Transdiagnostic research and the neurodiversity paradigm: commentary on the transdiagnostic revolution in neurodevelopmental disorders by Astle et al

A Mixed Method Systematic Review Into the Impact of ED Treatment in Autistic People and Those With High Autistic Traits

OBJECTIVE

Our understanding of the impact of eating disorders (ED) treatment in Autistic people remains elusive. Research has begun to explore ED treatment outcomes and experiences in this population, however current understandings are poorly integrated. The current review therefore sought to explore the impact of ED treatment on Autistic people and those with higher Autistic traits.

METHOD

A convergent, segregated approach was used, independently evaluating quantitative then qualitative studies before integrating findings into a coherent narrative synthesis.

RESULTS

Autistic people and people with higher Autistic traits report poorer experiences of treatment and may be at increased risk of inpatient admission and prolonged inpatient treatment, possibly explained by difficulties with treatment timeframes and a lack of autism-informed support. Both groups reported similar improvements in ED symptoms and BMI. Higher rates of psychosocial difficulties pre-and post-treatment were reported in those with higher Autistic traits, and emotion-focused interventions were felt to be particularly relevant to Autistic presentations of EDs. Concerns were reported as to how well aligned group-based programs and cognitive-based interventions are for Autistic individuals and those reporting higher Autistic traits.

DISCUSSION

Future research in diagnosed autism samples is urgently needed to develop a more robust understanding of Autistic outcomes and experiences. Review findings demonstrate the need for increased understanding of ED presentations and the possible need for treatment adaptations, for Autistic people or those with higher Autistic traits.

Camouflaging in neurodivergent and neurotypical girls at the transition to adolescence and its relationship to mental health: A participatory methods research study

Background

Adolescent girls with diagnoses of autism, ADHD and/or developmental coordination disorder (DCD) are at higher risk for mental health problems than boys with the same diagnoses and neurotypical girls. These girls are called neurodivergent here, though neurodivergence includes a broader range of diagnoses. One possible reason for this mental health disparity could be camouflaging, a coping strategy used more by girls. Camouflaging is when the individual pretends to be neurotypical, often involving substantial effort. This study aims to understand: (a) if the use of camouflaging has started by early adolescence, (b) how components of camouflaging (assimilation, masking, and compensation) present at this age, (c) if age predicts camouflaging and (d) what is the relationship with mental health.

Methods

Participatory methods: A co-production team of 15 adult neurodivergent women co-produced the project and ranked camouflaging as their most important research theme.

Main Study: Participants were 119 girls (70 neurodivergent, 49 neurotypical) aged 11-14 years. A transdiagnostic approach was adopted and the neurodivergent group had a diagnosis of autism, ADHD and/or DCD. Girls completed self-report measures of camouflaging, anxiety, and depression in an online meeting with a researcher.

Results

Neurodivergent and neurotypical girls presented similarly on two components of camouflaging namely masking and compensation, components related to presenting in a socially acceptable way and mimicry. Groups differed on the assimilation component, which is related to trying to fit in and involves the feelings of pretending/acting. Age had a medium effect on camouflaging with higher levels of camouflaging observed in older girls. Camouflaging scores strongly predicted anxiety and depression scores in both groups.

Conclusions

The use of camouflaging, specifically assimilation, is evident in a transdiagnostic sample of 11-14 year old neurodivergent girls. Importantly, the strong relationship between camouflaging and poor mental health is present at this early age, substantiating the co-production team's insights.

Conceptual framework for data harmonisation in mental health using the International Classification of Functioning, Disability and Health: an example with the R2D2-MH consortium

INTRODUCTION

Advancing research and support for neurologically diverse populations requires novel data harmonisation methods that are capable of aligning with contemporary approaches to understanding health and disability.

OBJECTIVES

We present the International Classification of Functioning, Disability and Health (ICF) as a conceptual framework to support harmonisation of mental health data and present a proof of principle within the Risk and Resilience in Developmental Diversity and Mental Health (R2D2-MH) consortium.

METHOD

138 measures from various mental health datasets were linked to the ICF following the WHO's established linking rules.

FINDINGS

Findings support the notion that the ICF can assist in the harmonisation of mental health data. The high level of shared ICF codes provides indications of where items may be readily harmonised to develop datasets that may align more readily with contemporary approaches to understanding health and disability. Although the linking process necessarily entails an element of subjectivity, the application of established rules can increase rigour and transparency of the harmonisation process.

CONCLUSIONS

We present the first steps towards data harmonisation in mental health that is compatible with contemporary approaches in psychiatry, being more capable of capturing diversity and aligning with more transdiagnostic and neurodiversity-affirmative ways of understanding data.

CLINICAL IMPLICATIONS

Our findings show promise, but future work is needed to address quantitative harmonisation. Similarly, issues related to the traditionally 'pathophysiological' frameworks that existing datasets are often embedded in can hinder the full potential of harmonisation based on the ICF.

Neurodivergence, intersectionality, and eating disorders: a lived experience-led narrative review

Autistic people and those with attention deficit hyperactivity disorder are at a high risk of developing an eating disorder. While there is limited evidence on the relationship between other forms of neurodivergence and eating disorders, research suggests associations between giftedness, intellectual disability, obsessive-compulsive disorder, psychosis, Tourette's syndrome, and disordered eating. Factors underlying disordered eating and/or eating disorder risk for neurodivergent people are multifaceted and complex, encompassing a wide range of intertwined psychosocial, environmental, and biological processes. Moreover, research shows that neurodivergent individuals experience poorer treatment outcomes compared to neurotypical individuals. However, there is a paucity of research in this area overall. More specifically, lived experience-led research remains rare, despite its critical role for improving individualised eating disorder care, as well as mental healthcare more broadly. Indeed, the importance of eating disorder care individuation is increasingly being recognised, particularly within the context of neurodivergence, given the heterogeneous experiences and support needs of neurodivergent people affected by disordered eating and/or eating disorders. Furthermore, despite documented overlaps between various forms of neurodivergence (e.g., co-occurring autism and attention deficit hyperactivity disorder), research looking at eating disorders in the context of neurodivergence through a transdiagnostic perspective is scarce. This lived experience-led narrative review aims to shed light on the intersectional factors underlying elevated disordered eating and/or eating disorder risk for neurodivergent individuals. First, an overview of prevalence data is provided, followed by a thematic framework identifying factors underlying disordered eating and/or eating disorder risk in relation to neurodivergence. A critical appraisal of current eating disorder research and care is then offered before suggestions for neurodiversity-affirming eating disorder care are made. In this view, this paper offers a foundation for future empirical work in this nascent field of inquiry by providing a lived experience-led, transdiagnostic, and intersectional account of eating disorders in the context of neurodivergence.

The neurodivergent perinatal experience - A systematic literature review on autism and attention deficit hyperactivity disorder

BACKGROUND

Neurodivergent individuals often face unique challenges during the perinatal period, which can significantly impact their experiences of pregnancy, childbirth, and early parenting. Despite growing awareness of neurodiversity, there remains a gap in perinatal care that fully addresses the lived experiences and needs of those with neurodivergent conditions such as Autism (ASD) and Attention-Deficit/Hyperactivity Disorder (ADHD).

OBJECTIVE

To compile and analyse recent literature on the perinatal experiences of neurodivergent parturients. To provide an overview of current knowledge, identify prevalent challenges, and suggest opportunities for improving perinatal services. Additionally, we aim to highlight research gaps that guide future studies and enhance care quality for neurodivergent individuals during the perinatal period.

METHODS

The Systematic Reviews methodological process was utilised to search relevant scientific databases to gather current research articles on neurodivergent perinatal experiences. Eleven studies met the inclusion criteria and were appraised using a rigorous quality checklist. Thematic analysis identified recurring themes across the selected papers.

RESULTS

Three major themes emerged: Care provider support, Perinatal mental health needs, and Resilience and growth of neurodivergent parturients. These themes highlight significant differences in perinatal experiences between neurodivergent and neurotypical individuals, underscoring the need for tailored care approaches.

CONCLUSION

The findings reveal that current perinatal care practices do not adequately address the specific challenges faced by perinatal neurodivergent individuals. There is a critical need for perinatal care systems to integrate neurodiversity-affirming practices. Future research should consider intersectionality to include marginalised and underrepresented neurodivergent voices.

Identifying autistic children: Priorities for research arising from a systematic review of parents' experiences of the assessment process

LAY ABSTRACT

Hearing about parents' experiences of having their child recognised as autistic could help improve the supports offered to parents. Our article may also help guide future research on this topic. We made a list of the type of research that interested us. We searched the studies already completed, only studying the research that matched our interests. After reading the studies, we rated their quality using the Critical Appraisal Skills Programme tool.It became clear that parents went through four phases during the identification process. The first phase occurred before their child was identified as autistic. The second involved the actual assessment of their child. Parents' emotional reactions to the news were the focus of the third phase. The final phase occurred after their child was identified as autistic. We discuss the findings of our research. As there are sensitivities involved in conducting research on this topic, we identify how researchers can ensure that their research is of the best quality. We are committed to respecting the human rights of all involved, so we emphasise the need for professionals to develop good relationships with the parents of autistic children. Researchers have recently come to see autism as typical of human diversity. We encourage the professionals involved to adopt this understanding of autistic children and make practical suggestions to enable them to do so.

A Genetic Bridge Between Medicine and Neurodiversity for Autism

Autism represents a large spectrum of diverse individuals with varying underlying genetic architectures and needs. For some individuals, a single de novo or ultrarare genetic variant has a large effect on the intensity of specific dimensions of the phenotype, while, for others, a combination of thousands of variants commonly found in the general population are involved. The variants with large impact are found in up to 30% of autistic individuals presenting with intellectual disability, significant speech delay, motor delay, and/or seizures. The common variants are shared with those found in individuals with attention-deficit/hyperactivity disorder, major depressive disorders, greater educational attainment, and higher cognitive performance, suggesting overlapping genetic architectures. The genetic variants modulate the function of chromatin remodeling and synaptic proteins that influence the connectivity of neuronal circuits and, in interaction with the environment of each individual, the subsequent cognitive and personal trajectory of the child. Overall, this genetic heterogeneity mirrors the phenotypic diversity of autistic individuals and provides a helpful bridge between biomedical and neurodiversity perspectives. We propose that participative and multidisciplinary research should use this information to understand better the assessment, treatments, and accommodations that individuals with autism and families need.

Where do neurodevelopmental conditions fit in transdiagnostic psychiatric frameworks? Incorporating a new neurodevelopmental spectrum

Features of autism spectrum disorder, attention-deficit/hyperactivity disorder, learning disorders, intellectual disabilities, and communication and motor disorders usually emerge early in life and are associated with atypical neurodevelopment. These "neurodevelopmental conditions" are grouped together in the DSM-5 and ICD-11 to reflect their shared characteristics. Yet, reliance on categorical diagnoses poses significant challenges in both research and clinical settings (e.g., high co-occurrence, arbitrary diagnostic boundaries, high within-disorder heterogeneity). Taking a transdiagnostic dimensional approach provides a useful alternative for addressing these limitations, accounting for shared underpinnings across neurodevelopmental conditions, and characterizing their common co-occurrence and developmental continuity with other psychiatric conditions. Neurodevelopmental features have not been adequately considered in transdiagnostic psychiatric frameworks, although this would have fundamental implications for research and clinical practices. Growing evidence from studies on the structure of neurodevelopmental and other psychiatric conditions indicates that features of neurodevelopmental conditions cluster together, delineating a "neurodevelopmental spectrum" ranging from normative to impairing profiles. Studies on shared genetic underpinnings, overlapping cognitive and neural profiles, and similar developmental course and efficacy of support/treatment strategies indicate the validity of this neurodevelopmental spectrum. Further, characterizing this spectrum alongside other psychiatric dimensions has clinical utility, as it provides a fuller view of an individual's needs and strengths, and greater prognostic utility than diagnostic categories. Based on this compelling body of evidence, we argue that incorporating a new neurodevelopmental spectrum into transdiagnostic frameworks has considerable potential for transforming our understanding, classification, assessment, and clinical practices around neurodevelopmental and other psychiatric conditions.

The Gestalt of functioning in autism revisited: First revision of the International Classification of Functioning, Disability and Health Core Sets

LAY ABSTRACT

Autistic people experience individual strengths and challenges as well as barriers and facilitators in their environment. All of these factors contribute to how well autistic people can cope in everyday life, fulfill the roles they choose, and meet their needs. The World Health Organization has developed a system aiming to capture the many factors within people (like how someone thinks and feels) and outside of people (things around a person) that influence their daily living, called the International Classification of Functioning, Disability and Health. The International Classification of Functioning, Disability and Health can be used for different purposes in research and practice to assess people's situations and plan support measures. Previously in 2019, the International Classification of Functioning, Disability and Health was adapted to autism by developing so-called Core Sets, which are shorter International Classification of Functioning, Disability and Health versions for use in specific conditions. Here, we present the first revisions of the International Classification of Functioning, Disability and Health Core Sets for autism, based on research, development results, and community feedback. Some factors influencing daily life for autistic people were added to the Core Sets, and other factors deemed less relevant were removed. Changes were also made in Core Sets designed for different age groups (0-5, 6-16, and ⩾17 years). Particularly, contents for sensory processing (like smell, touch, seeing, hearing) were added. We recommend these updated Core Sets for future use in autism research and practice. These changes to the Core Sets after 4 years indicate that there should be ongoing updates based on research and experience from practice and involvement of stakeholders.

Childhood neurodivergent traits, inflammation and chronic disabling fatigue in adolescence: a longitudinal case-control study

OBJECTIVES

To test whether inflammatory processes link the expression of childhood neurodivergent traits to chronic disabling fatigue in adolescence.

DESIGN

Longitudinal case-control study.

SETTING

We analysed data from The Avon Longitudinal Study of Parents and Children (ALSPAC).

PARTICIPANTS

8115 and 8036 children of the ALSPAC cohort at ages 7 and 9 years, respectively, 4563 of whom also completed self-report measures at age 18 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

We assessed if children scoring above screening threshold for autism/attention deficit hyperactivity disorder (ADHD) at ages 7 and 9 years had increased risk of chronic disabling fatigue at age 18 years, computing ORs and CIs for effects using binary logistic regression. Mediation analyses were conducted to test if an inflammatory marker (interleukin 6 (IL-6)) at age 9 years linked neurodivergent traits to chronic disabling fatigue at age 18 years.

RESULTS

Children with neurodivergent traits at ages 7 and 9 years were two times as likely to experience chronic disabling fatigue at age 18 years (likely ADHD OR=2.18 (95% CI=1.33 to 3.56); p=0.002; likely autism OR=1.78 (95% CI=1.17 to 2.72); p=0.004). Levels of IL-6 at age 9 were associated with chronic disabling fatigue at age 18 (OR=1.54 (95% CI=1.13 to 2.11); p=0.006). Inflammation at age 9 years mediated effects of neurodivergent traits on chronic disabling fatigue (indirect effect via IL-6: ADHD b=1.08 (95% CI=1.01 to 1.15); autism b=1.06; (95% CI=1.03 to 1.10)). All effects remained significant when controlling for the presence of depressive symptoms.

CONCLUSIONS

Our results indicate higher risk of chronic disabling fatigue for children with neurodivergent traits, likely linked to higher levels of inflammation. The implementation of transdiagnostic screening criteria to inform support strategies to counteract risk early in life is recommended.

A transdiagnostic examination of cognitive heterogeneity in children and adolescents with neurodevelopmental disorders

Children and adolescents with neurodevelopmental disorders demonstrate extensive cognitive heterogeneity that is not adequately captured by traditional diagnostic systems, emphasizing the need for alternative assessment and classification techniques. Using a transdiagnostic approach, a retrospective cohort study of cognitive functioning was conducted using a large heterogenous sample (n = 1529) of children and adolescents 7 to 18 years of age with neurodevelopmental disorders. Measures of short-term memory, verbal ability, and reasoning were administered to participants with attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), comorbid ADHD/ASD, and participants without neurodevelopmental disorders (non-NDD) using a 12-task, web-based neurocognitive testing battery. Unsupervised machine learning techniques were used to create a self-organizing map, an artificial neural network, in conjunction with k-means clustering to identify data-driven subgroups. The study aims were to: 1) identify cognitive profiles in the sample using a data-driven approach, and 2) determine their correspondence with traditional diagnostic statuses. Six clusters representing different cognitive profiles were identified, including participants with varying forms of cognitive impairment. Diagnostic status did not correspond with cluster-membership, providing evidence for the application of transdiagnostic approaches to understanding cognitive heterogeneity in children and adolescents with neurodevelopmental disorders. Additionally, the findings suggest that many typically developing participants may have undiagnosed learning difficulties, emphasizing the need for accessible cognitive assessment tools in school-based settings.

Short report: Evaluation of wider community support for a neurodiversity teaching programme designed using participatory methods

LAY ABSTRACT

Children with diagnoses such as autism, attention-deficit/hyperactivity disorder (ADHD), dyslexia and so on often experience bullying at school. This group can be described as neurodivergent, meaning they think and process information differently from most people. Previous research suggests that increasing people's knowledge can be an effective way to reduce stigma and bullying. Therefore, we decided to create a primary school resource to teach about neurodiversity - the concept that all humans vary in how our brains work. Working with educators, our research team - which included neurodivergent people - developed plans for a teaching programme called Learning About Neurodiversity at School (LEANS). Next, we wanted to know whether these plans, developed by our small neurodiverse team, would be endorsed by the wider community. To find out, we conducted an online feedback survey about our plans for the resource. We analysed feedback from 111 people who participated. Most of them identified as neurodivergent (70%) and reported being familiar with neurodiversity (98%), meaning they could provide an informed opinion on our plans. Over 90% of people expressed support for the planned programme content described in the survey, and 73% of them approved our intended definition of the resource's core concept, neurodiversity. From these results, we concluded that there was a high level of support for the planned LEANS programme content across those from the wider community who completed the survey. Consequently, we continued developing the LEANS programme in line with the initial plans from our neurodiverse team. The completed resource is now available as a free download.

A transdiagnostic approach to neurodiversity in a representative population sample: The N+ 4 model

Background

The concept of neurodiversity draws upon scientific research, and lessons from practice and lived experience to suggest new ways of thinking about neurodevelopmental conditions. Among the formative observations are that characteristics associated with neurodevelopmental conditions are part of a "broader phenotype" of variation across the whole population, and that there appear to be "transdiagnostic" similarities as well as differences in these characteristics. These observations raise important questions that have implications for understanding diversity in neurodevelopmental conditions and in neurocognitive phenotypes across the whole population.

Method

The present work examines broader phenotypes using seven widely used self-report assessments of traits associated with autism, ADHD, dyslexia, Developmental Coordination Disorder/dyspraxia, tic disorders/Tourette's, cortical hyperexcitability associated with subclinical epilepsy, and sensory sensitivities. A representative sample of 995 adults (aged 17-77) in the UK completed self-report measures of neurodiversity, wellbeing, generalized anxiety, and depression, and cognitive abilities (nonverbal intelligence and executive functioning).

Results

We used confirmatory factor analysis to test whether variation and covariation was better characterized (1) by traditional diagnostic labels, or (2) transdiagnostically according to similarities in functions, behaviours, or phenomena. Results indicated that neurodiversity characteristics were best explained using a bifactor model with one general "N" factor and four condition-specific factors.

Conclusion

This was the largest examination to date of the factor structure of broader phenotypes relevant to neurodevelopmental conditions. It provides critical benchmark data, and a framework approach for asking systematic questions about the structure of neurocognitive diversities seen in the whole population and in people with one or more diagnoses.

A maturational frequency discrimination deficit may explain developmental language disorder

Auditory perceptual deficits are widely observed among children with developmental language disorder (DLD). Yet, the nature of these deficits and the extent to which they explain speech and language problems remain controversial. In this study, we hypothesize that disruption to the maturation of the basilar membrane may impede the optimization of the auditory pathway from brainstem to cortex, curtailing high-resolution frequency sensitivity and the efficient spectral decomposition and encoding of natural speech. A series of computational simulations involving deep convolutional neural networks that were trained to encode, recognize, and retrieve naturalistic speech are presented to demonstrate the strength of this account. These neural networks were built on top of biologically truthful inner ear models developed to model human cochlea function, which-in the key innovation of the present study-were scheduled to mature at different rates over time. Delaying cochlea maturation qualitatively replicated the linguistic behavior and neurophysiology of individuals with language learning difficulties in a number of ways, resulting in (a) delayed language acquisition profiles, (b) lower spoken word recognition accuracy, (c) word finding and retrieval difficulties, (d) "fuzzy" and intersecting speech encodings and signatures of immature neural optimization, and (e) emergent working memory and attentional deficits. These simulations illustrate many negative cascading effects that a primary maturational frequency discrimination deficit may have on early language development and generate precise and testable hypotheses for future research into the nature and cost of auditory processing deficits in children with language learning difficulties. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Neurocognitive mechanisms of co-occurring math difficulties in dyslexia: Differences in executive function and visuospatial processing

Children with dyslexia frequently also struggle with math. However, studies of reading disability (RD) rarely assess math skill, and the neurocognitive mechanisms underlying co-occurring reading and math disability (RD+MD) are not clear. The current study aimed to identify behavioral and neurocognitive factors associated with co-occurring MD among 86 children with RD. Within this sample, 43% had co-occurring RD+MD and 22% demonstrated a possible vulnerability in math, while 35% had no math difficulties (RD-Only). We investigated whether RD-Only and RD+MD students differed behaviorally in their phonological awareness, reading skills, or executive functions, as well as in the brain mechanisms underlying word reading and visuospatial working memory using functional magnetic resonance imaging (fMRI). The RD+MD group did not differ from RD-Only on behavioral or brain measures of phonological awareness related to speech or print. However, the RD+MD group demonstrated significantly worse working memory and processing speed performance than the RD-Only group. The RD+MD group also exhibited reduced brain activations for visuospatial working memory relative to RD-Only. Exploratory brain-behavior correlations along a broad spectrum of math ability revealed that stronger math skills were associated with greater activation in bilateral visual cortex. These converging neuro-behavioral findings suggest that poor executive functions in general, including differences in visuospatial working memory, are specifically associated with co-occurring MD in the context of RD. RESEARCH HIGHLIGHTS: Children with reading disabilities (RD) frequently have a co-occurring math disability (MD), but the mechanisms behind this high comorbidity are not well understood. We examined differences in phonological awareness, reading skills, and executive function between children with RD only versus co-occurring RD+MD using behavioral and fMRI measures. Children with RD only versus RD+MD did not differ in their phonological processing, either behaviorally or in the brain. RD+MD was associated with additional behavioral difficulties in working memory, and reduced visual cortex activation during a visuospatial working memory task.

Assessing pragmatic language difficulties using the Revised Children's Communication Checklist-2. Exploratory structural equation modeling and associations with restricted and repetitive behaviors

In this paper, we investigated the psychometric properties of the Child Communication Checklist-Revised (CCC-R) for the first time with an English-speaking sample. We used a confirmatory application of exploratory structural equation modeling (ESEM) to re-evaluate the CCC-R's psychometric properties. We found strong support for its use as an assessment for pragmatic and structural language. Our second main aim was to explore associations between pragmatic and structural language and restricted and repetitive behaviors (RRBs), two hallmark characteristics of autism. We used the CCC-R and Repetitive Behavior Questionnaire (RBQ-2) to investigate these associations in a diverse non-clinical sample of children, taking a transdiagnostic approach. We intentionally excluded autism and other neurodevelopmental diagnoses to test, (1) the CCC-R in a broad sample and (2) the association between pragmatic language and RRB in children not already selected for that association. The sample comprised two groups of children, one was community sampled (n = 123) and the other (n = 143) included children with non-specific behavioral, emotional and/or cognitive difficulties referred to an assessment unit by schools. We found clear associations between pragmatic language difficulties and RRBs in both groups. Regression analysis showed that pragmatic language was the only significant contributor to RRBs even after Grammatical-Semantic score, age, sex, and socioeconomic status were controlled. The pattern was the same for both recruitment groups. However, the effects were stronger for the school-referred group which also had more pragmatic difficulties, grammatical-semantic difficulties and RRBs. A robust link between pragmatic language and RRBs, established in autism, has continuity across the broader non-clinical population.

Stigma and knowledge about autism in Brazil: A psychometric and intervention study

LAY ABSTRACT

To promote the full inclusion of autistic people, we must change the knowledge and attitudes of non-autistic individuals. Unfortunately, access to autism information and support remains limited in Brazil, and stigma is also common. Brazilian researchers reached out to a researcher in the United States to co-develop Brazilian surveys to measure autism stigma and knowledge. Together, they made Brazilian versions of stigma and knowledge surveys which autistic people in the United States had helped make. They also adapted an online autism training used in other countries with help from three Brazilian autistic people and the mother of an autistic child. They used the new measures to see if the autism training improved autism stigma and knowledge among Brazilians. The surveys, called EARPA and ECAT in Brazil, were translated into Portuguese in a previous study. In the first study in this article, 532 Brazilians completed the stigma measure and 510 completed the knowledge measure. The researchers used exploratory graph analysis, which uses the connections between items in a survey to understand which items belong together. Seventy-nine Brazilians participated in the training. They were mostly white, female university students. The EGA showed that the stigma survey measured one big idea while the knowledge survey measured four ideas: diagnosis/cause; socio-communicative development; stimming and special interests; and autism in adulthood. Both scales are promising and may be helpful in future Brazilian and cross-cultural studies about autism. Participants reported more knowledge and less stigma after the autism training, which has been found in other countries too.

Diagnostic assessment of autism in adults - current considerations in neurodevelopmentally informed professional learning with reference to ADOS-2

Services for the assessment and diagnosis of autism in adults have been widely criticized and there is an identified need for further research in this field. There is a call for diagnostic services to become more accessible, person-centered, neurodiversity affirming, and respectful. There is a need for workforce development which will increase capacity for diagnostic assessment and support for adults. ADOS-2 is a gold-standard diagnostic assessment tool for autism recommended in clinical guidelines. However, diagnostic procedures such as the ADOS-2 are rooted in the medical model and do not always sit comfortably alongside the neurodiversity paradigm or preferences of the autistic community. Training and educational materials need to account for the differences between these approaches and support clinicians to provide services which meet the needs of the adults they serve. The National Autism Implementation Team worked alongside ADOS-2 training providers to support clinicians in Scotland, to provide effective and respectful diagnostic assessment. The team engaged with clinicians who had attended ADOS training to identify areas of uncertainty or concern. Training materials were developed to support ADOS assessors to incorporate key principles including "nothing about us without us"; "difference not deficit"; "environment first"; "diagnosis matters," "language and mindsets matter"; and "a neurodevelopmental lens," to support the provision of neurodiversity affirming assessment practice. The National Autism Implementation Team also provided examples of actions which can be undertaken by clinicians to improve the assessment experience for those seeking a diagnosis. Training materials are based on research evidence, clinical experience, and the needs and wishes of autistic people.

Mental health challenges faced by autistic people

Mental health challenges impede the well-being of autistic people. This Review outlines contributing neurodevelopmental and physical health conditions, rates and developmental trajectories of mental health challenges experienced by autistic people, as well as unique clinical presentations. A framework is proposed to consider four contributing themes to aid personalized formulation: social-contextual determinants, adverse life experiences, autistic cognitive features, and shared genetic and early environmental predispositions. Current evidence-based and clinical-knowledge-informed intervention guidance and ongoing development of support are highlighted for specific mental health areas. Tailored mental health support for autistic people should be neurodivergence-informed, which is fundamentally humanistic and compatible with the prevailing bio-psycho-social frameworks. The personalized formulation should be holistic, considering physical health and transdiagnostic neurodevelopmental factors, intellectual and communication abilities, and contextual-experiential determinants and their interplay with autistic cognition and biology, alongside resilience. Supporting family well-being is integral. Mutual empathic understanding is fundamental to creating societies in which people across neurotypes are all empowered to thrive.

Investigating heterogeneity across autism, ADHD, and typical development using measures of cortical thickness, surface area, cortical/subcortical volume, and structural covariance

Introduction

Attention-deficit/hyperactivity disorder (ADHD) and autism are multi-faceted neurodevelopmental conditions with limited biological markers. The clinical diagnoses of autism and ADHD are based on behavioural assessments and may not predict long-term outcomes or response to interventions and supports. To address this gap, data-driven methods can be used to discover groups of individuals with shared biological patterns.

Methods

In this study, we investigated measures derived from cortical/subcortical volume, surface area, cortical thickness, and structural covariance investigated of 565 participants with diagnoses of autism [n = 262, median(IQR) age = 12.2(5.9), 22% female], and ADHD [n = 171, median(IQR) age = 11.1(4.0), 21% female] as well neurotypical children [n = 132, median(IQR) age = 12.1(6.7), 43% female]. We integrated cortical thickness, surface area, and cortical/subcortical volume, with a measure of single-participant structural covariance using a graph neural network approach.

Results

Our findings suggest two large clusters, which differed in measures of adaptive functioning (χ 2 = 7.8, P = 0.004), inattention (χ 2 = 11.169, P < 0.001), hyperactivity (χ 2 = 18.44, P < 0.001), IQ (χ 2 = 9.24, P = 0.002), age (χ 2 = 70.87, P < 0.001), and sex (χ 2 = 105.6, P < 0.001).

Discussion

These clusters did not align with existing diagnostic labels, suggesting that brain structure is more likely to be associated with differences in adaptive functioning, IQ, and ADHD features.

Taking stock of the present and looking to the future of ADHD research: a commentary on Sonuga-Barke et al. (2023)

The review by Sonuga-Barke and colleagues offers a thoughtful and wide-ranging appraisal of the current state of ADHD research, while also looking into the future to consider unresolved questions and critical next steps. Furthermore, it grapples with the tension between the need to define a coherent conceptualisation of ADHD for clinical and research purposes, while keeping an open mind to new research that challenges current consensus. In our commentary, we consider several cross-cutting ideas discussed in Sonuga-Barke et al., including the heterogeneous nature of ADHD, ensuring equity of translational research, and the importance of participatory research to support equitable and acceptable clinical practices for all individuals with ADHD.

Sex and gender in neurodevelopmental conditions

Health-related conditions often differ qualitatively or quantitatively between individuals of different birth-assigned sexes and gender identities, and/or with different gendered experiences, requiring tailored care. Studying the moderating and mediating effects of sex-related and gender-related factors on impairment, disability, wellbeing and health is of paramount importance especially for neurodivergent individuals, who are diagnosed with neurodevelopmental conditions with uneven sex/gender distributions. Researchers have become aware of the myriad influences that sex-related and gender-related variables have on the manifestations of neurodevelopmental conditions, and contemporary work has begun to investigate the mechanisms through which these effects are mediated. Here we describe topical concepts of sex and gender science, summarize current knowledge, and discuss research and clinical challenges related to autism, attention-deficit/hyperactivity disorder and other neurodevelopmental conditions. We consider sex and gender in the context of epidemiology, behavioural phenotypes, neurobiology, genetics, endocrinology and neighbouring disciplines. The available evidence supports the view that sex and gender are important contributors to the biological and behavioural variability in neurodevelopmental conditions. Methodological caveats such as frequent conflation of sex and gender constructs, inappropriate measurement of these constructs and under-representation of specific demographic groups (for example, female and gender minority individuals and people with intellectual disabilities) limit the translational potential of research so far. Future research and clinical implementation should integrate sex and gender into next-generation diagnostics, mechanistic investigations and support practices.

Transdiagnostic profiles of behaviour and communication relate to academic and socioemotional functioning and neural white matter organisation

BACKGROUND

Behavioural and language difficulties co-occur in multiple neurodevelopmental conditions. Our understanding of these problems has arguably been slowed by an overreliance on study designs that compare diagnostic groups and fail to capture the overlap across different neurodevelopmental disorders and the heterogeneity within them.

METHODS

We recruited a large transdiagnostic cohort of children with complex needs (N = 805) to identify distinct subgroups of children with common profiles of behavioural and language strengths and difficulties. We then investigated whether and how these data-driven groupings could be distinguished from a comparison sample (N = 158) on measures of academic and socioemotional functioning and patterns of global and local white matter connectome organisation. Academic skills were assessed via standardised measures of reading and maths. Socioemotional functioning was captured by the parent-rated version of the Strengths and Difficulties Questionnaire.

RESULTS

We identified three distinct subgroups of children, each with different levels of difficulties in structural language, pragmatic communication, and hot and cool executive functions. All three subgroups struggled with academic and socioemotional skills relative to the comparison sample, potentially representing three alternative but related developmental pathways to difficulties in these areas. The children with the weakest language skills had the most widespread difficulties with learning, whereas those with more pronounced difficulties with hot executive skills experienced the most severe difficulties in the socioemotional domain. Each data-driven subgroup could be distinguished from the comparison sample based on both shared and subgroup-unique patterns of neural white matter organisation. Children with the most pronounced deficits in language, cool executive, or hot executive function were differentiated from the comparison sample by altered connectivity in predominantly thalamocortical, temporal-parietal-occipital, and frontostriatal circuits, respectively.

CONCLUSIONS

These findings advance our understanding of commonly co-morbid behavioural and language problems and their relationship to behavioural outcomes and neurobiological substrates.

Emotion dysregulation in ADHD and other neurodevelopmental conditions: a co-twin control study

BACKGROUND

Emotion dysregulation (ED) is common in attention-deficit/hyperactivity disorder (ADHD) and often results in adverse outcomes. However, ED has been suggested as a transdiagnostic construct, why the specific association between ADHD and ED when adjusting for other mental health conditions needs further investigation. It is also important to determine the aetiological basis of the association between ADHD and ED to inform the theoretical conceptualization of ADHD.

METHOD

This study used a co-twin control design, including a sample of dizygotic (DZ) and monozygotic (MZ) twins (N = 389; 45.8% females, age = 8-31 years, MZ twin pairs 57.6%). ED was assessed using the dysregulation profile from the parent-rated Child Behaviour Checklist and its adult version. Regression analyses were used across individuals and within the pairs, while adjusting for diagnoses of autism, intellectual disability, other neurodevelopmental conditions and affective conditions.

RESULTS

ADHD was significantly associated with ED, even when adjusting for age, sex, attention problems and other mental health conditions, and was the diagnosis most strongly associated with ED. Within-pair analyses revealed that twins with ADHD had higher levels of ED compared to their co-twin without ADHD. This association remained within DZ twins and was non-significant in the MZ subsample, with non-overlapping confidence intervals between the DZ and MZ estimates.

CONCLUSION

ADHD is strongly and in part independently linked to ED, stressing the importance of early detection and treatment of emotional difficulties within this group. The findings from the within-pair analyses indicate a genetic influence on the association between ADHD and ED.

Experiences of peer support amongst parents of children with neurodevelopmental disorders: A qualitative systematic review

PROBLEM

Peer support is a form of social support that can address the complexities of support needs and challenges of parenting children with Neurodevelopmental Disorders (NDDs). However, there is paucity of research on the roles and influences of peer support experienced amongst parents of neurodivergent children. This qualitative systematic review therefore aimed to consolidate and synthesize the experiences of peer support amongst parents caring for neurodivergent children.

ELIGIBILITY CRITERIA

Articles were selected if they reported primary qualitative findings on the experiences of peer-support amongst parents of children diagnosed with at least one NDD as classified by DSM-5.

SAMPLE

Eleven articles were finalised and included in the review.

RESULTS

Four themes emerged: (1) reasons for seeking peer support, (2) different roles of peer support, (3) contributing elements of successful peer support, and (4) barriers against facilitating peer support. The findings of this review revealed that peer support was a valuable social support resource that met the complex support needs of parents. It enabled parents to provide quality care for their children whilst living with quality of life for themselves.

CONCLUSIONS

Peer support could be a valuable resource for parents of neurodivergent children as it could potentially enhance quality of life for parents while providing quality care for their children with complex needs.

IMPLICATIONS

Healthcare providers should integrate peer support as an adjunct resource of social support to help ease caregiver burdens of parents with neurodivergent children.