Modification and Validation of an Autism Observational Assessment Including ADOS-2® for Use with Children with Visual Impairment

Children with visual impairment (VI) are at risk of autism spectrum disorder (ASD); however standard observational diagnostic assessments are not validated for this population. The primary objective of the study is to validate a modified version of the Autism Diagnostic Observation Schedule (ADOS-2®, Module 3), for children with VI. A cross-sectional observational study was undertaken with 100 (mean 5½ years, SD 10.44 months, range 4-7 years; 59 (59%) males) children with congenital disorders of the peripheral visual system with moderate/severe-profound VI. As the primary objective, 83 (83%) who were 'verbally fluent' were assessed with the modified ADOS-2® (Module 3). Their scores were investigated for reliability, construct and criterion validity against expert clinician formulation and parent-rated social and communication questionnaires (Social Responsiveness Scale-2, SRS-2; Children's Communication Checklist-2). The secondary objective with the total sample was to report on frequency and distribution of ASD ratings in this VI population. The modified ADOS-2® (Module 3) was found to have strong internal coherence and construct validity (two factor model) and inter-rater reliability. A new VI diagnostic algorithm was established which showed high sensitivity and specificity against clinician formulation. Using the best cut-off threshold for 'High Risk for ASD', strong concurrent criterion validity was found according to parent-rated scores on the SRS-2. The modified ADOS-2® (Module 3) was shown to have promising reliability and validity in establishing children at 'High Risk of ASD' in this vulnerable population. Elevated rates of ASD were found across the sample, in line with previous estimates.

Parental Satisfaction with the Quality of Care in an Early Intervention Service for Children with Visual Impairment: A Retrospective Longitudinal Study

The fundamental role of vision during development and the nurturing role of early intersubjectivity have enabled the Robert Hollman Foundation to develop an early intervention program providing holistic support to visually impaired children and their families, where fostering parent-infant interactions is at the heart of our care. The aim of this study is to understand how parents perceive this approach. It is an eleven-year retrospective study of children following the Robert Hollman Foundation's early intervention program, in which parents' (n = 1086) perceptions of quality of care were measured through the administration of a specifically designed 4-point scale questionnaire. Annual longitudinal trends of parents' perceptions were calculated for every single response. Parents reported a very high satisfaction value in 21/23 questions (Mean > 3.7 out of a maximum score of 4, with the highest scores in human and soft skills of professionals) with a statistically positive trend (p < 0.05), throughout the period considered. Our core approach, based on an individualized nurturing relational support, has been appreciated and confirmed by the high satisfaction reported in the questionnaires by parents of children with visual impairment. We therefore hypothesize that parent-infant relationship-based and individualized approaches may help parents achieve better health, well-being, and quality of daily life for their children.

Visual Autism

Autism spectrum disorder (ASD) is a lifelong neurodevelopmental disorder characterized by deficits in social communication and restricted, repetitive behaviors. It affects approximately 2.2% of children. Both genetic and environmental risk factors have been identified for ASD. Visual comorbidities are relatively common among children with ASD. Between 20 and 44% of ASD children have visually significant refractive error, on-third have strabismus, and one-fifth have amblyopia. In addition, ASD is 30 times more common in children with congenital blindness. It is unknown whether the association of ASD with visual morbidity is causal, comorbid, or contributing. Structural and functional abnormalities have been identified in MRIs of ASD children, and ASD children have been noted to have aberrant eye tracking. ASD children with visually significant refractive errors and poor spectacle compliance (present in 30% of ASD children) offer the opportunity for investigation into how improved visual acuity influences ASD behaviors. In this review, we focus on what is known of the visual system, refractive surgery, and ASD.

Considerations for the identification of autism spectrum disorder in children with vision or hearing impairment: A critical review of the literature and recommendations for practice

OBJECTIVE

There is higher risk for autism spectrum disorder (ASD) across many pediatric neurological conditions characterized by vision impairment or hearing loss. Early and accurate identification of ASD is imperative in promoting access to appropriate and early evidenced-based intervention; however, differential diagnosis can be particularly challenging in children with sensory impairment given the heterogeneity of ASD combined with the impact of vision impairment or hearing loss/deafness on development and behavior. A neuropsychologist's unique expertise and appreciation of the interplay between sensory and behavioral manifestations can be valuable for making an early and accurate ASD diagnosis in children who are blind/visually impaired or deaf/hard-of-hearing. This article highlights clinical considerations when identifying ASD within the context of vision impairment or hearing loss/deafness.

METHOD

We discuss clinical considerations for the early identification of ASD in children who are blind/visually impaired and deaf/hard-of-hearing. Information presented in the article is based on a critical review of the literature and the expertise of the author group.

CONCLUSION

Ongoing development of clinical expertise and evidence-based assessment methods are important when informing the early differential diagnosis of ASD in individuals with sensory impairment. Accurate identification is also vital for the development of targeted interventions across the lifespan.

Autistic-Like Features in Visually Impaired Children: A Review of Literature and Directions for Future Research

There remains great interest in understanding the relationship between visual impairment (VI) and autism spectrum disorder (ASD) due to the extraordinarily high prevalence of ASD in blind and visually impaired children. The broad variability across individuals and assessment methodologies have made it difficult to understand whether autistic-like symptoms shown by some children with VI might reflect the influence of the visual deficit, or represent a primary neurodevelopmental condition that occurs independently of the VI itself. In the absence of a valid methodology adapted for the visually impaired population, diagnosis of ASD in children with VI is often based on non-objective clinical impression, with inconclusive prevalence data. In this review, we discuss the current state of knowledge and suggest directions for future research.

Adaptive behaviour and quality of life in school-age children with congenital visual disorders and different levels of visual impairment

BACKGROUND

Adaptive behaviours are vital skills that allow individuals to function independently and are potentially amenable to behavioural interventions. Previous research indicated that adaptive behaviours are reduced in children and adolescents with severe to profound VI, but it was unclear if this was also the case for children with mild to moderate VI.

AIM

The aim of the study was to assess differences in adaptive behaviour in children with congenital visual disorders and different levels of visual impairment and their influence on quality of life and everyday strengths and difficulties.

METHODS AND PROCEDURES

Questionnaires about adaptive behaviour, strengths and difficulties, and quality of life were completed by parents of school-age children with severe-to-profound VI (S/PVI, n = 9, 0.9 logMAR - light perception only), mild-to-moderate VI (MVI, n = 9, 0.1-0.7 logMAR), or typical sight (control, n = 18, -0.3 to 0.1 logMAR). Differences in questionnaire domains by the severity of VI and relationships between adaptive behaviour and quality of life were analysed in general linear models.

OUTCOMES AND RESULTS

The questionnaire ratings indicated reduced adaptive behaviour, more difficulties, and reduced quality of life in children with S/PVI compared to typically-sighted peers. Effects were smaller for children with MVI, but indicated a significant reduction in quality of life compared to typically-sighted children. The effect of visual impairment on quality of life in school was partially mediated by adaptive behaviour.

CONCLUSION AND IMPLICATION

Severe congenital visual impairment affects adaptive behaviour in children with verbal abilities in the typical range. This effect is less pronounced in children with mild-to-moderate VI, but still impacts on quality of life, particularly in school.

Insensitivity to Fearful Emotion for Early ERP Components in High Autistic Tendency Is Associated with Lower Magnocellular Efficiency

Low spatial frequency (LSF) visual information is extracted rapidly from fearful faces, suggesting magnocellular involvement. Autistic phenotypes demonstrate altered magnocellular processing, which we propose contributes to a decreased P100 evoked response to LSF fearful faces. Here, we investigated whether rapid processing of fearful facial expressions differs for groups of neurotypical adults with low and high scores on the Autistic Spectrum Quotient (AQ). We created hybrid face stimuli with low and high spatial frequency filtered, fearful, and neutral expressions. Fearful faces produced higher amplitude P100 responses than neutral faces in the low AQ group, particularly when the hybrid face contained a LSF fearful expression. By contrast, there was no effect of fearful expression on P100 amplitude in the high AQ group. Consistent with evidence linking magnocellular differences with autistic personality traits, our non-linear VEP results showed that the high AQ group had higher amplitude K2.1 responses than the low AQ group, which is indicative of less efficient magnocellular recovery. Our results suggest that magnocellular LSF processing of a human face may be the initial visual cue used to rapidly and automatically detect fear, but that this cue functions atypically in those with high autistic tendency.

Language and communication development in preschool children with visual impairment: A systematic review

Background

Language and communication difficulties of young children with visual impairment (VI) are ascribed to intellectual disability, multiple disabilities and autism spectrum disorder (ASD) rather than their sensory impairment. Consequently, the communication difficulties of children with VI may have been underestimated and undertreated.

Objectives

This report aims to critically appraise recent peer reviewed literature relating to communication and language development in children with VI.

Method

A systematic search of the literature (2003–2013) was completed using the PRISMA guidelines, and primary and secondary search phrases. Nine publications were reviewed in terms of the strength of recent evidence. Thematic analysis was used to describe the early language and communication characteristics of children with VI.

Results

All the selected articles (n = 9) were from developed countries and participants from seven of the studies had congenital VI. Five of the studies received an evidence level rating of III while four articles were rated as IIb. Two main themes emerged from the studies: early intervention, and multiple disabilities and ASD. Language and communication development is affected by VI, especially in the early stages of development. Speech-language therapists should therefore be included in early intervention for children with VI.

Conclusion

Recent evidence on the early language and communication difficulties of children with VI exists, but children in developing countries with acquired VI appear to not be investigated. The identified language and communication developmental characteristics may assist speech-language therapists to build a knowledge base for participation in early intervention for young children with VI and their families.

Mental health of children with vision impairment at 11 years of age

AIM

The purpose of the study was to compare the risk of psychiatric disturbance among sighted and vision-impaired children aged 11 years.

METHOD

Scores from the parent and teacher versions of the Strengths and Difficulties Questionnaire (SDQ) were used to compare sighted children with: vision-impaired children; vision-impaired children with no other reported disabilities or special educational needs; and children with vision impairment and additional disabilities or special educational needs. Logistic regression was used to measure the associations between the independent variables and SDQ scores, and to test for significance of the observed differences.

RESULTS

Both parents and teachers scored vision-impaired children significantly higher on the SDQ compared with sighted children (p≤0.000) and a significantly higher proportion of the vision-impaired children had SDQ scores in the abnormal range (p≤0.000). Children with vision impairment and other disabilities or special educational needs were rated as being at greatest risk of psychiatric disorder by both parents (30%) and teachers (22%).

INTERPRETATION

Vision impairment among children as young as 11 years of age is associated with an increased risk of psychiatric disorder.

Schizophrenia and cortical blindness: protective effects and implications for language

The repeatedly noted absence of case-reports of individuals with schizophrenia and congenital/early developed blindness has led several authors to argue that the latter can confer protective effects against the former. In this work, we present a number of relevant case-reports from different syndromes that show comorbidity of congenital and early blindness with schizophrenia. On the basis of these reports, we argue that a distinction between different types of blindness in terms of the origin of the visual deficit, cortical or peripheral, is crucial for understanding the observed patterns of comorbidity. We discuss the genetic underpinnings and the brain structures involved in schizophrenia and blindness, with insights from language processing, laying emphasis on the three structures that particularly stand out: the occipital cortex, the lateral geniculate nucleus (LGN), and the pulvinar. Last, we build on previous literature on the nature of the protective effects in order to offer novel insights into the nature of the protection mechanism from the perspective of the brain structures involved in each type of blindness.

Enhancing activity by means of tactile symbols: a study of a heterogeneous group of pupils with congenital blindness, intellectual disability and autism spectrum disorder

This study investigates responses to verbal versus tactile requests in children with congenital blindness, intellectual disability and autism spectrum disorder (ASD). Observation was conducted on two occasions. At T1, requests were given verbally, and at T2, tactile requests were given. All pupils perceived tactile symbols to be explicit requests to perform the act referred to by the symbols. The children seldom or never followed verbal requests. All children followed more tactile than verbal requests. Individual differences in verbal skills, motivations and the complexity of the activity are discussed. The availability of tactile symbols for individuals with congenital blindness, intellectual disability and ASD seems to increase their level of activity and their participation in school.

Theory of mind and neurodevelopmental disorders of childhood

To a large extent, the human infant is socialized through the acquisition of a specific cognitive mechanism known as theory of mind (ToM), a term which is currently used to explain a related set of intellectual abilities that enable us to understand that others have beliefs, desires, plans, hopes, information, and intentions that may differ from our own. Various neurodevelopmental disorders, such as autism spectrum disorders, attention deficit hyperactivity disorder, developmental language disorders, and schizophrenia, as well as acquired disorders of the right brain (and traumatic brain injury) impair ToM. ToM is a composite function, which involves memory, joint attention, complex perceptual recognition (such as face and gaze processing), language, executive functions (such as tracking of intentions and goals and moral reasoning), emotion processing-recognition, empathy, and imitation. Hence, ToM development is dependent on the maturation of several brain systems and is shaped by parenting, social relations, training, and education; thus, it is an example of the dense interaction that occurs between brain development and (social) environment.