Early markers of autism spectrum disorders in infants and toddlers prospectively identified in the Social Attention and Communication Study

Aided Enhanced milieu teaching to develop symbolic and social communication skills in children with autism spectrum disorder

Children who lack functional spoken language are candidates for augmentative and alternative communication (AAC). Aided AAC and naturalistic interventions offer the potential to extend the communication functions demonstrated by children with autism spectrum disorder (ASD) who are nonspeaking. Related intervention research, however, has been limited, in that interventions have generally targeted a limited range of communication functions taught in highly structured, decontextualized environments. The aim of this study was to investigate the efficacy of an intervention that combined aided AAC with a naturalistic intervention - enhanced milieu teaching (AEMT) - to increase symbolic communication in children with autism spectrum disorder. Three children with autism spectrum disorder participated in a multiple probe design, in which a range of communication functions were targeted using the AEMT. Results showed increases in the use of symbolic communication from baseline to intervention phases, which were found to be statistically significant for two of the three children (phi 0.7-0.81; p < .001). Intervention outcomes were generalized to a communication partner not involved in the intervention and maintained over time for all children. The study provides preliminary evidence that communication functions beyond object requests could be taught using a systematic, multi-element approach implemented across activities.

Predicting autism traits from baby wellness records: A machine learning approach

LAY ABSTRACT

Timely identification of autism spectrum conditions is a necessity to enable children to receive the most benefit from early interventions. Emerging technological advancements provide avenues for detecting subtle, early indicators of autism from routinely collected health information. This study tested a model that provides a likelihood score for autism diagnosis from baby wellness visit records collected during the first 2 years of life. It included records of 591,989 non-autistic children and 12,846 children with autism. The model identified two-thirds of the autism spectrum condition group (boys 63% and girls 66%). Sex-specific models had several predictive features in common. These included language development, fine motor skills, and social milestones from visits at 12-24 months, mother's age, and lower initial growth but higher last growth measurements. Parental concerns about development or hearing impairment were other predictors. The models differed in other growth measurements and birth parameters. These models can support the detection of early signs of autism in girls and boys by using information routinely recorded during the first 2 years of life.

Exploring early life social and executive function development in infants and risk for autism: a prospective cohort study protocol of NICU graduates and infants at risk for cerebral palsy

BACKGROUND

Delays in early social and executive function are predictive of later developmental delays and eventual neurodevelopmental diagnoses. There is limited research examining such markers in the first year of life. High-risk infant groups commonly present with a range of neurodevelopmental challenges, including social and executive function delays, and show higher rates of autism diagnoses later in life. For example, it has been estimated that up to 30% of infants diagnosed with cerebral palsy (CP) will go on to be diagnosed with autism later in life.

METHODS

This article presents a protocol of a prospective longitudinal study. The primary aim of this study is to identify early life markers of delay in social and executive function in high-risk infants at the earliest point in time, and to explore how these markers may relate to the increased risk for social and executive delay, and risk of autism, later in life. High-risk infants will include Neonatal Intensive Care Unit (NICU) graduates, who are most commonly admitted for premature birth and/or cardiovascular problems. In addition, we will include infants with, or at risk for, CP. This prospective study will recruit 100 high-risk infants at the age of 3-12 months old and will track social and executive function across the first 2 years of their life, when infants are 3-7, 8-12, 18 and 24 months old. A multi-modal approach will be adopted by tracking the early development of social and executive function using behavioural, neurobiological, and caregiver-reported everyday functioning markers. Data will be analysed to assess the relationship between the early markers, measured from as early as 3-7 months of age, and the social and executive function as well as the autism outcomes measured at 24 months.

DISCUSSION

This study has the potential to promote the earliest detection and intervention opportunities for social and executive function difficulties as well as risk for autism in NICU graduates and/or infants with, or at risk for, CP. The findings of this study will also expand our understanding of the early emergence of autism across a wider range of at-risk groups.

Correlation Between Gaze Behaviors and Social Communication Skills of Young Autistic Children: A Meta-Analysis of Eye-Tracking Studies

This meta-analysis examined correlations between eye-tracking measures of gaze behaviors manifested during dynamic salient social stimuli and behavioral assessment measures of social communication skills of young autistic children. We employed a multilevel model with random effects to perform three separate meta-analyses for correlation between social communication skills and (a) all gaze behaviors, (b) gaze duration, and (c) gaze transition. Subsequently, we performed meta-regression to assess the role of four moderators, including age, continuum of naturalness of stimuli, gaze metric, and area of interest, on correlation effect sizes that were heterogeneous at the population level. A total of 111 correlation coefficients from 17 studies for 1132 young autistic children or children with high-likelihood for autism (Mage range = 6-95 months) were included in this meta-analysis. The correlation effect sizes for all three meta-analyses were significant, supporting the relation between improved gaze behaviors and better social communication skills. In addition, age, gaze metric, and area of interest were significant moderators. This suggests the importance of identifying meaningful gaze behaviors related to social communication skills and the increasingly influential role of gaze behaviors in shaping social communication skills as young autistic children progress through the early childhood stage. The continuum of naturalness of stimuli, however, was revealed to trend towards having a significant moderating effect. Lastly, it is important to note the evidence of potential publication bias. Our findings are discussed in the context of early identification and intervention and unraveling the complex nature of autism.

Caregiver-reported infant motor and imitation skills predict M-CHAT-R/F

Altered motor and social-communicative abilities in infancy have been linked to later ASD diagnosis. Most diagnostic instruments for ASD cannot be utilized until 12 months, and the average child is diagnosed substantially later. Imitation combines motor and social-communicative skills and is commonly atypical in infants at risk for ASD. However, few measures have been developed to assess infant imitation clinically. One barrier to the diagnostic age gap of ASD is accessibility of screening and diagnostic services. Utilization of caregiver report to reliably screen for ASD mitigates such barriers and could aid in earlier detection. The present study developed and validated a caregiver-report measure of infant imitation at 4, 6, and 9 months and explored the relationship between caregiver-reported imitation and motor abilities with later ASD risk. Participants (N = 571) were caregivers of term and preterm infants recruited as part of a large multi-site study of PediaTrac™, a web-based tool for monitoring and tracking infant development. Caregivers completed online surveys and established questionnaires on a schedule corresponding to well-child visits from birth to 18 months, including the M-CHAT-R/F at 18 months. Distinct imitation factors were derived from PediaTrac at 4, 6, and 9 months via factor analysis. The results supported validity of the imitation factors via associations with measures of infant communication (CSBS; ASQ). Imitation and motor skills at 9 months predicted 18-month ASD risk over and above gestational age. Implications for assessment of infant imitation, detecting ASD risk in the first year, and contributing to access to care are discussed.

Imitation Performance in Children with Autism and the Role of Visual Attention in Imitation

In this study, we examined imitation performance, visual attention, and the relationship between imitation and visual attention of children with autism, developmental delay (DD), and typically developing (TD) children. The study findings revealed that children with autism and DD imitated less than TD children in all imitation tasks. Results also showed that children with autism spent less time looking at the model's face and movement area and more time looking at the external area. Lastly, the relationship between imitation and visual attention separated the study groups. The findings of the study provided new evidence that visual attention to movement area in children with autism was positively related to imitation performance in non-meaningful gestures.

Sleep quality and temperament in association with autism spectrum disorder among infants in Japan

BACKGROUND

Sleep problems and irritable temperaments are common among infants with autism spectrum disorder (ASD). The prospective association between such sleep problems and irritable temperaments and ASDs needs to be determined for elucidating the mechanism and exploring the future intervention study. Thus, in this study, we investigated whether sleep quality and temperament in 1-month-old infants are associated with the onset of ASD in 3-year-old children. We also assessed its sex-stratified associations.

METHODS

We conducted a longitudinal study using data from 69,751 mothers and infants from a large-cohort study, the Japan Environment and Children's Study. We examined the prospective association between infant sleep quality and temperament at 1 month of age and ASD diagnosis by 3 years of age.

RESULTS

Here we show infants with longer daytime sleep have a higher risk of later ASD than those with shorter daytime sleep (risk ratio [RR]: 1.33, 95% confidence interval [CI]: 1.01-1.75). Infants who experienced intense crying have a higher risk of ASD than those who did not (RR: 1.31, 95% CI: 1.00-1.72). There is a difference in sex in the association between a bad mood and later ASD. In particular, female infants experiencing bad moods have a higher risk of ASD than others (RR: 3.59, 95% CI: 1.91-6.75).

CONCLUSIONS

The study findings provide important information for future intervention to reduce the risk of future ASD.

Parent-Child Interactions May Help to Explain Relations Between Parent Characteristics and Clinically Observed Child Autistic Behaviours

The importance of supporting parent-child interactions has been noted in the context of prodromal autism, but little consideration has been given to the possible contributing role of parental characteristics, such as psychological distress. This cross-sectional study tested models in which parent-child interaction variables mediated relations between parent characteristics and child autistic behaviour in a sample of families whose infant demonstrated early signs of autism (N = 103). The findings suggest that associations between parent characteristics (psychological distress; aloofness) and child autistic behaviours may be mediated by the child's inattentiveness or negative affect during interactions. These findings have important implications in developing and implementing interventions in infancy which target the synchrony of parent-child interaction with the goal to support children's social communication development.

Continuity of temperament subgroup classifications from infancy to toddlerhood in the context of early autism traits

Our previous cross-sectional investigation (Chetcuti et al., 2020) showed that infants with autism traits could be divided into distinct subgroups based on temperament. This longitudinal study builds on this existing work by exploring the continuity of temperament subgroup classifications and their associations with behavioral/clinical phenotypic features from infancy to toddlerhood. 103 infants (68% male) showing early signs of autism were referred to the study by community healthcare professionals and seen for assessments when aged around 12-months (Time 1), 18-months (Time 2), and 24-months (Time 3). Latent profile analysis revealed inhibited/low positive, active/negative reactive, and sociable/well-regulated subgroups at each timepoint, and a unique reactive/regulated subgroup at Time 3. Cross-tabulations indicated a significant likelihood of children having a recurrent subgroup classification from one timepoint to the next, and no apparent patterns to the movement of children who did change from one subgroup to another over time. Temperament subgroups were associated with concurrent child social-emotional functioning and autism traits, but unrelated to child age, sex, or developmental level. These findings suggest that temperament subgroup classifications might represent a reliable and very early indicator of autism characteristics and social-emotional functioning among infants/toddlers with autism traits.

Play with Me: How Fathers and Mothers Play with Their Preschoolers with Autism

(1) Background: Children can develop cognitive and social skills during play. Most research has focused on mothers, but the paternal features in interaction with children with autism spectrum disorder (ASD) are mainly unexplored. This study aimed to compare fathers’ and mothers’ interactive behaviors with their children with ASD to identify similarities and differences during playful exchanges. (2) Methods: A total of 72 mothers and 72 fathers of paired children with ASD (chronological age: M = 44.61 months; SD = 13.37) took part in this study. Data were collected during 10 min of video-recorded semi-structured interactions with mothers and fathers separately in interaction with their children. (3) Results: Mothers showed more symbolic play (W = 3537; p < 0.001) than fathers, who displayed higher levels of exploratory play (t(139.44) = −2.52; p = 0.013) compared to mothers. However, child cognitive functioning impacts maternal play but not the father’s play characteristics. (4) Conclusions: Highlighting mother−child and father−child features may have important service delivery implications for implementing personalized parental-based interventions based on the strengths and weaknesses of both caregivers in a complementary system.

Case report: Preemptive intervention for an infant with early signs of autism spectrum disorder during the first year of life

Autism spectrum disorder (ASD) includes neurodevelopmental conditions traditionally considered to bring life long disabilities, severely impacting individuals and their families. Very early identification and intervention during the very first phases of life have shown to significantly diminish symptom severity and disability, and improve developmental trajectories. Here we report the case of a young child showing early behavioral signs of ASD during the first months of life, including diminished eye contact, reduced social reciprocity, repetitive movements. The child received a pre-emptive parent mediated intervention based on the Infant Start, an adaptation of the Early Start Denver Model (ESDM), specifically developed for children with ASD signs during the first year of life. The child here described received intervention from 6 to 32 months of age, in combination with educational services. Diagnostic evaluations performed at several time points (8, 14, 19, and 32 months) showed progressive improvements in his developmental level and ASD symptoms. Our case study supports the possibility of identifying ASD symptoms and providing services as soon as concerns emerge even during the first year of life. Our report, in combination with recent infant identification and intervention studies, suggests the need for very early screening and preemptive intervention to promote optimal outcomes.

Caregiver sensitivity predicts infant language use, and infant language complexity predicts caregiver language complexity, in the context of possible emerging autism

While theory supports bidirectional effects between caregiver sensitivity and language use, and infant language acquisition-both caregiver-to-infant and also infant-to-caregiver effects-empirical research has chiefly explored the former unidirectional path. In the context of infants showing early signs of autism, we investigated prospective bidirectional associations with 6-min free-play interaction samples collected for 103 caregivers and their infants (mean age 12-months; and followed up 6-months later). We anticipated that measures of caregiver sensitivity/language input and infant language would show within-domain temporal stability/continuity, but also that there would be predictive associations from earlier caregiver input to subsequent child language, and vice versa. Caregiver sensitive responsiveness (from the Manchester Assessment of Caregiver-Infant interaction [MACI]) predicted subsequent infant word tokens (i.e., amount of language, coded following the Systematic Analysis of Language Transcripts [SALT]). Further, earlier infant Mean Length of Utterance (MLU; reflecting language complexity, also derived from SALT coding) predicted later caregiver MLU, even when controlling for variability in infant ages and clear within-domain temporal stability/continuity in key measures (i.e., caregiver sensitive responsiveness and infant word tokens; and infant and caregiver MLU). These data add empirical support to theorization on how caregiver input can be both supportive of, and potentially influenced by, infant capacities, when infants have social-communication differences and/or communication/language delays suggestive of possible emerging autism.

RJAfinder: An automated tool for quantification of responding to joint attention behaviors in autism spectrum disorder using eye tracking data

Deficits in responding to joint attention (RJA) are early symptoms of autism spectrum disorder (ASD). Currently, no automated tools exist for identifying and quantifying RJA behaviors. A few eye tracking studies have investigated RJA in ASD children but have produced conflicting results. In addition, little is known about the trajectory of RJA development through developmental age. Here, a new video was designed including 12 clips of an actor pointing to or looking at an object. Eye tracking technology was used to monitor RJA in three groups: 143 ASD children assessed with the Autism Diagnostic Interview-Revised (ADI-R) and the Autism Diagnostic Observation Schedule (ADOS) (4-7 years old), 113 age- and gender-matched typically developing children (TDC), and 43 typically developing adults (TDA) (19-32 years old). RJAfinder was developed in R and MATLAB to quantify RJA events from the eye tracking data. RJA events were compared among the three groups. Spearman correlation coefficients between total number of RJA events in ASD and the Social Responsiveness Scale (SRS) scores were calculated. A logistic regression model was built using the average valid sampling rate and the total number of RJA events as two predictive variables to classify ASD and TDC groups. ASD children displayed statistically significantly less RJA events than the TDC and TDA groups with medium-to-large-sized effects. ASD and TDC children both displayed more RJA events in response to pointing stimuli than to looking stimuli. Our logistic regression model predicted ASD tendency with 0.76 accuracy in the testing set. RJA ability improved more slowly between the ages of 4-7 years old in the ASD group than in the TDC group. In ASD children, RJA ability showed negative correlation with SRS total T-score as well as the scores of five subdomains. Our study provides an automated tool for quantifying RJA and insights for the study of RJA in ASD children, which may help improve ASD screening, subtyping, and behavior interventions.

Parent experiences of obtaining an autism diagnosis for their daughter: An interpretative phenomenological analysis

LAY ABSTRACT

Autistic females are often diagnosed later than males and are also more likely to be misdiagnosed with other conditions. Co-occurring conditions may also be diagnosed at the time of the assessment but their autism diagnosis is missed. The majority of research examining the parent experience of obtaining an autism diagnosis for their child has included predominantly or exclusively male children in their samples. This study examines the experiences of parents in obtaining an autism diagnosis for their daughters in Australia through interview data which allowed for an exploration of their lived experiences. Several of the parents reported positive feelings of excitement or curiosity in relation to the assessment process which are emotions that have not been reported in earlier studies. While recent research advances have improved our understanding of gender differences in autistic behaviours, the findings of this study suggest that some practitioners have obsolete knowledge which may lead to misdiagnosis or missed diagnosis in some females. Although the extent that these experiences are representative of parents in the wider community is unknown, the fact that they are still being reported in the present day suggests that a proportion of health professionals continue to practice with outdated conceptualisations of autism.

A systematic review of telehealth screening, assessment, and diagnosis of autism spectrum disorder

There is a significant delay between parents having concerns and receiving a formal assessment and Autism Spectrum Disorder (ASD) diagnosis. Telemedicine could be an effective alternative that shortens the waiting time for parents and primary health providers in ASD screening and diagnosis. We conducted a systematic review examining the uses of telemedicine technology for ASD screening, assessment, or diagnostic purposes and to what extent sample characteristics and psychometric properties were reported. This study searched four databases from 2000 to 2022 and obtained 26 studies that met the inclusion criteria. The 17 applications used in these 26 studies were divided into three categories based on their purpose: screening, diagnostic, and assessment. The results described the data extracted, including study characteristics, applied methods, indicators seen, and psychometric properties. Among the 15 applications with psychometric properties reported, the sensitivity ranged from 0.70 to 1, and the specificity ranged from 0.38 to 1. The present study highlights the strengths and weaknesses of current telemedicine approaches and provides a basis for future research. More rigorous empirical studies with larger sample sizes are needed to understand the feasibility, strengths, and limitations of telehealth technologies for screening, assessing, and diagnosing ASD.

Early identification of autism in Egyptian children using Arabic version of checklist for autism in toddlers-23 (CHAT-23)

Background: Screening is the first important step in the diagnostic process. There is strong evidence that early diagnosis and management of autism spectrum disorder (ASD) can lead to a better prognosis. The purpose of this study was to develop an Arabic version of the Chinese Checklist for Autism in Toddlers-23 (CHAT-23) to distinguish children with ASD in the Egyptian community. Methods: The Arabic CHAT-23 checklist was applied to 100 Egyptian children with mental age 18-24 months including 30 autistic and 70 typically-developing children. Results and conclusion: Arabic CHAT-23 checklist is a valid and reliable tool for early identification of ASD in Egyptian children with high sensitivity (93.3%) and specificity (97%). Children failing any 15 of all 23 questions of the parental questionnaire should be observed with observational items. Failing any 3 of the 4 observational items would suggest ASD.

Symptoms of Autism Spectrum Disorders Measured by the Qualitative Checklist for Autism in Toddlers in a Large Sample of Polish Toddlers

This study aimed to assess some early symptoms of autism spectrum disorders (ASD) measured by a screening tool developed for an early detection of ASD. We investigated if the early symptoms were associated with toddlers’ age, gender or ASD familial risk status. We used the Polish version of the Quantitative Checklist for Autism in Toddlers (Q-CHAT) to assess 1024 children aged 16 to 36 months. The sample included four groups of participants: typically developing toddlers, toddlers with parent-reported ASD-specific concerns, toddlers at risk for autism due to having an older sibling with ASD, and toddlers with a developmental delay. We found that mean Q-CHAT scores were significantly higher in boys than in girls. We did not find any associations between Q-CHAT scores and age. We observed that toddlers with a familial risk for ASD and those with a developmental delay scored significantly higher than controls. We collated these results with previous studies that used the Q-CHAT and other instruments.

Diagnostic Accuracy of the Social Attention and Communication Surveillance-Revised With Preschool Tool for Early Autism Detection in Very Young Children

IMPORTANCE

Early identification of children on the autism spectrum is crucial to facilitate access to early supports and services for children and families. The need for improved early autism identification tools is highlighted by the lack of sufficient diagnostic accuracy in current tools.

OBJECTIVES

To examine the diagnostic accuracy of the Social Attention and Communication Surveillance-Revised (SACS-R) and SACS-Preschool (SACS-PR) tools when used with a large, community-based, convenience sample and identify the prevalence of autism in this sample.

DESIGN, SETTING, AND PARTICIPANTS

This diagnostic accuracy study was conducted in Melbourne, Australia, training maternal and child health nurses who monitored 13 511 children aged 11 to 42 months using the SACS-R and SACS-PR during their routine consultations (June 1, 2013, to July 31, 2018). Children identified as being at high likelihood for autism (12-24 months of age: n = 327; 42 months of age: n = 168) and at low likelihood for autism plus concerns (42 months of age: n = 28) were referred by their maternal and child health nurse for diagnostic assessment by the study team. Data analysis was performed from April 13, 2020, to November 29, 2021.

EXPOSURES

Children were monitored with SACS-R and SACS-PR at 12, 18, 24, and 42 months of age.

MAIN OUTCOMES AND MEASURES

Diagnostic accuracy of the SACS-R and SACS-PR was determined by comparing children's likelihood for autism with their diagnostic outcome using clinical judgment based on standard autism assessments (Autism Diagnostic Observation Schedule-Second Edition and Autism Diagnostic Interview-Revised).

RESULTS

A total of 13 511 children (female: 6494 [48.1%]; male: 7017 [51.9%]) were monitored at least once with the SACS-R at their 12-, 18-, and 24-month-old routine maternal and child health consultations (mean [SD] age, 12.3 [0.59] months at 12 months; 18.3 [0.74] months at 18 months; 24.6 [1.12] months at 24 months) and followed up at their 42-month maternal and child health consultation (mean [SD] age, 44.0 [2.74] months) with SACS-PR (8419 [62.3%]). At 12 to 24 months, SACS-R showed high diagnostic accuracy, with 83% positive predictive value (95% CI, 0.77-0.87) and 99% estimated negative predictive value (95% CI, 0.01-0.02). Specificity (99.6% [95% CI, 0.99-1.00]) was high, with modest sensitivity (62% [95% CI, 0.57-0.66]). When the SACS-PR 42-month assessment was added, estimated sensitivity increased to 96% (95% CI, 0.94-0.98). Autism prevalence was 2.0% (1 in 50) between 11 and 30 months of age and 3.3% (1 in 31) between 11 and 42 months of age.

CONCLUSIONS AND RELEVANCE

The SACS-R with SACS-PR (SACS-R+PR) had high diagnostic accuracy for the identification of autism in a community-based sample of infants, toddlers, and preschoolers, indicating the utility of early autism developmental surveillance from infancy to the preschool period rather than 1-time screening. Its greater accuracy compared with psychometrics of commonly used autism screening tools when used in community-based samples suggests that the SACS-R+PR can be used universally for the early identification of autism.

The role of head circumference and cerebral volumes to phenotype male adults with autism spectrum disorder

BACKGROUND

Autism spectrum disorder (ASD) has been repeatedly associated with enlargements of head circumference in children with ASD. However, it is unclear if these enlargements persist into adulthood. This is the first study to investigate head circumference in a large sample of adults with ASD.

METHODS

We apply a fully automated magnetic resonance imaging (MRI) based measurement approach to compute head circumference by combining 3D and 2D image processing. Head circumference was compared between male adults with ASD (n = 120) and healthy male controls (n = 136), from the Autism Brain Imaging Data Exchange (ABIDE) database. To explain which brain alterations drive our results, secondary analyses were performed for 10 additional morphological brain metrics.

RESULTS

ASD subjects showed an increase in head circumference (p = .0018). In addition, ASD patients had increased ventricular surface area (SA) (p = .0013). Intracranial volume, subarachnoidal cerebrospinal fluid (CSF) volume, and gray matter volume explained 50% of head circumference variance. Using a linear support vector machine, we gained an ASD classification accuracy of 73% (sensitivity 92%, specificity 68%) using head circumference and brain-morphological metrics as input features. Head circumference, ventricular SA, ventricular CSF volume, and ventricular asymmetry index contributed to 85% of feature weighting relevant for classification.

CONCLUSION

Our results suggest that head circumference increases in males with ASD persist into adulthood. Results may be driven by morphological alterations of ventricular CSF. The presented approach for an automated head circumference measurement allows for the retrospective investigation of large MRI datasets in neuropsychiatric disorders.

Preliminary Validation and Feasibility of the Autism Detection in Early Childhood-Virtual (ADEC-V) for Autism Telehealth Evaluations in a Hospital Setting

This study provided preliminary validation of the Autism Detection in Early Childhood-Virtual (ADEC-V) for telehealth assessment of possible autism. Participants were 121 children (24.79% female) aged 18–47 months who completed telehealth evaluations at a large pediatric hospital in the Midwestern United States between October 2020 and February 2021. The ADEC-V showed good sensitivity (0.82) and specificity (0.78) and was significantly correlated with other ASD symptom measures (i.e., CARS-2, ADI-R). Internal consistency was acceptable (α = 0.77). These results need replication in a larger and broader sample including more children without ASD. This preliminary validation study identifies the ADEC-V as a promising measure for telehealth ASD assessments in young children.

Predictive Model Construction for Social–Emotional Competence of Toddlers in Shanghai, China: A Population-Based Study

Objective

To construct a simple model containing predictors derived from Chinese Learning Accomplishment Profile (C-LAP) to better the evaluation of the social–emotional development of toddlers aged 24–36 months.

Method

The test results by C-LAP system and demographic information of toddlers aged 24–36 months were collected between 2013 and 2019 in Shanghai, China, whose guardians were voluntary to accept the investigation. We developed a norm with the dataset based on the study population. With the norm, stepwise regression and best subset analysis were applied to select predictors.

Results

Relying on the norm established and stepwise regression and also the best subset analysis, an optimal model containing only 6 indicators was finally determined and the nomogram of the model was constructed. In the training and validation dataset, the AUCs of the optimal model were 0.95 (95% CI: 0.94–0.96) and 0.88 (95% CI: 0.85–0.90), respectively. When the cutoff point of the model was set at 0.04, its sensitivity in training and validation dataset was 0.969 and 0.949, respectively, and the specificity in training and validation dataset is 0.802 and 0.736, respectively.

Conclusion

A simplified predictive model which includes only 6 items derived from C-LAP is developed to evaluate the probabilities of being at risk of developmental problem in social–emotional development for toddlers aged 24–36 months. Meanwhile, specificity and sensitivity of the model may be high enough for future fast screening.

Early detection of Australian Aboriginal and Torres Strait Islander infants at high risk of adverse neurodevelopmental outcomes at 12 months corrected age: LEAP-CP prospective cohort study protocol

INTRODUCTION

Neurodevelopmental disorders (NDD), including cerebral palsy (CP), autism spectrum disorder (ASD) and foetal alcohol spectrum disorder (FASD), are characterised by impaired development of the early central nervous system, impacting cognitive and/or physical function. Early detection of NDD enables infants to be fast-tracked to early intervention services, optimising outcomes. Aboriginal and Torres Strait Islander infants may experience early life factors increasing their risk of neurodevelopmental vulnerability, which persist into later childhood, further compounding the health inequities experienced by First Nations peoples in Australia. The LEAP-CP prospective cohort study will investigate the efficacy of early screening programmes, implemented in Queensland, Australia to earlier identify Aboriginal and Torres Strait Islander infants who are 'at risk' of adverse neurodevelopmental outcomes (NDO) or NDD. Diagnostic accuracy and feasibility of early detection tools for identifying infants 'at risk' of a later diagnosis of adverse NDO or NDD will be determined.

METHODS AND ANALYSIS

Aboriginal and/or Torres Strait Islander infants born in Queensland, Australia (birth years 2020-2022) will be invited to participate. Infants aged <9 months corrected age (CA) will undergo screening using the (1) General Movements Assessment (GMA); (2) Hammersmith Infant Neurological Examination (HINE); (3) Rapid Neurodevelopmental Assessment (RNDA) and (4) Ages and Stages Questionnaire-Aboriginal adaptation (ASQ-TRAK). Developmental outcomes at 12 months CA will be determined for: (1) neurological (HINE); (2) motor (Peabody Developmental Motor Scales 2); (3) cognitive and communication (Bayley Scales of Infant Development III); (4) functional capabilities (Paediatric Evaluation of Disability Inventory-Computer Adaptive Test) and (5) behaviour (Infant Toddler Social and Emotional Assessment). Infants will be classified as typically developing or 'at risk' of an adverse NDO and/or specific NDD based on symptomology using developmental and diagnostic outcomes for (1) CP (2) ASD and (3) FASD. The effects of perinatal, social and environmental factors, caregiver mental health and clinical neuroimaging on NDOs will be investigated.

ETHICS AND DISSEMINATION

Ethics approval has been granted by appropriate Queensland ethics committees; Far North Queensland Health Research Ethics Committee (HREC/2019/QCH/50533 (Sep ver 2)-1370), the Townsville HHS Human Research Ethics Committee (HREC/QTHS/56008), the University of Queensland Medical Research Ethics Committee (2020000185/HREC/2019/QCH/50533) and the Children's Health Queensland HHS Human Research Ethics Committee (HREC/20/QCHQ/63906) with governance and support from local First Nations communities. Findings from this study will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12619000969167.

EYE-C: Eye-Contact Robust Detection and Analysis during Unconstrained Child-Therapist Interactions in the Clinical Setting of Autism Spectrum Disorders

The high level of heterogeneity in Autism Spectrum Disorder (ASD) and the lack of systematic measurements complicate predicting outcomes of early intervention and the identification of better-tailored treatment programs. Computational phenotyping may assist therapists in monitoring child behavior through quantitative measures and personalizing the intervention based on individual characteristics; still, real-world behavioral analysis is an ongoing challenge. For this purpose, we designed EYE-C, a system based on OpenPose and Gaze360 for fine-grained analysis of eye-contact episodes in unconstrained therapist-child interactions via a single video camera. The model was validated on video data varying in resolution and setting, achieving promising performance. We further tested EYE-C on a clinical sample of 62 preschoolers with ASD for spectrum stratification based on eye-contact features and age. By unsupervised clustering, three distinct sub-groups were identified, differentiated by eye-contact dynamics and a specific clinical phenotype. Overall, this study highlights the potential of Artificial Intelligence in categorizing atypical behavior and providing translational solutions that might assist clinical practice.

Brief Report: Training New Zealand Well Child/Tamariki Ora Nurses on Early Autism Signs Using the Social Attention and Communication Surveillance-Revised

Universal developmental surveillance is considered best practice for early identification of autism. We analysed data from 175 New Zealand Well-Child/Tamariki Ora nurses who attended a 1-day training in developmental surveillance for autism using the social attention and communication surveillance-revised (SACS-R) tool. We used a survey to measure nurses’ knowledge of typical development, knowledge of early signs of autism, general autism knowledge, and confidence in identifying and discussing early signs, prior to the workshop, after the workshop, and at follow-up. We measured perceived acceptability of the SACS-R after the workshop and at follow-up. Nurses showed improvements on all measures from pre-workshop to post-workshop and pre-workshop to follow-up. Implementation of the SACS-R across different contexts appears feasible and acceptable.

Effect of Preemptive Intervention on Developmental Outcomes Among Infants Showing Early Signs of Autism: A Randomized Clinical Trial of Outcomes to Diagnosis

IMPORTANCE

Intervention for individuals with autism spectrum disorder (ASD) typically commences after diagnosis. No trial of an intervention administered to infants before diagnosis has shown an effect on diagnostic outcomes to date.

OBJECTIVE

To determine the efficacy of a preemptive intervention for ASD beginning during the prodromal period.

DESIGN, SETTING, AND PARTICIPANTS

This 2-site, single rater-blinded randomized clinical trial of a preemptive intervention vs usual care was conducted at 2 Australian research centers (Perth, Melbourne). Community sampling was used to recruit 104 infants aged 9 to 14 months showing early behaviors associated with later ASD, as measured by the Social Attention and Communication Surveillance-Revised. Recruitment occurred from June 9, 2016, to March 30, 2018. Final follow-up data were collected on April 15, 2020.

INTERVENTIONS

Infants were randomized on a 1:1 ratio to receive either a preemptive intervention plus usual care or usual care only over a 5-month period. The preemptive intervention group received a 10-session social communication intervention, iBASIS-Video Interaction to Promote Positive Parenting (iBASIS-VIPP). Usual care comprised services delivered by community clinicians.

MAIN OUTCOMES AND MEASURES

Infants were assessed at baseline (approximate age, 12 months), treatment end point (approximate age, 18 months), age 2 years, and age 3 years. Primary outcome was the combined blinded measure of ASD behavior severity (the Autism Observation Scale for Infants and the Autism Diagnostic Observation Schedule, second edition) across the 4 assessment points. Secondary outcomes were an independent blinded clinical ASD diagnosis at age 3 years and measures of child development. Analyses were preregistered and comprised 1-tailed tests with an α level of .05.

RESULTS

Of 171 infants assessed for eligibility, 104 were randomized; 50 infants (mean [SD] chronological age, 12.40 [1.93] months; 38 boys [76.0%]) received the iBASIS-VIPP preemptive intervention plus usual care (1 infant was excluded after randomization), and 53 infants (mean [SD] age, 12.38 [2.02] months; 32 boys [60.4%]) received usual care only. A total of 89 participants (45 in the iBASIS-VIPP group and 44 in the usual care group) were reassessed at age 3 years. The iBASIS-VIPP intervention led to a reduction in ASD symptom severity (area between curves, -5.53; 95% CI, -∞ to -0.28; P = .04). Reduced odds of ASD classification at age 3 years was found in the iBASIS-VIPP group (3 of 45 participants [6.7%]) vs the usual care group (9 of 44 participants [20.5%]; odds ratio, 0.18; 95% CI, 0-0.68; P = .02). Number needed to treat to reduce ASD classification was 7.2 participants. Improvements in caregiver responsiveness and language outcomes were also observed in the iBASIS-VIPP group.

CONCLUSIONS AND RELEVANCE

Receipt of a preemptive intervention for ASD from age 9 months among a sample of infants showing early signs of ASD led to reduced ASD symptom severity across early childhood and reduced the odds of an ASD diagnosis at age 3 years.

TRIAL REGISTRATION

http://anzctr.org.au identifier: ACTRN12616000819426.

Implementing and evaluating Social Attention and Communication Surveillance (SACS) to prospectively identify autism in very young children in Nepal

BACKGROUND

Although Autism Spectrum Disorder (ASD) can be identified as early as 12 months and diagnosed by 24 months, the mean age of diagnosis of ASD in Nepal is ∼58 months, with children missing the opportunity for early intervention.

AIMS

This study implemented and evaluated a Nepali version of the Social Attention and Communication Surveillance (SACS-N) tool, to identify children between 11-30 months who are at "high likelihood" of ASD in a local community in Nepal.

METHODS

Sixty Female Community Health Volunteers (FCHVs) were trained to monitor and identify the early signs of ASD using SACS-N.

RESULTS

Overall, 1926 children were monitored with the SACS-N, with 11 children (0.57 %) referred for further assessments at 11-15 months (n = 4), 16-21 months (n = 4), and 22-30 months (n = 3). Of these children, 10 children had a developmental disorder, including ASD and Global Developmental Delay; no information was available on one child who migrated. Hence, the positive predictive value (PPV) of SACS-N for all developmental disorders was 100 %. Of seven children attending a gold standard diagnostic/ developmental assessment, three had ASD (43 % PPV for ASD). The estimated prevalence of ASD ranged between 0.16 % to 0.26 %.

CONCLUSION

Community-based developmental monitoring of ASD and other developmental delays by FCHVs is a feasible, cost-effective and sustainable approach to promoting early identification of ASD in Nepal. Further training and awareness of autism is needed for more accurate and increased referral rates using the SACS-N, including regular supervision of FCHVs.

The process of Learn to Play Therapy with parent-child dyads with children who have autism spectrum disorder

INTRODUCTION

Learn to Play Therapy aims to build children's ability to spontaneously initiate pretend play. The purpose of this study was to explore evidence for this therapy for children with autism spectrum disorder by investigating the changes in a child's pretend play and key techniques used in the process of therapy.

METHODS

Six children with a diagnosis of autism spectrum disorder (mean age = 3.8 years; SD = 1.2 years) were engaged in therapy sessions with a parent. Four therapy session videos for each child were selected across four time points from 15 videos of each child, representing 6 months of therapy. Retrospective video analysis was used to investigate the changes in the child's ability by coding six play skills and enjoyment of play. Key techniques in the process of Learn to Play Therapy were analysed by frequency of occurrence during sessions.

RESULTS

There was a significant increase in the child's pretend play ability for play scripts (p = .042), sequences of play actions (p = .043), object substitution (p = .043), doll/teddy play (p = .028), social interaction (p = .043) and enjoyment (p = .026). There was a mirroring of the therapist, parent and child for all key techniques, with parents showing increased frequency rates after Time 1. Repetition with variation decreased by Time 4. Challenging the child showed higher rates in Times 2 and 4. Focussed attention remained stable, and the child's talk during play had the highest total frequency.

CONCLUSION

Learn to Play Therapy is an effective therapy in building pretend play ability in children with autism, with parents increasing their involvement in using the key techniques after Time 1. The results inform therapists on how the key techniques were used within the therapy sessions to increase the child's pretend play ability.

Caregiver Psychological Distress Predicts Temperament and Social-Emotional Outcomes in Infants with Autism Traits

Child temperament and caregiver psychological distress have been independently associated with social-emotional difficulties among individuals with autism. However, the interrelationship among these risk factors has rarely been investigated. We explored the reciprocal interplay between child temperament (surgency, negative affectivity, and self-regulation) and caregiver psychological distress in the development of child internalizing and externalizing symptoms, in a cohort of 103 infants showing early autism traits. Caregivers completed questionnaires when children were aged around 12-months (Time 1 [T1]), 18-months (Time 2 [T2]), and 24-months (Time 3 [T3]). Cross-lagged path models revealed a significant pathway from T1 caregiver psychological distress through lower T2 child self-regulation to subsequently greater T3 child internalizing symptoms. No such caregiver-driven pathway was evident through T2 child negative affectivity or in the prediction of T3 child externalizing symptoms. Further, no support was found for temperament-driven pathways through caregiver psychological distress to child social-emotional difficulties. Child surgency was mostly unrelated to caregiver psychological distress and social-emotional difficulties. These findings implicate the need to support the mental health of caregivers with an infant with autism traits in order to enhance the emotion regulation and social-emotional development of their infants.

The course and prognostic capability of motor difficulties in infants showing early signs of autism

Delays within the motor domain are often overlooked as an early surveillance marker for autism. The present study evaluated motor difficulties and its potential as an early predictive marker for later autism likelihood in a cohort of infants (N = 96) showing early behavioral signs of autism aged 9-14 months. The motor domain was evaluated using the motor subscales of the Mullen Scales of Early Learning at baseline, and at a 6-month follow-up. The Autism Diagnostic Observation Schedule - Toddler Module (ADOS-T) was completed at follow-up as a measure of autism likelihood. Motor difficulties were common at baseline, with 63/96 (65.6%) infants scoring very low or below average in the gross motor domain and 29/96 (30.2%) in the fine motor domain. At follow-up, gross motor difficulties had resolved for many, with 23/63 (36.5%) infants maintaining these difficulties. Fine motor difficulties resolved in fewer infants, with 20/29 (69.0%) continuing to present with fine motor delays at follow-up. Adjusted linear regression models suggested that fine motor scores at baseline (β = -0.12, SE = 0.04) and follow-up (β = -0.17, SE = 0.05) were associated with higher ADOS-T scores; with difficulties across both timepoints (β = 5.60, SE = 1.35) the strongest (largest in magnitude) association with ADOS-T scores of the predictors examined. Motor difficulties are prominent in children displaying emerging signs of autism, with persistent fine motor difficulties predictive of the developing autism phenotype. The findings indicate the potential clinical value of including evaluation of motor skills within early autism surveillance measures. LAY SUMMARY: This prospective study evaluated motor development over a 6-month period in infants showing early behavioral signs of autism. Atypical motor development was a common feature of infants showing early signs of autism and persistent fine motor difficulties were predictive of the emerging autism phenotype.

Research, Clinical, and Sociological Aspects of Autism

The concept of autism continues to evolve. Not only have the central diagnostic criteria that define autism evolved but understanding of the label and how autism is viewed in research, clinical and sociological terms has also changed. Several key issues have emerged in relation to research, clinical and sociological aspects of autism. Shifts in research focus to encompass the massive heterogeneity covered under the label and appreciation that autism rarely exists in a diagnostic vacuum have brought about new questions and challenges. Diagnostic changes, increasing moves towards early diagnosis and intervention, and a greater appreciation of autism in girls and women and into adulthood and old age have similarly impacted on autism in the clinic. Discussions about autism in socio-political terms have also increased, as exemplified by the rise of ideas such as neurodiversity and an increasingly vocal dialogue with those diagnosed on the autism spectrum. Such changes are to be welcomed, but at the same time bring with them new challenges. Those changes also offer an insight into what might be further to come for the label of autism.

Is Smiling the Key? Machine Learning Analytics Detect Subtle Patterns in Micro-Expressions of Infants with ASD

Time is a key factor to consider in Autism Spectrum Disorder. Detecting the condition as early as possible is crucial in terms of treatment success. Despite advances in the literature, it is still difficult to identify early markers able to effectively forecast the manifestation of symptoms. Artificial intelligence (AI) provides effective alternatives for behavior screening. To this end, we investigated facial expressions in 18 autistic and 15 typical infants during their first ecological interactions, between 6 and 12 months of age. We employed Openface, an AI-based software designed to systematically analyze facial micro-movements in images in order to extract the subtle dynamics of Social Smiles in unconstrained Home Videos. Reduced frequency and activation intensity of Social Smiles was computed for children with autism. Machine Learning models enabled us to map facial behavior consistently, exposing early differences hardly detectable by non-expert naked eye. This outcome contributes to enhancing the potential of AI as a supportive tool for the clinical framework.

Changes in Knowledge on the Signs of Autism in Young Children (11-30 Months) among Female Community Health Volunteers in Nepal

Nepalese Female Community Health Volunteers' (FCHVs) knowledge on social attention and communication development and the early signs of autism was evaluated before, immediately after, and 12-months following training on typical and atypical social-communicative development in infants/toddlers, early signs of autism, and monitoring of key "markers" of autism using Social Attention and Communication Surveillance. FCHVs (N = 60) significantly improved their knowledge about autism and reported increased perceived confidence in monitoring and referring young children at high likelihood of autism following training, which was sustained one year later. FCHVs also reported a positive impact of training on their work. These findings indicate the effectiveness of training in improving FCHVs' knowledge and perceived confidence to monitor and refer young children at high likelihood of autism.

Context-Specific Dyadic Attention Vulnerabilities During the First Year in Infants Later Developing Autism Spectrum Disorder

OBJECTIVE

Although some eye-tracking studies demonstrate atypical attention to faces by 6 months of age in autism spectrum disorder (ASD), behavioral studies in early infancy return largely negative results. We examined the effects of context and diagnosis on attention to faces during face-to-face live interactions in infants at high familial risk (HR) and low familial risk (LR) for ASD.

METHOD

Participants were 6-, 9-, and 12-month-old siblings of children with ASD who were later determined to have ASD (n = 21), other developmental challenges (HR-C; n = 74), or typical development (TD) (HR-TD; n = 32), and low-risk, typically developing controls (LR-TD; n = 49). Infants were administered the social orienting probes task, consisting of five conditions: dyadic bid, song, peek-a-boo, tickle, and toy play. Attention to an unfamiliar examiner's face was coded by blinded raters from video recordings.

RESULTS

At all ages, the ASD group spent less time looking at the examiner's face than the HR-C, HR-TD, and LR-TD groups during the Dyadic Bid and Tickle conditions (all p <.05), but not during the Song, Peek-a-Boo, or Toy Play conditions (all p >.23). Lower attention to faces during Dyadic Bid and Tickle conditions was significantly correlated with higher severity of autism symptoms at 18 months.

CONCLUSION

During the prodromal stages of the disorder, infants with ASD exhibited subtle impairments in attention to faces of interactive partners during interactions involving eye contact and child-directed speech (with and without physical contact), but not in contexts involving singing, familiar anticipatory games, or toy play. Considering the convergence with eye-tracking findings on limited attention to faces in infants later diagnosed with ASD, reduced attention to faces of interactive partners in specific contexts may constitute a promising candidate behavioral marker of ASD in infancy.

A Multistate Trial of an Early Surveillance Program for Autism Within General Practices in Australia

Background: The early detection of developmental conditions such as autism is vital to ensure children can access appropriate and timely evidence-based supports, services, and interventions. Children who have undetected developmental conditions early in life are more likely to develop later health, developmental, learning, and behavioral issues, which in turn can have a cumulative effect over the life course. Methods: The current protocol describes a multi-site, cluster randomized control trial comparing a developmental surveillance pathway for autism to usual care, using opportunistic visits to general practitioners (GPs). Units of randomization are GP clinics across two Australian states (New South Wales and Victoria), with thirty clinics within each state, each of which will aim to recruit approximately forty children aged between ~18- and 24-months, for a total of ~2,400 participants. Children will be randomized to two clusters; namely, an autism surveillance pathway (ASP) or surveillance as usual (SaU). The screening process for the ASP arm involves primary and secondary screenings for developmental concerns for autism, using both parent and GP reports and observations. Children in both arms who show signs of developmental concerns for autism will be offered a full developmental assessment by the research team at 24 months of age to determine the efficacy of developmental surveillance in successfully identifying children with autism. Trial Registration: The trial is registered with ANZCTR (ACTRN12619001200178) and reporting of the trial results will be according to recommendations in the CONSORT Statement.

A Comparison of Children Born Preterm and Full-Term on the Autism Spectrum in a Prospective Community Sample

Introduction: Previous research suggests children diagnosed with autism spectrum disorder (ASD or “autism”) born extremely and very preterm face substantially delayed development than their peers born full-term. Further, children born preterm are proposed to show a unique behavioral phenotype, which may overlap with characteristics of autism, making it difficult to disentangle their clinical presentation. To clarify the presentation of autism in children born preterm, this study examined differences in key indicators of child development (expressive language, receptive language, fine motor, and visual reception) and characteristics of autism (social affect and repetitive, restricted behaviors).

Materials and Methods: One fifty-eight children (136 full-term, twenty-two preterm) diagnosed with autism, aged 22–34 months, were identified prospectively using the Social Attention and Communication Surveillance tools during community-based, developmental surveillance checks in the second year of life. Those identified at “high likelihood” of an autism diagnosis were administered the Mullen Scales of Early Learning and the Autism Diagnostic Observation Schedule.

Results: The children born preterm and full-term did not differ significantly in their fine motor, visual reception, expressive language, or receptive language skills. No significant differences in social affect and repetitive and restrictive behavior traits were found.

Discussion: The findings of this study differs from previous research where children diagnosed with autism born very or extremely preterm were developmentally delayed and had greater autistic traits than their term-born peers. These null findings may relate to the large proportion of children born moderate to late preterm in this sample. This study was unique in its use of a community-based, prospectively identified sample of children diagnosed with autism at an early age. It may be that children in these groups differ from clinic- and hospital-based samples, that potential differences emerge later in development, or that within the autism spectrum, children born preterm and full-term develop similarly. It was concluded that within the current sample, at 2 years of age, children diagnosed with autism born preterm are similar to their peers born full-term. Thus, when clinicians identify characteristics of autism in children born preterm, it is important to refer the child for a diagnostic assessment for autism.

Performance of the Autism Observation Scale for Infants with community-ascertained infants showing early signs of autism

Often included within ‘high-risk sibling’ studies, the Autism Observation Scale for Infants (AOSI) has only one independent replication study and no evaluation with community-ascertained cohorts. We administered the AOSI and established clinical measures with 103 infants (68% male) at ‘high autism likelihood’ on the Social Attention and Communication Surveillance - Revised (SACS-R) tool, at 9–14 months of age and again 6 months later. AOSI Total scores showed adequate internal consistency and strong inter-rater agreement (live- or video-coded) and were approximately normally distributed at each visit. Modest significant associations presented between Time 1 AOSI scores and concurrent developmental/adaptive skills measures. Concurrent associations were stronger at Time 2, particularly between AOSI Total and Autism Diagnostic Observation Schedule (ADOS) Social Affect scores. AOSI scores were only moderately associated across Time 1 and 2 assessments, as were Time 1 AOSI with Time 2 ADOS scores. These data from a clinically indicated cohort broadly replicate previous AOSI validity accounts from ‘high-risk sibling’ studies, particularly beyond the first year. Strong inter-rater agreement indicates viable AOSI inclusion within protocols necessitating blinded evaluation (e.g. intervention trials). Moderate within-participant stability suggests that, like ‘high-risk siblings,’ community-ascertained infants experience variable early trajectories.

Lay Abstract

We investigated whether a commonly used research assessment – the Autism Observation Scale for Infants (AOSI) – accurately measures autism behaviours among infants showing early signs of autism identified within the community. The AOSI is often included in studies tracking the development of infants at increased likelihood of autism, such as the infant siblings of diagnosed children. However, the suitability of this measure has not previously been tested with community-referred infants. We administered the AOSI with infants when aged 9 to 14 months and again 6 months later. Our researchers – independent of the AOSI development team and newly trained on this measure – were able to administer the brief interactive assessment and score it accurately. The infants’ AOSI scores were linked to their scores on other established and validated clinical assessments, particularly at the second visit when average age was 18 months. Stronger correspondence of AOSI and other scores at this second visit suggests early autism behaviours are better established and more consistent by 18 months of age, even though these infants showed clear enough signs of possible autism to prompt referral to our study around 12 months of age. However, the moderate association of AOSI scores over time suggests that, like infant siblings – who mostly do not develop autism – community-identified infants showing early signs may also have variable developmental pathways in early life.

Gesture Development, Caregiver Responsiveness, and Language and Diagnostic Outcomes in Infants at High and Low Risk for Autism

We investigated gesture production in infants at high and low risk for autism spectrum disorder (ASD) and caregiver responsiveness between 12 and 24 months of age and assessed the extent to which early gesture predicts later language and ASD outcomes. Participants included 55 high-risk infants, 21 of whom later met criteria for ASD, 34 low-risk infants, and their caregivers. Results indicated that (a) infants with ASD outcomes used fewer gestures and a lower proportion of developmentally advanced gesture-speech combinations; (b) caregivers of all the infants provided similar rates of contingent responses to their infants' gestures; and (c) gesture production at 12 months predicted subsequent receptive language and ASD outcomes within the high-risk group.

Automatic Identification of High-Risk Autism Spectrum Disorder: A Feasibility Study Using Video and Audio Data Under the Still-Face Paradigm

It is reported that the symptoms of autism spectrum disorder (ASD) could be improved by effective early interventions, which arouses an urgent need for large-scale early identification of ASD. Until now, the screening of ASD has relied on the child psychiatrist to collect medical history and conduct behavioral observations with the help of psychological assessment tools. Such screening measures inevitably have some disadvantages, including strong subjectivity, relying on experts and low-efficiency. With the development of computer science, it is possible to realize a computer-aided screening for ASD and alleviate the disadvantages of manual evaluation. In this study, we propose a behavior-based automated screening method to identify high-risk ASD (HR-ASD) for babies aged 8-24 months. The still-face paradigm (SFP) was used to elicit baby's spontaneous social behavior through a face-to-face interaction, in which a mother was required to maintain a normal interaction to amuse her baby for 2 minutes (a baseline episode) and then suddenly change to the no-reaction and no-expression status with 1 minute (a still-face episode). Here, multiple cues derived from baby's social stress response behavior during the latter episode, including head-movements, facial expressions and vocal characteristics, were statistically analyzed between HR-ASD and typical developmental (TD) groups. An automated identification model of HR-ASD was constructed based on these multi-cue features and the support vector machine (SVM) classifier; moreover, its screening performance was satisfied, for all the accuracy, specificity and sensitivity exceeded 90% on the cases included in this study. The experimental results suggest its feasibility in the early screening of HR-ASD.

Subgroups of Temperament Associated with Social-Emotional Difficulties in Infants with Early Signs of Autism

Links between temperament and social-emotional difficulties are well-established in normative child development but remain poorly characterized in autism. We sought to characterize distinct temperament subgroups and their associations with concurrent internalizing and externalizing symptoms in a sample of 103 infants (M_age = 12.39 months, SD = 1.97; 68% male) showing early signs of autism. Latent profile analysis was used to identify subgroups of infants with distinct temperament trait configurations on the Infant Behavior Questionnaire-Revised. Derived subgroups were then compared in terms of internalizing and externalizing symptoms on the Infant-Toddler Social and Emotional Assessment. Three distinct temperament subgroups were identified: (a) inhibited/low positive (n = 22), characterized by low Smiling and Laughter, low High-Intensity Pleasure, low Vocal Reactivity, and low Approach; (b) active/negative reactive (n = 23), characterized by high Activity Level, high Distress to Limitations, high Sadness, high Fear, and low Falling Reactivity; and (c) well-regulated (n = 51), characterized by high Cuddliness, high Soothability, and high Low-Intensity Pleasure. There were no differences in infant sex ratio, mean age or developmental/cognitive ability. Inhibited/low-positive infants had significantly more behavioral autism signs than active/negative reactive and well-regulated infants, who did not differ. Inhibited/low-positive and active/negative reactive infants had higher internalizing symptoms, relative to well-regulated infants, and active/negative reactive infants also had higher externalizing symptoms. These findings align closely with those garnered in the context of normative child development, and point to child temperament as a putative target for internalizing and externalizing interventions. LAY SUMMARY: This study explored whether infants with early signs of autism could be grouped according to temperament characteristics (i.e., emotional, behavioral, and attentional traits). Three subgroups were identified that differed with respect to emotional and behavioral difficulties. Specifically, "inhibited/low-positive" infants had high emotional difficulties, "active/negative reactive" infants had high emotional and behavioral difficulties, while "well-regulated" infants had the lowest difficulties.

The Role of Negative Affectivity in Concurrent Relations Between Caregiver Psychological Distress and Social-Emotional Difficulties in Infants With Early Signs of Autism

Recent evidence suggests the link between caregiver psychological distress and offspring social-emotional difficulties may be accounted for by offspring temperament characteristics. However, existing studies have only focused on neurotypical children; thus, the current study sought to provide an initial examination of this process among children with varying levels of early autism features. Participants included 103 infants aged 9-16 months (M = 12.39, SD = 1.97; 68% male) and their primary caregiver (96% mothers) referred to a larger study by community healthcare professionals. We utilized caregiver-reported measures of psychological distress (Depression Anxiety Stress Scales), infant temperament (Infant Behavior Questionnaire-Revised) and internalizing and externalizing symptoms (Infant-Toddler Social and Emotional Assessment) and administered the Autism Observation Schedule for Infants (AOSI) at an assessment visit to quantify autism features. Infant negative affectivity was found to mediate positive concurrent relations between caregiver psychological distress and infant internalizing and externalizing symptoms, irrespective of the infants' AOSI score. While preliminary and cross-sectional, these results replicate and extend previous findings suggesting that the pathway from caregiver psychological distress to negative affectivity to social-emotional difficulties might also be apparent among infants with varying levels of autism features. More rigorous tests of causal effects await future longitudinal investigation. LAY SUMMARY: Offspring of caregivers experiencing psychological distress (i.e., symptoms of depression, anxiety, and/or stress) may themselves be at increased risk of poor mental health outcomes. Several previous studies conducted with neurotypical children suggest that this link from caregiver-to-child may be facilitated by children's temperament qualities. This study was a preliminary cross-sectional exploration of these relationships in infants with features of autism. We found that infants' elevated negative emotions were involved in the relation between caregiver heightened psychological distress and children's mental health difficulties, consistent with neurotypical development. Autism Res 2020, 13: 1349-1357. © 2020 International Society for Autism Research, Wiley Periodicals, Inc.

Autism spectrum disorder risk prediction: A systematic review of behavioral and neural investigations

A reliable diagnosis of autism spectrum disorder (ASD) is difficult to make until after toddlerhood. Detection in an earlier age enables early intervention, which is typically more effective. Recent studies of the development of brain and behavior in infants and toddlers have provided important insights in the diagnosis of autism. This extensive review focuses on published studies of predicting the diagnosis of autism during infancy and toddlerhood younger than 3 years using behavioral and neuroimaging approaches. After screening a total of 782 papers, 17 neuroimaging and 43 behavioral studies were reviewed. The features for prediction consist of behavioral measures using screening tools, observational and experimental methods, brain volumetric measures, and neural functional activation and connectivity patterns. The classification approaches include logistic regression, linear discriminant function, decision trees, support vector machine, and deep learning based methods. Prediction performance has large variance across different studies. For behavioral studies, the sensitivity varies from 20% to 100%, and specificity ranges from 48% to 100%. The accuracy rates range from 61% to 94% in neuroimaging studies. Possible factors contributing to this inconsistency may be partially due to the heterogeneity of ASD, different targeted populations (i.e., high-risk group for ASD and general population), age when the features were collected, and validation procedures. The translation to clinical practice requires extensive further research including external validation with large sample size and optimized feature selection. The use of multi-modal features, e.g., combination of neuroimaging and behavior, is worth further investigation to improve the prediction accuracy.

Study protocol for an evaluation of ASDetect - a Mobile application for the early detection of autism

Background

Autism Spectrum Conditions (ASC) can be reliably diagnosed by 24 months of age. However, despite the well-known benefits of early intervention, there is still a research-practice gap in the timely identification of ASC, particularly in low-resourced settings. The Social Attention and Communication Surveillance (SACS) tool, which assesses behavioural markers of autism between 12 to 24 months of age, has been implemented in Maternal and Child Health (MCH) settings, with excellent psychometric properties. ASDetect is a free mobile application based on the SACS, which is designed to meet the need for an effective, evidence-based tool for parents, to learn about children’s early social-communication development and assess their child’s ‘likelihood’ for ASC.

Study aims

The primary aim of this study is to evaluate the psychometric properties of ASDetect in the early detection of children with ASC. A secondary aim is to assess ASDetect’s acceptability and parental user experience with the application.

Methods

Families are recruited to download the application and participate in the study via social media, health professionals (e.g., MCH nurses, paediatricians) and word of mouth. All participating caregivers complete a demographic questionnaire, survey regarding their user experience, and the Social Responsiveness Scale-2 (SRS-2), an autism screening questionnaire; they are also invited to participate in focus groups. Children identified at ‘high likelihood’ for ASC based on the ASDetect results, the SRS-2 or parental and/or professional concerns undergo a formal, gold-standard, diagnostic assessment. Receiver Operating Characteristic analyses will be used to assess psychometric properties of ASDetect. Thematic analyses will be used to explore themes arising in the focus groups to provide insights regarding user experiences with the app. Multiple regression analyses will be carried out to determine the extent to which demographic factors, parental stress and beliefs on health surveillance and child results on ASDetect are associated with the parental user-experience of the application.

Discussion

With a strong evidence-base and global access, ASDetect has the potential to empower parents by providing them with knowledge of their child’s social-communication development, validating and reassuring any parental concerns, and supporting them in communicating with other health professionals, ultimately enhancing child and family outcomes and well-being.

Brief Report: Replication and Validation of the Brief Autism Detection in Early Childhood (BADEC) in a Clinical Sample

We investigated the clinical validity of the BADEC, an abbreviated, five-item version of the Autism Detection in Early Childhood, level-2 screening tool for autism. Initially developed by Nah et al. (2019) using a research sample, the present study replicated Nah et al. (2019) procedures in a clinical population. Using a cutoff score of five, five items were identified as most effective in discriminating children who later received an ASD diagnosis by an interdisciplinary team. This algorithm had improved validity compared to the original research algorithm. Results supported the efficacy of a very brief, easy to administer ASD screening tool in identifying children under three who are likely to have ASD.

Application of the Still-Face Paradigm in Early Screening for High-Risk Autism Spectrum Disorder in Infants and Toddlers

Background: Although autism spectrum disorder (ASD) can currently be diagnosed at the age of 2 years, age at ASD diagnosis is still 40 months or even later. In order to early screening for ASD with more objective method, behavioral videos were used in a number of studies in recent years. Method: The still-face paradigm (SFP) was adopted to measure the frequency and duration of non-social smiling, protest behavior, eye contact, social smiling, and active social engagement in high-risk ASD group (HR) and typical development group (TD) (HR: n = 45; TD: n = 43). The HR group was follow-up until they were 2 years old to confirm final diagnosis. Machine learning methods were used to establish models for early screening of ASD. Results: During the face-to-face interaction (FF) episode of the SFP, there were statistically significant differences in the duration and frequency of eye contact, social smiling, and active social engagement between the two groups. During the still-face (SF) episode, there were statistically significant differences in the duration and frequency of eye contact and active social engagement between the two groups. The 45 children in the HR group were reclassified into two groups after follow-up: five children in the N-ASD group who were not meet the criterion of ASD and 40 children in the ASD group. The results showed that the accuracy of Support Vector Machine (SVM) classification was 83.35% for the SF episode. Conclusion: The use of the social behavior indicator of the SFP for a child with HR before 2 years old can effectively predict the clinical diagnosis of the child at the age of 2 years. The screening model constructed using SVM based on the SF episode of the SFP was the best. This also proves that the SFP has certain value in high-risk autism spectrum disorder screening. In addition, because of its convenient, it can provide a self-screening mode for use at home. Trial registration: Chinese Clinical Trial Registry, ChiCTR-OPC-17011995.

Pre-emptive intervention versus treatment as usual for infants showing early behavioural risk signs of autism spectrum disorder: a single-blind, randomised controlled trial

BACKGROUND

Great interest exists in the potential efficacy of prediagnostic interventions within the autism spectrum disorder prodrome, but available evidence relates to children at high familial risk. We aimed to test the efficacy of a pre-emptive intervention designed for infants showing early behavioural signs of autism spectrum disorder.

METHODS

In this single-blind, randomised controlled trial done at two specialist centres in Australia, infants aged 9-14 months were enrolled if they were showing at least three early behavioural signs of autism spectrum disorder on the Social Attention and Communication Surveillance-Revised (SACS-R) 12-month checklist. Infants were randomly assigned (1:1) to receive a parent-mediated video-aided intervention (iBASIS-VIPP) or treatment as usual. Group allocation was done by minimisation, stratified by site, sex, age, and the number of SACS-R risk behaviours. Assessments were done at baseline (before treatment allocation) and at the 6 month endpoint. The primary outcome was Autism Observation Scale for Infants (AOSI), which measures early behavioural signs associated with autism spectrum disorder. Secondary outcomes were a range of infant and caregiver outcomes measured by Manchester Assessment of Caregiver-Infant interaction (MACI), Mullen Scales of Early Learning (MSEL), Vineland Adaptive Behaviour Scales, 2nd edition (VABS-2), MacArthur-Bates Communicative Development Inventory (MCDI), and Parenting Sense of Competence (PSOC) scale. This trial is registered with Australian New Zealand Clinical Trials Registry, number ANZCTR12616000819426.

FINDINGS

Between June 9, 2016, and March 30, 2018, 103 infants were randomly assigned, 50 to the iBASIS-VIPP group and 53 to the treatment-as-usual group. After the intervention, we observed no significant differences between groups on early autism spectrum disorder behavioural signs measured by the AOSI (difference estimate -0·74, 95% CI -2·47 to 0·98). We also observed no significant differences on secondary outcomes measuring caregiver non-directiveness (0·16, -0·33 to 0·65), caregiver sensitive responding (0·24, -0·15 to 0·63), and infant attentiveness (-0·19, -0·63 to 0·25) during parent-child interactions (MACI), as well as on researcher-administered measures of receptive (1·30, -0·48 to 3·08) and expressive language (0·54, -0·73 to 1·80), visual reception (0·31, -0·77 to 1·40), and fine motor skills (0·55, -0·32 to 1·41) using the MSEL. Compared with the treatment-as-usual group, the iBASIS-VIPP group had lower infant positive affect (-0·69, -1·27 to -0·10) on the MACI, but higher caregiver-reported receptive (37·17, 95% CI 10·59 to 63·75) and expressive vocabulary count (incidence rate ratio 2·31, 95% CI 1·22 to 4·33) on MCDI, and functional language use (difference estimate 6·43, 95% CI 1·06 to 11·81) on VABS. There were no significant group differences on caregiver-reported measures of MCDI infant gesture use (3·22, -0·60 to 7·04) and VABS social behaviour (3·28, -1·43 to 7·99). We observed no significant differences between groups on self-reported levels of parenting satisfaction (difference estimate 0·21, 95% CI -0·09 to 0·52), interest (-0·23, -0·62 to 0·16) and efficacy (-0·08, -0·38 to 0·22) on PSOC.

INTERPRETATION

A pre-emptive intervention for the autism spectrum disorder prodrome had no immediate treatment effect on early autism spectrum disorder symptoms, the quality of parent-child interactions, or researcher-administered measures of developmental skills. However, we found a positive effect on parent-rated infant communication skills. Ongoing follow-up of this infant cohort will assess longer-term developmental effects.

FUNDING

Western Australia Children's Research Fund, Autism Cooperative Research Centre, La Trobe University, and Angela Wright Bennett Foundation.

A systematic review of screening tools for the detection of autism spectrum disorder in mainland China and surrounding regions

Screening for autism spectrum disorder is the first step toward early detection and diagnosis, thereby impacting the likelihood of children accessing early intervention and, importantly, improving long-term outcomes. This systematic review aimed to (a) establish a clear baseline of autism spectrum disorder screening tools currently used throughout mainland China and surrounding regions, (b) identify the strengths and limitations of these instruments, and (c) develop specific recommendations regarding screening for autism spectrum disorder throughout Chinese-speaking countries. Databases were searched for recent (2015-2018) articles published in Chinese or English languages. Twenty-two studies (13 Chinese, 9 English) met inclusion criteria; two from Taiwan and the remainder from mainland China. Studies varied greatly in the extent of psychometric analyses and reported autism spectrum disorder prevalence. The majority of diagnoses were based on Diagnostic and Statistical Manual of Mental Disorders (4th ed. (DSM-IV) or 5th ed. (DSM-5)) criteria, although a small number of studies utilized gold-standard diagnostic assessment instruments. It is recommended that a systematic, multi-tiered, screening network be established to improve the identification of autism spectrum disorder in China and surrounding regions. Assessment and diagnosis need to be culturally appropriate, and amenable to low-resource settings. In addition, increased public awareness programs to reduce stigma will be important in improving outcomes for children with autism spectrum disorder.

Gender Differences During Toddlerhood in Autism Spectrum Disorder: A Prospective Community-Based Longitudinal Follow-Up Study

Relatively few studies have examined gender differences in infants and toddlers, and most focus on clinically referred samples or high-risk infant cohorts. The current study aimed to examine gender differences in early autism manifestations and cognitive development in a community-ascertained sample. In total, 46 males and 21 females with ASD were seen at approximately 24 and 48 months of age. No significant gender differences were observed on overall cognitive ability, verbal skills, non-verbal skills, overall autism severity, or restricted repetitive behaviours. However, females were found to exhibit more social communication impairments than males. These findings may indicate that female toddlers with less severe or different, social communication impairments may be more likely to be missed during routine surveillance during toddlerhood.

School Age Outcomes of Children with Autism Spectrum Disorder Who Received Community-Based Early Interventions

This study followed children with Autism Spectrum Disorder (ASD) from early intervention into their early schooling years, when they were aged between 6 and 9 years, on autism symptom severity and cognitive functioning. The children, matched at pre-intervention, were compared on type of community provided service: 31 were in receipt of community-based group Early Start Denver Model and 28 had received other community provisions for ASD. Irrespective of groups, cognitive functioning was found to have significantly improved by school age compared to pre-intervention. Autism symptom severity increased during the same developmental period, seemingly driven by an increase in restricted and repetitive behaviours over time. In contrast, both groups displayed improved social affect by school age.