Associations between co-occurring conditions and age of autism diagnosis: Implications for mental health training and adult autism research

Brief Report: Mental Health and Wellbeing Across the Autism Assessment Experience

PURPOSE

With growing frequency, young people are referred for autism assessment following the onset of mental health difficulties, such as anxiety and depression. Understanding the nature of these difficulties and how they change through the assessment process may be crucial in providing effective support; this study provided the first longitudinal assessment of that.

METHOD

Twenty-seven young people and their parents/carers completed questionnaire measures of mental health, wellbeing and quality of life while waiting for an autism assessment, at the point of assessment and three months after receiving their diagnostic outcome.

RESULTS

A range of clinically-significant mental health presentations were reported. Young people commonly reported more severe symptoms than their parents, while parents reported a more significant impact. Mental health symptoms were correlated with quality of life. There was not evidence that the potentially stressful experience of waiting for and completing an assessment negatively impacted young people's mental health or wellbeing.

CONCLUSION

Young people waiting for autism assessment experience varied, enduring and impactful difficulties with mental health: comprehensive assessment is required to meet their needs. At a group-level, there is no good reason to delay autism assessment for fear of worsening mental health symptoms.

Good Psychiatric Management of Borderline Personality Disorder and Co-Occurring Autism Spectrum Disorder

Borderline personality disorder has been estimated to occur among about 4% of those with autism spectrum disorder. This co-occurrence can escalate the challenges of treating either condition separately, and patients often face severe challenges in psychosocial and occupational functioning. Clinicians need guidance to manage a high degree of complexity, using standards of care and a synthesis of what is known so far, to navigate the currently limited armamentarium of clinical tools. This article reviews the available scientific research and clinical experience with respect to diagnosis, psychoeducation, treatment framework, safety management, other co-occurring disorders, and multimodal treatments. It also discusses future directions for generating new knowledge to improve the care of patients with this important co-occurrence. Although the discussion explores the unique complexity and relative lack of clinical guidelines at present, good psychiatric management serves as a clinical framework that anchors treatment approaches as the evidence base develops.

Determining rates of genetic testing in the evaluation of autism spectrum disorder and intellectual and developmental disorder

Genetic tests, such as Fragile X and Chromosomal Microarray, are recommended as a standard of care during the evaluation of autism spectrum disorder (ASD) and other neurodevelopmental disorders. However, previous research demonstrates low rates of genetic testing. This study aimed to identify the rates of genetic testing and patient demographic factors that may be associated by conducting a retrospective chart review of 7539 electronic health records of patients who were evaluated for ASD or other neurodevelopmental disorders within a university healthcare network. Researchers created a database that listed patient demographics (race, gender, insurance, zip code), records of ordered but not completed tests, genetic test results and reasons for declining genetic tests (if noted), and other known barriers to genetic testing. Statistical analyses were conducted to determine associations between genetic testing rates and sociodemographic factors. 30.57% of patients received at least one indicated genetic test, while 11.31% received recommended concordant genetic testing. Findings suggest that while gender did not impact whether a patient received at least one genetic test, race and insurance did. Our review demonstrates that genetic testing is not sufficiently offered by physicians, and there are multiple barriers preventing patients from receiving genetic testing, which must be further investigated.Lay abstractGenetic testing is recommended by various professional organizations as part of clinical guidelines during the evaluation of autism spectrum disorder (ASD) and other neurodevelopmental disorders. However, previous studies demonstrate that rates of genetic testing are low. This study aimed to identify the rates of genetic testing within a large university healthcare network and factors that may be associated with higher or lower rates. Researchers reviewed over 7500 electronic health records of patients who were evaluated for ASD or other neurodevelopmental disorders. Some factors that were recorded include patient demographics (race, gender, insurance, zip code), ordered but not completed tests, genetic test results and reasons for declining genetic tests if noted, and other known barriers to genetic testing such as blood draws and specialties of providers seen by patients. Statistical analysis was conducted to determine associations between rates of genetic testing and different factors recorded in our database. Our results demonstrate that less than half of patients received at least one indicated genetic test, while a smaller percentage received recommended genetic tests. While sex assigned at birth and gender did not impact whether a patient received at least one indicated genetic test, race and insurance did. Our review reveals that genetic testing is not sufficiently offered by physicians, and we have identified multiple obstacles that prevent patients from receiving genetic testing which must be further investigated.

Building Better Medicine: Translational Justice and the Quest for Equity in US Healthcare

Despite considerable scientific progress and the evolution of regulatory pathways to ensure safety and efficacy, US healthcare continues to see increasing health disparities. This suggests that clinical translation in of itself cannot be the only measure of its own success, especially when the most marginalized patients, are neglected in the development and implementation of medical innovations. This raises the question of whether a system that is narrowly focused on technical achievement can meet the moral obligations of medicine and public health. We argue that traditional technocratic standards are failing to integrate normative considerations into biomedical translation. What is needed is a translational domain that moves beyond safety and efficacy toward anticipating how proposed technologies will be effective in society as it exists. We propose an additional metric of success: translational justice.

Mental Health Care Needs and Access to Care for Adults With Intellectual Disabilities

BACKGROUND

Adults with intellectual disabilities (IDs) are at greater risk for psychiatric disorders than the general population. Yet, they have limited access to mental health services.

OBJECTIVES

To examine the prevalence of psychiatric disorders in adults with ID. To describe evidence-based interventions for this population, their access to mental health care, and outline opportunities for improved access.

DESIGN

This manuscript summarizes literature regarding psychiatric disorders in adults with ID and their access to behavioral health care. We considered articles referencing mental health care for adults with ID. PubMed and a variety of search terms were used. Studies published in English from 2010 to the date of the searches were included. Quantitative and qualitative study designs, review articles, program descriptions, and opinion papers were considered for inclusion. Additional references from the selected articles were also considered.

RESULTS

We identified 2864 records. One hundred two records were included, consisting of work commenting on mental health and ID and access to care in the United States. The articles describe increased psychiatric comorbidities in adults with ID. They highlight the few evidence-based interventions for psychiatric comorbidities and the limited access to care.

CONCLUSIONS

Our mental health care providers generally have minimal training and experience with people with ID, limiting access to appropriate care for these individuals. Improved access could be created by increasing education and experiences with these populations for mental health providers. Aligning policies, financing, and adequate insurance reimbursement to develop a continuum of care will be critical for these individuals.

Mental health care use of autistic adults: Identifying longitudinal patterns using sequence analysis

LAY ABSTRACT

Many autistic adults experience co-occurring mental health problems, which have a negative effect on their well-being and result in increased use of mental health services. To improve mental healthcare for autistic adults, a better understanding is needed of what type of support they use in real life. Clinical guidelines recommend three kinds of mental health interventions: therapy, counseling, and medication. We investigated the use of these types of interventions in a sample of 445 autistic adults (aged 18-87 years) across a 5-to-7-year period. We found evidence for four different patterns of intervention use, or so-called subgroups: (1) least intervention use, (2) mostly counseling, (3) mostly medication, and (4) mixed intervention use. The group with mixed intervention use consisted of relatively more females and individuals with co-occurring psychiatric conditions, especially compared to the subgroup with the least intervention use. It appeared that many, but not all, autistic individuals used mental health services for an extended period. However, there was considerable variability in the type, combination, and duration of intervention use. This means that determining the optimal support for autistic adults is often a complex task, which requires collaboration of clinical experts and autistic individuals themselves, to make informed decisions.

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.

Alexithymia, Inner Thinking Patterns, and Perceptions of Mental Health Therapy Strategies Among Autistic Adults

PURPOSE

Autistic adults are at high risk for mental health challenges, yet there has been limited research on mental health interventions for this population. Individual differences in how thoughts and emotions are perceived may directly relate to the success of specific therapy strategies. This study examined whether alexithymia and inner thinking patterns relate to helpfulness and ease of use of mental health therapy strategies among autistic adults.

METHOD

Participants (n = 269 autistic adults, ages 21-77) completed questionnaires assessing alexithymia, inner thinking patterns (i.e., self-talk, verbal thinking, visual thinking), and experiences with mental health therapy strategies. Ordinal logistic regressions were used to examine associations between alexithymia, inner thinking, and perceived helpfulness and ease of use of therapy strategies.

RESULTS

Autistic adults with greater alexithymia found cognitive strategies more difficult to use, while those with greater frequency of self-talk found them easier to use. By contrast, autistic adults with greater visual thinking found guided imagery strategies easier to use. There were no associations between alexithymia or inner thinking and perceived helpfulness or ease of use of behavioral strategies (exposure, behavioral activation), mind-body relaxation strategies (deep breathing, progressive muscle relaxation), or mindfulness meditation.

CONCLUSIONS

The findings suggest that some mental health strategies may be more difficult to implement for some autistic adults, depending on individual thinking profiles. However, alexithymia and inner thinking patterns were unrelated to the perceived helpfulness of mental health strategies. Overall, this highlights the importance of providing individualized supports and accommodations to optimize mental health therapy for autistic adults.

Longitudinal Analyses of Mental Health in Autistic Individuals: A Systematic Review

BACKGROUND/OBJECTIVES

Co-occurring mental health conditions affect autistic individuals at high rates, impacting their well-being and quality of life. Mental health conditions are often appropriate treatment targets that can improve the lives of autistic individuals. Because of this, there is growing interest in predictors of mental health and behavioral outcomes. Given the rapidly evolving evidence base and growing literature using longitudinal cohorts, it is unclear which predictors of symptoms of anxiety and depression are consistent, and which are not. Additionally, it is difficult to deduce which predictors of mental health symptoms at a given time also predict change over time. This can be partially due to the different statistical approaches that are implemented, including trajectory vs. non-trajectory methodologies.

METHODS

We conducted a systematic review to evaluate how non-trajectory and trajectory analyses inform our knowledge of how symptoms of anxiety and depression change over time. Additionally, we aimed to identify important predictors of change and later anxiety and depressive symptoms in autistic individuals.

RESULTS

There is variability in symptoms of anxiety and depression in autistic individuals. Adaptive skills arose as significant predictors of change and of later symptoms of both anxiety and depression. Peer relationships in school age seem to be particularly important in predicting later symptoms of depression.

CONCLUSIONS

This review provides evidence that there are different trajectories and different patterns of mental health symptoms over the lifespan, providing further evidence that autism is a developmental condition that changes over time in different ways for different people. Implications and future directions are further discussed.

Finding Similarities in Differences Between Autistic Adults: Two Replicated Subgroups

Autism is heterogeneous, which complicates providing tailored support and future prospects. We aim to identify subgroups in autistic adults with average to high intelligence, to clarify if certain subgroups might need support. We included 14 questionnaire variables related to aging and/or autism (e.g., demographic, psychological, and lifestyle). Community detection analysis was used for subgroup identification in an original sample of 114 autistic adults with an adulthood diagnosis (autism) and 58 non-autistic adults as comparison group (COMP), and a replication sample (NAutism = 261; NCOMP = 287), both aged 30-89 years. Next, we identified subgroups and assessed external validity (for cognitive and psychological difficulties, and quality of life [QoL]) in the autism samples. To test specificity, we repeated the analysis after adding 123 adults with ADHD, aged 30-80 years. As expected, the autism and COMP groups formed distinct subgroups. Among autistic adults, we identified three subgroups of which two were replicated. One of these subgroups seemed most vulnerable on the cluster variables; this subgroup also reported the most cognitive and psychological difficulties, and lowest QoL. Adding the ADHD group did not alter results. Within autistic adults, one subgroup could especially benefit from support and specialized care, although this must be tested in future studies.

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.

The effectiveness and safety of dialectical behavior therapy for suicidal ideation and behavior in autistic adults: a pragmatic randomized controlled trial

BACKGROUNDS

Many autistic people in mental health are suicidal. This study evaluated the effectiveness of dialectical behavior therapy (DBT) v. treatment as usual (TAU) in reducing suicidal ideation and suicide attempts.

METHODS

At six Dutch mental health centers, 123 outpatients (18-65 years) with DSM-5 diagnosed autism spectrum disorder (ASD) and suicidal behavior were randomly assigned to the DBT intervention group (n = 63) or TAU control group (n = 60). Assessments were conducted at baseline, post-treatment at 6 months and 12-month follow-up. The primary outcomes were severity of suicidal ideation and frequency of suicide attempts. The severity of depression and social anxiety were secondary outcomes.

RESULTS

At end-of-treatment, DBT significantly reduced both suicidal ideation (z = -2.24; p = 0.025; b = -4.41; s.e. = 197.0) and suicide attempts (z = -3.15; p = 0.002; IRR = 0.046; s.e. = 0.045) compared to TAU, but lost statistical significance at the 12-month follow-up. Depression severity significantly decreased with DBT (z = -1.99; p = 0.046: b = -2.74; s.e. = 1.37) remaining so at 12 months (z = -2.46; p = 0.014; b = -3.37; s.e. = 1.37). No effects were observed on social anxiety. Severe adverse events included two suicides in the TAU condition.

CONCLUSIONS

DBT is an acceptable, safe, and short-term effective intervention to reduce suicidal ideation and suicide attempts in autistic adults with suicidal behavior.

Aging Well and Autism: A Narrative Review and Recommendations for Future Research

With autism first recognized in the 1940s, the early cohorts of autistic children are beginning to enter older adulthood. Little is known about the experiences and outcomes of autistic older adults. In the general population, "successful aging" is a dominant model among gerontologists and is used to evaluate outcomes in older adulthood. This narrative review aims to provide a framework for understanding and supporting successful aging in older autistic adults. Using Fernández-Ballesteros' four-domain model of "aging well" we review knowledge on aging and autism by examining outcomes in health and functioning, cognitive and physical functioning, positive affect and control, and social participation and engagement. Findings indicate that outcomes in autistic older adults are generally poor, marked by increased medical conditions, low adaptive skills, elevated risk of cognitive decline, limited physical activity, high rates of mental health conditions, low quality of life, and reduced social or community participation. Patterns of challenges are similar across cognitive abilities and profiles of autistic traits. Challenges and next steps in aging and autism research are identified, and future directions for the field are discussed.

Autistic adults' experiences of financial wellbeing: Part II

LAY ABSTRACT

Money matters in people's lives. It helps to meet people's basic needs (food, clothes, shelter) and live the lives they want to. When people talk about 'financial wellbeing', they mean how much you feel in control over day-to-day finances and how much freedom you have to make choices to enjoy life. We don't know what autistic people think about these things. That's why we did our study. We spoke to 21 autistic adults (24-69 years) about how they felt about their financial situation. We deliberately spoke to people who had told us previously they felt 'financially well' or 'financially unwell' so we could hear a range of opinions. Autistic people told us financial wellbeing meant having enough money to pay for their basics needs, to have a safety net for unexpected bills and not having to worry about money now or in the future. But many felt that good financial wellbeing was not possible for them. They often did not have a stable income to cover day-to-day expenses. This limited the choices they could make. Despite these challenges, autistic people told us they worked hard to budget and save money when they could - because feeling financial insecure was just too stressful, especially when they could not rely on family or friends for support. It made them feel mentally unwell. Our study shows there are many factors that influence autistic people's financial wellbeing. We need more research to help us understand how autistic people can be supported to achieve financial security.

Benefit or Problem: Exploration of How Response Options Affect Self-Reported Behaviors and Interests in Autistic Adults

Assessment of restricted, repetitive behaviors (RRB) in autism evaluations often assumes that these behaviors negatively impact the individual. Qualitative studies of first-person accounts indicate the negative impact of the stigma associated with RRBs but also provide insights into the positive aspects. The current study explores how framing response options as negative (i.e., level of problem associated with occurrence) or positive (i.e., level of benefit associated with occurrence) affects RRB self-reports in autistic adults. Sixty-six autistic adults aged 18-59 filled out the Repetitive Behavior Scale-Revised (RBS-R) and a modified RBS-R+, assessing problems and benefits of reported behaviors, respectively. There was a moderate to strong correlation between the forms, each assessing problems and benefits in terms of the number of behaviors endorsed (r = 0.746) and the levels of benefits and problems (r = 0.637). Autistic adults reported a higher number of RRBs in the form that assessed problems, but the number of behaviors was comparable between the forms when counting in the response option of the occurrence of behavior without having a benefit. Despite some variability in the level of problems and the benefits across the subdomains of RRB, autistic adults largely rated comparable levels of associated benefits and problems, highlighting the complexity of RRBs as having both positive and negative impacts. Future screening and diagnostic tools for adults should aim to assess both positive and negative aspects of autistic features to afford a more nuanced understanding of individual experiences while still yielding diagnostically relevant information. Qualitative studies are needed to better understand the complex experiences associated with these behaviors; however, it may be important to ensure that options for endorsement of behaviors without a specific benefit are also needed to ensure some behaviors (e.g., self-injurious behaviors) are not missed.

The emotional support plan: Feasibility trials of a brief, telehealth-based mobile intervention to support coping for autistic adults

LAY ABSTRACT

Autistic adults may have difficulty coping during stressful periods, which could make them more vulnerable to depression and anxiety. We designed the emotional support plan (ESP) to help autistic people find ways to cope in stressful situations. Thirty-six autistic adults created an ESP and answered questions about their opinions of the ESP. Most autistic adults found the ESP to have a positive impact on them and many would recommend the ESP to another person. Feedback from autistic adults suggested ways that we might test the ESP in future studies. Overall, autistic adults in this study found the ESP to be useful and a worthwhile intervention to study more in the future. While more research is clearly needed, we hope that the brief nature of the ESP will make it helpful for autistic people who are trying to handle negative feelings during stressful life events.

Does camouflaging predict age at autism diagnosis? A comparison of autistic men and women

It is frequently reported that females are likely to receive an autism diagnosis at a later age than their male counterparts, despite similar levels of autistic traits. It has been suggested that this delay in diagnosis may in part reflect the propensity of females, more than males, to engage in camouflaging behaviors that reduce the appearance of autism-related traits. This article presents two studies which examined the relationship between gender/sex, camouflaging, and age at diagnosis in two samples of (cis-gender) autistic adults. Study 1 included data from three online samples including 242 autistic men and 570 autistic women aged 18-75 years. Study 2 included data from a longitudinal population-based sample including 24 autistic men and 35 autistic women aged 20-24 years. Camouflaging was measured with the self-report Camouflaging Autistic Traits Questionnaire (CAT-Q). Overall, the results showed that, on average, females were diagnosed later than males. There was a stronger relationship between camouflaging and age at autism diagnosis (AaD) for females, compared with males. Within sample one, there was a significant camouflaging-by-sex interaction; high-camouflaging females had a later AaD. The role of autistic traits and changes in attitudes towards female autism and camouflaging need further exploration. These findings highlight the need for greater clinician and key stakeholder awareness and understanding of camouflaging behavior, particularly for females, during the diagnostic process.

SPARKing New Insight Into Autism Across the Lifespan

Autism is heterogeneous at many levels, including clinical symptoms and etiology. A key strategy in studying heterogeneous conditions is having large enough sample sizes to stratify into smaller groups that are more homogeneous. SPARK and Simons Searchlight are large and growing research cohorts of individuals with autism in the United States and individuals with genetically defined neurodevelopmental conditions around the world, respectively. They both provide freely available phenotypic and genotypic data with the ability to re-contact participants through the research match program. Deep dives into each gene in Searchlight provide comprehensive natural history data to understand the differing clinical courses to inform proper clinical care, and work toward treatment for each condition. Moreover, pilots of genetically based newborn screening programs for neurogenetic disorders can provide opportunities for equitable and early diagnosis to try to improve outcomes with earlier interventions.

The impact of measurement on clinical trials: Comparison of preliminary outcomes of a brief mobile intervention for autistic adults using multiple measurement approaches

Initial studies of the emotional safety plan (ESP), a new, brief telehealth and mobile intervention to support autistic adults to cope with periods of distress, have reported feasibility and acceptability (Bal et al., 2023, Autism, 1-13). Herein we report the preliminary clinical outcomes of thirty-six autistic adults who developed a personalized ESP, with a specific interest in comparing "outcomes" demonstrated by different instruments and assessment frequencies in order to inform outcome measurement in future clinical trials. Comparison of pre-intervention baseline to post-monitoring outcome (pre-post) anxiety symptoms (Generalized Anxiety Disorder-7 [GAD-7]) and depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]) revealed medium effect sizes for reduction in symptoms, though, low effect sizes were observed for pre-post Adult Self-report Anxiety and Depressive Problems scales and the Emotion Dysregulation Inventory Reactivity and Dysphoria scales. Weekly assessments showed an initial decrease in GAD-7 anxiety symptoms but no effect on weekly PHQ-9 depressive ratings. Ecological momentary assessment (EMA) data suggested that, when participants reported feeling sad or agitated and used the ESP, reduced negative feelings and increased positive states were reported in subsequent EMA. Perhaps not surprisingly, preliminary outcomes of these feasibility trials differed depending on measure chosen. Implications for the design of clinical trials are discussed.

Assessment of Autism Spectrum Disorder

Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by challenges in social interaction and communication and the presence of restricted interests and repetitive behaviors. The importance of early detection of ASD and subsequent early intervention is well documented. Efforts have been made over the years to clarify ASD diagnostic criteria and develop predictive, accurate screening tools and evidence-based, standardized diagnostic instruments to aid in the identification of ASD. In this article, we review the most recent changes in ASD diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, summarize evidence-based instruments for ASD screening and diagnostic evaluations as well as the assessment of co-occurring conditions in ASD, the impact of COVID-19 on ASD assessment, and directions for future research in the field of ASD assessment.

Measuring the Autistic Women's Experience (AWE)

We developed a Dutch questionnaire called the Autistic Women's Experience (AWE) and compared its psychometric properties to the Autism Spectrum Quotient (AQ). Whilst attenuated gender differences on the AQ have been widely replicated, this instrument may not fully capture the unique experience of autistic women. The AWE was co-developed with autistic women to include items that reflect autistic women's experience. We investigated the AWE (49 items) and compared it with the AQ (50 items) in Dutch autistic individuals (N = 153, n = 85 women) and in the general population (N = 489, n = 246 women) aged 16+. Both the AQ and AWE had excellent internal consistency and were highly and equally predictive of autism in both women and men. Whilst there was a gender difference on the AQ among non-autistic people (men > women), there was no gender difference among autistic people, confirming all earlier studies. No gender differences were detected on the AWE overall scale, yet subtle gender differences were observed on the subscales. We conclude that the AQ is valid for both genders, but the AWE provides an additional useful perspective on the characteristics of autistic women. The AWE needs further validation in independent samples using techniques that allow for testing gender biases, as well as a confirmatory factor analysis in a larger sample.

Improving autism identification and support for individuals assigned female at birth: clinical suggestions and research priorities

Emerging evidence suggests that the higher prevalence of autism in individuals who are assigned male than assigned female at birth results from both biological factors and identification biases. Autistic individuals who are assigned female at birth (AFAB) and those who are gender diverse experience health disparities and clinical inequity, including late or missed diagnosis and inadequate support. In this Viewpoint, an international panel of clinicians, scientists, and community members with lived experiences of autism reviewed the challenges in identifying autism in individuals who are AFAB and proposed clinical and research directions to promote the health, development, and wellbeing of autistic AFAB individuals. The recognition challenges stem from the interplay between cognitive differences and nuanced or different presentations of autism in some AFAB individuals; expectancy, gender-related, and autism-related biases held by clinicians; and social determinants. We recommend that professional development for clinicians be supported by health-care systems, professional societies, and governing bodies to improve equitable access to assessment and earlier identification of autism in AFAB individuals. Autistic AFAB individuals should receive tailored support in education, identity development, health care, and social and professional sense of belonging.

App Characteristics and Accuracy Metrics of Available Digital Biomarkers for Autism: Scoping Review

BACKGROUND

Diagnostic delays in autism are common, with the time to diagnosis being up to 3 years from the onset of symptoms. Such delays have a proven detrimental effect on individuals and families going through the process. Digital health products, such as mobile apps, can help close this gap due to their scalability and ease of access. Further, mobile apps offer the opportunity to make the diagnostic process faster and more accurate by providing additional and timely information to clinicians undergoing autism assessments.

OBJECTIVE

The aim of this scoping review was to synthesize the available evidence about digital biomarker tools to aid clinicians, researchers in the autism field, and end users in making decisions as to their adoption within clinical and research settings.

METHODS

We conducted a structured literature search on databases and search engines to identify peer-reviewed studies and regulatory submissions that describe app characteristics, validation study details, and accuracy and validity metrics of commercial and research digital biomarker apps aimed at aiding the diagnosis of autism.

RESULTS

We identified 4 studies evaluating 4 products: 1 commercial and 3 research apps. The accuracy of the identified apps varied between 28% and 80.6%. Sensitivity and specificity also varied, ranging from 51.6% to 81.6% and 18.5% to 80.5%, respectively. Positive predictive value ranged from 20.3% to 76.6%, and negative predictive value fluctuated between 48.7% and 97.4%. Further, we found a lack of details around participants' demographics and, where these were reported, important imbalances in sex and ethnicity in the studies evaluating such products. Finally, evaluation methods as well as accuracy and validity metrics of available tools were not clearly reported in some cases and varied greatly across studies. Different comparators were also used, with some studies validating their tools against the Diagnostic and Statistical Manual of Mental Disorders criteria and others through self-reported measures. Further, while in most cases, 2 classes were used for algorithm validation purposes, 1 of the studies reported a third category (indeterminate). These discrepancies substantially impact the comparability and generalizability of the results, thus highlighting the need for standardized validation processes and the reporting of findings.

CONCLUSIONS

Despite their popularity, systematic evaluations and syntheses of the current state of the art of digital health products are lacking. Standardized and transparent evaluations of digital health tools in diverse populations are needed to assess their real-world usability and validity, as well as help researchers, clinicians, and end users safely adopt novel tools within clinical and research practices.

Development, delivery, and evaluation of a training program for the early identification of autism: Monitoring of Social Attention, Interaction, and Communication

Introduction

Early identification of Autistic children is an important precursor to diagnosis, and access to supports and services. Here we describe the training of the maternal and child health (MCH) workforce in the state of Victoria, Australia in the early identification of infants and toddlers with a high likelihood of autism.

Methods

In 2019, 1,428 MCH nurses completed early autism training held at venues across the state, with an additional 82 nurses completing online-only training. A training needs analysis enabled the research team to determine the workforce's current skill and knowledge levels, and to identify knowledge gaps, training needs and workplace barriers. The professional development program, known as Monitoring of Social Attention, Interaction, and Communication (MoSAIC), comprised: online pre-workshop modules; a face-to-face instructor-led workshop, which included the use of the Social Attention and Communication-Revised (SACS-R) tool; and online post-workshop modules, which included a recording of a face-to-face workshop with all accompanying resources. This was the first time that the MCH workforce received this training package. Attendees were asked to complete a training satisfaction survey immediately following the face-to-face instructor-led workshop and a follow-up survey regarding their autism knowledge and SACS-R implementation 4-6 weeks after the workshop.

Results

Over 90% (n = 325) of MCH nurses who completed the training satisfaction survey agreed or strongly agreed with statements that the training was clear and of high quality. Most nurses also reported that the training was well-presented and that they would recommend it to a colleague. In the 6 months following the training, a total of 82,581 SACS-R assessments were conducted by the MCH workforce, reflecting that MCH nurses had successfully integrated SACS-R assessments into their work practice after receiving the early autism identification training.

Discussion

This study demonstrated that training on the early identification of autism can be successfully designed, customized, and delivered to a large primary healthcare workforce for universal developmental surveillance of autism.

A mixed methods study of autistic adults' mental health therapy experiences

Autistic adults are at high risk for co-occurring mental health problems and need access to effective and appropriate mental health treatment. However, the relative effectiveness or acceptability of specific mental health strategies among autistic adults has not been previously examined. The current study sought to gain a deeper understanding of autistic adults' experiences and preferences regarding mental health strategies using a mixed methods approach. Autistic adults (n = 303, ages 21-77) completed online surveys and open-ended questions about their mental health and therapy experiences. Most (88.8%) had participated in therapy, with cognitive approaches being the most common. Regarding overall therapy experiences, qualitative analyses revealed four primary themes and nine subthemes. Therapist acceptance and understanding were seen as critical for therapy success, and many participants felt that therapy was helpful for personal growth. However, many participants found that talking in session was challenging and noted that aspects of the session format affected their ability to engage in therapy. Regarding specific strategies, four cross-cutting themes and eight strategy-specific subthemes were identified. A variety of strategies were seen as helpful for reducing anxiety and improving mood. However, autistic adults reported trouble generalizing strategies to daily life and found some techniques to be difficult to implement due, in part, to their unique autism-related needs. As the first study of its kind, the results underscore the importance of establishing a safe and accepting therapeutic relationship, providing accommodations to support communication needs, and considering individual differences and preferences when selecting mental health strategies for autistic clients.

Human pluripotent stem cell (hPSC) and organoid models of autism: opportunities and limitations

Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder caused by genetic or environmental perturbations during early development. Diagnoses are dependent on the identification of behavioral abnormalities that likely emerge well after the disorder is established, leaving critical developmental windows uncharacterized. This is further complicated by the incredible clinical and genetic heterogeneity of the disorder that is not captured in most mammalian models. In recent years, advancements in stem cell technology have created the opportunity to model ASD in a human context through the use of pluripotent stem cells (hPSCs), which can be used to generate 2D cellular models as well as 3D unguided- and region-specific neural organoids. These models produce profoundly intricate systems, capable of modeling the developing brain spatiotemporally to reproduce key developmental milestones throughout early development. When complemented with multi-omics, genome editing, and electrophysiology analysis, they can be used as a powerful tool to profile the neurobiological mechanisms underlying this complex disorder. In this review, we will explore the recent advancements in hPSC-based modeling, discuss present and future applications of the model to ASD research, and finally consider the limitations and future directions within the field to make this system more robust and broadly applicable.

Differential Diagnosis of ICD-11 Personality Disorder and Autism Spectrum Disorder in Adolescents

The International Classification of Diseases 11th Revision (ICD-11) introduces fundamentally new diagnostic descriptions for personality disorder and autism spectrum disorder. Instead of the traditional categorical taxonomies, both personality disorder and autism spectrum disorder are described as being on a continuum. Accumulating research has pointed out that, in some cases, adolescents with autism spectrum disorder are at risk of being confused with having a personality disorder, which particularly applies to female adolescents. Case reports describe how adult autistic women struggled with social and identity roles as children and adolescents, using compensatory strategies such as social imitation and other types of camouflaging. Furthermore, some adolescents with autism display emotion dysregulation and self-injury. The ICD-11 recognizes that features of autism spectrum disorder may resemble features of personality disorder, but the two diagnoses have not yet been formally compared to one another. The present article therefore sought to outline and discuss the overlap and boundaries between the ICD-11 definitions of personality disorder and autism spectrum disorder and propose guiding principles that may assist practitioners in differential diagnosis with female adolescents. We specifically highlight how aspects of the self and interpersonal functioning along with emotional, cognitive, and behavioral manifestations may overlap across the two diagnoses. Restricted, repetitive, and inflexible patterns of behavior, interests, and activities are core features of autism spectrum disorder, which may be masked or less pronounced in female adolescents. Collecting a developmental history of the early presence or absence of autistic features is vital for a conclusive diagnosis, including features that are typically camouflaged in females. A number of future directions for research and clinical practice are proposed.

Case report: Treatment-resistant depression, multiple trauma exposure and suicidality in an adolescent female with previously undiagnosed Autism Spectrum Disorder

High rates of co-occurring depression are commonly reported in youth with Autism Spectrum Disorder (ASD), especially in individuals without intellectual disability (ID). Depression in ASD undermines adaptive behavior and is associated with a higher risk of suicidality. Females with ASD may be particularly vulnerable due to their greater use of camouflaging strategies. Indeed, in comparison to males, ASD is underdiagnosed in females, despite higher rates of internalizing symptoms and suicidality. Trauma exposure may also play a role in the development of depressive symptoms in this population. Moreover, evidence for effective treatments of depression in autistic youth are lacking, with ASD individuals frequently experiencing low efficacy and side effects. We present the case of an adolescent female with previously undiagnosed ASD without ID, admitted for active suicidal plans and a treatment-resistant depression (TRD), occurred after a COVID-19 lockdown in the context of cumulative exposure to stressful life events. Comprehensive clinical assessments performed at intake confirmed severe depression with suicidality. Intensive psychotherapy and different changes in medications were carried out (SSRI, SNRI, SNRI + NaSSA, SNRI + aripiprazole), all of which were ineffective, with persistent suicidal thoughts, often requiring intensive individual monitoring. The patient was finally successfully treated with lithium augmentation of fluoxetine, with no side effects. During hospitalization she was also evaluated by an ASD specialized center, where a diagnosis of ASD was made according to the Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview-Revised (ADI-R) scores, as well as to clinical judgment of a senior psychiatrist. The present case report shows that clinicians should not overlook undiagnosed autism as a possible cause of TRD, especially in females without ID, where higher rates of under diagnosis may be in part related to their greater use of camouflage. It also suggests that ASD underdiagnosis and resulting unmet needs may be involved in vulnerability to stressful experiences, depression, and suicidality. Furthermore, it shows the complexity of providing care to TRD in youth with autism, suggesting that an augmentation therapy with lithium, a commonly recommended therapeutic strategy for refractory depression in typically developing samples, may also be effective in this population.

Machine Learning-Based Blood RNA Signature for Diagnosis of Autism Spectrum Disorder

Early diagnosis of autism spectrum disorder (ASD) is crucial for providing appropriate treatments and parental guidance from an early age. Yet, ASD diagnosis is a lengthy process, in part due to the lack of reliable biomarkers. We recently applied RNA-sequencing of peripheral blood samples from 73 American and Israeli children with ASD and 26 neurotypically developing (NT) children to identify 10 genes with dysregulated blood expression levels in children with ASD. Machine learning (ML) analyzes data by computerized analytical model building and may be applied to building diagnostic tools based on the optimization of large datasets. Here, we present several ML-generated models, based on RNA expression datasets collected during our recently published RNA-seq study, as tentative tools for ASD diagnosis. Using the random forest classifier, two of our proposed models yield an accuracy of 82% in distinguishing children with ASD and NT children. Our proof-of-concept study requires refinement and independent validation by studies with far larger cohorts of children with ASD and NT children and should thus be perceived as starting point for building more accurate ML-based tools. Eventually, such tools may potentially provide an unbiased means to support the early diagnosis of ASD.

Non-suicidal self-injury and its relation to suicide through acquired capability: investigating this causal mechanism in a mainly late-diagnosed autistic sample

BACKGROUND

Non-suicidal self-injury (NSSI) has been linked with a higher risk of suicide attempts in autistic and non-autistic people. In the general population, NSSI may confer acquired capability for suicide by eroding one's fear and avoidance of pain and death. The present study aimed to explore acquired capability as the mediator of increased suicide risk conferred by NSSI in autistic and non-autistic adults.

METHODS

Autistic and non-autistic adults (n = 314, n = 312) completed an online survey exploring lifetime suicide attempts, experience with NSSI, and acquired capability for suicide. We explored relationships between lifetime incidence of NSSI and lifetime suicide attempts via three facets of acquired capability (pain tolerance, reduced fear of death, and mental rehearsal of suicide). In self-harming participants (224 autistic and 156 non-autistic), we explored whether particular types and features of NSSI might be especially associated with capability and through that with suicide: namely engagement in scratching, cutting, and self-hitting, and engaging in more numerous forms of NSSI.

RESULTS

While a higher frequency of NSSI was associated with all three facets of acquired capability, only reduced fear of death and mental rehearsal of suicide mediated an indirect relationship with lifetime suicide attempts. NSSI also directly predicted more numerous suicide attempts. Autistic people tended towards reduced fear of death and mental rehearsal regardless of NSSI status. Among self-harming autistic and non-autistic participants, cutting and an increased number of NSSI behaviours were associated with lifetime suicide attempts directly and indirectly via acquired capability. In both groups, self-hitting was associated with lifetime suicide attempts only via acquired capability.

LIMITATIONS

Our cross-sectional methodology negates inferences of directionality. While we controlled for age, our samples were poorly matched, with the autistic group two times older on average. The autistic sample, predominantly late-diagnosed, female and highly qualified, were unrepresentative of the whole autistic community.

CONCLUSIONS

Our data suggest that acquired capability, as measured herein, is an incomplete explanation for the association between NSSI and suicide risk. A broader construct with stable and transient facets may offer greater explanatory power, but it is probable that other variables explain or provide additional means through which this association arises.