Modular Cognitive-Behavioral Therapy for a Young Adult With Autism Spectrum Disorder, Comorbid Obsessive Compulsive Disorder, and Social Anxiety Disorder

This case report outlines the use of a modular cognitive-behavioral therapy (CBT) protocol used to treat obsessive compulsive disorder (OCD) and social anxiety disorder (SAD) in an 18-year-old female, “Jaina,” with autism spectrum disorder (ASD). Jaina completed 16 weekly CBT sessions that lasted approximately 60 min each. On completing the program, Jaina’s symptom severity for treatment targets of OCD and SAD had reduced based on the Anxiety and Related Disorders Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM- 5; ADIS-5). In addition, overall anxiety symptom severity reduction was evident at posttreatment based on the Clinical Global Impression of Severity (CGI-S). This case report supports the use of a modular CBT program (developed for late adolescents and young adults with ASD and comorbid anxiety/OCD) for OCD and SAD.

Measurement properties of tools used to assess depression in adults with and without autism spectrum conditions: A systematic review

Depression is the most commonly experienced mental health condition in adults with autism spectrum conditions (ASC). However, it is unclear what tools are currently being used to assess depression in ASC, or whether tools need to be adapted for this group. This systematic review therefore aimed to identify tools used to assess depression in adults with and without ASC, and then evaluate these tools for their appropriateness and measurement properties. Medline, PsychINFO and Web of Knowledge were searched for studies of depression in: (a) adults with ASC, without co‐morbid intellectual disability; and (b) adults from the general population without co‐morbid conditions. Articles examining the measurement properties of these tools were then searched for using a methodological filter in PubMed, and the quality of the evidence was evaluated using the COSMIN checklist. Twelve articles were identified which utilized three tools to assess depression in adults with ASC, but only one article which assessed the measurement properties of one of these tools was identified and thus evaluated. Sixty‐four articles were identified which utilized five tools to assess depression in general population adults, and fourteen articles had assessed the measurement properties of these tools. Overall, two tools were found to be robust in their measurement properties in the general population—the Beck Depression Inventory (BDI‐II), and the patient health questionnaire (PHQ‐9). Crucially only one study was identified from the COSMIN search, which showed weak evidence in support of the measurement properties of the BDI‐II in an ASC sample. Implications for effective measurement of depression in ASC are discussed. Autism Res2018, 11: 738–754. © 2018 The Authors Autism Research published by International Society for Autism Research and Wiley Periodicals, Inc.

Lay Summary

Depression is the most common mental health problem experienced by adults with autism. However, the current study found very limited evidence regarding how useful tools developed for the general population are for adults with autism. We therefore suggest how these tools could be adapted to more effectively assess depression in adults with autism, and improve these individuals access to mental health assessment and support.

Protocol for a prospective longitudinal study investigating the participation and educational trajectories of Australian students with autism

INTRODUCTION

Autism is associated with high cost to individuals, families, communities and government. Understanding educational and participation trajectories during the school years, and factors influencing these, is fundamental to reducing financial and personal costs. The primary aim of this study is to document the trajectories of Australian students with autism during their education. The secondary aim is to examine personal (eg, student skills) and environmental (eg, school setting) factors associated with differing trajectories and outcomes.

METHODS AND ANALYSIS

The cross-sequential longitudinal study will recruit two cohorts of 120 parents/caregivers of children with autism. Cohort 1 aged between 4 and 5 years and cohort 2 between 9 and 10 years to start the study. Information will be gathered from parents, teachers and school principals at six annual time points (T1 to T6). Parents will be emailed a link to an online initial questionnaire (T1) and then contacted annually and asked to complete either an extended questionnaire (T3, T5 and T6) or an abbreviated questionnaire (T2, T4). Where consent is given, the child's current school will be contacted annually (T1 to T6) and teacher and school principal asked to complete questionnaires about the child and school. Parent and school questionnaires are comprised of questions about demographic and school factors that could influence trajectories and a battery of developmental and behavioural assessment tools designed to assess educational and participation trajectories and outcomes. Surveys will provide longitudinal data on educational and participation trajectories for children and adolescents with autism. In addition cross-sectional comparisons (within or between age groups) at each time point and cohort effects will be explored.

ETHICS AND DISSEMINATION

Ethics approvals have been granted for this study by all recruiting sites and universities in the project. Study findings will inform policy and practice to promote successful inclusion and participation of children with autism in education. Results will be disseminated through journal publication, conference and seminar presentation.

Child and Adult Factors Related to Quality of Life in Adults with Autism

The WHO Quality of Life-Brief questionnaire was used to assess quality of life (QoL) among 52 adults with autism (mean age 49 years) followed-up since childhood. Overall, assessments of QOL were more positive than measures of objective social outcome (jobs, independence, relationships etc.) but correlations between caregiver and self-reports were low. Informant ratings indicated few correlations between current QoL and any child or adult factors. On self-report ratings, QoL was significantly negatively correlated with severity of repetitive behaviours in childhood; higher QoL was positively associated with better adult social outcomes. However, only a minority of adults (n = 22) could provide self-report data and findings highlight the need to develop valid measures for assessing the well-being of adults with autism.

Demographic and Cognitive Profile of Individuals Seeking a Diagnosis of Autism Spectrum Disorder in Adulthood

Little is known about ageing with autism spectrum disorder (ASD). We examined the characteristics of adults referred to a specialist diagnostic centre for assessment of possible ASD, 100 of whom received an ASD diagnosis and 46 did not. Few demographic differences were noted between the groups. Comorbid psychiatric disorders were high in individuals with ASD (58 %) and non-ASD (59 %). Individuals who received an ASD diagnosis had higher self-rated severity of ASD traits than non-ASD individuals. Within the ASD group, older age was associated with higher ratings of ASD traits and better cognitive performance. One interpretation is that general cognitive ability and the development of coping strategies across the lifespan, do not necessarily reduce ASD traits but may mitigate their effects.

Sensory Clusters of Adults With and Without Autism Spectrum Conditions

We identified clusters of atypical sensory functioning adults with ASC by hierarchical cluster analysis. A new scale for commonly self-reported sensory reactivity was used as a measure. In a low frequency group (n = 37), all subscale scores were relatively low, in particular atypical sensory/motor reactivity. In the intermediate group (n = 17) hyperreactivity, sensory interests and sensory/motor issues were significantly elevated in relation to the first group, but not hyporeactivity. In a high frequency subgroup (n = 17) all subscale scores were significantly elevated and co-occurrence of hyper- and hyporeactivity was evident. In a population sample, a cluster of low scorers (n = 136) and high scorers relative to the other cluster (n = 26) was found. Identification of atypical sensory reactivity is important for targeting support.

Protective effect or missed diagnosis? Females with autism spectrum disorder

Autism spectrum disorder (ASD) has historically been diagnosed more frequently in males than females. One explanation for this is the ‘female protective effect’: that there is something inherent in being female that makes girls and women less susceptible to ASD. Another possibility is that ASD is under-diagnosed in girls and women, due to the existence of a ‘female autism phenotype’, which is not well captured by current, male-biased diagnostic criteria. To evaluate the ‘female protective effect’ and ‘female autism phenotype’ hypotheses, this narrative review describes recent developments exploring the genetic underpinning and behavioral expression of ASD in females. We then look at the ways to better identify females with ASD who may be missed under the current diagnostic criteria.

Putative Brain Networks Underlying Repetitive Negative Thinking and Comorbid Internalizing Problems in Autism

Many high-functioning individuals with autism spectrum disorder (ASD) also experience depression and anxiety, yet little is known about mechanisms underlying this comorbidity. Repetitive negative thinking (RNT) about self-referential information is a transdiagnostic cognitive vulnerability factor that may account for the relationship between these two classes of symptoms. We propose a model where self-referential processing and cognitive inflexibility interact to increase risk for RNT, leading to internalizing problems in ASD. Examination of interactions within and between two well-characterized large-scale brain networks, the default mode network and the salience network, may provide insights into neurobiological mechanisms underlying RNT in ASD. We summarize previous literature supporting this model, emphasizing moving towards understanding RNT as a factor accounting for the high rates of internalizing problems in ASD. Future research avenues include understanding heterogeneity in clinical presentation, and promise for identifying and treating cognitive flexibility and RNT to reduce comorbid internalizing problems in ASD.

Priority service needs and receipt across the lifespan for individuals with autism spectrum disorder

Individuals with Autism Spectrum Disorder (ASD) have a range of health, community, and social support needs across the lifespan that create age‐specific challenges in navigating service sectors. In this study, we set out to identify the priority needs of individuals with ASD across the lifespan, and the factors that predict receiving priority services. Participants included 3,317 individuals with ASD from a Canada‐wide online caregiver survey, stratified into five age groups (preschool, elementary school age, adolescence, emerging adulthood, adulthood). Priority receipt was calculated as a ratio of current services that corresponded to individualized priority need. Age‐stratified Poisson regression analyses were used to identify the sociodemographic, clinical and systemic predictors of priority receipt. Results indicate that the distribution of priority need varied by age, except for social skills programming, which was a high across all groups. The number of high and moderate priority needs diversified with age. Overall, 30% of individuals had none of their priority needs met and priority receipt decreased with age. Systemic factors were most consistently related to priority receipt across the lifespan. Understanding patterns and correlates of priority needs and use that currently exist in different age groups can inform policies to improve service access. Autism Res2017, 10: 1436–1447. © 2017 International Society for Autism Research, Wiley Periodicals, Inc.

Perceived social support in adults with autism spectrum disorder and attention-deficit/hyperactivity disorder

Perceived social support (PSS) has been related to physical and mental well-being in typically developing individuals, but systematic characterizations of PSS in autism spectrum disorder (ASD) are limited. We compared self-report ratings of the multidimensional scale of PSS (MSPSS) among age- and IQ-matched groups of adults (18-58 years) with cognitively high-functioning ASD (N = 41), or attention-deficit/hyperactivity disorder (ADHD; N = 69), and neurotypical controls (NC; N = 69). Accompanying group comparisons, we used machine learning random forest (RF) analyses to explore predictors among a range of psychopathological and socio-emotional variables. Relative to both ADHD and NC, adults with ASD showed lower MSPSS ratings, specifically for the friends subscale (MSPSS-f). Across ASD and ADHD, interindividual differences in autism severity, affective empathy, symptoms of anxiety related to social interactions, hyperactivity/impulsivity, and somatization best predicted MSPSS-f. These relationships did not differ between clinical groups. While group comparisons demonstrated greater impairment in individuals with ASD, analyzing individuals' characteristics revealed cross-diagnoses similarities in regard to their MSPSS-f relationships. This is consistent with the Research Domain Criteria framework, supporting a trans-diagnostic approach as on the path toward "precision medicine." Autism Res 2017, 10: 866-877. © 2017 International Society for Autism Research, Wiley Periodicals, Inc.

Autism spectrum disorder: outcomes in adulthood

PURPOSE OF REVIEW

Until recently, there has been little systematic study of adult life among individuals with autism spectrum disorder (ASD) but recognition of the high psychological and social costs of ASD has led to an increase in adult-focused research over the past decade. The aim of this review is to summarize recent empirical findings on outcomes for adults with ASD.

RECENT FINDINGS

Most research on adult outcomes in ASD indicates very limited social integration, poor job prospects and high rates of mental health problems. However, studies vary widely in their methodology, choice of measures and selection of participants. Thus, estimates of how many adults have significant social and mental health problems are often conflicting. There is little consistent information on the individual, familial or wider social factors that may facilitate more positive social and psychological outcomes. There is a particular dearth of research on older individuals with ASD.

SUMMARY

The very variable findings reported in this review reflect the problems of conducting research into lifetime outcomes for individuals with a condition as heterogeneous as ASD. Much more systematic research is needed to delineate different patterns of development in adulthood and to determine the factors influencing these trajectories.

'Suddenly the first fifty years of my life made sense': Experiences of older people with autism

Research on the experience of growing older with autism is very limited. In this study, 13 people with autism aged over 50 years participated in semi-structured interviews about their experiences of diagnosis, social support and getting older. Interviews were analysed using thematic analysis. Three overarching themes were generated: difference, life review and longing for connection. Prior to diagnosis, individuals had awareness of their difficulties, attributed these to intrinsic difference and engaged in a deliberate process of reducing the visibility of this difference. Diagnosis prompted a process of life review and externalisation, whereby past negative experiences were reattributed to autism as opposed to the self. Loneliness, isolation and yearning for interpersonal connection were ubiquitous and longstanding. Autism support and social groups were highly valued, offering opportunities for belonging, acceptance and social comparison. Results highlight the similarity to younger age groups in terms of lived experience and need for greater support, particularly with respect to reducing isolation and improving access to diagnosis.

Psychiatric Co-occurring Symptoms and Disorders in Young, Middle-Aged, and Older Adults with Autism Spectrum Disorder

Although psychiatric problems are less prevalent in old age within the general population, it is largely unknown whether this extends to individuals with autism spectrum disorders (ASD). We examined psychiatric symptoms and disorders in young, middle-aged, and older adults with and without ASD (N_max = 344, age 19–79 years, IQ > 80). Albeit comparable to other psychiatric patients, levels of symptoms and psychological distress were high over the adult lifespan; 79 % met criteria for a psychiatric disorder at least once in their lives. Depression and anxiety were most common. However, older adults less often met criteria for any psychiatric diagnosis and, specifically, social phobia than younger adults. Hence, despite marked psychological distress, psychiatric problems are also less prevalent in older aged individuals with ASD.