Characterization of a family with rare deletions in CNTNAP5 and DOCK4 suggests novel risk loci for autism and dyslexia

BACKGROUND

Autism spectrum disorders (ASDs) are characterized by social, communication, and behavioral deficits and complex genetic etiology. A recent study of 517 ASD families implicated DOCK4 by single nucleotide polymorphism (SNP) association and a microdeletion in an affected sibling pair.

METHODS

The DOCK4 microdeletion on 7q31.1 was further characterized in this family using QuantiSNP analysis of 1M SNP array data and reverse transcription polymerase chain reaction. Extended family members were tested by polymerase chain reaction amplification of junction fragments. DOCK4 dosage was measured in additional samples using SNP arrays. Since QuantiSNP analysis identified a novel CNTNAP5 microdeletion in the same affected sibling pair, this gene was sequenced in 143 additional ASD families. Further polymerase chain reaction-restriction fragment length polymorphism analysis included 380 ASD cases and suitable control subjects.

RESULTS

The maternally inherited microdeletion encompassed chr7:110,663,978-111,257,682 and led to a DOCK4-IMMP2L fusion transcript. It was also detected in five extended family members with no ASD. However, six of nine individuals with this microdeletion had poor reading ability, which prompted us to screen 606 other dyslexia cases. This led to the identification of a second DOCK4 microdeletion co-segregating with dyslexia. Assessment of genomic background in the original ASD family detected a paternal 2q14.3 microdeletion disrupting CNTNAP5 that was also transmitted to both affected siblings. Analysis of other ASD cohorts revealed four additional rare missense changes in CNTNAP5. No exonic deletions of DOCK4 or CNTNAP5 were seen in 2091 control subjects.

CONCLUSIONS

This study highlights two new risk factors for ASD and dyslexia and demonstrates the importance of performing a high-resolution assessment of genomic background, even after detection of a rare and likely damaging microdeletion using a targeted approach.

Impaired sadness recognition is linked to social interaction deficit in autism

Can autistic individuals use motion cues to identify simple emotions from 2D abstract animations? We compared emotion recognition ability using a novel test involving computerised animations, and a more conventional emotion recognition test using facial expressions. Adults with autism and normal controls, matched for age and verbal IQ, participated in two experiments. First, participants viewed a series of short (5s) animations. These featured an 'emotional' triangle, interacting with a circle. They were designed to evoke an attribution of emotion to the triangle, which was rated both in terms of anger, happiness, sadness or fear from its pattern of movement, and how animate ("living") it appeared to be. Second, emotion recognition was tested from standardised photographs of facial expressions. In both experiments, adults with autism were significantly impaired relative to comparisons in their perception of sadness. This is the first demonstration that, in autism, individuals can have difficulties both in the interpretation of facial expressions and in the recognition of equivalent emotions based on the movement of abstract stimuli. Poor performance in the animations task was significantly correlated with the degree of impairment in reciprocal social interaction, assessed by the Autism Diagnostic Observation Schedule. Our findings point to a deficit in emotion recognition in autism, extending beyond the recognition of facial expressions, which is associated with a functional impairment in social interaction skills. Our results are discussed in the context of the results of neuroimaging studies that have used animated stimuli and images of faces.

Listening to the autistic voice: Mental health priorities to guide research and practice in autism from a stakeholder-driven project

LAY ABSTRACT

Autistic adults commonly experience mental health conditions. However, research rarely involves autistic adults in deciding priorities for research on mental healthcare approaches that might work for them. The purpose of this article is to describe a stakeholder-driven project that involved autistic adults in co-leading and designing research about priorities to address mental health needs. Through a large online survey, two large meetings, and three face-to-face focus group discussions involving over 350 stakeholders, we identified five priorities for mental health research desired by autistic adults. These priorities and preferred outcomes should be used to guide research and practice for autistic adults.

Decreased GABA(B) receptors in the cingulate cortex and fusiform gyrus in autism

Autism is a behaviorally defined neurodevelopmental disorder and among its symptoms are disturbances in face and emotional processing. Emerging evidence demonstrates abnormalities in the GABAergic (gamma-aminobutyric acid) system in autism, which likely contributes to these deficits. GABA(B) receptors play an important role in modulating synapses and maintaining the balance of excitation-inhibition in the brain. The density of GABA(B) receptors in subjects with autism and matched controls was quantified in the anterior and posterior cingulate cortex, important for socio-emotional and cognitive processing, and the fusiform gyrus, important for identification of faces and facial expressions. Significant reductions in GABA(B) receptor density were demonstrated in all three regions examined suggesting that alterations in this key inhibitory receptor subtype may contribute to the functional deficits in individuals with autism. Interestingly, the presence of seizure in a subset of autism cases did not have a significant effect on the density of GABA(B) receptors in any of the three regions.

Decreased GAD65 mRNA levels in select subpopulations of neurons in the cerebellar dentate nuclei in autism: an in situ hybridization study

The laterally positioned dentate nuclei lie in a key position in the cerebellum to receive input from Purkinje cells in the lateral cerebellar hemisphere participating in both motor and cognitive functions. Although neuropathology of the four cerebellar nuclei using Nissl staining has been qualitatively reported in children and adults with autism, surprisingly the dentate nuclei appeared less affected despite reported reductions in Purkinje cells in the posterolateral cerebellar hemisphere. To determine any underlying abnormalities in the critically important GABAergic system, the rate-limiting GABA synthesizing enzyme, glutamic acid decarboxylase (GAD) type 65 was measured via in situ hybridization histochemistry in dentate somata. GAD65 mRNA labeling revealed two distinct subpopulations of neurons in adult control and autism postmortem brains: small-sized cells (about 10-12 microm in diameter, presumed interneurons) and larger-sized neurons (about 18-20 microm in diameter, likely feedback to inferior olivary neurons). A mean 51% reduction in GAD65 mRNA levels was found in the larger labeled cells in the autistic group compared with the control group (P=0.009; independent t-test) but not in the smaller cell subpopulation. This suggests a disturbance in the intrinsic cerebellar circuitry in the autism group potentially interfering with the synchronous firing of inferior olivary neurons, and the timing of Purkinje cell firing and inputs to the dentate nuclei. Disturbances in critical neural substrates within these key circuits could disrupt afferents to motor and/or cognitive cerebral association areas in the autistic brain likely contributing to the marked behavioral consequences characteristic of autism.

Acute pain experience in individuals with autism spectrum disorders: a review

In addition to the diagnostic criteria for autism spectrum disorder, a number of clinically important comorbid complaints, including sensory abnormalities, are also discussed. One difference often noted in these accounts is hyposensitivity to pain; however, evidence for this is limited. The purpose of the current review therefore was to examine sensitivity to pain of individuals with autism spectrum disorder. This review is interested in reports which consider differences in subjective experience of pain (i.e. different pain thresholds) and differences in behavioural response to pain (i.e. signs of pain-related distress). Studies were included if they were conducted with human subjects, included a clearly diagnosed autism spectrum disorder population and reported data pertaining to pain experience relative to the neurotypical population. Studies were classified as being self/parent report, clinical observations, observations of response to medical procedures or experimental examination of pain. Both self/parent report and clinical observations appeared to report hyposensitivity to pain, whereas observations of medical procedures and experimental manipulation suggested normal or hypersensitive responses to pain. This review suggests that contrary to classical reports, individuals with autism spectrum disorder do not appear to have systematically altered pain responses or thresholds. More systematic experimental examination of this area is needed to understand responses to pain of individuals with autism spectrum disorder.

Rare familial 16q21 microdeletions under a linkage peak implicate cadherin 8 (CDH8) in susceptibility to autism and learning disability

BACKGROUND

Autism spectrum disorder (ASD) is characterised by impairments in social communication and by a pattern of repetitive behaviours, with learning disability (LD) typically seen in up to 70% of cases. A recent study using the PPL statistical framework identified a novel region of genetic linkage on chromosome 16q21 that is limited to ASD families with LD.

METHODS

In this study, two families with autism and/or LD are described which harbour rare >1.6 Mb microdeletions located within this linkage region. The deletion breakpoints are mapped at base-pair resolution and segregation analysis is performed using a combination of 1M single nucleotide polymorphism (SNP) technology, array comparative genomic hybridisation (CGH), long-range PCR, and Sanger sequencing. The frequency of similar genomic variants in control subjects is determined through analysis of published SNP array data. Expression of CDH8, the only gene disrupted by these microdeletions, is assessed using reverse transcriptase PCR and in situ hybridisation analysis of 9 week human embryos.

RESULTS

The deletion of chr16: 60 025 584-61 667 839 was transmitted to three of three boys with autism and LD and none of four unaffected siblings, from their unaffected mother. In a second family, an overlapping deletion of chr16: 58 724 527-60 547 472 was transmitted to an individual with severe LD from his father with moderate LD. No copy number variations (CNVs) disrupting CDH8 were observed in 5023 controls. Expression analysis indicates that the two CDH8 isoforms are present in the developing human cortex.

CONCLUSION

Rare familial 16q21 microdeletions and expression analysis implicate CDH8 in susceptibility to autism and LD.

A Longitudinal Study of Local Gyrification Index in Young Boys With Autism Spectrum Disorder

Local gyrification index (LGI), a metric quantifying cortical folding, was evaluated in 105 boys with autism spectrum disorder (ASD) and 49 typically developing (TD) boys at 3 and 5 years-of-age. At 3 years-of-age, boys with ASD had reduced gyrification in the fusiform gyrus compared with TD boys. A longitudinal evaluation from 3 to 5 years revealed that while TD boys had stable/decreasing LGI, boys with ASD had increasing LGI in right inferior temporal gyrus, right inferior frontal gyrus, right inferior parietal lobule, and stable LGI in left lingual gyrus. LGI was also examined in a previously defined neurophenotype of boys with ASD and disproportionate megalencephaly. At 3 years-of-age, this subgroup exhibited increased LGI in right dorsomedial prefrontal cortex, cingulate cortex, and paracentral cortex, and left cingulate cortex and superior frontal gyrus relative to TD boys and increased LGI in right paracentral lobule and parahippocampal gyrus, and left precentral gyrus compared with boys with ASD and normal brain size. In summary, this study identified alterations in the pattern and development of LGI during early childhood in ASD. Distinct patterns of alterations in subgroups of boys with ASD suggests that multiple neurophenotypes exist and boys with ASD and disproportionate megalencephaly should be evaluated separately.

Meeting the 24-hr movement guidelines: An update on US youth with autism spectrum disorder from the 2016 National Survey of Children's Health

The purpose of this study was to examine how adherence to the physical activity (PA), screen-time (ST), and sleep duration guidelines differ between youth with autism spectrum disorder (ASD) and youth with typical development (TD). A secondary objective was to assess how PA, ST, and sleep duration varied among youth with ASD by age and ASD severity. Utilizing the 2016 National Survey of Children's Health data, parental reports of time spent by youth in PA, ST, and sleep were used to determine adherence to the 24-hr movement guidelines for 1008 youth with ASD and 34 489 youth with TD. Multivariate logistic regression analyses determined that children with ASD were less likely to meet the guidelines for PA, ST, and sleep duration, and adolescents with ASD were less likely to meet the guidelines for PA and ST than participants with TD. Furthermore, logistic regression analyses determined adolescents with severe ASD to be less likely to meet the sleep guideline compared to adolescents with mild ASD. Overall, youth with ASD were significantly less likely to adhere to all three guidelines. The findings highlight the breadth of health behaviors that require intervention to counteract the poorer health status among youth with ASD. Autism Res 2019, 12: 941-951. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: New health recommendations suggest children and adolescents should have at least 1 hr of physical activity, no more than 2 hr of screen-time (e.g., television), and 9-11 hr of sleep (or 8-10 hr for children aged 14 or older) every day. This article looked at how children and adolescents with autism meet these new guidelines. The two main results were that: (a) children with autism were less likely to meet all three guidelines compared to children without autism, and (b) adolescents with autism were less likely to meet the guidelines for physical activity and screen-time.

Autism spectrum disorders: an update on oral health management

Dental professionals caring for patients with a diagnosis of autism spectrum disorder (ASD) will need to provide oral health care based on a family-centered approach that involves a comprehensive understanding of parental concerns and preferences, as well as the unique medical management, behaviors, and needs of the individual patient.

BACKGROUND

With the rising prevalence of autism spectrum disorders (ASD), oral health providers will find themselves increasingly likely to care for these patients in their daily practice. The purpose of this article is to provide a comprehensive update on the medical and oral health management of patients with autism spectrum disorders.

METHODS

The authors conducted a literature review by searching for relevant articles written in English in the PubMed database pertaining to the medical and oral health management of autism, including caries status, preventive, behavioral, trauma, and restorative considerations.

CONCLUSIONS

A detailed family centered approach based on parental preferences and concerns, the patient's challenging behaviors, and related comorbidities can serve to improve the treatment planning and oral health management of dental patients with ASD.

Is cognitive inflexibility a missing link? The role of cognitive inflexibility, alexithymia and intolerance of uncertainty in externalising and internalising behaviours in young people with autism spectrum disorder

BACKGROUND

Internalising (anxiety and low mood) and externalising (aggressive or outburst behaviours, and irritability) difficulties are very common in autism spectrum disorder (ASD) across the life span, relatively stable over time and often associated with poorer quality of life. Understanding the cognitive mechanisms underlying internalising and externalising difficulties in ASD is essential for developing targeted supports and interventions. In the present study, we investigated established and less-researched cognitive factors hypothesised to contribute to internalising and/or externalising difficulties in ASD, namely cognitive inflexibility (CI), intolerance of uncertainty (IU) and alexithymia. Based on previous models and clinical experience, we hypothesised that IU would lead to internalising symptoms, with alexithymia contributing to this pathway, and that CI would have a direct effect on externalising behaviours and may indirectly contribute to internalising symptoms via increasing IU.

METHODS

Our sample consisted of 95 5- to 18-year-olds presenting to a specialist neurodevelopmental clinic and receiving a diagnosis of ASD. Parents/caregivers completed questionnaires assessing ASD symptomatology, internalising and externalising difficulties, CI, IU and alexithymia. Structural equation modelling was used to examine the hypothesised pathways and relationships between the main variables of interest.

RESULTS

Cognitive Inflexibility played a significant direct role in the pathway from ASD symptoms to externalising symptoms in ASD, and indirect role via IU in the pathway to internalising problems. Relationships between alexithymia and both internalising and externalising symptoms were weaker, with alexithymia predicting internalising difficulties via IU only.

CONCLUSIONS

The finding of a direct pathway from CI to externalising behaviours is novel, as is the indirect role of CI in internalising symptomatology. Of the three cognitive mechanisms examined, only CI significantly predicted externalising symptoms. Possible implications for interventions and supports targeting these cognitive processes in ASD are discussed.

Treating clients with Asperger's syndrome and autism

Asperger's syndrome (AS) is a form of autism spectrum disorder (ASD) affecting many individuals today. Although neurobiological correlates for AS have been identified, like many ASDs, AS is not completely understood. AS as a distinct disorder is also not universally accepted and in the DSM-5 AS is not considered a separate nosological entity. In contrast to some other ASDs, individuals with AS are commonly characterized by having standard or higher than average intelligence, yet difficulties in social skills and communication can present challenges for these individuals in everyday functioning. Counseling a person with AS or autism presents a unique challenge for the mental health care provider. We have compiled this review consisting of some recent ideas regarding counseling the client with AS with the goal of providing some clinical insights and practical clues. Although the focus of the present paper is largely on AS, many of these strategies could also apply to individuals with high-functioning autism (HFA).

Quantification of the stapedial reflex reveals delayed responses in autism

Autism is a developmental disorder characterized, in part, by sensory abnormalities. It is well established that most if not all patients with autism have problems with auditory processing, ranging from deafness to hyperacusis, and physiological testing of auditory function (i.e. auditory brain stem responses) implicates brain stem dysfunction in autism. Additionally, previous research from this lab has revealed significantly fewer auditory brain stem neurons in autistic subjects as young as 2 years of age. These observations have led us to hypothesize that objective, noninvasive measures of auditory function can be used as an early screening tool to identify neonates with an elevated risk of carrying a diagnosis of autism. Here, we provide a detailed quantitative investigation of the acoustic stapedial reflex (ASR), a three- or four-neuron brain stem circuit, in young autistic subjects and normal developing controls. Indeed, we find significantly lower thresholds, responses occurring at significantly longer latency and right-left asymmetry in autistic subjects. The results from this investigation support deficits in auditory function as a cardinal feature of autism and suggest that individuals with autism can be identified by their ASR responses.

Stability of child temperament: Multiple moderation by child and mother characteristics

This 3-wave longitudinal study focuses on stability of child temperament from 3 to 6 years and considers child age, gender, birth order, and term status as well as mother age, education, anxiety, and depression as moderators of stability. Mothers of approximately 10,000 children participating in the Avon Longitudinal Study of Parents and Children rated child temperament. Stability coefficients for child temperament scales were medium to large, and stability was generally robust across moderators except child gender and birth order and mother age and education, which had small moderating effects on reports of stability of child temperament. Statement of contribution What is already known on this subject? Some is known about the stability of temperament in infancy in small samples, but much less is known about the stability of temperament in early childhood or its moderation. What does this study add? This study uses a large sample (˜10,000) to trace the stability of temperament from 3 to 6 years in three waves and considers child age, gender, birth order, and term status as well as mother age, education, anxiety, and depression as moderators of stability.

Am I Autistic? Utility of the Girls Questionnaire for Autism Spectrum Condition as an Autism Assessment in Adult Women

This study aimed to explore the structure of a modified version of the Girls Questionnaire for Autism Spectrum Condition (GQ-ASC; Attwood et al. 2011) to test its utility as an autism screening measure for adult women. We recruited 672 cisgender and trans women aged between 18 and 72 online. The sample contained 350 autistic women (M age = 36.21, standard deviation [SD] = 10.10) and 322 nonautistic women (M age = 34.83, SD = 9.93), screened using the Autism Quotient. A principal component analysis and parallel analysis revealed a five-component solution that accounted for 40.40% of the total variance. The extracted components appear to be consistent with what is known about the way girls and women display their autistic traits and interpreted as (1) Imagination and play: Describes interest in fantasy, fiction, and reflection on the quality and content of imaginative play in childhood. (2) Camouflaging: Describes effortful attempts to reduce the visibility of autistic traits. (3) Sensory sensitivities: Describes sensory processing hyper- and hyposensitivities across various modalities. (4) Socializing: Describes barriers to social understanding and participation. (5) Interests: Describes age-advanced and nonstereotypically feminine interests. We observed significant differences between autistic and nonautistic women across all extracted components, and the total score. A receiver operating characteristic analysis indicated an excellent level of discrimination. When applying a cutoff score of 57, the GQ-ASC correctly identified 80.0% of cases. The modified GQ-ASC is an effective and highly discriminant screening tool for use in adult autistic women. It provides valuable insight into the shared features and experiences of this underrecognized and underrepresented subset of the autistic community.

Lay summary

Why was this study done?: A lot of autistic women do not get an accurate or timely autism diagnosis. We know that when they do receive an autism diagnosis, they often feel stronger in their identity and feel more confident in advocating for their needs. We wanted to find a quick and easy way for professionals to work out which women should be referred for an autism assessment. We also wanted to help autistic women who do not want to have an assessment done feel confident in self-identifying as autistic.What did the researchers do?: We changed the wording of an autism questionnaire that was designed for younger girls, and had 350 adult autistic cisgender and trans women aged between 18 and 71 years complete it. We looked at answers in a way that told us which questions were most useful for telling apart autistic women and nonautistic women.What were the results of the study?: We found that a number of questions were grouped together into different areas that were common for autistic women. These areas were as follows: (1)Imagination and play: Questions about interest in fantasy, fiction, and imaginative play in childhood.(2)Camouflaging: Questions about acting in certain ways to try to hide autistic traits.(3)Sensory sensitivities: Questions about feeling undersensitive or oversensitive to things such as touch, small, taste, and noise.(4)Socializing: Questions about feeling confused in social situations, and finding it difficult to join in.(5)Interests: Questions about interests that are not common for children who are the same age, and interests that are not common for many girls.What do these findings add to what was already known?: There are a lot of ideas about autism that do not always apply to autistic women. These findings will hopefully help professionals and nonexperts understand autistic women better.What are potential weaknesses in the study?: We do not know if any of the 350 autistic women who completed the survey have an intellectual disability, and we do not know if having an intellectual disability will change the results of the study. This is something that will be interesting to look into in the future.How will these findings help autistic adults now and in the future?: The findings of our study can help doctors and mental health professionals work out which women should be assessed for autism. Our findings may also help to change attitudes about who can be autistic, and what autism looks like.

Exploring the Career Motivations, Strengths, and Challenges of Autistic and Non-autistic University Students: Insights From a Participatory Study

Supports for the growing number of autistic university students often focus on helping them succeed in university. However, even educated autistic people experience discrimination and other challenges which can make it very difficult for them to obtain meaningful jobs. Little remains known about how universities can better support their autistic students and alumni in overcoming barriers to meaningful employment. In this participatory study, a team of autistic and non-autistic researchers asked autistic (n = 92) and non-autistic (n = 774) university students about their career aspirations, strengths they believe will help them succeed in their "dream jobs," and obstacles they expect to encounter. Autistic participants' top goal in attending college was to improve their career prospects. However, relatively few autistic students reported learning career-specific skills at university. Autistic students were more likely to seek an academic job and less likely to seek a career in healthcare than non-autistic students. Autistic students highlighted writing skills and detail orientation as strengths that could help them succeed in their dream jobs more often than non-autistic students. However, they were also more likely to expect discrimination, social, and psychological difficulties to stand in the way of their dream jobs. These findings suggest that universities should prioritize experiential learning opportunities to help autistic (and non-autistic) students develop employment-related skills while providing mental health supports. Universities should demonstrate their commitment to supporting diverse learners by seeking out and hiring autistic professionals and by teaching their own staff and employers how to appreciate and support autistic colleagues.

Comparing the writing skills of autistic and nonautistic university students: A collaboration with autistic university students

LAY ABSTRACT

We do not know very much about the writing skills of autistic university students. Studies with autistic children and teenagers show that some autistic young people have difficulties writing. Other autistic people are talented writers. In fact, some autistic people would rather write than speak. Good writers often imagine other people's points of view when writing. Autistic people sometimes have difficulties understanding others' points of view. Yet, autistic people often work much harder to understand others' points of view than not-autistic people do. We collaborated with autistic university student researchers to see if autistic university students are better or worse at writing than nonautistic students. Autistic university students in our study were better writers than nonautistic students. Autistic students in our study had higher nonverbal intelligence than nonautistic students. Autistic students also put themselves under more pressure to write perfectly than nonautistic students did. Autistic students did not show any difficulties understanding other minds. This study shows that some autistic university students have stronger writing skills and higher intelligence than nonautistic university students. Yet, autistic students may be too hard on themselves about their writing. Fun activities that help students explore their ideas without pressure (like theater games) may help autistic students be less hard on their writing. Teachers can help autistic students express themselves through writing by encouraging them to write about their interests, by giving them enough time to write, and by letting them write using computers if they want to. This study shows that collaborations with autistic people can help us understand strengths that can help autistic people succeed.

Structural Magnetic Resonance Imaging Demonstrates Abnormal Regionally-Differential Cortical Thickness Variability in Autism: From Newborns to Adults

Autism is a group of complex neurodevelopmental disorders characterized by impaired social interaction and restricted/repetitive behavior. We performed a large-scale retrospective analysis of 1,996 clinical neurological structural magnetic resonance imaging (MRI) examinations of 781 autistic and 988 control subjects (aged 0–32 years), and extracted regionally distributed cortical thickness measurements, including average measurements as well as standard deviations which supports the assessment of intra-regional cortical thickness variability. The youngest autistic participants (<2.5 years) were diagnosed after imaging and were identified retrospectively. The largest effect sizes and the most common findings not previously published in the scientific literature involve abnormal intra-regional variability in cortical thickness affecting many (but not all) regions of the autistic brain, suggesting irregular gray matter development in autism that can be detected with MRI. Atypical developmental patterns have been detected as early as 0 years old in individuals who would later be diagnosed with autism.

Comparison of fitness levels between elementary school children with autism spectrum disorder and age-matched neurotypically developing children

Low physical fitness is associated with reduced physical activity and increased cardiovascular diseases. To date, limited research has compared physical fitness levels between children with and without autism spectrum disorder (ASD). Therefore, the primary aim was to investigate if differences in fitness levels exist between children with ASD and age-matched neurotypically developing children (ND). The second aim was to examine if age, sex, height and weight could be used to predict potential fitness levels. The third aim was to examine if the developmental trajectory of fitness is comparable between children with ASD and ND children. The modified Eurofit test battery was used to compare fitness levels between 244 children aged 4-13 years old (n = 152 ND and n = 92 ASD). Independent samples t tests and regression analyses were used to investigate differences in fitness levels between the two groups. The results indicated that statistically significant differences exist in fitness levels between children with ASD when compared to ND children across all ages, favoring the ND children, with small to large effect sizes noted (p < 0.05, d = 0.36-1.13). Regression analysis could not accurately predict fitness measurements in children with ASD but could for ND children. The developmental trajectories were significantly delayed on the 20 m sprint and standing broad jump for children with ASD when compared to ND children. Future studies should seek to address the disparities in physical fitness experienced by children with ASD by using relevant neuromuscular interventions.

Fear Potentiated Startle in Children With Autism Spectrum Disorder: Association With Anxiety Symptoms and Amygdala Volume

Atypical responses to fearful stimuli and the presence of various forms of anxiety are commonly seen in children with autism spectrum disorder (ASD). The fear potentiated startle paradigm (FPS), which has been studied both in relation to anxiety and as a probe for amygdala function, was carried out in 97 children aged 9-14 years including 48 (12 female) with ASD and 49 (14 female) with typical development (TD). In addition, exploratory analyses were conducted examining the association between FPS and amygdala volume as assessed with magnetic resonance imaging in a subset of the children with ASD with or without an anxiety disorder with available MRI data. While the startle latency was increased in the children with ASD, there was no group difference in FPS. FPS was not significantly associated with traditional Diagnostic and Statistical Manual (DSM) or "autism distinct" forms of anxiety. Within the autism group, FPS was negatively correlated with amygdala volume. Multiple regression analyses revealed that the association between FPS and anxiety severity was significantly moderated by the size of the amygdala, such that the association between FPS and anxiety was significantly more positive in children with larger amygdalas than smaller amygdalas. These findings highlight the heterogeneity of emotional reactivity associated with ASD and the difficulties in establishing biologically meaningful probes of altered brain function. LAY SUMMARY: Many children with autism spectrum disorder (ASD) have additional problems such as anxiety that can greatly impact their lives. How these co-occurring symptoms develop is not well understood. We studied the amygdala, a region of the brain critical for processing fear and a laboratory method called fear potentiated startle for measuring fear conditioning, in children with ASD (with and without an anxiety disorder) and typically developing children. Results showed that the connection between fear conditioning and anxiety is dependent on the size of the amygdala in children with ASD.

Barriers to healthcare and a 'triple empathy problem' may lead to adverse outcomes for autistic adults: A qualitative study

LAY ABSTRACT

Autistic people live with more mental and physical health conditions and, on average, die younger than non-autistic people. Despite widespread commitments to tackling these issues, autistic people still report various barriers to accessing healthcare. This article aims to explore the area in depth, from the perspective of autistic people. This research benefits from being led by autistic people, for autistic people - all of the researchers are autistic, and most of us are also medical doctors. Data, in the form of written comments and stories, were collected as part of a large survey. Here, we explored these for common themes and possible deeper meaning within the experiences. People who took part reported a variety of barriers. Here, our article gives voice to their stories, in their own words. Themes included: early barriers; communication mismatch; doubt - in oneself and from doctors; helplessness and fear; and healthcare avoidance and adverse health outcomes. Our findings allowed us to create a model that aimed to understand and explain the reported barriers in the context of the previously known consequences. We also built on wider autism theories to explain our findings in more depth.

Knowledge, Awareness, and Perceptions Regarding Autism Among Parents in Karachi, Pakistan

Background

The prevalence of autism is growing worldwide. Owing to parents being the primary caregivers in most situations, their ability to recognize the signs and symptoms of autism and respond appropriately is of paramount importance in aiming to provide the best healthcare to autistic individuals. This study was conducted with the aim of ascertaining the parent’s knowledge and awareness of autism.

Methods

A cross-sectional survey was conducted among parents residing in Karachi, Pakistan. We excluded any individuals belonging to the medical profession, those who have autistic children, and those who couldn’t completely comprehend English and Urdu. A sample size of 339 parents was selected. A validated and pre-tested questionnaire was administered among the study participants to record demographic information, knowledge, and perceptions regarding autism and its signs and symptoms. Data were analyzed using Statistical Package for Social Sciences (SPSS version 23.0, IBM Corp., Armonk, NY, US). A knowledge score was calculated for opinions about autism and its sign and symptoms individually to reflect a participant’s overall knowledge regarding autism.

Results

From our study population, 75% of our population had heard of autism, with those who knew of someone with the disorder displaying greater awareness. However, our participants displayed poor knowledge scores, with a mean score of 5.59 in the section concerning correct opinions on autism and that of 6.84 in the section testing knowledge of signs and symptoms. Despite this, 95.6% of the participants were willing to get their children treated, in the event of them being diagnosed with autism.

Conclusion

Unfortunately, our population displayed a lack of awareness and knowledge regarding autism. To fill this gap, awareness programs should be conducted to promote parent’s knowledge regarding autism, so as to allow for early diagnoses and an appropriate treatment plan/therapy. On a positive note, most were willing to get their children tested and treated in case of a diagnosis. However, only a small number of participants knew of autism centers in Karachi. General practitioners are needed to play a key role in counseling parents about autism.

Critical Reflections on Employment Among Autistic Adults

Encouraging efforts have emerged in recent years to study and build employment opportunities for adults on the autism spectrum. In this Perspectives piece, we acknowledge this important work while offering critical reflections for consideration as the field of employment in autism advances. We call for five areas of increased focus: (1) nurturing long-term versus short-term employment success; (2) broadening employment readiness efforts beyond only the individual to the entire community employment ecosystem; (3) providing professional development that starts with an individual's strengths, and not with their disability; (4) building community employment support that can be independent of family support; and (5) striving for a good life versus just the next job. Overall, we aim to help galvanize the field toward greater consideration of individuals' quality of life and development, the broader community ecosystem around individuals and their families, and vocational stability over the life course, all on individuals' own terms.

Lay summary

Why is this topic important?: Despite encouraging international efforts for the past 15 years to advance employment for autistic adults, a low percentage of autistic adults are employed at any given point in time. Moreover, research shows that some who are employed struggle in their work situations.What is the purpose of this article?: Our goal is to begin a conversation about what we believe to be promising areas of future focus in advancing employment for autistic adults. We hope that autistic adults and their families, practitioners, researchers, and policy makers find these reflections useful as we work together toward better employment options for adults on the autism spectrum.What is the perspective of the authors?: As advocates, practitioners, researchers, and as a family member for one of us, we believe it is time to look beyond employment statistics and a historically short-term focus on employment. We would like to see a reorientation of our collective energies toward a longer-term view of employment that contributes to a good life for individuals, on their terms.What is already known about this topic?: Over the last 15 years, many employment advancement programs for autistic adults have shown promising results. We have seen positive impacts from evaluations of these programs that include improved skills, more hiring of autistic individuals, shifting employer attitudes, more inclusive work environments, and high levels of productivity among hired autistic adults. We also have increased our understanding about the characteristics of supportive work environments for autistic people. That said, we also know that there are continuing low levels of employment for autistic adults. Furthermore, whereas there are some successful stories of autistic adults gaining employment, there are also, as noted earlier, stories of adults who are struggling in the workplace, with some in low-paying jobs and not able to use their skills.What do the authors recommend?: We recommend five shifts in focus for the future: (1) nurture long-term rather than short-term employment success; (2) seek community-wide programming to support people on an ongoing basis, as opposed to a more narrow focus on individual-level job readiness; (3) provide professional development that starts with an individual's strengths, and not with their disability; (4) develop more comprehensive and accessible community resources instead of relying on families to offset community service gaps; and (5) uphold the goal of having a good life on one's own terms instead of only getting a job.How will these recommendations help autistic adults now or in the future?: We hope that these recommendations help spark new conversations and collective approaches toward improving the employment landscape for autistic individuals. These approaches would move beyond a short-term job focus and individual-level readiness programming to also build supportive community ecosystems around individuals over time. In this way, we hope that individuals can more easily achieve employment over the long term that both works for them and contributes to the important and overarching aim of quality of life.

The Gender-Diversity and Autism Questionnaire: A Community-Developed Clinical, Research, and Self-Advocacy Tool for Autistic Transgender and Gender-Diverse Young Adults

Background

Autistic transgender people face unique risks in society, including inequities in accessing needed care and related mental health disparities. Given the need for specific and culturally responsive accommodations/supports, the characterization of key experiences, challenges, needs, and resilience factors within this population is imperative. This study developed a structured self-report tool for autistic transgender young adults to communicate their experiences and needs in a report format attuned to common autistic thinking and communication styles.

Methods

This cross-nation project developed and refined the Gender-Diversity and Autism Questionnaire through an iterative community-based approach using Delphi panel methodology. This proof-of-principle project defined "expertise" broadly, employing a multi-input expert search approach to balance academic-, community-, and lived experience-based expertise.

Results

The expert collaborators (N = 24 respondents) completed a two-round Delphi study, which developed 85 mostly closed-ended items based on 90% consensus. Final item content falls within six topic areas: the experience of identities; the impact of experienced or anticipated discrimination, bias, and violence toward autistic people and transgender people; tasks and experiences of everyday life; gender diversity- or autism-related care needs and history; the experience of others doubting an individual's gender identity and/or autism; and the experience of community and connectedness. The majority of retained items relate to tasks and experiences of everyday life or the impact of experienced or anticipated discrimination, bias, and violence.

Conclusions

This study employed a multipronged multimodal search approach to maximize equity in representation of the expert measure development team. The resulting instrument, designed for clinical, research, and self-advocacy applications, has parallel Dutch and English versions and is available for immediate use. Future cross-cultural research with this instrument could help identify contextual risk and resilience factors to better understand and address inequities faced by this large intersectional population.

Preliminary findings of accelerated visual memory decline and baseline brain correlates in middle-age and older adults with autism: The case for hippocampal free-water

Research aimed at understanding cognitive and brain aging in adults with autism spectrum disorder (ASD) is growing, but critical longitudinal work is scant. Adults with ASD struggle with tasks involving visual memory compared with neurotypical adults (NT). This may be related to differences in size or integrity of the hippocampus and its' primary structural connectivity pathway, the fornix. The aim of this study was to describe preliminary findings of longitudinal aging trajectories in short- and long-term visual memory abilities in middle-age and older adults with ASD, compared with matched NT adults. We then evaluated baseline multi-modal imaging metrics of the hippocampal system, including the relatively novel metric of free-water, as potential correlates of longitudinal memory change in the ASD group. Middle-age and older adults with ASD (n = 25) and matched NT adults (n = 25) between the ages of 40 and 70 years were followed longitudinally at ~2-year intervals (range 2-5 years). Participants completed the Wechsler Memory Scale III Visual Reproduction task. Longitudinal mixed models were utilized to detect group differences in memory change with baseline age and sex as covariates. Hippocampal volume was measured via T1-weighted MRI images with FreeSurfer. Fornix fractional anisotropy and hippocampal and fornix free-water were measured from diffusion tensor imaging scans. Exploratory correlations were run between individual hippocampal system metrics and longitudinal slopes of visual memory change. There was a significant group by time interaction for long-term visual memory, such that middle-age and older adults with ASD declined faster than matched NT adults. There was no group by time interaction for short-term visual memory. Baseline hippocampal free-water was the only hippocampal system metric that correlated with long-term visual memory change in the ASD group. As one of the first longitudinal cognitive and brain aging studies in middle-age and older adults with ASD, our findings suggest vulnerabilities for accelerated long-term visual memory decline, compared to matched NT adults. Further, baseline hippocampal free-water may be a predictor of visual memory change in middle-age and older adults with ASD. These preliminary findings lay the groundwork for future prognostic applications of MRI for cognitive aging in middle-age and older adults with ASD.