Measurement matters: A commentary on the state of the science on patient reported outcome measures (PROMs) in autism research

High quality science relies upon psychometrically valid and reliable measurement, yet very few Patient Reported Outcome Measures (PROMs) have been developed or thoroughly validated for use with autistic individuals. The present commentary summarizes the current state of autism PROM science, based on discussion at the Special Interest Group (SIG) at the 2022 International Society for Autism Research (INSAR) Annual Meeting and collective expertise of the authors. First, we identify current issues in autism PROM research including content and construct operationalization, informant-structure, measure accessibility, and measure validation and generalization. We then enumerate barriers to conducting and disseminating this research, such as a lack of guidance, concerns regarding funding and time, lack of accessible training and professionals with psychometric skills, difficulties collecting large representative samples, and challenges with dissemination. Lastly, we offer future priorities and resources to improve PROMs in autism research including a need to continue to evaluate and develop PROMs for autistic people using robust methods, to prioritize diverse and representative samples, to expand the breadth of psychometric properties and techniques, and to consider developing field specific guidelines. We remain extremely optimistic about the future directions of this area of autism research. This work is well positioned to have an immense, positive impact on our scientific understanding of autism and the everyday lives of autistic people and their families.

Psychometric exploration of the RAADS-R with autistic adults: Implications for research and clinical practice

LAY ABSTRACT

Surveys used to screen for autism are being used much more by adults. Adults and clinicians want to be confident that the results from their surveys are accurate. If scores are not accurate, it is not possible to compare the scores of different groups of individuals. There are also concerns that these surveys do not accurately identify autistic individuals. This study explored the accuracy of two commonly used autism screening surveys for adults: the RAADS-R and the RAADS-14. The accuracy of these two screening tools was measured using a sample of 839 adults. Adults in the study were in one of the following categories: (1) diagnosed with autism, (2) adults who considered themselves to be autistic but had not been diagnosed, (3) adults who were unsure whether they were autistic, and (4) adults who did not consider themselves to be autistic and had not been diagnosed. The study found that the RAADS-R and the RAADS-14 are accurate. The study also found that a person's age, gender, autism diagnosis, or whether an individual considered themselves to be autistic did not impact how they understood the survey. Survey accuracy could be improved by changing the number of question responses from four to two. Importantly, individuals with a clinical diagnosis of autism and those who considered themselves to be autistic responded to survey items in a very similar way. Individuals with autism diagnoses and those who were unsure whether they were autistic were more different in their responses. Four specific survey items related to sensory experiences and social interaction identified key differences between autistic and non-autistic adults.

Discrimination and Harassment Experiences of Autistic College Students and Their Neurotypical Peers: Risk and Protective Factors

This study examines autistic and non-autistic college students' experiences of discrimination and harassment and identifies protective and risk factors. A nationwide survey was used to match autistic students (N = 290) and non-autistic students (N = 290) on co-occurring diagnoses and demographic characteristics. Multiple regression and interaction analysis revealed that faculty support was protective against discrimination and harassment regardless of autism status. Habits of mind was particularly protective for autistic students against harassment. Any student who engaged in school-facilitated events was more likely to experience discrimination and harassment, but the risk was heightened for autistic students. Findings highlight the importance of faculty support in fostering positive interpersonal experiences on campus, and demonstrate the need to address deeper college campus issues with respect to neurodiversity.

Predictors of Sexual Victimization Among Autistic and Non-Autistic College Students

PURPOSE

This study examined predictors of sexual victimization among autistic and non-autistic college students. Specifically, we aimed to determine whether autistic students are more likely than non-autistic students to experience unwanted sexual contact and sexual assault, controlling for co-occurring diagnoses. We also aimed to determine whether students with other disabilities, specifically ADHD, learning disability (LD), and psychological disorders, are more likely than students without these disabilities to experience unwanted sexual contact and sexual assault.

METHODS

Autistic students (n=270) and non-autistic students (n=270) who had participated in a nationwide survey were matched on demographic characteristics and co-occurring diagnoses. Logistic regression analyses were conducted to address the research questions and evaluate predictors of unwanted sexual contact and sexual assault.

RESULTS

Autistic students were as likely as non-autistic students to have experienced unwanted sexual contact and sexual assault, controlling for co-occurring diagnoses. Regardless of autism diagnostic status, students with ADHD were more likely than students without ADHD to have experienced unwanted sexual contact and sexual assault.

CONCLUSIONS

Although autism diagnostic status was not a significant predictor of unwanted sexual contact or sexual assault, other factors associated with increased risk of sexual victimization, such as co-occurring ADHD, are likely to be found in autistic populations. This study highlights the importance of educational, social, and institutional supports to decrease sexual victimization among college students with neurodevelopmental disabilities.

Examining indicators of psychosocial risk and resilience in parents of autistic children

Background

Parents of autistic children experience increased levels of caregiver strain and adverse mental health outcomes, even in comparison to parents of children with other neurodevelopmental disabilities. Previous studies have largely attributed these increased levels of mental health concerns to their child behavioral concerns and autism symptomatology, but less attention has been given to other potential child factors, such as child adaptive functioning. Additionally, little is known about potential protective factors, such as parents' emotion regulation (ER) abilities, that may ameliorate the experience of caregiver strain, anxiety, and depression.

Objective

The current study examined the impact of child characteristics (restricted and repetitive behaviors, adaptive functioning and behavioral concerns) on parent mental health outcomes (caregiver strain, anxiety, depression and wellbeing). Additionally, we explore parents' ER abilities as a moderator of the impact of child characteristic on parents' mental health outcomes.

Results

Results of linear mixed effect models indicated a significant relationship between parents' ER abilities and all four parent outcomes. Additionally, children's adaptive functioning abilities and repetitive behaviors (RRBs) were significant predictors of caregiving strain. Parents' ER abilities were a significant moderator of the effect of children's repetitive behaviors and adaptive functioning challenges on caregiver strain, such that better ER abilities mitigated the impact of child clinical factors on caregiver strain. Finally, a significant difference was detected for mothers' and fathers' mental health, with mothers reporting higher caregiver strain, and more symptoms of anxiety and depression than did fathers.

Conclusion

This study leveraged a large sample of autistic children and their biological parents to examine the relationship between children's clinical characteristics and parents' psychological wellbeing. Results indicate that, although parents of autistic children do experience high rates of internalizing mental health concerns that relate to child adaptive functioning and RRBs, parent ER abilities act as a protective factor against parents' adverse mental health outcomes. Further, mothers in our sample reported significantly higher rates of depression, anxiety, and caregiver strain, as compared with fathers.

Dual Identification: Trajectories to English Proficiency for English Learners with Autism Spectrum Disorder

BACKGROUND

There are an increasing number of English Learners (EL) served in schools, including children with Autism Spectrum Disorder (ASD). However, little is known about students who receive school-based services as EL and under autism eligibility.

PURPOSE & METHODS

The present study aimed to examine the sociodemographic characteristics, time to English Language Proficient status by survival analysis, and predictors of English fluency utilizing a logistic regression for dually identified EL and autism eligible students in a large urban school district during the 2011-2019 academic school years.

RESULTS

Overall, dually identified students (N = 849) educated in segregated settings (N = 372) became English proficient at lower rates and at older ages than students included in general education (N = 477).

CONCLUSION

Students placed in segregated special education classrooms were significantly less likely to achieve English Language Proficient classification. The present study begins to illustrate the time to English proficiency of dually identified students and the potential impact it has on their educational opportunities.

Adjustment Across the First College Year: A Matched Comparison of Autistic, Attention-Deficit/Hyperactivity Disorder, and Neurotypical Students

Background

Although the number of autistic students attending higher education has grown substantially in recent decades, little is known about factors that support their retention and persistence in college. First-year experiences and adaptability to the college environment greatly impact students' decisions to remain enrolled. Despite the importance of first-year adjustment to persistence and retention, few studies have examined the adjustment experiences of first-year autistic students compared to those of matched nonautistic students.

Methods

This study used national survey data to compare the first-year college adjustment experiences of 222 freshmen, including 74 self-identified autistic students, 74 students with attention-deficit/hyperactivity disorder (ADHD), and 74 students without diagnoses (referred to as neurotypical; NT), matched on mental health and demographic characteristics. Students were compared on measures of academic, social, emotional, and institutional adjustment at the end of freshman year. Separate general linear models were used to investigate predictors of positive self-reported first-year adjustment.

Results

Autistic students reported significantly lower levels of social self-confidence than their NT and ADHD peers at the end of freshman year. On all other adjustment domains, students in the autism, ADHD, and NT groups did not significantly differ. Autistic students were not significantly different from their ADHD and NT peers in terms of satisfaction with their college experience or sense of belonging to their institution. Social factors, including social self-confidence and ease of making friends, emerged as important contributors to positive first-year adjustment outcomes across all groups.

Conclusions

When controlling for demographic factors and mental health characteristics entering college, autistic students do not significantly differ from their NT and ADHD peers on several domains of college adjustment. Future studies should further investigate the impact of mental health and student characteristics on college trajectories and outcomes for autistic students.

Inhibitory control in youth with Tourette's Disorder, attention-deficit/hyperactivity disorder and their combination and predictors of objective tic suppressibility

The present study investigated inhibitory control deficits in Tourette's Disorder (TD)-only, Attention Deficit/Hyperactivity Disorder (ADHD)-only, and TD+ADHD and explored the degree to which measures of inhibitory control, and tic and ADHD severity predicted objective tic suppressibility. Participants were youth ages 9 to 14 (M = 11.15) with TD-only (n = 24), TD+ADHD (n = 19), ADHD-only (n = 139), and typically-developing controls (n = 59) drawn from a larger study. Groups were compared on computer-based and paper and pencil neurocognitive inhibitory control tasks. Among youth with TD, neurocognitive measures of inhibitory control, subjective tic-suppressibility (Premonitory Urge for Tics Scale, item 10), and ADHD symptom severity were evaluated as predictors of objective tic suppressibility (i.e., laboratory-based tic suppression task), controlling for total tic severity. There were significant group differences on Color-Word inhibition/switching performance, though post-hoc comparisons yielded no significant pairwise group contrasts. Subjective tic suppressibility was the only significant predictor of objective tic suppressibility. The evident intact neurocognitive inhibitory control among youth with TD suggests that individuals with TD may use compensatory neural mechanisms to support typical speed and accuracy of response. The role of cognitive flexibility in mechanisms of tic suppression should also be further explored.

Personalized autism symptom assessment with the Youth Top Problems Scale: Observational and parent-report formats for clinical trials applications

Few measures of autism-related symptoms have been established as both psychometrically robust and sensitive to the effects of treatment. In the present study, a personalized measure of autism-related symptoms using the Youth Top Problems (YTP) method (Weisz et al., 2011) was evaluated. Participants included 68 children with diagnoses of autism (ages 6-13 years), and their parents, who were randomized to cognitive behavioral therapy (CBT) or enhanced standard community treatment (ESCT) addressing autism-related symptoms. At pretreatment, parents described their child's top autism-related problems (YTPs) in their own words and rated the severity of these problems on a Likert-type scale. Parents also made daily severity ratings on the child's top three YTPs for 5 days prior to treatment and 5 days following treatment while videorecording their child's behavior at home on each of these days. Trained observers coded these videorecordings, focusing on the same YTPs that the parents rated. Parents also completed standardized checklists of autism-related symptoms and general mental health symptoms. There was evidence of convergent and discriminant validity as well as good test-retest reliability for the YTP measures. YTP severity scores converged with the standardized measure of autism-related symptoms. Parent-reported YTP scores predicted observers' YTP scores at the daily level, and both parent-reported and observers' YTP scores decreased from pre- to post treatment. Observers' ratings of the videorecordings exhibited sensitivity to treatment condition. These applications of the YTP method are promising and may complement standardized symptom checklists for clinical trials focusing on autism-related symptoms. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Advancing methodologies to improve RRB outcome measures in autism research: Evaluation of the RBS-R

This study evaluates the psychometric properties (dimensionality, item bias, reliability) of the Repetitive Behavior Scale-Revised (RBS-R), provides scoring guidelines for the dimensional measure, and makes recommendations for future RRB measure development. Participants included individuals from three large autism data repositories; Simon Foundation Powering Autism Research for Knowledge (SPARK), Simons Simplex Collection (SSC), and National Database for Autism Research (NDAR). The total sample included N = 15,318 autistic individuals ages 3-18. Confirmatory factor analysis was used to evaluate competing theoretical factor structures. Item response theory (IRT) was used to evaluate differential item functioning, estimate the reliability of each RBS-R subdomain, and score the subdomains. A unidimensional factor structure demonstrated clearly inadequate model fit, calling into question the practice of reporting a total score on the RBS-R. A five-dimensional factor structure was supported by the theoretical and empirical evidence, though the fifth factor (restricted interests) was not sufficiently reliable for use. IRT-based scoring tools were generated for use in research. The present study illustrates the promise in the future development of measures for RRBs, particularly in the development of measures to separately and specifically assess RRB constructs using rigorous methodological guidelines. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Who gains and who loses? Sociodemographic disparities in access to special education services among autistic students

Little is known about differences in the allocation of special education services to students with autism compared with students with other primary learning differences (e.g., intellectual disability [ID], specific learning disability [SLD]) and the comparative impact of sociodemographic factors on special education service receipt. The present study aimed to compare allocation of services (i.e., quantity and types) between students eligible for special education services under autism, SLD and ID, and to identify differences in sociodemographic predictors (e.g., race, neighborhood income) of service allocation. Data were culled from special education administrative records from a large urban, primarily Hispanic, Latino, or Spanish-serving school district from academic years 2011-2012 to 2016-2017. Participants included N = 76,428 students (N_autism  = 18,151, N_SLD  = 54,001, N_ID  = 4,276) ages 2-18. Results showed that autistic students received, on average, more services than students with SLD. Services received by students served under autism and SLD eligibility were more congruent with areas of need (e.g., language, occupational therapy) relative to students served under ID. Student-level socioeconomic status (free and reduced lunch) was more positively predictive of the number of special education services received than the neighborhood income of the school the student attended. Finally, the most significant racial disparities in service allocation were observed among students served under autism eligibility. The present study demonstrates the critical role of economic resources in the quantity and types of services received, and the desirability of a public education for well-resourced families who are possibly best situated to navigate special education services. LAY SUMMARY: An eligibility of autism in special education confers a significant advantage in the number of services a student receives. Disparity in the quantity of special education services exists among autistic students across many sociodemographic factors. Most notably, greater allocation of services to non-Hispanic, Latino, or Spanish, White American, European American, or Middle Eastern American students and students who do not receive free and reduced lunch.

Academic and psychosocial characteristics of incoming college freshmen with autism spectrum disorder: The role of comorbidity and gender

There is a pressing need to better characterize the college-bound population of individuals with autism spectrum disorder (ASD), as prior studies have included small samples, consisting of individuals who are either recruited due to diagnosis or are treatment seeking. As postsecondary institutions look to respond to the growing need for support services for individuals with ASD, insights derived from large, population-based samples is a necessity. The current study included a sample of over 2000 incoming postsecondary students who self-identified with ASD as a part of surveys distributed by institutions nationally. The impact of heterogeneity (gender, comorbid attention-deficit/hyperactivity disorder [ADHD], and/or learning disability) on demographic characteristics, and psychosocial (psychological health, interpersonal self-confidence) and academic (self-regulated learning, intellectual self-confidence) domains critical for success in postsecondary education were compared to a matched sample of students with ADHD or no diagnoses. College-bound students with ASD broadly endorsed similar rates of ADHD, LD, and psychological disorder comorbidity to clinic-referred samples, and were more similar than different from their typically developing peers. A comorbid diagnosis of ADHD was associated with greater academic disengagement. Females with ASD and those with any comorbid disorder were more likely to self-report poorer psychological health. Findings revealed that self-reported levels of functioning in critical domains differed by self-reported comorbid disorders and gender. Findings have implications for targeted support service recommendations based on unique sources of heterogeneity (e.g., gender, presenting comorbid disorders) and are detailed in the current study. Autism Res 2019, 12: 931-940. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: College-bound students with ASD feel academically competent; however feel less confident with their peers. Students with ASD and another diagnosis (e.g., ADHD, learning disability) and girls with ASD may be particularly at risk of experiencing poorer psychological health while enrolled in postsecondary education. Using this information, postsecondary institutions can provide more targeted support services to students with ASD enrolled in postsecondary education.

Double-Blind, Sham-Controlled, Pilot Study of Trigeminal Nerve Stimulation for Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Trigeminal nerve stimulation (TNS), a minimal-risk noninvasive neuromodulation method, showed potential benefits for attention-deficit/hyperactivity disorder (ADHD) in an unblinded open study. The present blinded sham-controlled trial was conducted to assess the efficacy and safety of TNS for ADHD and potential changes in brain spectral power using resting-state quantitative electroencephalography.

METHOD

Sixty-two children 8 to 12 years old, with full-scale IQ of at least 85 and Schedule for Affective Disorders and Schizophrenia-diagnosed ADHD, were randomized to 4 weeks of nightly treatment with active or sham TNS, followed by 1 week without intervention. Assessments included weekly clinician-administered ADHD Rating Scales (ADHD-RS) and Clinical Global Impression (CGI) scales and quantitative electroencephalography at baseline and week 4.

RESULTS

ADHD-RS total scores showed significant group-by-time interactions (F1,228 = 8.12, p = .005; week 4 Cohen d = 0.5). CGI-Improvement scores also favored active treatment (χ21,168 = 8.75, p = .003; number needed to treat = 3). Resting-state quantitative electroencephalography showed increased spectral power in the right frontal and frontal midline frequency bands with active TNS. Neither group had clinically meaningful adverse events.

CONCLUSION

This study demonstrates TNS efficacy for ADHD in a blinded sham-controlled trial, with estimated treatment effect size similar to non-stimulants. TNS is well tolerated and has minimal risk. Additional research should examine treatment response durability and potential impact on brain development with sustained use.

CLINICAL TRIAL REGISTRATION INFORMATION

Trigeminal Nerve Stimulation for ADHD; http://clinicaltrials.gov/; NCT02155608.

Changes in Sleep Problems Across Attention-Deficit/Hyperactivity Disorder Treatment: Findings from the Multimodal Treatment of Attention-Deficit/Hyperactivity Disorder Study

Objective: Stimulant medication and behavior therapy are efficacious for youth with attention-deficit/hyperactivity disorder (ADHD). However, research suggests that stimulants may start and/or worsen sleep problems for youth. Further, the impact of behavior therapy for ADHD on sleep is unknown. This study examined the frequency of sleep problems and effects of stimulant medication, behavior therapy, and their combination on sleep problems in youth with ADHD. This study also explored the influence of dimensional baseline ratings of ADHD symptom subtype and psychiatric comorbidity on sleep outcomes. Methods: Participants were 576 children (aged 7-9 years) with ADHD-Combined type from the Multimodal Treatment of ADHD study that compared methylphenidate, behavior therapy, and their combination to community care. Before treatment, parents completed the Child Behavior Checklist used to derive a total sleep problems score. Parents also completed ratings of oppositionality and ADHD symptom severity, whereas youth completed ratings of depression and anxiety. These ratings were readministered after treatment. Results: General linear mixed-effects models were used to assess change in total sleep problems across treatment. The combined group exhibited a statistically significant reduction in total sleep problems (z = -5.81, p < 0.001). Reductions in total sleep problems in methylphenidate (z = -3.11, p = 0.05), behavior therapy (z = -2.99, p = 0.08), or community care (z = -1.59, p > 0.99) did not reach statistical significance. Change in psychiatric symptoms did not significantly moderate change in total sleep problems by treatment assignment. Greater baseline oppositional defiant disorder severity predicted less reduction in total sleep problems, χ²(1) = 3.86, p < 0.05. Conclusions: Findings suggest that combination of methylphenidate and behavior therapy is efficacious for reducing parent-reported sleep problems in young children with ADHD-Combined type relative to community care. However, potential ameliorative effects of monotherapy treatments (i.e., methylphenidate, behavior therapy) should be examined. Future replication is needed to confirm findings.

SMARTer Approach to Personalizing Intervention for Children With Autism Spectrum Disorder

PURPOSE

This review article introduces research methods for personalization of intervention. Our goals are to review evidence-based practices for improving social communication impairment in children with autism spectrum disorder generally and then how these practices can be systematized in ways that personalize intervention, especially for children who respond slowly to an initial evidence-based practice.

METHOD

The narrative reflects on the current status of modular and targeted interventions on social communication outcomes in the field of autism research. Questions are introduced regarding personalization of interventions that can be addressed through research methods. These research methods include adaptive treatment designs and the Sequential Multiple Assignment Randomized Trial. Examples of empirical studies using research designs are presented to answer questions of personalization.

CONCLUSION

Bridging the gap between research studies and clinical practice can be advanced by research that attempts to answer questions pertinent to the broad heterogeneity in children with autism spectrum disorder, their response to interventions, and the fact that a single intervention is not effective for all children.

PRESENTATION VIDEO

https://doi.org/10.23641/asha.7298021.

Genetic fingerprinting of salmon louse (Lepeophtheirus salmonis) populations in the North-East Atlantic using a random forest classification approach

Caligid sea lice represent a significant threat to salmonid aquaculture worldwide. Population genetic analyses have consistently shown minimal population genetic structure in North Atlantic Lepeophtheirus salmonis, frustrating efforts to track louse populations and improve targeted control measures. The aim of this study was to test the power of reduced representation library sequencing (IIb-RAD sequencing) coupled with random forest machine learning algorithms to define markers for fine-scale discrimination of louse populations. We identified 1286 robustly supported SNPs among four L. salmonis populations from Ireland, Scotland and Northern Norway. Only weak global structure was observed based on the full SNP dataset. The application of a random forest machine-learning algorithm identified 98 discriminatory SNPs that dramatically improved population assignment, increased global genetic structure and resulted in significant genetic population differentiation. A large proportion of SNPs found to be under directional selection were also identified to be highly discriminatory. Our data suggest that it is possible to discriminate between nearby L. salmonis populations given suitable marker selection approaches, and that such differences might have an adaptive basis. We discuss these data in light of sea lice adaption to anthropogenic and environmental pressures as well as novel approaches to track and predict sea louse dispersal.

Autonomic arousal in anxious and typically developing youth during a stressor involving error feedback

Anxiety has been proposed to influence psychophysiological reactivity in children and adolescents. However, the extant empirical literature has not always found physiological reactivity to be associated with anxiety in youth. Further, most investigations have not examined psychophysiological reactivity in real time over the course of acute stress. To test the impact of anxiety disorder status on autonomic arousal in youth, we compared youth with primary anxiety disorders (N = 24) to typically developing (TD) youth (N = 22) on heart rate (HR), heart rate variability (HRV), and respiratory sinus arrhythmia (RSA) during an acute stressor in which youth received error-related feedback. We also conducted exploratory analyses on youth performance during the task. Youth ages 9-17 participated in the arithmetic portion of the Trier Social Stress Test for Children (Buske-Kirschbaum et al., Psychosom 59:419-426, 1997), during which time they received consecutive, standardized feedback that they made calculation errors. Results indicated that, compared to their TD counterparts, the anxious group demonstrated elevated HR and suppressed HRV during initial provision of error feedback and during the recovery period. No group differences were found for RSA. Additionally, overall TD youth made a greater proportion of errors than anxious youth. Clinically, these findings may provide preliminary support for anxious youth exhibiting physiological reactivity in response to receipt of error-related feedback, and may have implications for understanding biological processes during stress. This work underscores the need for further study of when and how anxiety may influence autonomic reactivity over the course of stress.

Development and validation of an item response theory-based Social Responsiveness Scale short form

BACKGROUND

Research and practice in autism spectrum disorder (ASD) rely on quantitative measures, such as the Social Responsiveness Scale (SRS), for characterization and diagnosis. Like many ASD diagnostic measures, SRS scores are influenced by factors unrelated to ASD core features. This study further interrogates the psychometric properties of the SRS using item response theory (IRT), and demonstrates a strategy to create a psychometrically sound short form by applying IRT results.

METHODS

Social Responsiveness Scale analyses were conducted on a large sample (N = 21,426) of youth from four ASD databases. Items were subjected to item factor analyses and evaluation of item bias by gender, age, expressive language level, behavior problems, and nonverbal IQ.

RESULTS

Item selection based on item psychometric properties, DIF analyses, and substantive validity produced a reduced item SRS short form that was unidimensional in structure, highly reliable (α = .96), and free of gender, age, expressive language, behavior problems, and nonverbal IQ influence. The short form also showed strong relationships with established measures of autism symptom severity (ADOS, ADI-R, Vineland). Degree of association between all measures varied as a function of expressive language.

CONCLUSIONS

Results identified specific SRS items that are more vulnerable to non-ASD-related traits. The resultant 16-item SRS short form may possess superior psychometric properties compared to the original scale and emerge as a more precise measure of ASD core symptom severity, facilitating research and practice. Future research using IRT is needed to further refine existing measures of autism symptomatology.

Evaluating the Hierarchical Structure of ADHD Symptoms and Invariance Across Age and Gender

The bifactor model of attention-deficit/hyperactivity disorder (ADHD) has been extensively explored, yet the tendency of the bifactor model to overfit data necessitates investigation of alternative, more parsimonious models, such as a modified bifactor structure. The present study used item response theory to compare unidimensional, correlated factors, bifactor, and modified bifactor models of ADHD symptoms in a clinical sample of youth ( N = 1,612) and examined differential item functioning (DIF) by age (<11 and ≥11 years) and gender. Results suggested that two restricted bifactor models showed superior fit compared with alternative models, and support strong general and inattention dimensions, with unreliable hyperactivity and impulsivity dimensions. No DIF was found across gender or age. The present study confirms that the general dimension (i.e., inhibition) and one specific dimension (i.e., sustained attention) represent distinct variability in ADHD symptoms that may improve prediction of symptom persistence, treatment response, or functional outcomes.

Acute and Long-Term Cardiovascular Effects of Stimulant, Guanfacine, and Combination Therapy for Attention-Deficit/Hyperactivity Disorder

OBJECTIVES

This study examines cardiovascular (CV) effects of guanfacine immediate-release (GUAN-IR), dexmethylphenidate extended-release (DMPH), and their combination (COMB) during acute and long-term treatment of youth with attention-deficit/hyperactivity disorder.

METHODS

Two hundred seven participants aged 7-14 years enrolled in an 8-week double-blind randomized trial of GUAN-IR (1-3 milligrams (mg)/day), DMPH (5-20 mg/day), or COMB with fixed-flexible dosing and titrated to optimal behavioral response. Heart rate, systolic blood pressure (BP), diastolic BP, and electrocardiograms were assessed at baseline, end of blinded optimization, and over a 1-year open-label maintenance phase.

RESULTS

During acute titration, GUAN-IR decreased heart rate, systolic BP, and diastolic BP; DMPH increased heart rate, systolic BP, diastolic BP, and corrected QT (QTc) interval; COMB increased diastolic BP, but had no effects on heart rate, systolic BP, or QTc. During maintenance, GUAN-IR-associated decreases in heart rate and DMPH-associated increases in systolic BP returned to baseline values. Other variables across the three groups remained unchanged from the end of blinded titration. There were no discontinuations due to CV adverse events.

CONCLUSION

GUAN-IR, DMPH, and COMB were well tolerated and safe. Expected changes in CV parameters during acute titration were seen in GUAN-IR and DMPH groups, with COMB values falling intermediately between the two other treatment groups. No serious CV events occurred in any participant. GUAN-IR- and DMPH-associated CV changes generally returned to baseline with sustained therapy. These data suggest that COMB treatment might attenuate long-term CV effects of GUAN-IR and stimulant monotherapy, possibly reducing risk of the small but statistically significant changes associated with either single treatment. Clinicaltrials.gov Identifier: NCT00429273.

Effects of d-Methylphenidate, Guanfacine, and Their Combination on Electroencephalogram Resting State Spectral Power in Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Psychostimulant medications are the gold standard of treatment for attention-deficit/hyperactivity disorder (ADHD); however, a significant minority (∼30%) of individuals with ADHD fail to respond favorably. Noradrenergic agents are increasingly used as ADHD monotherapies or adjuncts for suboptimal stimulant response, yet knowledge of their cortical effects is limited. This study is the first to examine comparative effects of guanfacine (an α adrenergic 2A agonist), psychostimulant, and their combination on resting state cortical activity in ADHD.

METHOD

The sample comprised 179 participants aged 7 to 14 years old with ADHD (113 boys, 55 girls). Participants were randomized to 1 of 3 blinded conditions: guanfacine (GUAN), d-methylphenidate (DMPH), or the combination (COMB). Electroencephalography (EEG) was performed pre-, mid-, and post-medication titration, with concomitant assessment of behavioral and cognitive functioning.

RESULTS

Analyses of spectral power measures during resting EEG suggested that each medication condition displayed a distinct profile of effects on cortical activity. Significant time effects suggested that GUAN decreased global alpha band (8-12 hertz [Hz]) power, DMPH and COMB increased centro-parietal beta band (13-21 Hz) power, and COMB resulted in decreased theta band (4-7 Hz) power. Relative to other medication groups, COMB was associated with significantly lower theta band power and DMPH with higher beta band power compared with those in the GUAN group. Medication-related changes in theta power were correlated with improvements in behavioral and cognitive functioning.

CONCLUSION

These data reveal distinct underlying medication-related effects on neural mechanisms. The COMB condition uniquely exhibited an EEG profile that was associated with improved behavioral and cognitive functioning. Clinical trial registration information-Single Versus Combination Medication Treatment for Children With Attention Deficit Hyperactivity Disorder; http://clinicaltrials.gov/; NCT00429273.

Combined Stimulant and Guanfacine Administration in Attention-Deficit/Hyperactivity Disorder: A Controlled, Comparative Study

OBJECTIVE

Because models of attention-deficit/hyperactivity disorder (ADHD) therapeutics emphasize benefits of both enhanced dopaminergic and noradrenergic signaling, strategies to enhance D1 and α2A agonism may yield enhanced clinical and cognitive responses. This study tested the hypothesis that combined effects of a dopamine and noradrenergic agonist, d-methylphenidate extended-release (DMPH) with guanfacine (GUAN), an α2A receptor agonist, would be clinically superior to either monotherapy and would have equal tolerability.

METHOD

An 8-week, double-blind, 3-arm, comparative trial randomized 7- to 14-year-olds with DSM-IV ADHD to GUAN (1-3 mg/day), DMPH (5-20 mg/day), or a combination (COMB) with fixed-flexible dosing. Outcome measures were the ADHD Rating Scale IV (ADHD-RS-IV) and the Clinical Global Impression-Improvement (CGI-I) scale. Data on adverse events and safety measures were obtained.

RESULTS

A total of 207 participants were randomized and received drug. Analyses showed significant treatment group main effects for ADHD-RS-IV ADHD total (p = .0001) and inattentive symptoms (p = .0001). COMB demonstrated small but consistently greater reductions in ADHD-RS-IV Inattentive subscale scores versus monotherapies (DMPH: p = .05; f(2) = .02; and GUAN: p = .02; f(2) = .02), and was associated with a greater positive response rate by CGI-I (p = .01). No serious cardiovascular events occurred. Sedation, somnolence, lethargy, and fatigue were greater in both guanfacine groups. All treatments were well tolerated.

CONCLUSION

COMB showed consistent evidence of clinical benefits over monotherapies, possibly reflecting advantages of greater combined dopaminergic and α2A agonism. Adverse events were generally mild to moderate, and COMB treatment showed no differences in safety or tolerability.

CLINICAL TRIAL REGISTRATION INFORMATION

Single Versus Combination Medication Treatment for Children With Attention Deficit Hyperactivity Disorder (Project1); http://clinicaltrials.gov/; NCT00429273.

Cognitive Effects of Stimulant, Guanfacine, and Combined Treatment in Child and Adolescent Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Psychostimulants are partially effective in reducing cognitive dysfunction associated with attention-deficit/hyperactivity disorder (ADHD). Cognitive effects of guanfacine, an alternative treatment, are poorly understood. Given its distinct action on α2A receptors, guanfacine may have different or complementary effects relative to stimulants. This study tested stimulant and guanfacine monotherapies relative to combined treatment on cognitive functions important in ADHD.

METHOD

Children with ADHD (n = 182; aged 7-14 years) completed an 8-week, double blind, randomized, controlled trial with 3 arms: d-methylphenidate (DMPH), guanfacine (GUAN), or combination treatment with DMPH and GUAN (COMB). A nonclinical comparison group (n = 93) had baseline testing, and a subset was retested 8 weeks later (n = 38). Analyses examined treatment effects in 4 cognitive domains (working memory, response inhibition, reaction time, and reaction time variability) constructed from 20 variables.

RESULTS

The ADHD group showed impaired working memory relative to the nonclinical comparison group (effect size = -0.53 SD unit). The treatments differed in effects on working memory but not other cognitive domains. Combination treatment improved working memory more than GUAN but was not significantly better than DMPH alone. Treatment did not fully normalize the initial deficit in ADHD relative to the comparison group.

CONCLUSION

Combined treatment with DMPH and GUAN yielded greater improvements in working memory than placebo or GUAN alone, but the combined treatment was not superior to DMPH alone and did not extend to other cognitive domains. Although GUAN may be a useful add-on treatment to psychostimulants, additional strategies appear to be necessary to achieve normalization of cognitive function in ADHD.

CLINICAL TRIAL REGISTRATION INFORMATION

Single Versus Combination Medication Treatment for Children With Attention Deficit Hyperactivity Disorder; http://clinicaltrials.gov/; NCT00429273.

Comparative glaucomatous diagnosis using macular optical coherence tomography and perimetry with centrally condensed stimuli: English version

The presentation and measurement of the internal retinal layers by current optical coherence tomography (OCT) instruments allow a precise topographic localization of macular glaucomatous damage. Ganglion cell analysis in particular can reveal slight central defects and can effectively be correlated with perimetric strategies with centrally condensed stimuli, so that small glaucomatous defects can be confirmed earlier and more confidently. Progression can also be verified in the early stages of the disease as enlargement and deepening of small localized defects. Macular OCT (mOCT) cannot sufficiently detect peripheral glaucomatous defects and may be impaired by macular pathologies; therefore, mOCT should be combined with other morphometric examinations. In order to take advantage of the technical capabilities of current OCT devices appropriate perimetric strategies should also be applied. As the algorithms for documentation and evaluation of the results of current OCT instruments are far less advanced than the technical capabilities, OCT results still have to be visually scrutinized together with the visual field results to benefit from the technical possibilities provided by modern OCT devices.

The second European evidenced-based consensus on reproduction and pregnancy in inflammatory bowel disease

Trying to conceive and being pregnant is an emotional period for those involved. In the majority of patients suffering from inflammatory bowel disease, maintenance therapy is required during pregnancy to control the disease, and disease control might necessitate introduction of new drugs during a vulnerable period. In this updated consensus on the reproduction and pregnancy in inflammatory bowel disease reproductive issues including fertility, the safety of drugs during pregnancy and lactation are discussed.

Deep-water anoxygenic photosythesis in a ferruginous chemocline

Ferruginous Lake Matano, Indonesia hosts one of the deepest anoxygenic photosynthetic communities on Earth. This community is dominated by low-light adapted, BChl e-synthesizing green sulfur bacteria (GSB), which comprise ~25% of the microbial community immediately below the oxic-anoxic boundary (OAB; 115-120 m in 2010). The size of this community is dependent on the mixing regime within the lake and the depth of the OAB-at ~117 m, the GSB live near their low-light limit. Slow growth and C-fixation rates suggest that the Lake Matano GSB can be supported by sulfide even though it only accumulates to scarcely detectable (low μm to nm) concentrations. A model laboratory strain (Chlorobaculum tepidum) is indeed able to access HS- for oxidation at nm concentrations. Furthermore, the GSB in Lake Matano possess a full complement of S-oxidizing genes. Together, this physiological and genetic information suggests that deep-water GSB can be supported by a S-cycle, even under ferruginous conditions. The constraints we place on the metabolic capacity and physiology of GSB have important geobiological implications. Biomarkers diagnostic of GSB would be a good proxy for anoxic conditions but could not discriminate between euxinic and ferruginous states, and though GSB biomarkers could indicate a substantial GSB community, such a community may exist with very little metabolic activity. The light requirements of GSB indicate that at light levels comparable to those in the OAB of Lake Matano or the Black Sea, GSB would have contributed little to global ocean primary production, nutrient cycling, and banded iron formation (BIF) deposition in the Precambrian. Before the proliferation of oxygenic photosynthesis, shallower OABs and lower light absorption in the ocean's surface waters would have permitted greater light availability to GSB, potentially leading to a greater role for GSB in global biogeochemical cycles.

A potential electroencephalography and cognitive biosignature for the child behavior checklist-dysregulation profile

OBJECTIVE

The Child Behavior Checklist-Dysregulation Profile (CBCL/DP) identifies youth at increased risk for significant psychopathology. Although the genetic architecture and several biological correlates of the CBCL/DP have been described, little work has elucidated its underlying neurobiology. We examined the potential utility of electroencephalography (EEG), along with behavioral and cognitive assessments, in differentiating individuals based on the CBCL/DP.

METHOD

Participants aged 7 to 14 years of age were categorized into 3 age- and sex-matched groups based on clinical assessment and CBCL/DP: typically developing controls without attention-deficit/hyperactivity disorder (ADHD) (n = 38), individuals with ADHD without the CBCL/DP (ADHD/DP-) (n = 38), and individuals with the CBCL/DP (CBCL/DP+) (n = 38). Groups were compared with EEG and measures of clinical phenomenology and cognition.

RESULTS

ADHD/DP- and CBCL/DP+ groups had increased inattention, but the CBCL/DP+ group had increased hyperactive/impulsive symptoms, disruptive behavior, mood, and anxiety comorbidities compared with the group with ADHD alone. Cognitive profiles suggested that ADHD/DP-participants had fast impulsive responses, whereas CBCL/DP+ participants were slow and inattentive. On EEG, CBCL/DP+ had a distinct profile of attenuated δ-band and elevated α-band spectral power in the central and parietal regions compared to ADHD/DP- and controls. The low-δ/high-α profile was correlated with measures of emotion and behavior problems and not with inattentive symptomatology or cognitive measures. There were no EEG differences between the ADHD/DP- and control groups.

CONCLUSIONS

An EEG/cognitive profile suggests a distinct pattern of underlying neural dysfunction with the CBCL/DP that might ultimately serve as a biosignature. Further work is required to identify potential relationships with clinically defined psychiatric disorders, particularly those of dysregulated mood.

Efficacy, safety and tolerability of vidofludimus in patients with inflammatory bowel disease: the ENTRANCE study

BACKGROUND

Vidofludimus (SC12267) is a novel oral immunomodulator inhibiting dihydroorotate dehydrogenase (DHODH) and the expression of proinflammatory cytokines including interleukin-17 (IL17A and IL17F) and interferon-gamma. The objective of the study was to explore the efficacy, safety and tolerability of vidofludimus in steroid-dependent inflammatory bowel disease (IBD).

METHODS

The open label uncontrolled ENTRANCE study (ClinicalTrials.gov NCT00820365) has been conducted at 13 study centers in Germany, Bulgaria and Romania. Thirty-four steroid-dependent patients with a confirmed diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) were treated with a once daily 35mg oral dose of vidofludimus over 12weeks. Steroids were tapered during the first 8weeks followed by a steroid-free treatment period of 4weeks. Complete response was defined as steroid-free clinical remission at week 12; partial response was defined as being in remission at steroid dose equal or lower than the individual patient's threshold dose for relapse.

RESULTS

Of the thirty-four patients enrolled in this trial 26 were evaluable for primary efficacy assessment. After completion of the 12weeks treatment phase 8 out of 14 (57.1%) patients with CD and 6 out of 12 (50.0%) patients with UC were in steroid-free remission (complete responders). Another 4 (28.6%) patients in CD and 5 (41.7%) patients in UC were partial responders. Vidofludimus was well tolerated, no drug-related serious adverse events were observed.

CONCLUSIONS

This trial provides first evidence of clinical efficacy of vidofludimus in IBD. Although the safety and tolerability profile seems favorable, long-term controlled studies are needed to further investigate its potential as novel IBD therapy.

[Rational and efficient diagnosis in different stages of Crohn's disease]

The treatment of patients with inflammatory bowel disease has become more complex in recent years through the introduction of various immunosuppressive agents as well as the approval of monoclonal antibodies. Patients receiving such treatment must be carefully monitored. National and international guidelines define a diagnostic and therapeutic context for the practitioner, but can only partially respond to specific questions on the procedure for individual patients. Within the framework of a project initiated by Abbott entitled "IBD ahead" 34 German IBD experts have elaborated concrete proposals for the utility of clinical symptom assessment, endoscopy and the use of laboratory parameters including foecal markers of inflammation. Furthermore, we discuss the significance of conventional X-rays, computed tomography, ultrasound and magnetic resonance tomography. These recommendations are illustrated by case studies from everyday practice in the participating centres.

[IBD ahead 2010--Answering important questions in Crohn's disease treatment]

The treatment of patients with inflammatory bowel disease has become more complex in recent years through the introduction of various immunosuppressive agents as well as the approval of monoclonal antibodies against TNF-α and patients receiving such treatment must be carefully monitored. National and international guidelines define a diagnostic and therapeutic context for the practitioner, but can only partially respond to specific questions on the procedure for individual patients. Within the framework of a project initiated by Abbott entitled "IBD ahead" 38 German IBD experts have elaborated concrete proposals for dealing with corticosteroids, immunosuppressants and TNF-α antibodies on the basis of the published literature and their own personal experience in order to close the gap between these guidelines and daily clinical practice. Statements were developed on the choice of correct timing of initiation, dose and duration of the individual substances and on how to proceed with patients exhibiting treatment failure. Moreover, recommendations are also made on drug combination strategies, safety monitoring and the risks regarding the development of infectious complications and malignancies. These recommendations are illustrated by case studies from everyday practice in participating centres.