Establishing motion control in children with autism and intellectual disability: Applications for anatomical and functional MRI

Optimizing Care for Autistic Patients in Health Care Settings: A Scoping Review and Call to Action

OBJECTIVE

We conducted a scoping review of interventions designed to improve the health care experiences of autistic individuals and assessed the methodology and outcomes used to evaluate them.

METHODS

Literature from January 2005 to October 2020 was searched using PubMed, Excerpta Medica dataBASE (EMBASE), Cumulated Index to Nursing and Allied Health Literature (CINAHL), PsycINFO as well as hand searching. Studies included described an intervention for autistic individuals in inpatient or outpatient settings and evaluated the intervention using standardized methodology. Results were exported to Covidence software. Ten reviewers completed abstract screening, full text review, and then systematic data extraction of the remaining articles. Two reviewers evaluated each article at each stage, with a third reviewer arbitrating differences.

RESULTS

A total of 38 studies, including three randomized controlled trials (RCTs) were included. Twenty-six (68%) took place in dental, psychiatric, or procedural settings. Interventions primarily focused on visit preparation and comprehensive care plans or pathways (N = 29, 76%). The most frequent outcome was procedural compliance (N = 15), followed by intervention acceptability (N = 7) and parent satisfaction (N = 6). Two studies involved autistic individuals and caregivers in study design, and no studies assessed racial/ethnic diversity on intervention impact.

CONCLUSIONS

Well-designed evaluations of interventions to support autistic individuals in pediatric health care settings are limited. There is a need to conduct large multi-site intervention implementation studies.

Promoting Reciprocal Relations across Subfields of Behavior Analysis via Collaborations

Several barriers may inhibit the growth of behavior analysis as a more integrated and collaborative field. Two such barriers are siloed environments that reinforce a basic-applied distinction, and a lack of translational research pathways. We describe the perils of silos, and elaborate on potential solutions to increase reciprocal relations among subfields in behavior analysis. We promote a five-tiered system to classify research in behavior analysis, and discuss literature on cultivating effective intra and cross-disciplinary collaborations, including using the framework of metacontingencies to understand collaborations. We also propose quantitative and qualitative measures to examine whether the potential solutions increase intra and interdisciplinary interactions. These measures include bibliometric (e.g., citations across fields), sociometric (e.g., social network analysis), and narrative analysis. We apply some of these measures to publications from 2011-2022 from the Journal of the Experimental Analysis of Behavior and Journal of Applied Behavior Analysis, and argue that behavior analysis overall may benefit from a more collaborative approach.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40614-023-00386-x.

Autonomic Arousal and Adherence with Dental Appointments

Individuals with developmental disabilities sometimes display avoidance responses such as a lack of cooperation, aggression, and vocal refusal when completing health-care routines such as dental cleanings, physicals, and haircuts. This study evaluated the effects of both graduated exposure and a differential reinforcement procedure on the acquisition, maintenance, and generalization of cooperation with dental routines. In addition, autonomic responses were used as an ancillary measure of distress or comfort and were included in the decision tree of practitioner actions. Procedures were completed in a simulated context of a dental examination. The results of this study may lead to more comprehensive treatment plans that include the use of physiological responses in addition to cooperation with procedures as an indicator that an avoidance response has been extinguished. Assessing autonomic arousal may be a useful addition to the procedures of exposing participants to dental visit routines, to improve adaptation, cooperation, and generalization.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40617-023-00808-x.

Increasing Face Mask Wearing in Autistic Individuals Using Behavior Analytic Interventions: A Systematic Review and Meta-analysis

The current review aimed to evaluate the effectiveness of behavior-analytic procedures in increasing face mask-wearing in autistic individuals. This comes following recommended guidance during the COVID-19 pandemic. A systematic review and meta-analysis were completed of peer-reviewed and grey literature. Six databases were searched and seven studies using single-case experimental designs met the eligibility criteria which were then quality appraised. Data were extracted on participant characteristics, study design, independent and dependent variables, fidelity, generalization, maintenance, and social validity outcomes. Both the non-overlap of all pairs and Baseline Corrected TAU were used to estimate effect size. Two studies were rated strong and borderline strong quality and five were rated as adequate or below. All studies showed positive outcomes for mask-wearing, with an average of 0.92 for non-overlap of all pairs and 0.47 for Baseline Corrected Tau effect sizes. The most common and effective procedures for increasing mask-wearing were graded exposure and differential and positive reinforcement. Factors such as mode of delivery, implementer, and setting did not appear to influence study outcomes. Procedures were found to be rated as acceptable by parents and professionals in five of the studies. The existing literature on increasing face mask-wearing in autistic individuals provides promising findings to add to existing literature around increasing tolerance to medical equipment and hygiene practices in autistic populations. However, these findings are based on a small sample size, with six of the studies taking place in the United States with varying study quality.

Quantifying MR Head Motion in the Rhineland Study - A Robust Method for Population Cohorts

Head motion during MR acquisition reduces image quality and has been shown to bias neuromorphometric analysis. The quantification of head motion, therefore, has both neuroscientific as well as clinical applications, for example, to control for motion in statistical analyses of brain morphology, or as a variable of interest in neurological studies. The accuracy of markerless optical head tracking, however, is largely unexplored. Furthermore, no quantitative analysis of head motion in a general, mostly healthy population cohort exists thus far. In this work, we present a robust registration method for the alignment of depth camera data that sensitively estimates even small head movements of compliant participants. Our method outperforms the vendor-supplied method in three validation experiments: 1. similarity to fMRI motion traces as a low-frequency reference, 2. recovery of the independently acquired breathing signal as a high-frequency reference, and 3. correlation with image-based quality metrics in structural T1-weighted MRI. In addition to the core algorithm, we establish an analysis pipeline that computes average motion scores per time interval or per sequence for inclusion in downstream analyses. We apply the pipeline in the Rhineland Study, a large population cohort study, where we replicate age and body mass index (BMI) as motion correlates and show that head motion significantly increases over the duration of the scan session. We observe weak, yet significant interactions between this within-session increase and age, BMI, and sex. High correlations between fMRI and camera-based motion scores of proceeding sequences further suggest that fMRI motion estimates can be used as a surrogate score in the absence of better measures to control for motion in statistical analyses.

Effectiveness of mock scanners and preparation programs for successful magnetic resonance imaging: a systematic review and meta-analysis

This review aimed to summarise the effectiveness of preparation programs for magnetic resonance imaging (MRI) in children using mock scanners and the success rates by systematically reviewing the current literature. We initially identified 67 articles using the search terms "MRI," "mock" and "child" on online databases. All studies involving a preparation programme for MRI on children ages 18 years or younger, healthy children and those with medical diagnoses were included. The authors extracted data on study design, participant data, details of the MRI protocol and the total numbers of patients who underwent preparation programs and were scanned while awake, without sedation or general anesthesia. Twenty-three studies were included in this review. Preparation programs included in-home and hospital/research facility components; these consisted of a mock scanner, explanatory booklets, recorded MRI scan sounds and other educational materials. The success rate of MRI after the preparation programme reported in each study ranged from 40% to 100%. When all participants from studies that specifically assessed the efficacy of preparation programs were combined, participants who underwent a preparation programme (n = 196) were more likely to complete a successful MRI than those who did not undergo a preparation programme (n = 263) (odds ratio [OR] = 1.98). Our results suggest that preparation programs may help reduce the risk of children failing MRI scans.

Can this data be saved? Techniques for high motion in resting state scans of first grade children

Motion remains a significant technical hurdle in fMRI studies of young children. Our aim was to develop a straightforward and effective method for obtaining and preprocessing resting state data from a high-motion pediatric cohort. This approach combines real-time monitoring of head motion with a preprocessing pipeline that uses volume censoring and concatenation alongside independent component analysis based denoising. We evaluated this method using a sample of 108 first grade children (age 6-8) enrolled in a longitudinal study of math development. Data quality was assessed by analyzing the correlation between participant head motion and two key metrics for resting state data, temporal signal-to-noise and functional connectivity. These correlations should be minimal in the absence of noise-related artifacts. We compared these data quality indicators using several censoring thresholds to determine the necessary degree of censoring. Volume censoring was highly effective at removing motion-corrupted volumes and ICA denoising removed much of the remaining motion artifact. With the censoring threshold set to exclude volumes that exceeded a framewise displacement of 0.3 mm, preprocessed data met rigorous standards for data quality while retaining a large majority of subjects (83 % of participants). Overall, results show it is possible to obtain usable resting-state data despite extreme motion in a group of young, untrained subjects.

Application of Quantitative Magnetic Resonance Imaging in the Diagnosis of Autism in Children

Objective

To explore the application of quantitative magnetic resonance imaging in the diagnosis of autism in children.

Methods

Sixty autistic children aged 2–3 years and 60 age- and sex-matched healthy children participated in the study. All the children were scanned using head MRI conventional sequences, 3D-T1, diffusion kurtosis imaging (DKI), enhanced T2*- weighted magnetic resonance angiography (ESWAN) and 3D-pseudo continuous Arterial Spin-Labeled (3D-pcASL) sequences. The quantitative susceptibility mapping (QSM), cerebral blood flow (CBF), and brain microstructure of each brain area were compared between the groups, and correlations were analyzed.

Results

The iron content and cerebral blood flow in the frontal lobe, temporal lobe, hippocampus, caudate nucleus, substantia nigra, and red nucleus of the study group were lower than those in the corresponding brain areas of the control group (P < 0.05). The mean kurtosis (MK), radial kurtosis (RK), and axial kurtosis (AK) values of the frontal lobe, temporal lobe, putamen, hippocampus, caudate nucleus, substantia nigra, and red nucleus in the study group were lower than those of the corresponding brain areas in the control group (P < 0.05). The mean diffusivity (MD) and fractional anisotropy of kurtosis (FAK) values of the frontal lobe, temporal lobe and hippocampus in the control group were lower than those in the corresponding brain areas in the study group (P < 0.05). The values of CBF, QSM, and DKI in frontal lobe, temporal lobe and hippocampus could distinguish ASD children (AUC > 0.5, P < 0.05), among which multimodal technology (QSM, CBF, DKI) had the highest AUC (0.917) and DKI had the lowest AUC (0.642).

Conclusion

Quantitative magnetic resonance imaging (including QSM, 3D-pcASL, and DKI) can detect abnormalities in the iron content, cerebral blood flow and brain microstructure in young autistic children, multimodal technology (QSM, CBF, DKI) could be considered as the first choice of imaging diagnostic technology.

Clinical Trial Registration

[http://www.chictr.org.cn/searchprojen.aspx], identifier [ChiCTR2000029699].

A systematic review of person-centred adjustments to facilitate magnetic resonance imaging for autistic patients without the use of sedation or anaesthesia

LAY ABSTRACT

Autistic patients often undergo magnetic resonance imaging examinations. Within this environment, it is usual to feel anxious and overwhelmed by noises, lights or other people. The narrow scanners, the loud noises and the long examination time can easily cause panic attacks. This review aims to identify any adaptations for autistic individuals to have a magnetic resonance imaging scan without sedation or anaesthesia. Out of 4442 articles screened, 53 more relevant were evaluated and 21 were finally included in this study. Customising communication, different techniques to improve the environment, using technology for familiarisation and distraction have been used in previous studies. The results of this study can be used to make suggestions on how to improve magnetic resonance imaging practice and the autistic patient experience. They can also be used to create training for the healthcare professionals using the magnetic resonance imaging scanners.

Application of Three-Dimensional Pseudocontinuous Arterial Spin Labeling Perfusion Imaging in the Brains of Children With Autism

Objective

To explore the application of three-dimensional pseudocontinuous arterial spin labeling (3D-PCASL) perfusion imaging in the brains of children with autism and to understand the characteristics of cerebral blood perfusion in children with autism.

Methods

A total of 320 children with autism (160 men and 160 women) aged between 2 and 18 years and 320 age- and sex-matched healthy children participated in the study. All children were scanned by 3.0 T magnetic resonance axial T1 fluid-attenuated inversion recovery (FLAIR), T2 FLAIR, 3D-T1, and 3D-PCASL sequences. After postprocessing, cerebral blood flow (CBF) values in each brain region of children with autism and healthy children at the same age were compared and analyzed. Furthermore, CBF characteristics in each brain region of autistic children at various ages were determined.

Results

The CBF values of the frontal lobe, hippocampus, temporal lobe, and caudate nucleus of children with autism are lower than those of healthy children (P < 0.05). Additionally, as the ages of children with autism increase, the number of brain regions with decreased CBF values gradually increases. A receiver operating characteristic (ROC) analysis results show that the CBF values of the frontal lobe, hippocampus, temporal lobe, and caudate nucleus can distinguish children with autism [area under the ROC curve (AUC) > 0.05, P < 0.05].

Conclusion

The 3D-PCASL shows lower brain CBF values in children with autism.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier: ChiCTR2000034356.

A Scoping Review of the Healthcare and Hygiene Literature for Individuals with Intellectual and Developmental Disabilities

OBJECTIVES

Previous reviews highlight the similarities in teaching healthcare and hygiene routines to individuals with and without intellectual and developmental disabilities. Additionally, similar interventions are used when interfering behaviors occur. Although these routines are topographically distinct, there are enough similarities to suggest effective procedures for one routine may be used to inform another. This scooping review aims to identify effective teaching and intervention procedures for healthcare and hygiene routines specifically for individuals with intellectual and developmental disabilities. We also evaluated the extent to which functional analyses were conducted; a dimension not included in previous reviews.

METHODS

Eligible articles targeted compliance or tolerance within the context of a defined healthcare or hygiene routine as a dependent variable and used an experimental design with a demonstration of experimental control. Articles were identified through PsycINFO, PubMed, and Academic Search Premier databases. Additionally, a hand search of five related journals was conducted. Data were collected on dependent variables, functional analyses, baseline contingencies, teaching procedures, and additional experimental components.

RESULTS

A total of 52 articles met inclusion criteria. Most experiments produced positive outcomes. The findings show all experiments involved a treatment package with multiple components. The most common teaching procedures were graduated exposure and DRA. A lack of functional analyses and social validity was noted.

CONCLUSIONS

Component analyses are needed to identify the most effective and efficient procedures. Pyramidal training to teach medical professionals how to provide preventative pyramidal training should be explored.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s41252-022-00249-7.

A callosal biomarker of behavioral intervention outcomes for autism spectrum disorder? A case-control feasibility study with diffusion tensor imaging

Tentative results from feasibility analyses are critical for planning future randomized control trials (RCTs) in the emerging field of neural biomarkers of behavioral interventions. The current feasibility study used MRI-derived diffusion imaging data to investigate whether it would be possible to identify neural biomarkers of a behavioral intervention among people diagnosed with autism spectrum disorder (ASD). The corpus callosum has been linked to cognitive processing and callosal abnormalities have been previously found in people diagnosed with ASD. We used a case-control design to evaluate the association between the type of intervention people diagnosed with ASD had previously received and their current white matter integrity in the corpus callosum. Twenty-six children and adolescents with ASD, with and without a history of parent-managed behavioral intervention, underwent an MRI scan with a diffusion data acquisition sequence. We conducted tract-based spatial statistics and a region of interest analysis. The fractional anisotropy values (believed to indicate white matter integrity) in the posterior corpus callosum was significantly different across cases (exposed to parent-managed behavioral intervention) and controls (not exposed to parent-managed behavioral intervention). The effect was modulated by the intensity of the behavioral intervention according to a dose-response relationship. The current feasibility case-control study provides the basis for estimating the statistical power required for future RCTs in this field. In addition, the study demonstrated the effectiveness of purposely-developed motion control protocols and helped to identify regions of interest candidates. Potential clinical applications of diffusion tensor imaging in the evaluation of treatment outcomes in ASD are discussed.

Why Intellectual Disability Poses a Challenge to the Received View of Capacity and a Potential Response

While copious quantities of ink have been spilled on the topic of autonomy in the context of health care, little has been written about autonomy in relation to intellectual disability. After presenting the received account of capacity, we argue that it cannot account for the moral permissibility of limiting an individual with intellectual disability's access to diet soda. In cases of preventative medicine and intellectual disability, the philosophical motivation for the received account of capacity is incompatible with the actions it recommends. We consider and reject several potential solutions; then, drawing on applied behavior analysis and the phenomenon of automatic reinforcement, we propose our own solution. The article concludes by considering the broader implications of our discussion.

Predicting multiscan MRI outcomes in children with neurodevelopmental conditions following MRI simulator training

Pediatric brain imaging holds significant promise for understanding neurodevelopment. However, the requirement to remain still inside a noisy, enclosed scanner remains a challenge. Verbal or visual descriptions of the process, and/or practice in MRI simulators are the norm in preparing children. Yet, the factors predictive of successfully obtaining neuroimaging data remain unclear. We examined data from 250 children (6–12 years, 197 males) with autism and/or attention-deficit/hyperactivity disorder. Children completed systematic MRI simulator training aimed to habituate to the scanner environment and minimize head motion. An MRI session comprised multiple structural, resting-state, task and diffusion scans. Of the 201 children passing simulator training and attempting scanning, nearly all (94%) successfully completed the first structural scan in the sequence, and 88% also completed the following functional scan. The number of successful scans decreased as the sequence progressed. Multivariate analyses revealed that age was the strongest predictor of successful scans in the session, with younger children having lower success rates. After age, sensorimotor atypicalities contributed most to prediction. Results provide insights on factors to consider in designing pediatric brain imaging protocols.

A Systematic Review of Interventions to Improve Healthcare Experiences and Access in Autism

Autistic individuals report barriers to accessing and receiving healthcare, and experience increased morbidity and mortality. This systematic review synthesizes 31 research studies evaluating interventions implemented to improve the healthcare experiences and/or access of autistic persons. Interventions were most commonly patient-focused (58.1%), focused on supporting the autistic individual to engage with, tolerate, or anticipate medical procedures, care, or settings. Fewer studies were provider-focused (48.4%) or organization-focused (6.5%). Interventions were typically evaluated using measures of reactions (45.2%) or behavior (48.4%), and outcomes were predominantly positive (80.6%). Further research is imperative and should look to how providers and organizations must change. Future research must be inclusive of the autistic community, must measure what matters, and must offer complete detail on interventions implemented.

Electromyography of diurnal bruxism during assessment and treatment

Diurnal bruxism among individuals with intellectual disabilities is often measured on the basis of its auditory products, thereby precluding the contingent presentation of stimuli during silent bruxism events. Electromyography (EMG) offers a technological solution to the identification of all bruxism events. EMG has not been previously evaluated in nonvocal clients with intellectual disabilities in the context of functional analysis and treatment. In the current series of analyses, we suggest a set of methods to implement EMG technology with this population. In Analysis 1, we propose a strategy for systematically identifying bruxism events. In Analysis 2 we evaluate an EMG staff-training package with naïve interventionists without past experience with EMG technology. Finally, Analysis 3 presents a practical example of this method during the functional analysis and treatment of a client with frequent diurnal bruxism.

The Feasibility of Magnetic Resonance Imaging in a Non-Selective Comprehensive Clinical Trial in Pediatric Autism Spectrum Disorder

There is an increasing interest in using magnetic resonance imaging (MRI) as a tool for precision medicine in autism spectrum disorder (ASD). This study investigated the feasibility of MRI scanning in a large comprehensive, inclusive and test heavy clinical trial for children (aged 3-12 years) with ASD, without functioning constraints for participation. Of the 71 participants enrolled who consented to the MRI, 24 participants (38%) successfully completed an MRI scan at baseline along with other assessments. This scanning followed a familiarization procedure at two preceding visits. At post-treatment, 21 participants successfully completed the MRI scan. This study highlights the challenge of completing MRI assessments in ASD populations when conducted as one of a number of tests in a clinical trial.

Tolerance of face coverings for children with autism spectrum disorder

Healthcare professionals and government officials have advised the use of personal protective equipment, such as face masks and face shields, to assist with limiting the spread of the SARS‐CoV‐2 (COVID‐19). Due to the prevalence of challenging behavior associated with other medical routines, the present study evaluated a treatment package composed of graduated exposure, prompts, reinforcement, and escape extinction on tolerance of wearing a face covering for up to 5 min for 12 children with ASD in a systematic replication of Cox et al. (2017) and Sivaraman et al. (2020). We also extended previous research by measuring generalization of face covering type (i.e., face shield) and the efficacy of a treatment extension for tolerating a face covering for up to 15 min during the participants' trial‐based instruction and play periods.

Increasing passive compliance to wearing a facemask in children with autism spectrum disorder

The current study taught 6 children with autism spectrum disorder (ASD) to increase passive compliance of wearing a facemask across sequentially increasing durations of time. A changing-criterion design embedded within a nonconcurrent multiple baseline design was used to evaluate the effectiveness of a resetting differential reinforcement of other behavior (DRO) without escape extinction procedure on passive compliance. Terminal probe sessions determined DRO fading intervals. Results showed that 2 participants acquired mastery level passive compliance (30 min) without fading during the initial baseline sessions. The remaining 4 participants acquired mastery level passive compliance following fading intervals within the DRO intervention. Participants' passive compliance generalized across 2 novel settings. This study replicates previous studies and extends empirical support for the use of DRO without escape extinction interventions for increasing passive compliance with medical devices in children with ASD.

Opportunities for ABA intervention in Phelan-McDermid syndrome

Phelan-McDermid syndrome (PMS), also called 22q13.3 deletion syndrome, is a rare genetic disorder affecting at least 2,000 people worldwide (Phelan-McDermid Syndrome Foundation, 2019, How rare is Phelan-McDermid?). PMS has many distinguishing characteristics and many medical specialties have been recommended to treat the clinical features. While many therapies, including behavioral therapy, have been speculated to be beneficial in treating PMS, there is little known regarding their effectiveness [Costales, J. L. and Kolevzon, A. 2015. Phelan-McDermid syndrome and SHANK3: Implications for treatment. Neurotherapeutics: The Journal of the American Society for Experimental Neurotherapeutics, 12, 620-630.]. Behavior analysis has the capability to help in many areas of treatment for PMS either directly through, for example, behavior treatment to address aggressive behavior, or through collaborating with other specialties treating PMS by combining, for example, behavioral principles in the alleviation of medical issues such as constipation. Currently, there is a role for the behavior analyst to expand our field and identify effective treatments for those with PMS while we wait for a cure. In this paper, we discuss how medical considerations may affect behavior interventions and make recommendations for the behavior analyst working with PMS.

Evaluation of DISORDER: Retrospective Image Motion Correction for Volumetric Brain MRI in a Pediatric Setting

BACKGROUND AND PURPOSE

Head motion causes image degradation in brain MR imaging examinations, negatively impacting image quality, especially in pediatric populations. Here, we used a retrospective motion correction technique in children and assessed image quality improvement for 3D MR imaging acquisitions.

MATERIALS AND METHODS

We prospectively acquired brain MR imaging at 3T using 3D sequences, T1-weighted MPRAGE, T2-weighted TSE, and FLAIR in 32 unsedated children, including 7 with epilepsy (age range, 2-18 years). We implemented a novel motion correction technique through a modification of k-space data acquisition: Distributed and Incoherent Sample Orders for Reconstruction Deblurring by using Encoding Redundancy (DISORDER). For each participant and technique, we obtained 3 reconstructions as acquired (Aq), after DISORDER motion correction (Di), and Di with additional outlier rejection (DiOut). We analyzed 288 images quantitatively, measuring 2 objective no-reference image quality metrics: gradient entropy (GE) and MPRAGE white matter (WM) homogeneity. As a qualitative metric, we presented blinded and randomized images to 2 expert neuroradiologists who scored them for clinical readability.

RESULTS

Both image quality metrics improved after motion correction for all modalities, and improvement correlated with the amount of intrascan motion. Neuroradiologists also considered the motion corrected images as of higher quality (Wilcoxon z = -3.164 for MPRAGE; z = -2.066 for TSE; z = -2.645 for FLAIR; all P < .05).

CONCLUSIONS

Retrospective image motion correction with DISORDER increased image quality both from an objective and qualitative perspective. In 75% of sessions, at least 1 sequence was improved by this approach, indicating the benefit of this technique in unsedated children for both clinical and research environments.

Thalamocortical connectivity is associated with autism symptoms in high-functioning adults with autism and typically developing adults

Alterations in sensorimotor functions are common in individuals with autism spectrum disorder (ASD). Such aberrations suggest the involvement of the thalamus due to its key role in modulating sensorimotor signaling in the cortex. Although previous research has linked atypical thalamocortical connectivity with ASD, investigations of this association in high-functioning adults with autism spectrum disorder (HFASD) are lacking. Here, for the first time, we investigated the resting-state functional connectivity of the thalamus, medial prefrontal, posterior cingulate, and left dorsolateral prefrontal cortices and its association with symptom severity in two matched cohorts of HFASD. The principal cohort consisted of 23 HFASD (mean[SD] 27.1[8.9] years, 39.1% female) and 20 age- and sex-matched typically developing controls (25.1[7.2] years, 30.0% female). The secondary cohort was a subset of the ABIDE database consisting of 58 HFASD (25.4[7.8] years, 37.9% female) and 51 typically developing controls (24.4[6.7] years, 39.2% female). Using seed-based connectivity analysis, between-group differences were revealed as hyperconnectivity in HFASD in the principal cohort between the right thalamus and bilateral precentral/postcentral gyri and between the right thalamus and the right superior parietal lobule. The former was associated with autism-spectrum quotient in a sex-specific manner, and was further validated in the secondary ABIDE cohort. Altogether, we present converging evidence for thalamocortical hyperconnectivity in HFASD that is associated with symptom severity. Our results fill an important knowledge gap regarding atypical thalamocortical connectivity in HFASD, previously only reported in younger cohorts.

Telehealth mask wearing training for children with autism during the COVID-19 pandemic

SARS‐CoV‐2 is the virus causing COVID‐19 and is spread through close person‐to‐person contact. The use of face masks has been described as an important strategy to slow its transmission. We evaluated the effects of coaching caregivers via telehealth technologies to teach face mask wearing to children with autism spectrum disorder. Six participants with a history of challenging behavior associated with mask wearing were recruited from different parts of the world, and trained using graduated exposure, shaping, and contingent reinforcement. By the end of the intervention, all participants wore a face mask for a period of 10 min without exhibiting challenging behavior. The skills generalized to a novel mask or a community setting. Mask wearing did not affect the percentage of oxyhemoglobin saturation of participants, and caregivers found the intervention useful. The findings support previous tolerance training treatment evaluations in children with developmental disorders exhibiting resistance to healthcare routines.

Reduced Expression of Cerebral Metabotropic Glutamate Receptor Subtype 5 in Men with Fragile X Syndrome

Glutamatergic receptor expression is mostly unknown in adults with fragile X syndrome (FXS). Favorable behavioral effects of negative allosteric modulators (NAMs) of the metabotropic glutamate receptor subtype 5 (mGluR5) in fmr1 knockout (KO) mouse models have not been confirmed in humans with FXS. Measurement of cerebral mGluR5 expression in humans with FXS exposed to NAMs might help in that effort. We used positron emission tomography (PET) to measure the mGluR5 density as a proxy of mGluR5 expression in cortical and subcortical brain regions to confirm target engagement of NAMs for mGluR5s. The density and the distribution of mGluR5 were measured in two independent samples of men with FXS (N = 9) and typical development (TD) (N = 8). We showed the feasibility of this complex study including MRI and PET, meaning that this challenging protocol can be accomplished in men with FXS with an adequate preparation. Analysis of variance of estimated mGluR5 expression showed that mGluR5 expression was significantly reduced in cortical and subcortical regions of men with FXS in contrast to age-matched men with TD.

A Neuroimaging Preparation Protocol Tailored for Autism

This paper describes the key basic elements required for a successful multi-parametric MRI data acquisition in awake children with autism. The procedure was designed by taking into account methodological challenges arising from the acquisition of Resting State fMRI (RS fMRI) data, and factors such as cost, time, and staff availability. The ultimate aim was to prepare an imaging preparation protocol with high transferability to the whole autism spectrum, adaptable for use in a multi-site research with multiple time points. As part of a randomized pharmaco-intervention study, 31 children aged 4-10 years with Neurofibromatosis 1 and autism underwent MR imaging at baseline and end of intervention. The protocol consisted of tailored habituation instructions including gradual exposure to scanner noise, a social stories booklet, positive incentive strategies, and Play Therapy support. Success rate for initial acquisition was 71% for GABA+ MR spectroscopy at either location, 87% for perfusion, and 67% for diffusion assessment, and 71% for RS fMRI. Qualitative data indicated that 84% parents found the habituation protocol helpful. LAY SUMMARY: Here we describe a protocol for brain Magnetic Resonance Imaging (MRI) tailored for children with ASD to help reduce stress and avoid sedation during scanning. This procedure can make advanced medical imaging more accessible and promote a better MRI experience for families of children with ASD.

Quantitative susceptibility mapping shows lower brain iron content in children with autism

OBJECTIVE

To explore the application of quantitative susceptibility mapping (QSM) of brain iron content in children with autism.

METHODS

For the control group, 40 normal children aged 2-3, 3-4, 4-5, and 5-6 years were prospectively selected from June 2018 to December 2018, with equal numbers of males and females in each age group. For the study group, 40 children with autism aged 2-3, 3-4, 4-5, and 5-6 years were prospectively selected from January 2019 to October 2019; once again, there were equal numbers of males and females in each age group. All children received routine head MRI scans and enhanced T2*-weighted angiography (ESWAN) sequence scans, and the ESWAN sequence images were processed by software to obtain magnetic susceptibility maps. The regions of interest (ROIs) of the frontal white matter, frontal gray matter, thalamus, red nucleus, substantia nigra, dentate nucleus, globus pallidus, putamen nucleus, caudate nucleus, pons, and splenium of the corpus callosum were selected, and the magnetic susceptibility values were measured. The differences in magnetic susceptibility between the two groups were compared in children at the same age.

RESULTS

For the children aged 2-3 years, the magnetic susceptibility values in the caudate nucleus, dentate nucleus, and splenium of the corpus callosum in the study group were lower than those in the control group (p < 0.05). For the children aged 3-4, 4-5, and 5-6 years, the magnetic susceptibility values in the frontal white matter, caudate nucleus, red nucleus, substantia nigra, dentate nucleus, and splenium of the corpus callosum in the study group were lower than those in the control group (p < 0.05).

CONCLUSION

The brain iron content of children with autism is lower than that of normal children.

TRIAL REGISTRATION

This study protocol was registered at the Chinese clinical trial registry (registration number: ChiCTR2000029699; http://www.chictr.org.cn/searchprojen.aspx ).

KEY POINTS

• In this study, the brain iron content of normal children and children with autism was compared to identify the differences, which provided a new objective basis for the early diagnosis of children with autism. • This study examined the iron content values in various brain regions of normal children aged 2-6 years in this region and established a reference range for iron content in various brain regions of normal children in one geographical area, providing a reliable and objective standard for the diagnosis and treatment of some brain diseases in children. • The results of this study indicate that the brain iron content of preschool children with autism is lower than that of normal preschool children.

Adventitious reinforcement during long-duration DRO exposure

Differential reinforcement of other behavior (DRO) is a procedure often used to decrease problem behavior, but the processes responsible for behavior reduction are not well understood. This study assessed whether adventitious reinforcement of other behavior contributes to DRO effectiveness when, relative to previous research, DRO exposure is prolonged. Two response options were presented on a computer and target responding was reinforced on a variable-ratio schedule. Response rates were then compared during DRO versus yoked variable-time or extinction probes. Across 2 experiments, DRO decreased target responding and increased other responding more than control conditions. However, increases in other responding did not usually maintain despite target responding remaining at low levels. DRO might adventitiously reinforce other responses transiently but the decreases in target behavior could not be entirely explained by adventitious reinforcement of the other response. Instead, reductions in target responding likely depend on the discriminability of the DRO contingency.

An evaluation of differential reinforcement with stimulus fading as an intervention for medical compliance

Individuals with autism spectrum disorder (ASD) often exhibit noncompliance during medical exams. One intervention used to address this concern is differential reinforcement. Although differential reinforcement includes extinction, it may not be feasible or safe to implement extinction during medical exams. In the current study, we evaluated differential reinforcement without extinction and differential reinforcement without extinction plus stimulus fading, for increasing compliance during routine medical exams exhibited by 4 individuals with ASD. An indirect assessment identified problematic medical procedures, and a functional analysis showed that participants' disruptive behavior was maintained by escape from medical tasks. Differential reinforcement without extinction was insufficient in increasing medical compliance with 3 of 4 participants. The addition of a modified stimulus fading procedure that involved gradually introducing smaller components of problematic exam steps was effective in increasing medical compliance with all exam steps.

Individualised MRI training for paediatric neuroimaging: A child-focused approach

Magnetic Resonance Imaging (MRI) in paediatric cohorts is often complicated by reluctance to enter the scanner and head motion-related imaging artefacts. The process is particularly challenging for children with neurodevelopmental disorders where coping with novel task demands in an unfamiliar setting may be more difficult due to symptom-related deficits or distress. These issues often give rise to excessive head motion that can significantly reduce the quality of images acquired, or render data unusable. Here we report an individualised MRI training procedure that enables children with Autism Spectrum Disorders (ASD) to better tolerate the MRI scanner environment based on a child-focused approach and individualised familiarisation strategies, including a pre-visit interview, familiarisation package, and personalised rewards. A medical imaging mobile application was utilised to familiarise participants to multi-sensory aspects of the neuroimaging experience through a variety of themed mini-games and activities. The MRI training procedure was implemented for monozygotic twins (n = 12; 6 twin pairs; age range 7.1–12.9 years) concordant or discordant for ASD. MRI image quality indices were better or comparable to images acquired from a large independent multi-centre ASD cohort. Present findings are promising and suggest that child-focused strategies could improve the quality of paediatric neuroimaging in clinical populations.

Using a motion-tracking device to facilitate motion control in children with ASD for neuroimaging

Purpose: Conducting neurological scans of children with disabilities is difficult because participants exhibit excessive motion. We examined whether a motion-tracking system that combined real-time visual feedback with positive reinforcement and shaping could facilitate motion control in two children with autism spectrum disorder. Methods: Using a modified changing criterion design, we evaluated whether the intervention could facilitate decreases in the participants' range of motion and increases in duration of motion control in a mock scanner. Results: Participants restricted head motion to increasingly smaller distance windows for 2 min. Once participants limited head displacement to 3 mm for 2 min, duration of motion control increased to a range of 7-20 min. Summary-level data from the actual scan suggests increases in motion control generalized outside of the intervention context. Conclusion: This study adds to the limited research on the use of behavioral interventions to increase motion control for neuroimaging in children with disabilities.

Distinct Patterns of Atypical Functional Connectivity in Lower-Functioning Autism

BACKGROUND

Functional magnetic resonance imaging research on autism spectrum disorders (ASDs) has been largely limited to individuals with near-average intelligence. Although cognitive impairment is common in ASDs, functional network connectivity in this population remains poorly understood. Specifically, it remains unknown whether lower-functioning individuals exhibit exacerbated connectivity abnormalities similar to those previously detected in higher-functioning samples or specific divergent patterns of connectivity.

METHODS

Resting-state functional magnetic resonance imaging data from 88 children (44 ASD, 44 typically developing; average age: 11 years) were included. Based on IQ, individuals with ASDs were assigned to either a lower-functioning group (mean IQ = 77 ± 6) or a higher-functioning group (mean IQ = 123 ± 8). Two typically developing comparison groups were matched to these groups on head motion, handedness, and age. Seeds in the medial prefrontal cortex, posterior cingulate cortex, posterior superior temporal sulcus, insula, and amygdala were used to contrast whole-brain functional connectivity across groups.

RESULTS

Lower-functioning ASD participants (compared with higher-functioning ASD participants) showed significant underconnectivity within the default mode network and the ventral visual stream. Higher-functioning ASD participants (compared with matched typically developing participants) showed significantly decreased anticorrelations among default mode, salience, and task-positive regions. Effect sizes of detected differences were large (Cohen's d > 1.46).

CONCLUSIONS

Lower- and higher-functioning individuals with ASDs demonstrated distinct patterns of atypical connectivity. Findings suggest a gross pattern of predominantly reduced network integration in lower-functioning ASDs (affecting default mode and visual networks) and predominantly reduced network segregation in higher-functioning ASDs. Results indicate the need for stratification by general functional level in studies of functional connectivity in ASDs.

Patients with autism spectrum disorders display reproducible functional connectivity alterations

Despite the high clinical burden, little is known about pathophysiology underlying autism spectrum disorder (ASD). Recent resting-state functional magnetic resonance imaging (rs-fMRI) studies have found atypical synchronization of brain activity in ASD. However, no consensus has been reached on the nature and clinical relevance of these alterations. Here, we addressed these questions in four large ASD cohorts. Using rs-fMRI, we identified functional connectivity alterations associated with ASD. We tested for associations of these imaging phenotypes with clinical and demographic factors such as age, sex, medication status, and clinical symptom severity. Our results showed reproducible patterns of ASD-associated functional hyper- and hypoconnectivity. Hypoconnectivity was primarily restricted to sensory-motor regions, whereas hyperconnectivity hubs were predominately located in prefrontal and parietal cortices. Shifts in cortico-cortical between-network connectivity from outside to within the identified regions were shown to be a key driver of these abnormalities. This reproducible pathophysiological phenotype was partially associated with core ASD symptoms related to communication and daily living skills and was not affected by age, sex, or medication status. Although the large effect sizes in standardized cohorts are encouraging with respect to potential application as a treatment and for patient stratification, the moderate link to clinical symptoms and the large overlap with healthy controls currently limit the usability of identified alterations as diagnostic or efficacy readout.

Does pre-scanning training improve the image quality of children receiving magnetic resonance imaging?: A meta-analysis of current studies

BACKGROUND

Magnetic resonance imaging (MRI) is often used in children for its clear display of body parts. But it is usually hard to acquire high-quality images, for the uncooperative ability of children. It is believed that pre-MRI training could ensure the high quality of images. The current meta-analysis was done to analyze the current evidences in this field.

METHODS

PubMed, Cochrane Library, and Web of Science were systematically searched up to July 2018, for studies assessing the effects of training on pediatric MRI. Data, including image quality, failed scanning rate, and sedation use, were extracted and analyzed using Revman 5.2 software.

RESULTS

There were 5 studies with 379 subjects in the meta-analysis. Training and control groups were quite comparable when accepted image quality was reviewed (P = .30), but a lower rate of excellent image quality was found in subjects with training (P = .02). The pooling results found no significance between training and control group in sedation use (P = .09) and successful MRI scanning (P = .63).

CONCLUSIONS

It is cautious to conclude that pre-MRI training does not improve the image quality and reduce sedation use among children, for the limited number of studies and sample size. More trials should be encouraged to demonstrate this issue.

Functional MRI connectivity of children with autism and low verbal and cognitive performance

Background

Functional neuroimaging research in autism spectrum disorder has reported patterns of decreased long-range, within-network, and interhemispheric connectivity. Research has also reported increased corticostriatal connectivity and between-network connectivity for default and attentional networks. Past studies have excluded individuals with autism and low verbal and cognitive performance (LVCP), so connectivity in individuals more significantly affected with autism has not yet been studied. This represents a critical gap in our understanding of brain function across the autism spectrum.

Methods

Using behavioral support procedures adapted from Nordahl, et al. (J Neurodev Disord 8:20–20, 2016), we completed non-sedated structural and functional MRI scans of 56 children ages 7–17, including LVCP children (n = 17, mean IQ = 54), children with autism and higher performance (HVCP, n = 20, mean IQ = 106), and neurotypical children (NT, n = 19, mean IQ = 111). Preparation included detailed intake questionnaires, video modeling, behavioral and anxiety reduction techniques, active noise-canceling headphones, and in-scan presentation of the Inscapes movie paradigm from Vanderwal et al. (Neuroimage 122:222–32, 2015). A high temporal resolution multiband echoplanar fMRI protocol analyzed motion-free time series data, extracted from concatenated volumes to mitigate the influence of motion artifact. All participants had > 200 volumes of motion-free fMRI scanning. Analyses were corrected for multiple comparisons.

Results

LVCP showed decreased within-network connectivity in default, salience, auditory, and frontoparietal networks (LVCP < HVCP) and decreased interhemispheric connectivity (LVCP < HVCP=NT). Between-network connectivity was higher for LVCP than NT between default and dorsal attention and frontoparietal networks. Lower IQ was associated with decreased connectivity within the default network and increased connectivity between default and dorsal attention networks.

Conclusions

This study demonstrates that with moderate levels of support, including readily available techniques, information about brain similarities and differences in LVCP individuals can be further studied. This initial study suggested decreased network segmentation and integration in LVCP individuals. Further imaging studies of LVCP individuals with larger samples will add to understanding of origins and effects of autism on brain function and behavior.

Electronic supplementary material

The online version of this article (10.1186/s13229-018-0248-y) contains supplementary material, which is available to authorized users.

Translating Behavior Analysis: a Spectrum Rather than a Road Map

Much has been written about the potential benefits of translational research in behavior analysis, but a lack of consensus about what constitutes "translational" creates a barrier to effective knowledge-practice innovation within the discipline and across other sciences. We propose a tiered system, adapted from a biomedical translational pathway, for classifying behavior analysis research on a basic-applied spectrum. Tier 0 is blue sky basic science in which the subjects, behaviors, stimuli, and settings are selected for convenience. Tier 1 is use-inspired basic science with a socially important end game and research subject. Tier 2 is solution-oriented research that attempts to solve a specific problem in a socially important subject, but 1 or more aspects of the research are selected for purposes of experimental control rather than social importance. Tier 3 is applied behavior analysis research that studies a problem of social significance for the subject and involves behaviors, stimuli, and settings that are socially important. Tier 4 is impact assessment in which behavioral technology is applied with a direct benefit to society. We provide examples of behavior-analytic research in each tier and evaluate the potential benefits of organizing behavior analysis in this way.

Annual Research Review: Understudied populations within the autism spectrum - current trends and future directions in neuroimaging research

BACKGROUND

Autism spectrum disorders (ASDs) are a heterogeneous group of neurodevelopmental conditions that vary in both etiology and phenotypic expression. Expressions of ASD characterized by a more severe phenotype, including autism with intellectual disability (ASD + ID), autism with a history of developmental regression (ASD + R), and minimally verbal autism (ASD + MV) are understudied generally, and especially in the domain of neuroimaging. However, neuroimaging methods are a potentially powerful tool for understanding the etiology of these ASD subtypes.

SCOPE AND METHODOLOGY

This review evaluates existing neuroimaging research on ASD + MV, ASD + ID, and ASD + R, identified by a search of the literature using the PubMed database, and discusses methodological, theoretical, and practical considerations for future research involving neuroimaging assessment of these populations.

FINDINGS

There is a paucity of neuroimaging research on ASD + ID, ASD + MV, and ASD + R, and what findings do exist are often contradictory, or so sparse as to be ungeneralizable. We suggest that while greater sample sizes and more studies are necessary, more important would be a paradigm shift toward multimodal (e.g. imaging genetics) approaches that allow for the characterization of heterogeneity within etiologically diverse samples.