Sex Differences in Mental Health Problems and Psychiatric Hospitalization in Autistic Young Adults

Lifetime stressor exposure is related to suicidality in autistic adults: A multinational study

Despite very high rates of suicidal thoughts and behaviors (STB) in autistic adults, the key psychosocial drivers of this phenomenon remain unknown. To investigate, we examined how lifetime stressor exposure and severity, which have been found to predict STB in non-autistic populations, related to STB in a multinational dataset of 226 autistic adults from the United Kingdom and Australia (67% female; Mage = 41.8, SD = 13.6, range = 19-73 years old). Results revealed that autistic men and women differ with respect to the count, severity, and type of stressors they experienced over the life course. Whereas autistic men were exposed to more numerous legal/crime-related stressors, autistic women experienced more stressors related to social relationships and chronic humiliation and typically experienced stressors as more severe. In addition, whereas chronic interpersonal loss was related to STB for men, acute stressors involving physical danger and lower exposure to chronic entrapment were related to STB in autistic women. These findings indicate that certain lifetime stressors may be differentially experienced, and relevant to STB, in autistic men versus women. They also suggest that screening for lifetime stressor exposure may help identify autistic individuals at greatest risk of suicide.Lay abstractWhen we encounter life events that we experience as stressful ("stressors"), it sets off a biological stress response that can impact mental health and contribute to suicidal thoughts and behaviors (STB). Although we know about specific stressors that are associated with STB in the general population, little is known about the kinds of stressors that increase the risk of STB in autistic people and whether these associations differ by gender. To examine this issue, we cataloged the life stressors that autistic men and women experienced over the entire life course and investigated how these stressors were related to STB. Data were derived from a multinational sample of 226 autistic adults from the United Kingdom and Australia who completed the Stress and Adversity Inventory for Adults. We found that autistic men and women differed in terms of both the lifetime stressors they experienced as well as their perceived severity. Whereas men experienced more legal/crime-related stressors, women experienced more stressors related to relationships with other people and more long-lasting stressors associated with humiliation. Autistic women often perceived life stressors as more severe than men, which is important given that it is the perceived severity of stressors that most strongly affects our health. We also found that different stressors may predict STB in autistic men versus women. Whereas loss of loved ones was most strongly associated with STB for men, for women, physically dangerous stressors were most relevant. In addition, women with fewer lifetime stressors involving entrapment had higher lifetime STB. These results suggest that lifetime stressor exposure may be important to assess to understand suicide risk in autistic people. Additional research is needed to confirm these associations and to examine possible mechanisms linking stress and STB.

Health service utilization among autistic youth in Aotearoa New Zealand: A nationwide cross-sectional study

Many autistic youth have complex healthcare needs, resulting in high rates of health service utilization. However, many characteristics of this health service utilization remain unknown. Using whole-of-population data, this study aimed to quantify and compare rates of psychiatric and non-psychiatric health service utilization among autistic and non-autistic youth, with and without co-occurring intellectual disability. A national retrospective cohort study was employed using linked individual-level administrative data for Aotearoa New Zealand youth (aged 0-24 years). Health service utilization outcomes included 11 psychiatric and non-psychiatric domains. Propensity score matching on a range of sociodemographic measures compared groups across health service utilization outcomes. Data were obtained for 19,479 autistic youth, 29% of whom had a co-occurring intellectual disability and 1,561,278 non-autistic youth. Results demonstrated higher rates of mental health service utilization among autistic compared with non-autistic youth, including inpatient (prevalence ratio 5.85; 95% confidence interval 4.93-6.94) and outpatient (prevalence ratio 4.96; 95% confidence interval 4.75-5.18) service use and psychotropic medication dispensing (prevalence ratio 6.83; 95% confidence interval 6.65-7.02), particularly among autistic youth without intellectual disability. Rates of non-psychiatric hospital admissions (prevalence ratio 1.93; 95% confidence interval 1.85-2.01), potentially avoidable hospitalizations (prevalence ratio 1.91; 95% confidence interval 1.82-2.00) and outpatient visits (prevalence ratio 1.99; 95% confidence interval 1.95-2.01) were also higher among autistic youth. Research implications for delivery of healthcare services are discussed.Lay abstractAutistic youth generally use healthcare services more often than non-autistic youth. However, we know very little about the factors that can affect health service use and the types of services that are used, and this has not been explored in Aotearoa New Zealand. We analysed data from New Zealand to compare health service use among autistic and non-autistic youth (0 to 24-year-olds). Data were available for 19,479 autistic youth and 1,561,278 non-autistic youth. We compared hospitalizations, specialist visits, emergency department visits and use of different types of medications. In this study, autistic youth were found to have been hospitalized for medical and mental health reasons, more often than non-autistic youth. Autistic youth were also more likely to have attended specialist appointments and to have been given medication. These differences were particularly large for medications commonly used for mental health conditions (e.g. anxiety, depression, attention deficit hyperactivity disorder) or associated symptoms. Autistic youth who also had an intellectual disability were more likely to use healthcare services for physical health conditions, but were less likely to use mental health services, when compared with autistic youth who did not have an intellectual disability. These findings, along with other research, suggest that the healthcare needs of autistic youth are not always being met. Further work is needed to enhance our understanding of co-occurring conditions among autistic youth, including those that result in high rates of health service use, in order to inform the development of healthcare services and training for healthcare professionals to better cater to the needs of autistic youth.

Association between autism diagnosis rates and adolescent depression: A population-based study in Sweden

INTRODUCTION

The association between increasing diagnosis rates of autism-related disorders (ASD-R) in Swedish regions and diagnosis rates of major depressive disorders (MDD) in adolescents remains unexplored.

METHODS

Following STROBE guidelines, this pre-registered (https://osf.io/duvq7) observational study, utilizing registry data from 2008 to 2022 across the 21 Swedish regions, employed a generalized linear mixed model (GLMM) to analyze the association between ASD-R (ICD-10: F84) and MDD diagnosis rates (ICD-10: F32) in 15-19 year olds, with registered primary diagnoses considered. The GLMM included psychiatric care affiliation rates (PCAR) as fixed effects and variations across years and regions as random intercepts. The model incorporated bipolar disorder (BD) rates and the male-to-female ratio of ASD-R diagnoses when justified. Separate models were created for combined sexes, males, and females.

RESULTS

A significant inverse relationship was observed between ASD-R and MDD diagnosis rates across all sex groups. In the combined-sex model, the mean ratio was 0.40 (P = 0.003), while the sex-specific models showed ratios of 0.28 for males (P < 0.001) and 0.37 for females (P = 0.017). All ratios were significantly below 1, indicating a negative association between ASD-R and MDD diagnosis rates.

CONCLUSIONS

The study's observational nature limits causal inferences, but findings reveal that higher primary diagnosis rates of ASD-R correlate with lower primary diagnosis rates of MDD in adolescents of both sexes, although more pronounced in males. These results highlight the importance of further research on the relationship between ASD-R and MDD diagnosis rates, emphasizing the need for prospective, longitudinal, and individualized register data that include both primary and co-diagnoses.

Autistic and transgender/gender diverse people's experiences of health and healthcare

BACKGROUND

Autistic people and transgender/gender diverse people experience poorer healthcare experiences and greater risk of diagnosed, suspected, and assessment recommended health conditions, compared to non-autistic and cisgender individuals, respectively. Despite this, there is a paucity of studies on the healthcare experiences and health outcomes of transgender/gender diverse autistic individuals.

METHODS

We compared the healthcare experiences and health outcomes of cisgender autistic (n = 1094), transgender/gender diverse autistic (n = 174), and cisgender non-autistic adults (n = 1295) via an anonymous, self-report survey. All individuals whose sex assigned at birth did not match their current gender identity were categorized as transgender/gender diverse; this was possible to determine, as the survey asked about sex assigned at birth and gender in separate questions. Unfortunately, n = 57 transgender/gender diverse non-autistic participants were excluded from these analyses a priori, due to low power. Unadjusted and adjusted binomial logistic regression models with FDR correction were employed to assess healthcare experiences and rates of co-occurring mental and physical health conditions.

RESULTS

Both transgender/gender diverse and cisgender autistic adults had higher rates of all health conditions (including conditions that are formally diagnosed, suspected, or recommended for assessment), compared to cisgender non-autistic adults. Transgender/gender diverse autistic adults were 2.3 times more likely to report a physical health condition, 10.9 times more likely to report a mental health condition, and 5.8 times more likely to report self-harm than cisgender non-autistic adults. Both autistic groups also reported significantly poorer healthcare experiences across 50/51 items.

LIMITATIONS

These data were not originally collected to understand the experiences of transgender/gender diverse individuals. In addition, our recruitment strategies, use of a convenience sampling method, and the use of a self-report survey limit the generalizability of the study. As our sample was biased towards white individuals, UK residents, relatively highly educated individuals, those assigned female at birth, and those who currently identify as female, our findings may be less applicable to individuals of differing demographics. Finally, the present study does not include information on the experiences of transgender/gender diverse non-autistic people.

CONCLUSIONS

Autistic people have poorer self-reported health and healthcare; however, being gender diverse is associated with further risk for certain adverse experiences and outcomes. Future research on the health and healthcare experiences of transgender/gender diverse autistic people is urgently needed. In particular, forthcoming studies in this area should aim to recruit large-scale and representative studies and should compare the experiences of transgender/gender diverse autistic people to those of transgender/gender diverse non-autistic people. Greater recognition of challenges and reasonable adjustments are essential for people with marginalized, intersectional identities in clinical practice.

Patterns and correlates of two-year changes in depressive symptoms for autistic adults

Background

Autistic adults are at elevated risk for depression. However, longitudinal data on the trajectory of depressive symptoms and its associated factors in autistic adults are scarce.

Methods

A community sample of 315 autistic adults participated in a two-year longitudinal study from the beginning of (March 2020) to the recovery from the COVID-19 pandemic (March 2022). They provided five waves of data on self-reported depressive symptoms and sociodemographic and life circumstances information.

Results

Multilevel model results showed that autistic adults reported large between-individual variability in self-reported depressive symptoms, and on average, they experienced an increase (i.e., worsening) in self-reported depressive symptoms over the two years of the study. Autistic adults with a depression history and lower annual household income reported higher levels of depressive symptoms. More importantly, autistic adults reported lower depressive symptoms when they were engaged in work or school, and those who had higher levels of depressive symptoms at the start of the study were more reactive to changes in work or school participation.

Conclusions

Findings from the current study have implications for potential venues of depression treatment in autistic adults around promoting employment/education, providing symptom monitoring, and addressing mental health disparities for those with lower incomes.

Borderline Personality as a Factor in Late, Missed, and Mis-Diagnosis in Autistic Girls and Women: A Conceptual Analysis

Autism without intellectual disability is diagnosed later and with greater difficulty in girls/women relative to boys/men. For autistic girls and women, the journey to an autism diagnosis may include one or more misdiagnoses. Misdiagnosis with borderline personality disorder (BPD) or borderline traits may be particularly common, and characteristics often observed in autistic girls and women may contribute specifically to a risk of misdiagnosis with BPD. This review draws from a burgeoning literature on autism in girls and women to provide a detailed discussion of differential diagnosis of BPD and autism in cisgender girls/women, with a focus on phenotypic traits and/or their presentation that may be more common in autistic girls/women and that may be particularly prone to miscategorization as BPD. Distinctions between autism and BPD are identified, emphasizing the need for scrutiny of an individual's clinical presentation to tease apart differences between the autism and BPD phenotypes. We highlight instances in which similar phenotypic expressions may be driven by differing underlying factors. Implications for the distinction of autism and BPD/borderline traits in informing appropriate therapeutic intervention are discussed.

Time is of the essence: Age at autism diagnosis, sex assigned at birth, and psychopathology

LAY ABSTRACT

Previous research has shown that girls/women are diagnosed later than boys/men with autism. Individuals who are diagnosed later in life, especially girls/women, have greater anxious and depressive symptoms. Previous research has been limited due to narrow inclusionary criteria for enrollment in studies. The present study uses two samples-one clinic-based, large "real-world" sample and another research-based sample with strict criteria for autism diagnosis-to understand the relationships between diagnostic age, sex assigned at birth, and symptoms of anxiety/depression. In both samples, those who were diagnosed later had greater anxious/depressive symptoms, and anxiety was not predicted by sex. In the clinic-based but not research-based sample, those assigned female at birth were diagnosed later than those assigned male at birth. In the clinic-based sample only, individuals assigned female at birth and who were later diagnosed experienced greater symptoms of anxiety/depression compared to those assigned male who benefited from earlier diagnostic timing. Within the research-based sample, those assigned female at birth had greater depressive symptoms than those assigned male. These findings highlight the importance of timely identification of autism, especially for girls/women who are often diagnosed later. Community-based samples are needed to better understand real-world sex-based and diagnostic age-based disparities in mental health.

Prevalence and heritability of parental-reported speech and/or language difficulties in a Swedish population-based twin sample

Background

Research on genetic and environmental influences on speech and/or language difficulties (SaLD) is sparse, with inconsistent heritability estimates. We aimed to estimate the prevalence of parental reported SaLD and the relative contributions of genetic and environmental factors for the phenotype using a Swedish population-based twin sample. We hypothesized that there would be a stronger genetic than environmental effect on SaLD.

Methods

Data were collected from The Child and Adolescent Twin Study in Sweden. The study sample included 16,774 twin pairs (16,946 males, 16,602 females), of which 5141 were monozygotic, 5861 dizygotic (DZ), and 5772 opposite-sex DZ pairs. The language items in the Autism-Tics, Attention-Deficit Hyperactivity Disorder, and other Comorbidities inventory were used to categorize individuals as having parental-reported SaLD. A classical twin design was used to estimate the relative contribution of genetic and environmental factors to the liability of SaLD.

Results

The prevalence of SaLD was 7.85% (95% confidence interval (CI) [7.57%-8.15%]) and 7.27% (95% CI [6.99%-7.55%]) when excluding individuals with autism and intellectual disability (ID). We also found that SaLD were significantly more prevalent in males than females with a ratio of 2:1. The heritability was estimated to be 75% (95% CI [67%-83%]) for SaLD. Shared environment played a significant role with an estimated contribution of 22% (95% CI [14%-30%]). The heritability estimate was reduced to 70% but with overlapping CI when excluding individuals with autism and ID.

Conclusions

We provide evidence that SaLD is common in the population and under strong genetic influence. Future studies should focus on mapping the genetic architecture of SaLD and related disorders.

Factors mediating pre-existing autism diagnosis and later suicidal thoughts and behaviors: A follow-up cohort study

LAY ABSTRACT

Autistic people are more likely to experience suicidal thoughts and behaviors. The underlying relationships between potential risk factors and suicidal thoughts and behaviors in autistic individuals remain unclear. To understand this, we investigated whether specific factors in childhood/youth explain the effects of pre-existing autism spectrum disorder (ASD) diagnoses on later suicidal thoughts and behaviors in adolescence/adulthood. We assessed internalizing and externalizing problems, bullying experiences, and executive functions (including cognitive flexibility, sustained attention, and spatial working memory) at an average baseline age of 13.4 years and suicidal thoughts and behaviors at an average follow-up age of 19.2 years among 129 autistic and 121 typically developing (TD) individuals. During the follow-up period in adolescence/adulthood, autistic individuals were more likely to report suicidal thoughts than TD individuals. Being bullied partially accounted for the relationship between a pre-existing ASD diagnosis and later-reported higher suicidal thoughts. Contrary to our hypothesis, higher (instead of lower) cognitive flexibility in some autistic young people appeared to partially explain their higher rates of suicidal thoughts compared with typically developing young people. The findings imply that school bullying prevention and tailored intervention programs for autistic people, especially those with higher cognitive flexibility, are warranted to reduce their risks of experiencing suicidal thoughts.

Effect of per- and polyfluoroalkyl substances on neurodevelopment: Evidence-based risk assessment in the TRAEC strategy context

Although emerging evidence on the association between per- and polyfluoroalkyl substances (PFASs) and neurodevelopment have been investigated, there is no consensus on the effect of maternal PFASs on neurodevelopment in offspring. Here, we assessed the risk of maternal PFASs exposure on the neurodevelopment of offspring using a novel Targeted Risk Assessment of Environmental Chemicals (TRAEC) strategy based on multiple evidence. The evidence from five online databases were analyzed the effect of PFASs on neurodevelopment. The potential neurodevelopment risk of PFASs was evaluated by the TRAEC strategy, which was conducted on a comprehensive scoring system with reliability, correlation, outcome fitness and integrity. The studies from five databases and additional researchers' experiments were included the present study to proceed following risk assessment. Based on the framework with TRAEC strategy, the comprehensive evaluation of health risks was classified as low (absolute value 0-4), medium (absolute value 4-8), high (absolute value 8-10). In the present study, the effect of PFASs exposure on neurodevelopment was a medium-risk level with 5.61 overall risk-score. The population-attributable risk (PAR) was 8.26 % for maternal PFASs exposure. The study identified a low-risk effect of prenatal PFASs exposure on ASD and behavioral disabilities. The chain length, type of PFASs and neurodevelopmental trajectories contributed to the risk of maternal PFASs on the neurodevelopment of offspring. Consistent with results of four criteria-based tools (ToxRTool, SciRAP, OHAT and IRIS), health risk assessment based on the TRAEC strategy demonstrated robustness and reliability in the present study. These results illustrated a medium-risk effect of maternal PFASs exposure on neurodevelopmental disorders of offspring. In addition, the TRAEC strategy provided a scientific and structured method for effect evaluation between prenatal PFASs and neurodevelopmental disorders, promoting the consistency and validation in risk assessment.

Pourcain B, Robinson EB, Bourgeron T, Baron-Cohen S, Børglum AD, Martin HC, Warrier V. An axis of genetic heterogeneity in autism is indexed by age at diagnosis and is associated with varying developmental and mental health profiles

There is growing recognition that earliest signs of autism need not clearly manifest in the first three years of life. To what extent is this variation in developmental trajectories associated with age at autism diagnosis? Does the genetic profile of autism vary with age at autism diagnosis? Using longitudinal data from four birth cohorts, we demonstrate that two different trajectories of socio-emotional behaviours are associated with age at diagnosis. We further demonstrate that the age at autism diagnosis is partly heritable (h2 SNP = 0.12, s.e.m = 0.01), and is associated with two moderately correlated (rg = 0.38, s.e.m = 0.07) autism polygenic factors. One of these factors is associated with earlier diagnosis of autism, lower social and communication abilities in early childhood. The second factor is associated with later autism diagnosis, increased socio-emotional difficulties in adolescence, and has moderate to high positive genetic correlations with Attention-Deficit/Hyperactivity Disorder, mental health conditions, and trauma. Overall, our research identifies an axis of heterogeneity in autism, indexed by age at diagnosis, which partly explains heterogeneity in autism and the profiles of co-occurring neurodevelopmental and mental health profiles. Our findings have important implications for how we conceptualise autism and provide one model to explain some of the diversity within autism.

Support in Daily Living for Young Adults with Neurodevelopmental Conditions in Sweden: A Qualitative Description of Current Practice

In Sweden, people living independently and requiring daily living support can access 'housing support', a form of practical, educational, and social support provided by the municipalities. About two-thirds of those receiving this support have neurodevelopmental conditions, primarily autism or ADHD. Many are young adults in the process of adapting to new roles and expectations in different life domains, including education, work, and accommodation. This study aimed to provide a qualitative description of support workers' views on current practice in housing support for young adults (aged 18 to 29) with neurodevelopmental conditions. Semi-structured telephone interviews were conducted with 34 housing support workers across 19 Swedish regions. An inductive qualitative content analysis approach was used. The interviews depicted a complex service, subject to organizational aspects (roles, responsibilities, availability, and allocation), the joint effort of key players (young adults, relatives, and support workers), and practical aspects of service provision (finding common ground for the work, and delivery of support). Some elements of the service were poorly designed for the target group. The support workers expressed a need for more knowledge about neurodevelopmental conditions, but also described new insights related to remote delivery of support. The results raise important questions about how housing support should be organized and delivered to strike the right balance between support and autonomy, meet specific needs, and ensure equal services across municipalities. Future research should adopt multiple perspectives and approaches, to help translate best practice and available evidence into a flexible and sustainable service.

Associations and attributable burdens in late-life exposure to PM2.5 and its major components and depressive symptoms in middle-aged and older adults: A nationwide cohort study

BACKGROUND

Depression in late life has been associated with reduced quality of life and increased mortality. Whether the chronic fine particular matter (PM2.5) and its components exposure are contributed to the older depression symptoms remains unclear.

METHOD

Middle-aged and older adults (>45 years) were selected from the China Health and Retirement Longitudinal Study during the four waves of interviews. The concentrations of PM2.5 and its major constituents were calculated using near real-time data at a spatial resolution of 10 km during the study period. The depressive symptom was evaluated by the Depression Center for Epidemiologic Studies Depression (CES-D)-10 score. The fix-effect model was applied to evaluate the association between PM2.5 and its major constituents with depressive symptoms. Three three-step methods were used to explore the modification role of sleep duration against the depressive symptoms caused by PM2.5 exposure.

RESULTS

In our study, a total of 52,683 observations of 16,681 middle-aged and older adults were assessed. Each interquartile range (IQR) level of PM2.5 concentration exposure was longitudinally associated with a 2.6 % (95 % confidence interval [CI]: 1.3 %, 4.0 %) increase in the depression CES-D-10 score. Regarding the major components of PM2.5, OM, NO3-, and NH4+ showed the leading toxicity effects, which could increase the depression CES-D-10 score by 2.2 % (95 %CI: 1.0 %, 3.4 %), 2.2 % (0.6 %, 3.9 %), and 2.0 % (95 %CI: 0.6 %, 3.4 %) correspondingly. Besides, males were more susceptible to the worse depressive symptoms caused by PM2.5 and its major components exposure than female subpopulations. Shortened sleep duration might be the mediator of PM2.5-associated depressive symptoms.

CONCLUSION

Our results suggest that long-term exposure to PM2.5 and its major components were associated with an increased risk for depressive symptoms in middle-aged and older adults. Reducing the leading components of PM2.5 may cost-effectively alleviate the disease burden of depression and promote healthy longevity in heavy pollutant countries.

Testing the social motivation theory of autism: the role of co-occurring anxiety

BACKGROUND

The Social Motivation Theory proposes that social reward processing differences underlie autism. However, low social motivation has also been linked to higher anxiety. Given the co-occurrence between autism and anxiety, it is possible that anxiety drives the association between social motivation and autistic characteristics. This study tests the mechanisms underlying the association between social motivation and autistic traits.

METHODS

Participants were 165 adolescents (71 male), aged 10-16 years, from the Mapping profiles of cognition, motivation and attention in childhood (C-MAPS) study, enriched for autistic traits (70 participants with an autism diagnosis, 37 male). Participants completed a battery of online experimental tasks, including a Choose-a-Movie social motivation task and social cognition measures (theory of mind; emotion recognition), alongside parent-reported child anxiety and autistic traits.

RESULTS

Higher social motivation was significantly associated with lower autistic traits (β = -.26, p < .001). Controlling for social cognition did not change the association between social motivation and autistic traits. Controlling for anxiety did significantly reduce the strength of the association (unstandardized coefficient change: p = .003), although social motivation remained associated with autistic traits (β = -.16, p = .004). Post hoc analyses demonstrated differential sex-effects: The association between social motivation and autistic traits was significant only in the females (β = -.38, p < .001), as was the attenuation by anxiety (unstandardized coefficient change: p < .001).

CONCLUSIONS

The association between social motivation and autistic traits could be partially attributed to co-occurring anxiety. Sex-specific effects found in females may be due to environmental factors such as increased social demands in adolescent female relationships. Results are consistent with self-report by autistic individuals who do not identify as having reduced social motivation.

"A perfect storm": Autistic experiences of menopause and midlife

LAY ABSTRACT

Previous studies report that menopause can be a very difficult transition for some autistic people. This study focuses on how autistic people experience menopause and what support and information might help them. Autistic Community Research Associates played an important role in the research and co-authored this article. We held four focus groups and eight interviews online with 24 autistic participants who lived in either Canada (n = 13) or the United Kingdom (n = 11). We analysed participant conversations using a method called reflexive thematic analysis. Participants described many intense challenges during menopause. Four themes and eight subthemes were identified across participant groups: (1) Complexity, multiplicity and intensity of symptoms (0 subthemes); (2) Life experience and adversity converging at midlife (three subthemes); (3) The importance of knowledge and connection (two subthemes); and (4) Barriers to support and care (three subthemes). The experiences of our participants may not be the same as other autistic people, and the study could have been more inclusive of diverse autistic groups. However, hearing about the experiences of others may provide reassurance to autistic people who struggle with menopause and let them know they are not alone.

Are autistic females at greater risk of suicide? A call for clarity to advance suicide prevention for the whole community

Understanding suicide risk is critical for supporting prevention. A growing body of evidence shows autistic people are at greater risk for multiple suicide-related outcomes than non-autistic people. This commentary is in response to an observed pattern of miscommunication in scientific and community spaces about autistic females having higher risk of suicide. However, it is not always clear who they are being compared with in these statements. To address this confusion, we summarize the current population-based evidence on autistic suicide risk, highlighting findings related to sex similarities and differences, which actually indicates comparable rates of suicide death among autistic males and females, and mixed findings related to sex differences in risk of other suicidal behaviors. We call for greater clarity in suicide risk communication moving forward focused on outcomes, measurement, sampling methods, and comparison groups to reflect accurate conclusions about existing evidence. Further research is needed about the full range of suicide-related outcomes for autistic people, including a greater understanding of sex differences as well as potential gender differences to include transgender and nonbinary autistic people. However, studies of sex and gender differences should not overshadow the compelling need for efforts to understand and address the elevated risk of suicidal thoughts, behaviors, and death among autistic people across sex and gender boundaries.

Perceived misdiagnosis of psychiatric conditions in autistic adults

Background

Many autistic people, particularly women, do not receive an autism diagnosis until adulthood, delaying their access to timely support and clinical care. One possible explanation is that autistic traits may initially be misinterpreted as symptoms of other psychiatric conditions, leading some individuals to experience misdiagnosis of other psychiatric conditions prior to their autism diagnosis. However, little is currently known about the frequency and nature of psychiatric misdiagnoses in autistic adults.

Methods

Using data collected in the first half of 2019 from an ongoing longitudinal register of autistic adults in the Netherlands, this study explored the frequency of perceived psychiatric misdiagnoses before receiving an autism diagnosis. Gender differences were also explored. A sample of 1211 autistic adults (52.6% women, mean age 42.3 years), the majority of whom were Dutch and relatively highly educated, was evaluated.

Findings

Results showed that 24.6% (n = 298) of participants reported at least one previous psychiatric diagnosis that was perceived as a misdiagnosis. Personality disorders were the most frequent perceived misdiagnoses, followed by anxiety disorders, mood disorders, chronic fatigue syndrome/burnout-related disorders, and attention-deficit/hyperactivity disorder. Autistic women (31.7%) reported perceived misdiagnoses more frequently than men (16.7%). Women were specifically more likely than men to report perceived misdiagnoses of personality disorders, anxiety disorders, and mood disorders. Women also reported prior psychiatric diagnoses more often in general (65.8% versus 34.2% in men). Within the group of individuals with a prior diagnosis, perceived misdiagnoses were equally likely for men and women.

Interpretation

One in four autistic adults, and one in three autistic women, reported at least one psychiatric diagnosis, obtained prior to being diagnosed with autism, that was perceived as a misdiagnosis. Inaccurate diagnoses are linked to long diagnostic pathways and delayed recognition of autism. These findings highlight the need for improved training of mental health practitioners, in order to improve their awareness of the presentation of autism in adulthood and of the complex relationship between autism and co-occurring conditions. The current study constitutes a first step towards showing that autistic adults, and particularly women, may be at greater risk of experiencing misdiagnoses. Future studies based on larger, more representative samples are required, to replicate current findings and provide more reliable estimates of the overall frequency of misdiagnoses as well as the frequency of misdiagnoses for specific psychiatric conditions.

Funding

This study was made possible by funding from the Netherlands Organisation for Health Research and Development (ZonMW), project number 60-63600-98-834.

Mental Health Crises in Autistic Children: A Framework for Prevention and Intervention in Primary Care

Children with autism are at high risk for experiencing a mental health crisis, which occurs when psychiatric and behavioral symptoms become a danger and caregivers do not have the resources to safely manage the event. Our current mental health systems of care are not fully prepared to manage crisis in autistic individuals, due to the shortage of available mental health providers and programs that are tailored for autistic children. However, new strategies to address crisis are gradually emerging. This article provides a framework to define crisis and implement prevention and intervention approaches that could potentially mitigate risk for crisis.

Chronic Pain in Autistic Youth: Clinical Prevalence and Reflections on Tailoring Evidence-Based Interventions from an Interdisciplinary Treatment Team

Though there is growing awareness of the overrepresentation of autistic patients in chronic pain clinics, potential adaptations for the assessment and treatment of chronic pain in this population have not yet been established. To address this gap, a retrospective review of electronic medical records and discussions by an interdisciplinary pain treatment team were summarized to inform potential biopsychosocial factors affecting the presentation, assessment, and treatment of chronic pain in autistic youth. Our sample included a record review of 95 patients receiving treatment in an interdisciplinary outpatient pediatric pain clinic. Results indicated that 9% (n = 9) of the patients presented to the clinic with a prior diagnosis of autism, but an additional 21% (n = 20) were identified as likely meeting criteria for autism based on the clinical assessment of the developmental history, behaviors observed during the clinical encounter(s), and expert clinical judgment, suggesting that the prevalence rate of autism may be closer to 30% in our outpatient pediatric pain clinic. Over half (52%) of the autistic youth presented to the clinic with widespread pain, 60% identified as female, and 6% identified as gender expansive or transgender. Qualitative insights revealed that most of the autistic patients had co-occurring sensory-processing challenges and difficulty in describing their pain, emotions, and somatic experiences and exhibited cognitive inflexibility and social challenges. We summarize our team's clinical reflections on how autism-relevant biopsychosocial vulnerability factors may contribute to the experience of pain in autistic youth and propose treatment targets and adaptations for the assessment and treatment of pain in this population. Finally, we recommend the need for interventions focused on sensorimotor integration, especially for autistic youth, and describe how pain clinics may be particularly helpful for identifying and supporting autistic females, for whom the potential role of autism in pain experiences had not been considered until receiving treatment in our clinic.

X-Chromosome Dependent Differences in the Neuronal Molecular Signatures and Their Implications in Sleep Patterns

Biological factors and mechanisms that drive sex differences observed in sleep disturbances are understudied and poorly understood. The extent to which sex chromosome constitution impacts on sex differences in circadian patterns is still a knowledge void in the sleep medicine field. Here we focus on the neurological consequences of X-chromosome functional imbalances between males and females and how this molecular inequality might affect sex divergencies on sleep. In light of the X-chromosome inactivation mechanism in females and its implications in gene regulation, we describe sleep-related neuronal circuits and brain regions impacted by sex-biased modulations of the transcriptome and the epigenome. Benefited from recent large-scale genetic studies on the interplay between X-chromosome and brain function, we list clinically relevant genes that might play a role in sex differences in neuronal pathways. Those molecular signatures are put into the context of sleep and sleep-associated neurological phenotypes, aiming to identify biological mechanisms that link X-chromosome gene regulation to sex-biased human traits. These findings are a significant step forward in understanding how X-linked genes manifest in sleep-associated transcriptional networks and point to future research opportunities to address female-specific clinical manifestations and therapeutic responses.

Mental health challenges faced by autistic people

Mental health challenges impede the well-being of autistic people. This Review outlines contributing neurodevelopmental and physical health conditions, rates and developmental trajectories of mental health challenges experienced by autistic people, as well as unique clinical presentations. A framework is proposed to consider four contributing themes to aid personalized formulation: social-contextual determinants, adverse life experiences, autistic cognitive features, and shared genetic and early environmental predispositions. Current evidence-based and clinical-knowledge-informed intervention guidance and ongoing development of support are highlighted for specific mental health areas. Tailored mental health support for autistic people should be neurodivergence-informed, which is fundamentally humanistic and compatible with the prevailing bio-psycho-social frameworks. The personalized formulation should be holistic, considering physical health and transdiagnostic neurodevelopmental factors, intellectual and communication abilities, and contextual-experiential determinants and their interplay with autistic cognition and biology, alongside resilience. Supporting family well-being is integral. Mutual empathic understanding is fundamental to creating societies in which people across neurotypes are all empowered to thrive.

Autism in adult psychiatric out-patients: self-reported suicidal ideation, suicide attempts and non-suicidal self-injury

BACKGROUND

The prevalence of self-reported suicidal ideation, suicide attempts and non-suicidal self-injury (NSSI) remains unclear among adults with autism unrecognised in childhood who attend psychiatric services.

AIMS

We aimed to estimate the prevalence of suicidal ideation, suicide attempts and NSSI; identify factors associated with suicide attempts and NSSI; and describe NSSI in this group.

METHOD

Sixty-three new patients at an adult psychiatric out-patient clinic (57% women, mean age 32 years) who met full (n = 52) or subthreshold (two A criteria and minimum of two B criteria; n = 11) DSM-5 criteria for autism spectrum disorder were included in the study. Clinical assessments included overall diagnostic review, Paykel's questions on passive and active suicidality, evaluation of NSSI with the Functional Assessment of Self-Mutilation, and results of cognitive tests. One follow-up of medical records was made.

RESULTS

In this sample of psychiatric out-patients identified as first having autism in adulthood, almost a third (31%) of patients reported suicidal ideation during the past month, 86% had lifetime suicidal ideation and 25% reported at least one suicide attempt. Factors associated with suicide attempts included hazardous or harmful alcohol use and/or drug-related problems, and severity of depression. A total of 44% reported NSSI. Factors associated with NSSI were female sex, history of suicidal plans and antisocial personality disorder. Substance or alcohol use were often overlooked, especially in women.

CONCLUSIONS

Suicidal ideation, suicide attempts and NSSI were very common in adults with autism who were recently referred to an out-patient psychiatric service. Suicidal ideation and NSSI were more common than suicide attempts. Clinicians should always consider suicidal ideation and NSSI in adult psychiatric patients with autism.

Self-Harm Events and Suicide Deaths Among Autistic Individuals in Ontario, Canada

IMPORTANCE

Reasons for elevated suicide risks among autistic people are unclear, with insufficient population-based research on sex-specific patterns to inform tailored prevention and intervention.

OBJECTIVES

To examine sex-stratified rates of self-harm events and suicide death among autistic individuals compared with nonautistic individuals, as well as the associated sociodemographic and clinical risk factors.

DESIGN, SETTING, AND PARTICIPANTS

This population-based matched-cohort study using linked health administrative databases in Ontario, Canada included all individuals with physician-recorded autism diagnoses from April 1, 1988, to March 31, 2018, each matched on age and sex to 4 nonautistic individuals from the general population. Self-harm events resulting in emergency health care from April 1, 2005, to December 31, 2020, were examined for one cohort, and death by suicide and other causes from April 1, 1993, to December 31, 2018, were examined for another cohort. Statistical analyses were conducted between October 2021 and June 2023.

EXPOSURE

Physician-recorded autism diagnoses from 1988 to 2018 from health administrative databases.

MAIN OUTCOMES AND MEASURES

Autistic and nonautistic individuals who were sex stratified a priori were compared using Andersen-Gill recurrent event models on self-harm events, and cause-specific competing risk models on death by suicide or other causes. Neighborhood-level income and rurality indices, and individual-level broad diagnostic categories of intellectual disabilities, mood and anxiety disorders, schizophrenia spectrum disorders, substance use disorders, and personality disorders were covariates.

RESULTS

For self-harm events (cohort, 379 630 individuals; median age at maximum follow-up, 20 years [IQR, 15-28 years]; median age of first autism diagnosis claim for autistic individuals, 9 years [IQR, 4-15 years]; 19 800 autistic females, 56 126 autistic males 79 200 nonautistic females, and 224 504 nonautistic males), among both sexes, autism diagnoses had independent associations with self-harm events (females: relative rate, 1.83; 95% CI, 1.61-2.08; males: relative rate, 1.47; 95% CI, 1.28-1.69) after accounting for income, rurality, intellectual disabilities, and psychiatric diagnoses. For suicide death (cohort, 334 690 individuals; median age at maximum follow-up, 19 years [IQR, 14-27 years]; median age of first autism diagnosis claim for autistic individuals, 10 years [IQR, 5-16 years]; 17 982 autistic females, 48 956 autistic males, 71 928 nonautistic females, 195 824 nonautistic males), there was a significantly higher crude hazard ratio among autistic females (1.98; 95% CI, 1.11-3.56) and a nonsignificantly higher crude hazard ratio among autistic males (1.34; 95% CI, 0.99-1.82); the increased risks were associated with psychiatric diagnoses.

CONCLUSIONS AND RELEVANCE

This cohort study suggests that autistic individuals experienced increased risks of self-harm events and suicide death. Psychiatric diagnoses were significantly associated with the increased risks among both sexes, especially for suicide death, and in partially sex-unique ways. Autism-tailored and autism-informed clinical and social support to reduce suicide risks should consider multifactorial mechanisms, with a particular focus on the prevention and timely treatment of psychiatric illnesses.

Linkage of whole genome sequencing and administrative health data in autism: A proof of concept study

Whether genetic testing in autism can help understand longitudinal health outcomes and health service needs is unclear. The objective of this study was to determine whether carrying an autism-associated rare genetic variant is associated with differences in health system utilization by autistic children and youth. This retrospective cohort study examined 415 autistic children/youth who underwent genome sequencing and data collection through a translational neuroscience program (Province of Ontario Neurodevelopmental Disorders Network). Participant data were linked to provincial health administrative databases to identify historical health service utilization, health care costs, and complex chronic medical conditions during a 3-year period. Health administrative data were compared between participants with and without a rare genetic variant in at least 1 of 74 genes associated with autism. Participants with a rare variant impacting an autism-associated gene (n = 83, 20%) were less likely to have received psychiatric care (at least one psychiatrist visit: 19.3% vs. 34.3%, p = 0.01; outpatient mental health visit: 66% vs. 77%, p = 0.04). Health care costs were similar between groups (median: $5589 vs. $4938, p = 0.4) and genetic status was not associated with odds of being a high-cost participant (top 20%) in this cohort. There were no differences in the proportion with complex chronic medical conditions between those with and without an autism-associated genetic variant. Our study highlights the feasibility and potential value of genomic and health system data linkage to understand health service needs, disparities, and health trajectories in individuals with neurodevelopmental conditions.

Finding the Proportion of Females with Autistic Spectrum Disorder Who Develop Anorexia Nervosa, the True Prevalence of Female ASD and Its Clinical Significance

It appears that up to 80% of females with autistic spectrum disorder (ASD) have not been diagnosed by the age of 18. This translates to a prevalence of about 5-6%, and if true, has serious implications for female mental health. One way of finding the true value is to use Bayes' Theorem with a comorbid condition as a more easily recognizable flag. An obvious choice is anorexia nervosa (AN), but it transpires that the proportion of women with ASD who develop AN is unknown. This study uses published data in novel ways to provide two methods of estimating a range for this variable, and gives a median value of 8.3% for AN in ASD and, with four other methods, a median prevalence of 6% for female ASD. The clinical implications of the diagnosis and management of ASD and its comorbidities are discussed and, as an example, a solution is provided for the rate of ASD in symptomatic generalized joint hypermobility. It is probable that one in six women with a mental health condition is autistic.