What are we targeting when we treat autism spectrum disorder? A systematic review of 406 clinical trials

Development and Psychometric Examination of a New Social Competence Outcome Measure for Children with Autism Spectrum Disorder: The Observational Social Competence Assessment

Current assessments of social competence for children with autism spectrum disorder (ASD) are mostly designed for screening or diagnosis, not for measuring outcomes. This study aimed to develop a professional-administrated outcome measure, the Observational Social Competence Assessment (OSCA), and examine its psychometric properties. The OSCA was constructed based on a multidimensional view of social competence (i.e., social skill elements, social reciprocity, and social adjustment). For psychometric evaluation, 89 children with ASD between 3 and 12 years (mean = 70.69 months, SD = 15.31) were assessed with the OSCA and with assessments of ASD symptoms, verbal comprehension ability, and adaptive function. The results show that the OSCA has good internal consistency (Cronbach's α = 0.820-0.954), test-retest reliability (intraclass correlation coefficients [ICC] = 0.917-0.960), and inter-rater reliability (ICC = 0.905-0.974). The OSCA also has good convergent (r = 0.508-0.703, p < 0.01) and divergent validity (r = 0.105, p = 0.496), as well as good responsiveness to changes in the social adjustment dimension (Cohen's d = 1.26 and standardized response mean [SRM] = 1.92). Conclusively, these results show that the OSCA is sufficiently reliable, valid and responsive to be applied as an outcome measure of social competence in children with ASD.

Autism interventions designed or adapted for the Black/African American population: A systematic review

LAY ABSTRACT

Black/African American people in the United States who have a diagnosis of autism often experience service-related disparities, including not having the same access to high-quality autism and related care (e.g. behavioral interventions), and are less likely to have sustained treatment engagement across their lifespan. While interventions to support autistic people are typically designed to be universal, there is concern that these interventions not being tailored to the Black/African American population could reduce the overall impact due to a lack of responsiveness to the needs of the Black children or families who receive the intervention. The current systematic review summarized research on interventions developed for the Black autism community, including Black children with autism and their caregivers. After a comprehensive, systematic search, eight peer-reviewed publications were identified that met the study's inclusion criteria. The majority of the interventions were tailored to Black caregivers of children with autism. Autism researchers demonstrate different strategies for engaging Black caregivers in culturally responsive ways; however, more research into these interventions is needed in order to assess their effectiveness. In addition, there are still limited interventions adapted to be culturally responsive to Black/African American autistic people. The Cultural Adaptation Checklist framework is a novel approach with promise to become the standard for adapting interventions to meet the needs of culturally diverse groups. Cultural responsiveness is an important facet in the development of interventions that produce optimal outcomes for the range of diversity in the United States and is an important step to achieving equitable autism research practices.

A Passing Problem: Evaluating Harm and Benefit in Autism Research

Autism research frequently seeks to evaluate interventions or inform their development. Unfortunately, researchers often assume that autism intervention should reduce autistic traits, effectively setting as a goal of treatment that autistic people attempt to "pass" as nonautistic. A growing body of evidence highlights serious potential harms from passing demands. We discuss why it is important for institutional review boards (IRBs) to scrutinize autism research for clinical passing demands, and we document the existence of such demands in outcome measures commonly employed in autism research. We propose an ethical framework for IRBs and others to make use of in evaluating the ethical appropriateness of particular treatment goals in autism intervention or intervention-adjacent research, emphasizing that treatment goals should be in pursuit of a beneficial nonpassing purpose and be the least burdensome means of accomplishing such a purpose. We also highlight potential promising practices for IRBs, investigators, and other stakeholders seeking to address these issues in autism research.

Longitudinal studies of challenging behaviours in autistic children and adults: A systematic review and meta-analysis

Autistic children and adults are at increased risk of showing behaviours that may be described as challenging, however, little is known about whether or how these behaviours may change over time. Given the profound impact that challenging behaviour can have on both the autistic individual and their support network, it is critical that the trajectory of challenging behaviours be better understood. This systematic review and meta-analysis identified and synthesised observational longitudinal studies of challenging behaviour in autistic individuals. Fifty-six studies were included in the systematic review, and the effect sizes of 37 independent samples arising from 34 of these reports were examined through meta-analysis. Crucially, across the 37 samples, scores on the measures of challenging behaviour reduced by a small, yet significant, extent over time. Although age of the sample at baseline assessment did not moderate the effect, the time between the baseline assessment and final follow-up and age at final follow-up both moderated the magnitude of the effect, with challenging behaviour scores reducing to a larger extent in (a) studies with longer intervals between baseline and final follow-up and (b) studies with older samples at follow-up. The results from the current systematic review and meta-analysis have both theoretical and practical implications for understanding challenging behaviour over time in autistic individuals. Avenues for future research are also highlighted that may allow better understanding, and therefore support of, challenging behaviour in autistic individuals.

Efficacy of very early interventions on neurodevelopmental outcomes for infants and toddlers at increased likelihood of or diagnosed with autism: A systematic review and meta-analysis

The aim of this systematic review was to determine the efficacy of very early interventions for infants and toddlers at increased likelihood of or diagnosed with autism for autism symptomatology, developmental outcomes and/or neurocognitive markers. Eight databases were searched (14 April 2022) with inclusion criteria: (i) RCTs with care as usual (CAU) comparison group, (ii) participants at increased likelihood of or diagnosed with autism and aged <24 months corrected age (CA), (iii) parent-mediated and/or clinician directed interventions, and (iv) outcome measures were autism symptomatology, cognition, language, adaptive skills, or neurocognitive assessments (EEG and eye tracking). Quality was assessed using Risk of Bias 2 and GRADE. Nineteen publications from 12 studies reported on 715 infants and toddlers. There was low to moderate certainty evidence that clinician-assessed outcomes did not show significant treatment effects for: autism symptomatology (ADOS CSS: MD -0.08, 95% CI -0.61, 0.44, p = 0.75), cognitive outcome (Mullen Scales of Early Learning-Early Learning Composite (MSEL-ELC): SMD 0.05, 95% CI -0.19, 0.29, p = 0.67), receptive language (MSEL-Receptive Language: SMD 0.04, 95% CI -0.21, 0.3, p = 0.74) or expressive language (MSEL-Expressive Language: SMD 0.06, 95% CI -0.1, 0.23, p = 0.45). Neurocognitive outcomes (EEG and eye tracking) were heterogeneous, with inconsistent findings. There is low to moderate certainty evidence that very early interventions have limited impact on neurodevelopmental outcomes by age 3 years.

Agreement between parents' and clinical researchers' ratings of behavioral problems in children with fragile X syndrome and chromosome 15 imprinting disorders

BACKGROUND

Despite the increasing number of clinical trials involving children with neurodevelopmental disorders, appropriate and objective outcome measures for behavioral symptoms are still required.

AIM

This study assessed the agreement between parents' and clinical researchers' ratings of behavioral problem severity in children with fragile X syndrome (FXS) and chromosome 15 imprinting disorders.

METHODS AND PROCEDURES

The cohort comprised 123 children (64% males), aged 3-17 years, with FXS (n = 79), Prader-Willi (PWS; n = 19), Angelman (AS; n = 15), and Chromosome 15q duplication (n = 10) syndromes. Specific items from the Autism Diagnostic Observation Schedule-Second Edition and Aberrant Behavior Checklist-Community Edition mapping to corresponding behavioral domains were selected ad-hoc, to assess behavioral problems.

OUTCOMES AND RESULTS

Inter-rater agreement for the cohort was slight for self-injury (Intraclass Correlation Coefficient (ICC) = 0.12), fair for tantrums/aggression (0.24) and mannerisms/stereotypies (0.25), and moderate for hyperactivity (0.48). When stratified by diagnosis, ICC ranged from poor (0; self-injury, AS and PWS) to substantial (0.48; hyperactivity, females with FXS).

CONCLUSIONS AND IMPLICATIONS

The high level of inter-rater disagreement across most domains suggests that parents' and researchers' assessments led to discrepant appraisal of behavioral problem severity. These findings have implications for treatment targets and outcome measure selection in clinical trials, supporting a multi-informant approach.

The Quality of Life for Children with Autism Spectrum Disorder Scale: Factor Analysis, MIMIC Modeling, and Cut-Off Score Analysis

Our purpose in this study was to further examine the psychometric properties of the Quality of Life for Children with Autism Spectrum Disorder (QOLASD-C) scale. We first investigated the factor structure and the internal consistency of the scale. The bifactor model showed good fit and strong reliability. Second, we used multiple-indicators multiple-causes (MIMIC) modeling to examine the associations between demographic variables and the QOLASD-C dimensions. Results showed differences on overall QOL based on age, race/ethnicity, and autism spectrum disorder severity, but no relationships with gender. All demographic variables were associated with one or all three subscales (i.e., interpersonal relationships, self-determination, emotional well-being) of the QOLASD-C. Third, an optimal cut-off score of 37 was identified. Implications for research and practice are discussed.

Concordance between patient-centered and adaptive behavior outcome measures after applied behavior analysis for autism

BACKGROUND

Applied behavior analysis (ABA) is an evidence-based approach to autism spectrum disorder that has been shown in clinical trials to improve child functional status. There is substantial focus in ABA on setting and tracking individualized goals that are patient-centered, but limited research on how to measure progress on such patient-centered outcomes.

PURPOSE

The purpose of this investigation was to assess concordance between patient-centered and standard outcome measures of treatment progress in a real-world clinical sample of children receiving ABA for autism spectrum disorder.

METHODS

This observational study used a clinical sample of children ages 3 to 16 years (N = 154) who received 24 months of ABA from an integrated health system. Concordance between three outcome measures after ABA was assessed using a correlation matrix: (1) patient-centered measures of progress on individualized treatment goals, (2) caregiver-centered measure of progress on treatment participation goals, and (3) the Vineland Adaptive Behavior Scales adaptive behavior composite.

RESULTS

There was limited concordance among measures at both 12 and 24 months of ABA. None of the patient-centered measures showed significant positive correlation with adaptive behavior composite difference scores at either 12 or 24 months, nor did the caregiver measure. The percentage of children achieving clinically meaningful gain on patient-centered goal measures increased between 12 and 24 months of ABA, while the percentage of children achieving clinically meaningful gains in adaptive behavior declined during the same time period.

CONCLUSIONS

In a health system implementation of ABA, there was limited concordance between patient-centered and standard measures of clinically meaningful treatment progress for children with ASD. Clinicians should have ongoing dialogue with patients and parents/caregivers to ensure that interventions for ASD are resulting in progress towards outcomes that are meaningful to patients and families.

Music therapy for autistic people

BACKGROUND

Social interaction and social communication are among the central areas of difficulty for autistic people. Music therapy uses music experiences and the relationships that develop through them to enable communication and expression, thus attempting to address some of the core problems of autistic people. Music therapy has been applied in autism since the early 1950s, but its availability to autistic individuals varies across countries and settings. The application of music therapy requires specialised academic and clinical training which enables therapists to tailor the intervention to the specific needs of the individual. The present version of this review on music therapy for autistic people is an update of the previous Cochrane review update published in 2014 (following the original Cochrane review published in 2006).

OBJECTIVES

To review the effects of music therapy, or music therapy added to standard care, for autistic people.

SEARCH METHODS

In  August 2021, we searched  CENTRAL, MEDLINE, Embase, eleven other databases and two trials registers. We also ran citation searches, checked reference lists, and contacted study authors to identify additional studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs), quasi-randomised trials and controlled clinical trials comparing music therapy (or music therapy alongside standard care) to 'placebo' therapy, no treatment, or standard care for people with a diagnosis of autism spectrum disorder were considered for inclusion.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Four authors independently selected studies and extracted data from all included studies. We synthesised the results of included studies in meta-analyses. Four authors independently assessed risk of bias (RoB) of each included study using the original RoB tool as well as the certainty of evidence using GRADE.   MAIN RESULTS: We included 16 new studies in this update which brought the total number of included studies to 26 (1165 participants). These studies examined the short- and medium-term effect of music therapy (intervention duration: three days to eight months) for autistic people in individual or group settings. More than half of the studies were conducted in North America or Asia. Twenty-one studies included children aged from two to 12 years. Five studies included children and adolescents, and/or young adults. Severity levels, language skills, and cognition were widely variable across studies. Measured immediately post-intervention, music therapy compared with 'placebo' therapy or standard care was more likely to positively effect global improvement (risk ratio (RR) 1.22, 95% confidence interval (CI) 1.06 to 1.40; 8 studies, 583 participants; moderate-certainty evidence; number needed to treat for an additional beneficial outcome (NNTB) = 11 for low-risk population, 95% CI 6 to 39; NNTB = 6 for high-risk population, 95% CI 3 to 21) and to slightly increase quality of life (SMD 0.28, 95% CI 0.06 to 0.49; 3 RCTs, 340 participants; moderate-certainty evidence, small to medium effect size). In addition, music therapy probably results in a large reduction in total autism symptom severity (SMD -0.83, 95% CI -1.41 to -0.24; 9 studies, 575 participants; moderate-certainty evidence). No clear evidence of a difference between music therapy and comparison groups at immediately post-intervention was found for social interaction (SMD 0.26, 95% CI -0.05 to 0.57, 12 studies, 603 participants; low-certainty evidence); non-verbal communication (SMD 0.26, 95% CI -0.03 to 0.55; 7 RCTs, 192 participants; low-certainty evidence); and verbal communication (SMD 0.30, 95% CI -0.18 to 0.78; 8 studies, 276 participants; very low-certainty evidence). Two studies investigated adverse events with one (36 participants) reporting no adverse events; the other study found no differences between music therapy and standard care immediately post-intervention (RR 1.52, 95% CI 0.39 to 5.94; 1 study, 290 participants; moderate-certainty evidence).  AUTHORS' CONCLUSIONS: The findings of this updated review provide evidence that music therapy is probably associated with an increased chance of global improvement for autistic people, likely helps them to improve total autism severity and quality of life, and probably does not increase adverse events immediately after the intervention. The certainty of the evidence was rated as 'moderate' for these four outcomes, meaning that we are moderately confident in the effect estimate. No clear evidence of a difference was found for social interaction, non-verbal communication, and verbal communication measured immediately post-intervention. For these outcomes, the certainty of the evidence was rated as 'low' or 'very low', meaning that the true effect may be substantially different from these results. Compared with earlier versions of this review, the new studies included in this update helped to increase the certainty and applicability of this review's findings through larger sample sizes, extended age groups, longer periods of intervention and inclusion of follow-up assessments, and by predominantly using validated scales measuring generalised behaviour (i.e. behaviour outside of the therapy context). This new evidence is important for autistic individuals and their families as well as for policymakers, service providers and clinicians, to help in decisions around the types and amount of intervention that should be provided and in the planning of resources. The applicability of the findings is still limited to the age groups included in the studies, and no direct conclusions can be drawn about music therapy in autistic individuals above the young adult age. More research using rigorous designs, relevant outcome measures, and longer-term follow-up periods is needed to corroborate these findings and to examine whether the effects of music therapy are enduring.

Health and wellbeing outcomes and social prescribing pathways in community-based support for autistic adults: A systematic mapping review of reviews

Adults on the autism spectrum are affected by health disparities which significantly reduce life expectancy and experience barriers to accessing healthcare. Social prescribing is a holistic approach that diverts patients from primary care to health-enhancing activities in communities. However, there has been a lack of research attention to how autistic people navigate the social prescribing pathway and the ability of these approaches to address existing disparities. This mapping review aimed to synthesise features of non-medical, community-based interventions for autistic adults to assess their suitability for a social prescribing approach. A systematic search and screening process was used to identify literature reviews from medical databases (Embase, Medline, PsycINFO, CINAHL and Cochrane reviews) and grey literature. We extracted data from 24 reviews and 19 studies including types of services, participants, outcomes, settings and procedures. A narrative and visual synthesis is used to map the variety of services and interventions identified, the outcome measures used, and the barriers and facilitators to progression through services in relation to a realist social prescribing framework. The review found that there has been minimal evaluation of holistic, low intensity services for autistic adults, such as those offered in social prescribing approaches. Outcome measures remain focused on features of autism and reveal less about the effects of interventions on health and wellbeing. Aspects of the social prescribing model were identified in the features of service pathways, but findings also suggested how social prescribing could be adapted to improve accessibility for autistic people.

Response (minimum clinically relevant change) in ASD symptoms after an intervention according to CARS-2: consensus from an expert elicitation procedure

The lack of consensual measures to monitor core change in Autism Spectrum Disorder (ASD) or response to interventions leads to difficulty to prove intervention efficacy on ASD core symptoms. There are no universally accepted outcome measures developed for measuring changes in core symptoms. However, the CARS (Childhood Autism Rating Scale) is one of the outcomes recommended in the EMA Guideline on the clinical development of medicinal products for the treatment of ASD. Unfortunately, there is currently no consensus on the response definition for CARS among individuals with ASD. The aim of this elicitation process was to determine an appropriate definition of a response on the CARS2 scale for interventions in patients with Autism Spectrum Disorder (ASD). An elicitation process was conducted following the Sheffield Elicitation Framework (SHELF). Five experts in the field of ASD and two experts in expert knowledge elicitation participated in an 1-day elicitation workshop. Experts in ASD were previously trained in the SHELF elicitation process and received a dossier of scientific evidence concerning the topic. The response definition was set as the mean clinically relevant improvement averaged over all patients, levels of functioning, age groups and clinicians. Based on the scientific evidence and expert judgment, a normal probability distribution was agreed to represent the state of knowledge of this response with expected value 4.03 and standard deviation 0.664. Considering the remaining uncertainty of the estimation and the available literature, a CARS-2 improvement of 4.5 points has been defined as a threshold to conclude to a response after an intervention. A CARS-2 improvement of 4.5 points could be used to evaluate interventions' meaningfulness in indivudals. This initial finding represents an important new benchmark and may aid decision makers in evaluating the efficacy of interventions in ASD.

Efficacy of psychosocial interventions for Autism spectrum disorder: an umbrella review

INTRODUCTION

The wide range of psychosocial interventions designed to assist people with Autism Spectrum Disorder (ASD) makes it challenging to compile and hierarchize the scientific evidence that supports the efficacy of these interventions. Thus, we performed an umbrella review of published meta-analyses of controlled clinical trials that investigated the efficacy of psychosocial interventions on both core and related ASD symptoms.

METHODS

Each meta-analysis that was identified was re-estimated using a random-effects model with a restricted maximum likelihood estimator. The methodological quality of included meta-analyses was critically appraised and the credibility of the evidence was assessed algorithmically according to criteria adapted for the purpose of this study.

RESULTS

We identified a total of 128 meta-analyses derived from 44 reports. More than half of the non-overlapping meta-analyses were nominally statistically significant and/or displayed a moderate-to-large pooled effect size that favored the psychosocial interventions. The assessment of the credibility of evidence pointed out that the efficacy of early intensive behavioral interventions, developmental interventions, naturalistic developmental behavioral interventions, and parent-mediated interventions was supported by suggestive evidence on at least one outcome in preschool children. Possible outcomes included social communication deficits, global cognitive abilities, and adaptive behaviors. Results also revealed highly suggestive indications that parent-mediated interventions improved disruptive behaviors in early school-aged children. The efficacy of social skills groups was supported by suggestive evidence for improving social communication deficits and overall ASD symptoms in school-aged children and adolescents. Only four meta-analyses had a statistically significant pooled effect size in a sensitivity analysis restricted to randomized controlled trials at low risk of detection bias.

DISCUSSION

This umbrella review confirmed that several psychosocial interventions show promise for improving symptoms related to ASD at different stages of life. However, additional well-designed randomized controlled trials are still required to produce a clearer picture of the efficacy of these interventions. To facilitate the dissemination of scientific knowledge about psychosocial interventions for individuals with ASD, we built an open-access and interactive website that shares the information collected and the results generated during this umbrella review.

PRE-REGISTRATION

PROSPERO ID CRD42020212630.

Medicinal cannabis in children and adolescents with autism spectrum disorder: A scoping review

BACKGROUND

Autism spectrum disorder (ASD) is a neurodevelopmental condition estimated to affect 1 in 66 children in Canada and 1 in 270 individuals worldwide. As effective therapies for the management of ASD core and associated symptoms are limited, parents are increasingly turning to clinicians for advice regarding the use of medicinal cannabis to manage behavioural disturbances.

OBJECTIVE

The objective of this scoping review was to identify and map symptoms, outcomes and adverse events related to medicinal cannabis treatment for ASD-related behaviours.

METHODS

Ovid MEDLINE, Embase, CINAHL, PsycInfo, Web of Science Core Collection, Google Scholar and grey literature sources were searched up to 5 January 2020 for studies. Included studies met the following criteria: (1) investigate the use of medicinal cannabis, (2) at least 50% participants had ASD, (3) at least 50% of the study population was 0-18 years old and (4) any study design (published or unpublished).

RESULTS

We identified eight completed and five ongoing studies meeting the inclusion criteria. All studies reported substantial behaviour and symptom improvement on medicinal cannabis, with 61% to 93% of subjects showing benefit. In the three studies reporting on concomitant psychotropic medication usage and with cannabis use, up to 80% of participants observed a reduction in concurrent medication use. Adverse events related to cannabis use were reported in up to 27% of participants related, and two participants had psychotic events.

CONCLUSIONS

Early reports regarding medicinal cannabis in paediatric ASD symptom management are presented as positive; the evidence, however, is limited to very few retrospective cohort and observational studies. Evidence of safety and efficacy from prospective clinical trials is needed.

Assessment of Anxiety in Cognitive-Behavior Therapy in Young University Students with Autism Spectrum Disorders: A Review

The university provides academic support to disabled students, however, few institutions provide academic, extra-academic or preventive support to students with Autism Spectrum Disorders High-Functioning (ASD-HF). Among the most commonly requested needs is support for coping with anxiety arising from academic and social activity itself. When planning an intervention program, it is necessary to screen those who have problems and are likely to benefit from such a program. In this article we propose a systematic search for measures of anxiety for young people and adults with ASD-HF. Of a total of 683 documents, only 7 met the selection criteria. Of these, a total of 35 tools were detected, of which only 11 mediated anxiety. Screening should be carried out for all students, so that we can detect the "risk" of anxiety disturbance in all cases and, in particular, in students with ASD-HF. However, the instruments eligible for assessing intervention outcomes should be agreed upon in order to be able to compare results from different trials.

Baseline behaviour moderates movement skill intervention outcomes among young children with autism spectrum disorder

LAY ABSTRACT

It is common for children with autism spectrum disorder to experience delays in their movement skills. These skills are important for participation in play and physical activity. Previous research has found that movement skills can be improved with movement skill interventions. This study explored the behavioural factors of young children with autism spectrum disorder that make them most likely to improve their movement skills following a 12-week intervention. The study found that children with higher levels of adaptive behaviour and lower levels of emotional and behavioural challenges at the start of the intervention were more likely to have greater improvements in their movement skills following the intervention. These findings may help clinicians and caregivers plan which types of interventions are best suited for individual children with autism spectrum disorder.

Still a Long Way to Go. Editorial for the Special Issue "Understanding Autism Spectrum Disorder"

Although many years have passed since the first descriptions of autism spectrum disorder (ASD) [...].

Efficacy and safety of lurasidone in children and adolescents: Recommendations for clinical management and future research

Lurasidone is a novel azapirone derivative, and atypical antipsychotic agent with a high binding affinity for dopaminergic (D2), serotoninergic (5-HT2A), and 5-HT7 receptors (antagonist), a moderate affinity for 5-HT1A receptors (partial agonist), and no appreciable affinity for histaminergic (H1) and muscarinic (M1) receptors. It was recently included by the European Medication Agency among the in-label pharmacological treatments for children and adolescents affected by early onset schizophrenia. As a dopamine and serotonin antagonist, lurasidone acts on a variety of receptors and showed its efficacy both as an antipsychotic and an activating compound. Administered with food or within 30 minutes from a meal, it presents sufficient bioavailability and does not interact ith most of the other drugs during metabolism. With little effects on hormones and weight gain, potential procognitive profile due to its 5-HT7 antagonism, and reduced extrapyramidal side effects, lurasidone could be a good choice in terms of both effectiveness and tolerability, particularly for patients headed towards a long-term treatment. This article aims to summarize the available scientific evidence from the literature on the use of lurasidone in children and adolescents and to provide recommendations for clinical management and future research.

Imputing the Number of Responders from the Mean and Standard Deviation of CGI-Improvement in Clinical Trials Investigating Medications for Autism Spectrum Disorder

INTRODUCTION

Response to treatment, according to Clinical Global Impression-Improvement (CGI-I) scale, is an easily interpretable outcome in clinical trials of autism spectrum disorder (ASD). Yet, the CGI-I rating is sometimes reported as a continuous outcome, and converting it to dichotomous would allow meta-analysis to incorporate more evidence.

METHODS

Clinical trials investigating medications for ASD and presenting both dichotomous and continuous CGI-I data were included. The number of patients with at least much improvement (CGI-I ≤ 2) were imputed from the CGI-I scale, assuming an underlying normal distribution of a latent continuous score using a primary threshold θ = 2.5 instead of θ = 2, which is the original cut-off in the CGI-I scale. The original and imputed values were used to calculate responder rates and odds ratios. The performance of the imputation method was investigated with a concordance correlation coefficient (CCC), linear regression, Bland-Altman plots, and subgroup differences of summary estimates obtained from random-effects meta-analysis.

RESULTS

Data from 27 studies, 58 arms, and 1428 participants were used. The imputation method using the primary threshold (θ = 2.5) had good performance for the responder rates (CCC = 0.93 95% confidence intervals [0.86, 0.96]; β of linear regression = 1.04 [0.95, 1.13]; bias and limits of agreements = 4.32% [-8.1%, 16.74%]; no subgroup differences χ2 = 1.24, p-value = 0.266) and odds ratios (CCC = 0.91 [0.86, 0.96]; β = 0.96 [0.78, 1.14]; bias = 0.09 [-0.87, 1.04]; χ2 = 0.02, p-value = 0.894). The imputation method had poorer performance when the secondary threshold (θ = 2) was used.

DISCUSSION

Assuming a normal distribution of the CGI-I scale, the number of responders could be imputed from the mean and standard deviation and used in meta-analysis. Due to the wide limits of agreement of the imputation method, sensitivity analysis excluding studies with imputed values should be performed.

Two Faces of a Coin? A Systematic Review of Source Monitoring and Its Relationship with Memory in Autism

The ability to discriminate the origin of stimuli, known as source monitoring, is crucial for self–other distinction and the integration of internally generated and externally generated experiences. Despite its valence, evidence on source monitoring in autism is yet scarce and unclear. We systematically reviewed literature concerning source monitoring in autism and its relationship with other constructs, such as memory type, encoding effects, social cognition, general intelligence, and clinical factors. Source-monitoring performance (operationalized as error or accuracy) was reduced in autistic participants in 9 of the 15 studies that met the inclusion criteria. When explicitly investigated, free-recall memory impairments in autism were shown to influence source monitoring deficits. General intelligence was another important factor linked to source-monitoring performance. Conversely, other memory types or encoding effects were not impaired in autism, and no univocal association could be found with source monitoring. Social cognition and clinical symptoms were rarely assessed in spite of their possible involvement in source monitoring. The heterogeneity of the task design, outcome measures and demographical factors limited study comparability. As a research framework on source monitoring as a construct of primary interest in autism is still lacking, we propose preliminary indications for future investigations based on the collected findings.

Autistic Self-Advocacy and the Neurodiversity Movement: Implications for Autism Early Intervention Research and Practice

The growth of autistic self-advocacy and the neurodiversity movement has brought about new ethical, theoretical and ideological debates within autism theory, research and practice. These debates have had genuine impact within some areas of autism research but their influence is less evident within early intervention research. In this paper, we argue that all autism intervention stakeholders need to understand and actively engage with the views of autistic people and with neurodiversity as a concept and movement. In so doing, intervention researchers and practitioners are required to move away from a normative agenda and pay diligence to environmental goodness-of-fit, autistic developmental trajectories, internal drivers and experiences, and autistic prioritized intervention targets. Autism intervention researchers must respond to these debates by reframing effectiveness, developing tools to measure autistic prioritized outcomes, and forming partnerships with autistic people. There is a pressing need for increased reflection and articulation around how intervention practices align with a neurodiversity framework and greater emphasis within intervention programmes on natural developmental processes, coping strategies, autonomy, and well-being.

Attunement in Music Therapy for Young Children with Autism: Revisiting Qualities of Relationship as Mechanisms of Change

This study examined whether musical and emotional attunement predicts changes in improvisational music therapy with children with autism (4–7 years, N = 101, majority: no/limited speech, low IQ), assessed over 12 months. Attunement, as observed from session videos, and changes in generalized social skills, judged by blinded assessors and parents, were evaluated using standardized tools (Assessment of the Quality of Relationship, Improvisational Music Therapy Principles, ADOS, SRS). In contrast to the smaller pilot, we did not find significant effects between attunement and changes in outcomes, only tendencies in the same direction are observed. Findings suggest that symptom severity is associated with the therapist’s ability to attune to the child. They further raise questions concerning outcome selection and user involvement.

Challenges Surrounding the Diagnosis of Autism in Children

This comprehensive thematic review aims to highlight and familiarize readers with the challenges and pitfalls encountered in differential diagnosis of autism spectrum disorders (ASD) in children to facilitate the process of accurate identification by stakeholders. Accordingly, articles that best answer our questions and highlight our concerns were chosen from well-established publishers with prime peer reviewed journals. Included are studies showing alternate views of the issues so as to point readers to other possibilities. ASD, a complex dynamic biological-neurodevelopmental disorder, is underscored by its heterogeneous symptomology, severity, and phenotypes - all characterized by social communication deficits and presence of restricted interests and repetitive behaviours (RRBs), the core symptoms in ASD. Language and intellectual capacities do not form ASD core symptoms although vary considerably. Accurate identification is challenging as ASD is often enmeshed with other neurodevelopmental disorders, and medical comorbidities, a situation now recognized as the rule rather than the exception in child psychiatry and developmental medicine. ASD is a disorder with varying performance and severity of symptoms over time, including unexpected loss of early skills, and lost diagnosis in some children following treatment. The review reiterates the urgency in accurate diagnosis in face of the rapid rise in ASD prevalence globally, and risk-increase in delayed or denied treatment with undesirable life-long consequences for most of the affected children. In addition, a call for change is advised to circumvent the ethical dilemma posed by the present "deficit model" in ASD diagnosis. Here, ASD prevalence is presented first, followed by emphasis on importance of accurate early diagnosis, and challenges in its accomplishment due to flaws in diagnostic instruments and other contributing factors. Next follow the required criteria for accurate identification, and its difficulties attributed to comorbid conditions, gender differences, and socio-economic and cultural influences. The conclusion includes future directions and a take away message.

Early Intervention with Parents of Children with Autism Spectrum Disorders: A Review of Programs

The aim of this article was to analyze the evidence regarding the effectiveness of intervention programs for children with autism based on the participation of their parents. To obtain the data, a systematic search was carried out in four databases (PsycARTICLES (ProQuest), ERIC (ProQuest), PubMed (ProQuest), and Scopus). The retrieved documents were refined under the inclusion/exclusion criteria, and a total of 51 empirical studies were selected. These studies were first classified according to the function of the intervention objective and, later, by the methodology applied (19 studies were based on comprehensive interventions, 11 focused on the nuclear symptoms of autism spectrum disorder (ASD), 12 focused on the promotion of positive parenting, and nine interactions focused on child play). Once all of the documents had been analyzed, the evidence indicated scientific efficacy in most studies, mainly in those based on child development and the application of behavioral analysis principles. Moreover, the positive influence of parent participation in such programs was demonstrated.

Utility of the Autism Diagnostic Observation Schedule and the Brief Observation of Social and Communication Change for Measuring Outcomes for a Parent-Mediated Early Autism Intervention

Measuring outcomes for autistic children following social communication interventions is an ongoing challenge given the heterogeneous changes, which can be subtle. We tested and compared the overall and item-level intervention effects of the Brief Observation of Social Communication Change (BOSCC), Autism Diagnostic Observation Schedule (ADOS-2) algorithm, and ADOS-2 Calibrated Severity Scores (CSS) with autistic children aged 2-5 years from the Preschool Autism Communication Trial (PACT). The BOSCC was applied to Module 1 ADOS assessments (ADOS-BOSCC). Among the 117 children using single or no words (Module 1), the ADOS-BOSCC, ADOS algorithm, and ADOS CSS each detected small non-significant intervention effects. However, on the ADOS algorithm, there was a medium significant intervention effect for children with "few to no words" at baseline, while children with "some words" showed little intervention effect. For the full PACT sample (including ADOS Module 2, total n=152), ADOS metrics evidenced significant small (CSS) and medium (algorithm) overall intervention effects. None of the Module 1 item-level intervention effects reached significance, with largest changes observed for Gesture (ADOS-BOSCC and ADOS), Facial Expressions (ADOS), and Intonation (ADOS). Significant ADOS Module 2 item-level effects were observed for Mannerisms and Repetitive Interests and Stereotyped Behaviors. Despite strong psychometric properties, the ADOS-BOSCC was not more sensitive to behavioral changes than the ADOS among Module 1 children. Our results suggest the ADOS can be a sensitive outcome measure. Item-level intervention effect plots have the potential to indicate intervention "signatures of change," a concept that may be useful in future trials and systematic reviews. LAY SUMMARY: This study compares two outcome measures in a parent-mediated therapy. Neither was clearly better or worse than the other; however, the Autism Diagnostic Observation Schedule produced somewhat clearer evidence than the Brief Observation of Social Communication Change of improvement among children who had use of "few to no" words at the start. We explore which particular behaviors are associated with greater improvement. These findings can inform researchers when they consider how best to explore the impact of their intervention.

How do core autism traits and associated symptoms relate to quality of life? Findings from the Longitudinal European Autism Project

Previous studies have reported reduced quality of life in autism. Improving quality of life for autistic people is, therefore, a key priority for clinical research and practice. However, the relative impact of core autism traits (e.g. social-communication difficulties), as compared to associated mental health symptoms (e.g. anxiety, depression) on quality of life remains poorly understood. This is despite at least 20%–50% of autistic individuals experiencing associated anxiety and/or depression symptoms. Hence, we measured subjective quality of life in 573 six to thirty-year-olds (autism spectrum disorder N = 344), using two widely validated questionnaires. Adults self-reported on the World Health Organization Quality of Life–Brief instrument. Parents of children/adolescents completed the Child Health and Illness Profile. We assessed individual variability across both measures and modelled associations between quality of life, core autism traits, anxiety, and depression symptoms. Across both age groups and quality of life measures, autistic individuals scored lower than comparison individuals, on average, particularly for physical health in adults (d = −1.24, 95% confidence interval: [−1.56, −0.93]) and school achievement for children/adolescents (d = −1.06, 95% confidence interval: [−1.29, −0.84]). However, a notable proportion of autistic individuals (36%–71% across quality of life domains) did not have reduced quality of life. Across ages and quality of life measures, severity of associated symptoms was significantly related to reduced quality of life on several domains, after accounting for core autism traits. Most notably, depression symptoms were related to reduced physical/psychological well-being in both adults (β ⩾ −0.34) and children/adolescents (β = −0.29, 95% confidence interval: [−0.36, −0.14]). For children/adolescents, anxiety symptoms (β ⩾ −0.28) and core social-communication difficulties (β ⩾ −0.22) were also related to subjective quality of life outcomes. Overall, findings indicate that not all autistic individuals experience reduced subjective quality of life. Variability in quality of life is significantly influenced by associated symptoms, across developmental stage. This may provide a tractable target for mental health services to improve quality of life for autistic individuals over the lifespan.

Placebo response in pharmacological and dietary supplement trials of autism spectrum disorder (ASD): systematic review and meta-regression analysis

Background

Placebo response in autism spectrum disorder (ASD) might dilute drug-placebo differences and hinder drug development. Therefore, this meta-analysis investigated placebo response in core symptoms.

Methods

We searched ClinicalTrials.gov, CENTRAL, EMBASE, MEDLINE, PsycINFO, WHO-ICTRP (up to July 8, 2018), and PubMed (up to July 4, 2019) for randomized pharmacological and dietary supplement placebo-controlled trials (RCTs) with a minimum of seven days of treatment. Single-group meta-analyses were conducted using a random-effects model. Standardized mean changes (SMC) of core symptoms in placebo arms were the primary outcomes and placebo positive response rates were a secondary outcome. Predictors of placebo response were investigated with meta-regression analyses. The protocol was registered with PROSPERO ID CRD42019125317.

Results

Eighty-six RCTs with 2360 participants on placebo were included in our analysis (87% in children/adolescents). The majority of trials were small, single-center with a duration of 8–12 weeks and published after 2009. Placebo response in social-communication difficulties was SMC = − 0.32, 95% CI [− 0.39, − 0.25], in repetitive behaviors − 0.23[− 0.32, − 0.15] and in scales measuring overall core symptoms − 0.36 [− 0.46, − 0.26]. Overall, 19%, 95% CI [16–22%] of participants were at least much improved with placebo. Caregiver (vs. clinician) ratings, lower risk of bias, flexible-dosing, larger sample sizes and number of sites, less recent publication year, baseline levels of irritability, and the use of a threshold of core symptoms at inclusion were associated with larger placebo response in at least a core symptom domain.

Limitations

About 40% of the trials had an apparent focus on core symptoms. Investigation of the differential impact of predictors on placebo and drug response was impeded by the use of diverse experimental interventions with essentially different mechanisms of action. An individual-participant-data meta-analysis could allow for a more fine-grained analysis and provide more informative answers.

Conclusions

Placebo response in ASD was substantial and predicted by design- and participant-related factors, which could inform the design of future trials in order to improve the detection of efficacy in core symptoms. Potential solutions could be the minimization and careful selection of study sites as well as rigorous participant enrollment and the use of measurements of change not solely dependent on caregivers.

Cannabinoids for People with ASD: A Systematic Review of Published and Ongoing Studies

The etiopathogenesis of autism spectrum disorder (ASD) remains largely unclear. Among other biological hypotheses, researchers have evidenced an imbalance in the endocannabinoid (eCB) system, which regulates some functions typically impaired in ASD, such as emotional responses and social interaction. Additionally, cannabidiol (CBD), the non-intoxicating component of Cannabis sativa, was recently approved for treatment-resistant epilepsy. Epilepsy represents a common medical condition in people with ASD. Additionally, the two conditions share some neuropathological mechanisms, particularly GABAergic dysfunctions. Hence, it was hypothesized that cannabinoids could be useful in improving ASD symptoms. Our systematic review was conducted according to the PRISMA guidelines and aimed to summarize the literature regarding the use of cannabinoids in ASD. After searching in Web of Knowledge^TM, PsycINFO, and Embase, we included ten studies (eight papers and two abstracts). Four ongoing trials were retrieved in ClinicalTrials.gov. The findings were promising, as cannabinoids appeared to improve some ASD-associated symptoms, such as problem behaviors, sleep problems, and hyperactivity, with limited cardiac and metabolic side effects. Conversely, the knowledge of their effects on ASD core symptoms is scarce. Interestingly, cannabinoids generally allowed to reduce the number of prescribed medications and decreased the frequency of seizures in patients with comorbid epilepsy. Mechanisms of action could be linked to the excitatory/inhibitory imbalance found in people with ASD. However, further trials with better characterization and homogenization of samples, and well-defined outcomes should be implemented.

A Systematic Review of Behaviour-Related Outcome Assessments for Children on the Autism Spectrum with Intellectual Disabilities in Education Settings

A systematic review was completed to identify assessments used with children with intellectual disabilities to assess adaptive behaviour, challenging behaviour and autism-related behaviour and consider their appropriateness for use by special education teachers with autistic pupils. The findings of this review led to the recommendation that the Pervasive Development Disorder Behavior Inventory, Aberrant Behavior Checklist, Autism Treatment Evaluation Checklist and the Teacher Autism Progress Scale are currently the most appropriate assessments for these purposes, although some limitations of these assessments exist. Additional recommendations included teacher input during the development of robust assessments to show progress for autistic children with intellectual disabilities and further evaluation of commonly used assessments with an appropriate sample in a relevant education setting.