prenatal PM2.5 or major PM2.5 components on ASD risk.

METHODS

In a population-based pregnancy cohort of children born between 2001 and 2014 in Southern California, 318,751 mother-child pairs were followed through electronic medical records (EMR); 4,559 children were diagnosed with ASD before age 5. Four broad categories of MIA-related conditions were classified, including infection, hypertension, maternal asthma, and autoimmune conditions. Average exposures to PM2.5 and four PM2.5 components, black carbon (BC), organic matter (OM), nitrate (NO3-), and sulfate (SO42-), were estimated at maternal residential addresses during pregnancy. We estimated the ASD risk associated with MIA-related conditions, air pollution, and their interactions, using Cox regression models to adjust for covariates.

RESULTS

ASD risk was associated with MIA-related conditions [infection (hazard ratio 1.11; 95% confidence interval 1.05-1.18), hypertension (1.30; 1.19-1.42), maternal asthma (1.22; 1.08-1.38), autoimmune disease (1.19; 1.09-1.30)], with higher pregnancy PM2.5 [1.07; 1.03-1.12 per interquartile (3.73 μg/m3) increase] and with all four PM2.5 components. However, there were no interactions of each category of MIA-related conditions with PM2.5 or its components on either multiplicative or additive scales.

CONCLUSIONS

MIA-related conditions and pregnancy PM2.5 were independently associations with ASD risk. There were no statistically significant interactions of MIA conditions and prenatal PM2.5 exposure with ASD risk.

Predictors, Parental Views, and Concordance Across Diagnostic Sources of Autism in Male Youth with Fragile X Syndrome: Clinical Best Estimate and Community Diagnoses

Persons with fragile X syndrome (FXS) with cooccurring autism spectrum disorder (ASD) are at risk for poorer educational, medical, employment, and independent living outcomes. Thus, the identification of ASD in those with FXS is fundamental to ensuring access to appropriate supports to achieve good quality of life. Yet, optimal diagnostic methods and the exact rate of ASD comorbidity remains controversial, and description of ASD identification in the community in FXS has been limited. This study characterized ASD in a sample of 49 male youth with FXS across multiple diagnostic sources: parent-reported community diagnoses, classification derived from ADOS-2 and ADI-R thresholds, and clinical best-estimate classifications from an expert multidisciplinary team. High concordance was found between ADOS-2/ADI-R and clinical best estimate classifications, with both methods supporting ASD in ~ 75% of male youth with FXS. In contrast, 31% had a community diagnosis. Findings supported gross under-identification of ASD in male youth with FXS in community settings; 60% of those who met clinical best estimate criteria for ASD had not received a diagnosis in the community. Moreover, community diagnoses were poorly aligned with the presence of ASD symptoms as perceived by parents and professionals and, unlike clinical best estimate diagnoses, were not associated with cognitive, behavioral, or language features. Findings highlight under-identification of ASD in community settings as a significant barrier to service access for male youth with FXS. Clinical recommendations should emphasize the benefits of seeking a professional ASD evaluation for children with FXS who are noted to display key ASD symptoms.

Relationship of Nonsteroidal Anti-Inflammatory Drug Use During Pregnancy with Autism Spectrum Disorder and Intellectual Disability Among Offspring

Objective: This study aimed to examine the association of nonsteroidal anti-inflammatory drug (NSAID) use by pregnant women during pregnancy with autism spectrum disorder (ASD) and intellectual disability (ID) in their children among Medicaid-insured mother-child dyads. Materials and Methods: We conducted a retrospective cohort study linking multiple datasets of South Carolina for the years between 2010 and 2017, in which the main exposure variable was NSAID use during pregnancy and outcome variables were ASD only, ID only, and ASD with ID. We conducted a multinomial logistic regression analysis, controlling for identified risk factors for ASD (mother's age, race, body-mass index, preeclampsia, and gestational diabetes). Results: NSAID use during pregnancy was found to be associated with ID only in both unadjusted and adjusted analyses. Children with mothers who had NSAID prescriptions were 26% more likely to have ID in comparison with children whose mothers did not have NSAID prescriptions (odds ratio: 1.26 [1.10-1.46]). The other risk factors identified for ASD were maternal age, race, preeclampsia, smoking, low birth weight, and obesity. For ID, the risk factors were maternal age, race, smoking, birth weight, overweight, and obesity, all of which were also associated with ASD with ID, except for overweight. Conclusions: NSAID usage during pregnancy was found to be associated with ID only and not with ASD. However, more research is needed to validate the effect of NSAIDs during pregnancy on ASD and ID among children.

Screening for Autism in 2-Year-Old Children: The Application of the Systematic Observation of Red Flags to the Screening Tool for Autism in Toddlers and Young Children

PURPOSE

A multimeasure approach was developed to capitalize on the strengths of two screening measures: the Screening Tool for Autism in Toddlers and Young Children (STAT), an observational measure of social communication, and the Systematic Observation of Red Flags (SORF), a checklist including restricted and repetitive behavior (RRB) items. This approach offers a novel method of identifying autism in toddlers.

METHOD

This was a retrospective study of data collected from a multidisciplinary diagnostic program for 24- to 36-month-olds with developmental delays. Raters with autism expertise but naïve to diagnoses applied the SORF to STAT videos. Psychometrics were derived for the SORF on STAT observations and a multiple-measure approach that used a Least Absolute Shrinkage and Selection Operator modeling framework to construct a STAT-SORF RRB Hybrid, retaining SORF RRB items based on individual predictive abilities.

RESULTS

The SORF alone correctly classified 84% of the sample (84% sensitivity and 86% specificity). The STAT-SORF RRB Hybrid model, which retained four SORF RRB items, correctly classified 90% of a validation sample (95% sensitivity and 75% specificity).

CONCLUSION

These findings highlight the potential utility of using multiple autism identification tools and regression-based scoring to establish presumptive eligibility and facilitate early access to autism interventions.

Neural Tracking in Infancy Predicts Language Development in Children With and Without Family History of Autism

During speech processing, neural activity in non-autistic adults and infants tracks the speech envelope. Recent research in adults indicates that this neural tracking relates to linguistic knowledge and may be reduced in autism. Such reduced tracking, if present already in infancy, could impede language development. In the current study, we focused on children with a family history of autism, who often show a delay in first language acquisition. We investigated whether differences in tracking of sung nursery rhymes during infancy relate to language development and autism symptoms in childhood. We assessed speech-brain coherence at either 10 or 14 months of age in a total of 22 infants with high likelihood of autism due to family history and 19 infants without family history of autism. We analyzed the relationship between speech-brain coherence in these infants and their vocabulary at 24 months as well as autism symptoms at 36 months. Our results showed significant speech-brain coherence in the 10- and 14-month-old infants. We found no evidence for a relationship between speech-brain coherence and later autism symptoms. Importantly, speech-brain coherence in the stressed syllable rate (1-3 Hz) predicted later vocabulary. Follow-up analyses showed evidence for a relationship between tracking and vocabulary only in 10-month-olds but not in 14-month-olds and indicated possible differences between the likelihood groups. Thus, early tracking of sung nursery rhymes is related to language development in childhood.

Otizm Spektrum Bozukluğu Olan Hastalarda Öğrenme ve Hafıza Bozukluklarının NEURL1 ve RGS14 Genleri ile İlişkisi

Aim: We aimed to evaluate the relationship between learning-memory difficulties and NEURL1 and RGS14 genes in patients with autism spectrum disorders (ASD). Method: Forty children with ASD (20 ASD, 20 high functioning autism (HFA)) and 20 healthy controls were enrolled in this study. NEURL1 and RGS14 gene expressions in the blood samples of volunteers were assessed by quantitative Real-Time PCR (qRT-PCR). The clinical and demographical findings in patients were determined and examined relation with the gene expressions. Results: According to our findings, NEURL1 gene expression was decreased in both patient groups compared to the control (p0.05). A statistically significant correlation was found between learning and memory difficulties and RGS14 gene expression in HFA patients (p = 0.045). There was a positive correlation between between NEURL1 and RGS14 gene expressions of ASD patients (p=0.032, r=0,59). Conclusion: According to this study, NEURL1 gene may be proposed as a candidate gene for ASD. Nonetheless, we recommend that both genes be studied with more patients and preferably with brain tissues. These genes were evaluated for the first time in a clinical study on autism, and we believe that they will contribute to the literature in this respect.

Evidence of susceptibility to autism risks associated with early life ambient air pollution: A systematic review

BACKGROUND

Many studies have found associations between early life air pollution exposure and subsequent onset of autism spectrum disorder (ASD). However, characteristics that affect susceptibility remain unclear.

OBJECTIVE

This systematic review examined epidemiologic studies on the modifying roles of social, child, genetic and maternal characteristics in associations between prenatal and early postnatal air pollution exposure and ASD.

METHODS

A systematic literature search in PubMed and Embase was conducted. Studies that examined modifiers of the association between air pollution and ASD were included.

RESULTS

A total of 19 publications examined modifiers of the associations between early life air pollution exposures and ASD. In general, estimates of effects on risk of ASD in boys were larger than in girls (based on 11 studies). Results from studies of effects of family education (2 studies) and neighborhood deprivation (2 studies) on air pollution-ASD associations were inconsistent. Limited data (1 study) suggest pregnant women with insufficient folic acid intake might be more susceptible to ambient particulate matter less than 2.5 μm (PM2.5) and 10 μm (PM10) in aerodynamic diameter, and to nitrogen dioxide (NO2). Children of mothers with gestational diabetes had increased risk of ozone-associated ASD (1 study). Two genetic studies reported that copy number variations may amplify the effect of ozone, and MET rs1858830 CC genotype may augment effects of PM and near-roadway pollutants on ASD.

CONCLUSIONS

Child's sex, maternal nutrition or diabetes, socioeconomic factors, and child risk genotypes were reported to modify the effect of early-life air pollutants on ASD risk in the epidemiologic literature. However, the sparsity of studies on comparable modifying hypotheses precludes conclusive findings. Further research is needed to identify susceptible populations and potential targets for preventive intervention.

Cognitive Predictors of Social Interaction in Daily Contexts Among Children With Autism Spectrum Disorder

IMPORTANCE

Theory of mind (ToM) and executive function (EF) are often used to explain social interaction deficits in children with autism spectrum disorder (ASD), but no behavioral studies have specifically examined their relationship.

OBJECTIVE

To investigate the cognitive correlates of social interaction in daily contexts by ToM as well as cool and hot EFs among children with ASD.

DESIGN

Cross-sectional study.

SETTING

Teaching hospitals, clinics, and developmental centers.

PARTICIPANTS

One hundred thirty-two children with ASD and their caregivers.

OUTCOMES AND MEASURES

Measurements included the Vineland Adaptive Behavior Scales, Theory of Mind Task Battery, Dimensional Change Card Sort, and Children's Gambling Task, respectively, for children's daily social interaction, ToM, cool EF, and hot EF. Pearson's correlation analyses and three hierarchical regression models were conducted to identify the significant predictors of daily social interaction while controlling for verbal comprehension, measured using the Verbal Comprehension Index (VCI) of two Wechsler scales.

RESULTS

ToM and cool EF were significant cognitive predictors of social interaction in daily contexts in children with ASD whose verbal comprehension was average or above average.

CONCLUSIONS AND RELEVANCE

Our results suggest that ToM and cool EF are predictors of social interaction in daily contexts when considering children's verbal comprehension. Hot EF was not a significant predictor, contrary to our hypothesis. This behavioral study fills a research gap by enhancing the understanding of important cognitive correlates of social interaction in daily contexts for children with ASD to improve evaluation and intervention planning with this population. What This Article Adds: This study identified two cognitive predictors, ToM and cool EF, of social interaction in daily contexts for children with ASD. In addition to verbal comprehension, occupational therapy practitioners should assess ToM and cool EF to inform more comprehensive evaluation and intervention planning to improve social interaction in daily contexts for children with ASD.

Comorbidity of Attention-Deficit Hyperactivity Disorder and Autism Spectrum Disorders: Current Status and Promising Directions

High rates of co-occurring Attention-Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorders (ASD) suggest common causal pathways, which await elucidation. What is well-established, however, is the negative impact of comorbid ADHD and ASD on outcomes for everyday living, particularly in social interaction and communication and on broader psychopathology. Neurocognitive approaches suggest correlates of comorbidity are rooted in functional connectivity networks associated with executive control. There is support for familial origins, with molecular-genetic studies suggesting a causal role of pleiotropic genes. Further investigation is needed to elucidate fully how genetic risk for ADHD and ASD affects neurodevelopment and to identify structural and functional neural correlates and their behavioral sequelae. Identification of intermediate phenotypes is necessary to advance understanding, which requires studies that include the full spectrum of ASD and ADHD symptom severity, use longitudinal designs and multivariate methods to probe broad constructs, such as executive and social function, and consider other sources of heterogeneity, such as age, sex, and other psychopathology. Randomized efficacy trials targeting comorbid symptomatology are needed to mitigate negative developmental outcomes.

Play in Relation to Autism Traits in Young Children at Elevated Likelihood for Autism Spectrum Disorder

Play of younger siblings of children with autism spectrum disorder (ASD) (siblings; n = 44), very preterm children (preterms; n = 44), and children at typical likelihood for ASD (n = 36) was observed at 24 months. Children with ASD and atypical development engaged less in spontaneous (pre-)symbolic play than typically developing children. Total duration of spontaneous and elicited (pre-)symbolic play was associated with later ASD traits in siblings. However, no association between most play variables and ASD traits was found in preterms. This suggests possible different ASD-trajectories between siblings and preterms. Thus, spontaneous (pre-)symbolic play may be indicative of developmental challenges across several populations, and results highlight the need to move beyond studying only siblings in order to broaden our understanding of ASD.

The first five minutes: Initial impressions during autism spectrum disorder diagnostic evaluations in young children

Diagnosticians report that autism spectrum disorder (ASD) is immediately apparent in some, but not all, children ultimately diagnosed. Clinicians' initial diagnostic impressions have implications for ASD early detection, yet the literature raises questions about their accuracy. This study explores diagnostic impressions of ASD specialists made within the first 5 minutes of meeting a young child and investigates factors associated with the match between initial impressions and final diagnoses. Participants were children (n = 294, aged 12-53 months) referred for an ASD evaluation as part of multi-site ASD screening studies. After 5 minutes observing each child, clinicians with expertise diagnosing ASD recorded if they thought the child would meet criteria for ASD following a complete evaluation, and recorded their confidence in this impression. Clinicians' initial impressions matched the final diagnosis in 81% of cases. Ninety-two percent of cases initially thought to have ASD met criteria following a full evaluation; however, 24% of cases initially thought not to have ASD also met criteria, suggesting a high miss rate. Clinicians were generally confident in their initial impressions, reporting highest confidence for children initially thought correctly not to have ASD. ASD behavioral presentation, but not demographic characteristics or developmental level, were associated with matching initial impression and final diagnosis, and confidence. Brief observations indicating ASD should trigger referral to intervention services, but are likely to under-detect positive cases and should not be used to rule out ASD, highlighting the need to incorporate information beyond initial clinical impression. LAY SUMMARY: When children come in for an autism evaluation, clinicians often form early impressions-before doing any formal testing-about whether the child has autism. We studied how often these early impressions match the final diagnosis, and found that clinicians could not easily rule out autism (many children who initially appeared not to have autism were ultimately diagnosed), but were generally accurate ruling in autism (when a child appeared to have autism within 5 minutes, they were almost always so diagnosed).

Implicit learning in 3-year-olds with high and low likelihood of autism shows no evidence of precision weighting differences

Predictive Processing accounts of autism claim that autistic individuals assign higher precision to their prediction errors than non-autistic individuals, that is, autistic individuals update their predictions more readily when faced with unexpected sensory input. Since setting the level of precision is a fundamental part of perception and learning, we propose that such differences should be detectable in various domains at a very early age, before clinical symptoms have fully emerged. We therefore tested 3-year-old younger siblings of autistic children, with a high likelihood of later receiving an autism diagnosis themselves, and low-likelihood children with an older sibling without autism. We used a novel implicit learning paradigm to examine the effect of sensory noise on the predictions participants built. In order to learn a sequence, our participants had to select which visual information to attend to and disregard low-level prediction errors caused by the sensory noise, which the theory claims is more difficult for autistic individuals. Contrary to the proposed higher precision-weighting of prediction errors in autism, the high-likelihood children did not show signs of updating their predictions more readily when we added sensory noise compared to the low-likelihood children, either in their reaction times or in the recurrence and determinism of their response locations. These results raise challenges for Predictive Processing theories of autism, specifically for the notion that prediction errors are inflexibly highly weighted by individuals with autism.

Behavioral Affect in Children with Autism Spectrum Disorder during School Closures Due to the COVID-19 Pandemic in Japan: A Case-Controlled Study

Children with autism spectrum disorder (ASD) could experience more stress due to the changes consequent to school closures because of the coronavirus disease 2019 (COVID-19) pandemic. This study investigated differences in behavioral affect between children with ASD and typically developing children (TD). We conducted an online survey with mothers. The data of 84 children with ASD and 361 TD children aged 6 to 18 years were analyzed. Children with ASD were more frustrated due to the changes in their schedule and engaged more in restricted and repetitive behavior. Children with ASD had different types of behavioral affect compared to TD.

Visual preference for social vs. non-social images in young children with autism spectrum disorders. An eye tracking study

Autism Spectrum Disorders (ASD) are associated to social attention (SA) impairments. A gaze bias to non-social objects over faces has been proposed as an early marker of ASD. This bias may be related to the concomitant circumscribed interests (CI), which question the role of competing objects in this atypical visual behavior. The aim of this study was to compare visual attention patterns to social and non-social images in young children with ASD and matched typical controls (N = 36; age range 41-73 months) assessing the role of emotion in facial stimuli and the type of competing object. A paired preference task was designed pairing happy, angry, and neutral faces with two types of objects (related or not related to autism CI). Eye tracking data were collected, and three indexes were considered as dependent variables: prioritization (attentional orientation), preference, and duration (sustained attention). Results showed that both groups had similar visual pattern to faces (prioritization, more attention and longer visits to faces paired with objects non-related to their CI); however, the ASD group attended to faces significantly less than controls. Children with ASD showed an emotional bias (late orientation to angry faces and typical preference for happy faces). Finally, objects related to their CI captured attention in both groups, significantly reducing SA in children with ASD. Atypical SA is present in young children with ASD regardless the competing non-social object. Identifying strengths and difficulties in SA in this population may have substantial repercussion for early diagnosis, intervention, and ultimately prognosis.

Validation of the Modified Checklist for Autism in Toddlers, Revised with Follow-up in a Population Sample of 30-Month-Old Children in Iceland: A Prospective Approach

The Modified Checklist for Autism in Toddlers, Revised with Follow-up was validated on a population sample in Reykjavik, Iceland. The participants (N = 1585) were screened in well-child care at age 30 months and followed up for at least 2 years to identify autism cases. The sensitivity, specificity, positive and negative predictive values were 0.62, 0.99, 0.72, and 0.99, respectively. True-positive children were diagnosed 10 months earlier than false-negative children. Autism symptom severity and the proportions of children with verbal and performance IQs/DQs < 70 were similar between groups. Although the sensitivity was suboptimal, the screening contributed to lowering the age at diagnosis for many children. Adding autism-specific screening to the well-child care program should be considered.

Family navigation to increase evaluation for autism spectrum disorder in toddlers: Screening and Linkage to Services for Autism pragmatic randomized trial

LAY ABSTRACT

Young children with autism spectrum disorder can benefit from early detection and intervention to moderate autism spectrum disorder's effect on their development. Routine screening with standardized instruments facilitates early identification. However, many screen-positive children do not receive referrals for evaluation, complete diagnostic evaluations, or engage in services. This is especially true for children of color and those from less educated or low-income families. The Screening and Linkage to Services for Autism trial evaluated the effect of family navigation on referral and evaluation for autism spectrum disorder in screen-positive toddlers. The trial was conducted in an urban, low-income population. It was designed to test "real-world" implementation of family navigation. We randomly assigned 275 children aged 16-30 months with an initial positive autism spectrum disorder screen to receive navigation if indicated or usual care. Navigation increased the number of at-risk toddlers who were evaluated for autism spectrum disorder. It also improved the quality of autism spectrum disorder screening in primary care clinics. However, many children failed to receive indicated referrals for evaluation. Navigation did not improve referral rates. Furthermore, nearly half of families who were potentially eligible for navigation could not be contacted. Other ways of structuring the navigation program may be necessary to improve families' access to and acceptance of navigation, especially in the setting of financial, cultural, and linguistic barriers. Our trial nevertheless showed that family navigation may be an important tool for reducing systemic inequalities in the early identification and treatment of young children with autism spectrum disorder.

Early non-social behavioural indicators of autism spectrum disorder (ASD) in siblings at elevated likelihood for ASD: a systematic review

We aimed at identifying early non-social behavioural indicators that predict later ASD. Likewise, we were interested in the moment in which non-social signs discriminate between children at elevated likelihood for ASD with a later diagnosis of ASD, and children at elevated likelihood for ASD with a typical developmental outcome. In addition, we intended to explore the developmental evolution of children's symptomatology over time. A systematic literature search was conducted for longitudinal studies on early non-social behavioural indicators among siblings at elevated likelihood for ASD. The following databases were searched: PUBMED, Web of Science, PsycINFO, CINAHL and EMBASE. The study identification process was conducted by two reviewers independently. Compared to siblings at elevated likelihood for ASD with a typical developmental outcome, siblings at elevated likelihood for ASD with later ASD show impairments in attention disengagement, in gross and fine motor development and characteristic restricted and repetitive interests and behaviours, starting at 12 months of age. Moreover, early attention disengagement exerts a predictive role towards a later ASD diagnosis, given that from 12 months siblings at elevated likelihood for ASD who will receive an independent ASD diagnosis towards 24-36 months present marked difficulties in disengaging in comparison with siblings at elevated likelihood for ASD that will not satisfy the criteria for an ASD diagnosis. The findings call for a more comprehensive vision on early indicators of ASD. Further research is needed to extend results to other behavioural domains.

Migración diagnóstica entre Trastorno Específico del Lenguaje y Trastorno del Espectro Autista:

Trastorno específico del lenguaje (TEL) y trastorno del espectro autista (TEA) son trastornos del neurodesarrollo muy similares a edades tempranas, lo que dificulta el diagnóstico diferencial temprano. El fenómeno ‘migración diagnóstica’ alude al cambio diagnóstico por evolución del trastorno o modificación de criterios diagnósticos, instrumentos o técnicas de evaluación. El objetivo de este estudio fue analizar la incidencia y el impacto del fenómeno en los centros de atención infantil temprana (CAITs) de la provincia de Córdoba. A través de un cuestionario en formato online habilitado desde marzo a mayo de 2020, los responsables de los CAITs proporcionaron datos cuantitativos sobre este fenómeno y su valoración del impacto en la intervención, el pronóstico y las familias de población infantil de 0 a 6 años. Diez CAITs con financiación pública respondieron al cuestionario. Los resultados arrojaron una alta incidencia del fenómeno migración diagnóstica, principalmente desde TEA hacia TEL. También se observó una diferencia significativa en el número de casos diagnosticados en ambos trastornos, siendo TEA el diagnóstico mayoritario. El impacto de este fenómeno sobre el pronóstico del niño y la familia se estimó positivo, ya que generalmente suponía una evolución hacia un trastorno más leve. Estos resultados ofrecen una aproximación hacia un tema de importancia y escasa investigación hasta la fecha. Continuar esta línea de investigación ampliando la muestra de centros, la información sociodemográfica de los mismos e incluyendo la perspectiva de las familias mejoraría el conocimiento de estos trastornos y favorecería la práctica clínica en el ámbito de la atención temprana.

Predicting cognitive development and early symptoms of autism spectrum disorder in preterm children: The value of temperament and sensory processing

This study was the first to longitudinally explore the extent to which early temperament and sensory processing were of predictive value for cognitive development and Autism Spectrum Disorder (ASD) symptomatology in a sample of preterm children (N = 50, 22 girls, mean gestational age 27 weeks). At the corrected ages of 10, 18, and 24 months, sensory processing and temperament were assessed, as were cognitive development and ASD symptoms at 36 months. Better cognitive development was predicted by fewer hospitalisation days at birth and by lower Activity Level at 18 months. Temperamental subscales of Negative Affect showed associations with both parent-reported and observational measures of ASD symptomatology, whereas sensory processing only had predictive value for parent-reported symptoms of ASD. The usefulness of temperament and sensory processing for prediction of ASD symptom severity and cognitive outcomes became clear in the second year of life. The results indicate that this area of research is worth additional investigation in the extreme and very preterm population, to explore in further detail whether these two concepts might be able to provide information about which preterms are more likely to develop ASD or cognitive impairments.

Clinical Characteristics of Developmentally Delayed Children based on Interdisciplinary Evaluation

The aim of this study is to examine the clinical characteristics of children suspected to have neurodevelopmental disorders and to present features that could be helpful diagnostic clues at the clinical assessment stage. All children who visited the interdisciplinary clinic for developmental problems from May 2001 to December 2014 were eligible for this study. Medical records of the children were reviewed. A total of 1,877 children were enrolled in this study. Most children were classified into four major diagnostic groups: global developmental delay (GDD), autism spectrum disorder (ASD), developmental language disorder (DLD) and motor delay (MD). GDD was the most common (43.9%), and boys were significantly more predominant than girls in all groups. When evaluating the predictive power of numerous risk factors, the probability of GDD was lower than the probability of ASD among boys, while the probability of GDD increased as independent walking age increased. Compared with GDD and DLD, the probability of GDD was increased when there was neonatal history or when the independent walking age was late. Comparison of ASD and DLD showed that the probability of ASD decreased when a maternal history was present, whereas the probability of ASD increased with male gender. To conclude, the present study revealed the clinical features of children with various neurodevelopmental disorders. These results are expected to be helpful for more effectively flagging children with potential neurodevelopmental disorders in the clinical setting.

Altered neuronal activity in the auditory brainstem following sound stimulation in thalidomide-induced autism model rats

Auditory hypersensitivity in autism is frequently observed in clinics. Dysfunction in the auditory brainstem has been suspected. We have established autism model rats using prenatal thalidomide exposure. Here we investigated whether abnormal response occurs in the brainstem following sound stimulus in autism model rats. Autism model rats were prepared by prenatal exposure to thalidomide on embryonic days 9 and 10 in pregnant rats. Then, the animals were exposed to 16-kHz pure tone auditory stimulus and c-Fos immunostaining was performed to examine the neuronal activity on postnatal day 49 to 51. Following sound stimulus, increased number of c-Fos-positive neurons was observed in the medial nucleus of the trapezoid body of autism model rats compared with the control rats. These results suggest that prenatal thalidomide might cause altered processing of auditory stimulus, leading to the characteristics of auditory hypersensitivity in autism.

Effects of Mini-Basketball Training Program on Executive Functions and Core Symptoms among Preschool Children with Autism Spectrum Disorders

This study examined the effects of a 12-week mini-basketball training program (MBTP) on executive functions and core symptoms among preschoolers with autism spectrum disorder (ASD). In this quasi-experimental pilot study, 33 ASD preschoolers who received their conventional rehabilitation program were assigned to either a MBTP group (n = 18) or control group (n = 15). Specifically, the experimental group was required to take an additional 12-week MBTP (five days per week, one session per day, and forty minutes per session), while the control group was instructed to maintain their daily activities. Executive functions and core symptoms (social communication impairment and repetitive behavior) were evaluated by the Childhood Executive Functioning Inventory (CHEXI), the Social Responsiveness Scale-Second Edition (SRS-2), and the Repetitive Behavior Scale-Revised (RBS-R), respectively. After the 12-week intervention period, the MBTP group exhibited significantly better performances in working memory (F = 7.51, p < 0.01, partial η² = 0.195) and regulation (F = 4.23, p < 0.05, partial η² = 0.12) as compared to the control group. Moreover, the MBTP significantly improved core symptoms of ASD preschoolers, including the social communication impairment (F = 6.02, p < 0.05, partial η² = 0.020) and repetitive behavior (F = 5.79, p < 0.05, partial η² = 0.016). Based on our findings, we concluded that the 12-week MBTP may improve executive functions and core symptoms in preschoolers with ASD, and we provide new evidence that regular physical exercise in the form of a MBTP is a promising alternative to treat ASD.

Received Cradling Bias During the First Year of Life: A Retrospective Study on Children With Typical and Atypical Development

A population-level left cradling bias exists whereby 60-90% of mothers hold their infants on the left side. This left biased positioning appears to be mutually beneficial to both the mother and the baby's brain organization for processing of socio-emotional stimuli. Previous research connected cradling asymmetries and Autism Spectrum Disorders (ASD), entailing impairment in socio-communicative relationships and characterized by an early hypo-lateralization of brain functions. In this explorative study, we aimed to provide a contribution to the retrospective investigations by looking for early behavioral markers of neurodevelopmental disorders such as ASD. We hypothesized that an atypical trajectory in maternal cradling might be one of the possible signs of an interference in mother-infant socio-emotional communication, and thus of potential neurodevelopmental dysfunctions. To this aim, we examined photos depicting mother-child early cradling interactions by consulting family albums of 27 children later diagnosed with ASD and 63 typically developing children. As regards the first half of the first year of life, no differences were shown between maternal cradling-side preferences in typical and ASD groups, both exhibiting the left-cradling bias in the 0-3 months period, but not in the 3-6 months period. However, our results show dissimilar patterns of cradling preferences during the second half of the first year of life. In particular, the absence of left-cradling shown in typical mothers was not observed in ASD mothers, who exhibited a significant left-cradling bias in the 6-12 months age group. This difference might reflect the fact that mother-infant relationship involving children later diagnosed with ASD might remain "basic" because mothers experience a lack of social activity in such children. Alternatively, it may reflect the overstimulation in which mothers try to engage infants in response to their lack of responsiveness and social initiative. However, further investigations are needed both to distinguish between these two possibilities and to define the role of early typical and reversed cradling experiences on neurodevelopment.

Serotonergic innervation of the amygdala is increased in autism spectrum disorder and decreased in Williams syndrome

BACKGROUND

Williams syndrome (WS) and autism spectrum disorder (ASD) are neurodevelopmental disorders that demonstrate overlapping genetic associations, dichotomous sociobehavioral phenotypes, and dichotomous pathological differences in neuronal distribution in key social brain areas, including the prefrontal cortex and the amygdala. The serotonergic system is critical to many processes underlying neurodevelopment and is additionally an important neuromodulator associated with behavioral variation. The amygdala is heavily innervated by serotonergic projections, suggesting that the serotonergic system is a significant mediator of neuronal activity. Disruptions to the serotonergic system, and atypical structure and function of the amygdala, are implicated in both WS and ASD.

METHODS

We quantified the serotonergic axon density in the four major subdivisions of the amygdala in the postmortem brains of individuals diagnosed with ASD and WS and neurotypical (NT) brains.

RESULTS

We found opposing directions of change in serotonergic innervation in the two disorders, with ASD displaying an increase in serotonergic axons compared to NT and WS displaying a decrease. Significant differences (p < 0.05) were observed between WS and ASD data sets across multiple amygdala nuclei.

LIMITATIONS

This study is limited by the availability of human postmortem tissue. Small sample size is an unavoidable limitation of most postmortem human brain research and particularly postmortem research in rare disorders.

CONCLUSIONS

Differential alterations to serotonergic innervation of the amygdala may contribute to differences in sociobehavioral phenotype in WS and ASD. These findings will inform future work identifying targets for future therapeutics in these and other disorders characterized by atypical social behavior.

The agreement between the referrer, practitioner and research diagnosis of autistic spectrum conditions among children attending child and adolescent mental health services

We aimed to explore the levels of agreement about the diagnoses of Autistic Spectrum Conditions between the referrer, CAMHS practitioner and a research diagnosis, as well as the stability of the practitioner's diagnosis over time in a secondary analysis of data from 302 children attending two Child and Adolescent Mental Health Services over two years. Kappa coefficient was used to assess the agreement between the referrer and research diagnosis. Kendall's tau b coefficient was used to assess the agreement between the practitioner and the research diagnosis assigned using the Development and Well-Being Assessment, as well as the agreement between the referrer's indication of presenting problems and the practitioner diagnosis. Diagnostic stability was explored in children with and without a research diagnosis of Autistic Spectrum Condition. There was a moderate level of agreement between the referrer and research diagnosis (Kappa = 0.51) and between practitioner's and research diagnosis (Kendall's tau = 0.60) at baseline, which reduced over the subsequent two years. Agreement between the referrer and practitioner's diagnosis at baseline was fair (Kendall's tau = 0.36).The greatest diagnostic instability occurred among children who practitioners considered to have possible Autistic Spectrum Conditions but who did not meet research diagnostic criteria. Further studies could explore the approaches used by practitioners to reach diagnoses and the impact these may have on diagnostic stability in Autistic Spectrum Conditions. Standardised assessment using a clinically rated diagnostic framework has a potential role as an adjunct to standard clinical care and might be particularly useful where practitioners are uncertain.

Temporal and Geographical Variability of Prevalence and Incidence of Autism Spectrum Disorder Diagnoses in Children in Catalonia, Spain

This study aims to estimate the prevalence of autism spectrum disorders (ASD) in 2017 and the ASD diagnosis incidence between 2009 and 2017 in children living in Catalonia region in Spain, and their temporal and geographical variability. We used administrative data for all children aged 2–17 years who were insured in the public Catalan Health System between 2009 and 2017. We identified all ASD cases diagnosed between 2009 and 2017 (ICD‐9 codes 299.0, 299.1, 299.8, and 299.9). We estimated the ASD prevalence in 2017 and the overall annual incidence between 2009 and 2017, then stratified by sex, age group, and healthcare area. We used Poisson regression models to assess temporal trends in the incidence and mixed‐effects Poisson regression models to assess geographical variability. We observed an ASD prevalence of 1.23% (95% confidence interval [CI] 1.21–1.25) in 2017, with 1.95% (95% CI 1.92–1.99) for boys and 0.46% (95% CI 0.44–0.48) for girls, the highest prevalence being in 11‐ to 17‐year‐olds (1.80%, 95% CI 1.76–1.83). The ASD diagnosis incidence increased from 0.07% (95% CI 0.06–0.09) in 2009 to 0.23% (95% CI 0.21–0.24) in 2017, with a higher increase in girls, and in children aged 2–5 years at the time of diagnosis. We only observed geographical differences in prevalence in the 2017 data. We also detected a threefold increase in the diagnosis incidence overall, which was even more pronounced in girls and at early ages. In conclusion, the ASD prevalence observed in this study was 1.23% in 2017, with a sex ratio of 4.5 in favor of boys, which is consistent with previous studies. Autism Res2019. © 2019 International Society for Autism Research, Wiley Periodicals, Inc.

Lay Summary

Autism spectrum disorders (ASD) are currently well known in our society as one of the most common neurodevelopmental disorders during childhood. The results of our study showed that, in 2017 in Catalonia, slightly more than one in a 100 children had an ASD diagnosis, it was more common in boys than in girls, and also in older children. In addition, between 2009 and 2017, we observed an increase in the number of new cases diagnosed each year. The data presented in this study will assist in planning and evaluating the needs of health services in this geographical region.

Stability of Autism Spectrum Disorder in Young Children with Diverse Backgrounds

Determining diagnostic stability of ASD, as well stability of functioning in early childhood, is relevant to prevalence, best practices for communicating early ASD diagnoses to caregivers, families' experiences, and developmental trajectories. Generalizability of findings from prior research has been limited by small and homogenous samples, short follow-up time intervals, and inconsistent diagnostic procedures. This report presents follow-up evaluations of 60 children (86.7% male, mean age: 51.3 months) with diverse backgrounds (79.7% racial/ethnic minorities) who received initial ASD diagnoses before 36 months of age (mean age: 27 months). Fifty-three children (88.3%) met diagnostic criteria for ASD at follow-up, a proportion consistent with previous studies. On average, children demonstrated significant cognitive gains and ASD symptom improvement. Clinical implications of findings are discussed.

Developmental screening and early intervention in a childcare setting for young children at risk for autism and other developmental delays: A feasibility trial

Efforts to decrease disparity in diagnosis and treatment for under-resourced children with developmental delays, such as autism spectrum disorder, have led to increased interest in developing programs in community settings. One potential setting that has already demonstrated feasibility in conducting universal screening is the childcare setting. The current study conducted developmental screening in a total of 116 children ages 16-80 months of age in an urban low-income community childcare center. Parents of 20 children who screened positive were enrolled in the intervention phase of the study, where children received a staff-delivered targeted early intervention or a waitlist control condition. Given the small and imbalanced sample sizes, confidence intervals from mixed effect models were used to measure changes across time for each group. Of the children who received treatment, there was an average increase in child initiated joint engagement, symbolic play, and language use. This study provides initial feasibility data for the implementation of a screening and early intervention program to service a predominantly low-resource and ethnically diverse population within the childcare system in a large metropolitan city. Autism Res 2019, 12: 1423-1433. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Identifying and delivering treatment services for young children with developmental delays, such as autism spectrum disorder, may be most successful in community settings, especially for those children from under-resourced areas. This study found preliminary evidence that the childcare setting is a good place to conduct screening and deliver early interventions for children at risk for autism and other developmental delays.

[The prevalence of autism: genuine and imaginary]

In this review, the authors analyze the causes of the high prevalence of autism spectrum disorders (ASD) in recent decades. It is shown that the expansion of the boundaries of the 'autistic spectrum' concept led to a significant spread of data on its prevalence, depending on the time, diagnostic criteria, country and region. Stability of the diagnosis of ASD is not high and depends on the age of the child. Diagnostic practice in comorbid psychiatric disorders unfairly shifted toward ASD. At the same time, the hypothesis on the uniqueness of autistic manifestations in infancy is not convincingly confirmed. The practical aspect of the problem of the epidemiology of autism does not exclude, but on the contrary, presupposes early detection of nonspecific mental disorders followed by medical-psychological-pedagogical correction.

Barriers to an Information Effect on Diagnostic Disparities of Autism Spectrum Disorder in Young Children

Objectives:

Autism spectrum disorder (ASD) is underdiagnosed in children from minority and low socioeconomic status families, and reports indicate that parental “lack of awareness” of symptoms is a factor, which implicates the adoption of the category globally. However, parental knowledge of ASD has failed to explain emerging clusters of cases. The objective of the present research was to identify and describe barriers to an “information effect” in diagnosis.

Methods:

Interviews were conducted with the parents of 54 children with ASD in Costa Rica, many living within clusters that appeared after a genetic study conducted an information campaign for recruitment. The interviews explored factors influencing symptom recognition and help-seeking behaviors. Several barriers were identified that prevent information about ASD or exposure to diagnosed cases from influencing parents’ help-seeking behaviors.

Results:

Early symptoms in most children gave parents no reason to suspect ASD. Later, parents’ understanding of ASD depended on caricatures of the disorder. Parents often received unsolicited advice from strangers, although rarely from family, and it was always seen as critical of their parenting; furthermore, the advice was too late to influence the referral process, which was well underway by the time classical symptoms of ASD appeared, if they did at all. Postdiagnosis, the interviewees occasionally gave advice to other parents, mostly strangers, but none had apparently been diagnosed.

Conclusions:

The results implicate efforts to educate parents about symptoms of ASD, where a focus on generic developmental delays and neurodevelopmental disorders in general may be more effective than ASD-specific information.

Improving Efficiency and Quality of the Children's ASD Diagnostic Pathway: Lessons Learned from Practice

The 'autism diagnosis crisis' and long waiting times for assessment are as yet unresolved, leading to undue stress and limiting access to effective support. There is therefore a significant need for evidence to support practitioners in the development of efficient services, delivering acceptable waiting times and effectively meeting guideline standards. This study reports statistically significant reductions in waiting times for autism diagnostic assessment following a children's health service improvement programme. The average wait between referral and first appointment reduced from 14.2 to 10.4 weeks (t(21) = 4.3, p < 0.05) and between referral and diagnosis shared, reduced from 270 to 122.5 days, (t(20) = 5.5, p < 0.05). The proportion of girls identified increased from 5.6 to 2.7:1. Methods reported include: local improvement action planning; evidence based pathways; systematic clinical data gathering and a training plan. This is a highly significant finding for many health services wrestling with the challenges of demand and capacity for autism diagnosis and assessment.

The Need for a Developmentally Based Measure of Social Communication Skills

The ability to demonstrate and quantify changes in social communication skills has been hindered by a lack of existing measures with appropriate standardization and psychometric properties. Such a measure would be helpful for research in many populations but would be particularly crucial for detecting incremental changes in youth with neurodevelopmental disorders who might gain skills but still lag substantially behind same-age peers. Although study designs and statistical methods are under development to try to account for slow and/or nonlinear, but potentially meaningful, improvements,¹ there is a dearth of measures designed to capture growth and loss of social communication skills. This opinion piece outlines the argument for such a measure and the primary issues to consider in its development.

Case-contrast study about parent-infant interaction in a Brazilian sample of siblings of children with autism spectrum disorders

Siblings of children with autism spectrum disorders (ASD) present greater susceptibility to developmental problems, in comparison with siblings of typically developing children. The greater prevalence of mental health disorders among parents of children with ASD increases younger siblings' vulnerability to emotional problems. The aim of this study is to compare the interaction between carers and babies aged 2 to 26 months (M = 11.7, SD = 6.9) who are siblings of children with ASD (ASD dyads) with the interaction of dyads of siblings of typically developing children (TD dyads). The protocol of Clinical Indicators of Risk for Child Development and the Coding Interactive Behaviour measures were used to evaluate interaction. ASD dyads presented higher scores of constriction in their interaction, P = .024, with babies presenting higher scores of withdrawal behavior, P = .003, and carers presenting higher scores of depressive mood, P = .008, when compared to TD dyads. The ASD dyads have interactive impairments more frequently than do the TD dyads.

Beyond pass-fail: Examining the potential utility of two thresholds in the autism screening process

Access to early intervention as early in development as possible is critical to maximizing long-term outcomes for children with autism spectrum disorders (ASD). However, despite the fact that ASD can be reliably diagnosed by 24 months, the average age of diagnosis is 2 years later. Waitlists for specialized developmental evaluations are one barrier to early diagnosis. The purpose of this study was to examine one potential approach to reducing wait time for an ASD diagnostic evaluation by examining the utility of using more than one threshold for an autism screening tool, the Screening Tool for Autism in Toddlers and Young Children (STAT). Participants included 171 children between 24 and 36 months of age who received a medical diagnostic evaluation through Illinois' Early Intervention Program. This study directly compared the performance of the STAT when scored: (a) using the original single threshold, (b) using seven equally weighted items using a single threshold, and (c) using all items differentially weighted based on how strongly that item predicts a later ASD diagnosis. In addition, this study explored the potential utility of using two thresholds rather than a single threshold for each scoring method. Results of this study suggest that using a two-threshold logistic regression method has potential psychometric advantages over a single threshold and categorical scoring. Using this approach may reduce the wait time for specialty ASD diagnostic evaluations by maximizing true negatives and true positives, such that specialty evaluations may be reserved for those cases that are more ambiguous or more complex. Autism Research 2019, 12: 112-122. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: This study examined the benefits of using two versus one cutoff score when screening for autism. Results indicate that having two scores and weighting test items based on predictive association with an autism diagnosis is better than using a single score and weighting each item equally. Using such an approach may reduce the wait time for specialty autism diagnostic evaluations, such that specialty evaluations may be reserved for those cases that are more ambiguous or more complex.

Initiating joint attention use in infants at high-risk for autism spectrum disorder

BACKGROUND

Impairment in initiating joint attention (IJA) is associated with autism spectrum disorder (ASD) in children, although it is unclear when impairments arise. Due to the early development of IJA use and late diagnosis of ASD, groups at high-risk of ASD, such as infants with an older sibling with ASD (ASIBs) and infants with fragile X syndrome (FXS), provide opportunities to study early IJA behaviours for children who are later diagnosed with ASD. This study analysed these two groups to determine if IJA use differed compared with typically developing (TD) peers at 12 months and whether IJA was associated with later ASD outcomes.

METHOD

An experimental attention task was used to analyse IJA gaze shifts and gestures in the high-risk groups. Clinical best estimate diagnoses were given to each participant to compare IJA behaviours to ASD severity.

RESULTS

No differences in the frequency of IJA gaze shifts and gestures were found between 12-month-old ASIBs and TD controls, but infants with FXS demonstrated a significantly reduced range of IJA gaze shifts relative to TD controls. Additionally, ASD outcomes at 24 months were related to IJA use for infants with FXS at 12 months, but not infant ASIBs, although these findings were explained by differences in nonverbal cognitive development.

CONCLUSIONS

Although previous studies have reported delays in IJA use in children with FXS and ASIBs at ages 21 and 14 months, respectively, our results suggest IJA behaviours for these high-risk groups are not distinct from TD children at 12 months. When differences were found at 12 months, they were explained by nonverbal cognitive development, particularly for infants with FXS. Differences in IJA use at 12 months in this study were too small to serve as a potential indicator of later ASD.

Delayed autism spectrum disorder recognition in children and adolescents previously diagnosed with attention-deficit/hyperactivity disorder

Phenotypic elements of autism spectrum disorder can be masked by attention-deficit/hyperactivity disorder symptoms, potentially leading to a misdiagnosis or delaying an autism spectrum disorder diagnosis. This study explored differences in the age of autism spectrum disorder diagnosis between participants with previously diagnosed attention-deficit/hyperactivity disorder versus autism spectrum disorder–only respondents. Children and adolescents, but not adults, initially diagnosed with attention-deficit/hyperactivity disorder received an autism spectrum disorder diagnosis an average of 1.8 years later than autism spectrum disorder–only children, although the findings regarding the adult sample should be interpreted with caution. Gender differences were also explored, revealing that the delay in receiving an autism diagnosis was 1.5 years in boys and 2.6 years in girls with pre-existing attention-deficit/hyperactivity disorder, compared with boys and girls without prior attention-deficit/hyperactivity disorder. No significant gender differences were observed in the adult sample. We argue that overlapping symptoms between autism spectrum disorder and attention-deficit/hyperactivity disorder might delay a formal diagnosis of autism either by leading to a misdiagnosis of attention-deficit/hyperactivity disorder or by making it difficult to identify the presence of co-occurring autism spectrum disorder conditions once an initial diagnosis of attention-deficit/hyperactivity disorder has been obtained. Current findings highlight the need to recruit multidimensional and multidisciplinary screening procedures to assess for potential emerging autism spectrum disorder hallmarks in children and adolescents diagnosed or presenting with attention-deficit/hyperactivity disorder symptoms.

Juvenile Shank3b deficient mice present with behavioral phenotype relevant to autism spectrum disorder

Autism spectrum disorder (ASD) is a pervasive, multifactorial neurodevelopmental disorder diagnosed according to deficits in three behavioral domains: communication, social interaction, and stereotyped/repetitive behaviors. Mutations in Shank genes account for ∼1% of clinical ASD cases with Shank3 being the most common gene variant. In addition to maintaining synapses and facilitating dendritic maturation, Shank genes encode master scaffolding proteins that build core complexes in the postsynaptic densities of glutamatergic synapses. Male mice with a deletion of the PDZ domain of Shank3 (Shank3B KO) were previously shown to display ASD-like behavioral phenotypes with reported self-injurious repetitive grooming and aberrant social interactions. Our goal was to extend these previous findings and use a comprehensive battery of highly detailed ASD-relevant behavioral assays including an assessment of mouse ultrasonic communication carried out on key developmental days and male and female Shank3B KO mice. We demonstrate that ASD-related behaviors, atypical reciprocal social interaction and indiscriminate repetitive grooming, are apparent in juvenile stages of development of Shank3B KO mice. Our findings underscore the importance of utilizing Shank mutant models to understand the impact of this gene in ASD etiology, whichmay enable future studies focusing on etiological gene-environment interactions in ASD.

Evaluating Efficacy and Preference for Prompt Type During Discrete-Trial Teaching

The components of discrete-trial teaching (DTT) may be individualized to each learner during instruction (e.g., the type of prompts used). However, there is limited research on the relative efficiency and effectiveness of these different prompt types. In addition, the learner's preference for how they are taught is not always considered. The present study compared relative effectiveness of three prompt types (i.e., a gesture, modeling, physical guidance) to a no-prompt control condition during a receptive identification task with three boys with autism. One participant met the mastery criterion first in the model prompt condition, and two participants in the physical prompt condition. All participants selected the physical prompt during a concurrent-chains preference assessment. In addition, all participants completed a chained task using the most effective prompt type.