Parent-Rated Anxiety Symptoms in Children with Pervasive Developmental Disorders: Frequency and Association with Core Autism Symptoms and Cognitive Functioning

Prevalence of anxiety disorders in a clinical sample of Chinese children with autism spectrum disorder in Hong Kong

Little is known about the prevalence of anxiety disorders in Han Chinese children with Autism Spectrum Disorder (ASD). This is an important topic for research as symptoms may be written off as being due to ASD alone.ObjectiveTo provide prevalence rates of anxiety disorders in a clinical sample of Han Chinese children with ASD and identify correlates which may be amenable to intervention.MethodThe pre-existing ASD diagnosis of 165 Hong Kong Han Chinese was confirmed with the Chinese version of the Developmental, Dimensional and Diagnostic Interview (3Di). Anxiety comorbidities were confirmed with the Chinese version of the Diagnostic Interview Schedule for Children-Version Four (DISC-IV): parent version.ResultsThe prevalence of comorbid anxiety disorders was 52.1%. The prevalence rate of specific phobis was 44.8%, separation anxiety disorder was 11.5%, social anxiety disorder was 9.1%, agoraphobia 0.6%, selective mutism 0.6%, panic disorder 0% and generalized anxiety disorder 0%. Autistic disorder subtype and more severe 3Di scores were significantly associated with anxiety rates, whereas high household income was protective.ConclusionPrevalence rates of comorbid anxiety are high in Hong Kong Han Chinese children with ASD and imperative to catch for early intervention.

Early detection of anxiety symptoms in Autism Spectrum Disorder: An exploratory study in a Spanish sample of 3-6 year old children

Current research often overlooks anxiety symptoms in preschoolers with Autism Spectrum Disorder (ASD), focusing on older children. This study examines anxiety symptomatology primarily in young children with ASD by analyzing data from 82 Spanish children aged 3- to 6 years. Parents completed the Anxiety Scale for Children with ASD and the Social Communication Questionnaire. Results indicate that 30.48% of the children exhibit significant anxiety symptoms, "with anxious uncertainty" being the most prevalent. Factor analysis reveals three principal components of the Anxiety Scale, supporting its reliability. Regression analysis highlights stereotypical behaviors as significant predictors of anxiety levels. These findings underscore the importance of early assessment and adaptation of assessment tools for preschoolers with ASD. Stereotypical behaviors are identified as key predictors of anxiety in this population.

A systematic review and meta-analysis of the relationship between sensory processing differences and internalising/externalising problems in autism

There is evidence to suggest that sensory processing differences (SPDs) to external stimuli are a plausible underlying mechanism for mental health problems among autistic people. In the current systematic review, we examined the associations between, on the one hand, eleven types of SPDs and, on the other hand, internalising and externalising problems. The literature search was conducted on five databases (MEDLINE, PsycINFO, Web of Science, EMBASE, and CINAHL) between 1990 and August 2024. Studies with autistic people aged under 65 years-old that reported correlations between SPDs and internalising/externalising problems were included. Three-level and random-effects meta-analyses and narrative synthesis were conducted. In total, we included 63 articles (11,659 participants) in the current review. Overall, higher levels of all SPD subtypes were found to be associated with greater internalising/externalising problems. Hypersensitivity, visual, auditory, and tactile sensitivities were strongly associated with internalising/externalising problems, while smaller effects were observed for unusual processing of smell and taste. Sensation seeking was highly linked with externalising problems, whereas it was the least associated sensory subtype with internalising problems. Future studies could address the limitations in the extant literature (e.g., heterogeneity in the estimates of associations, a lack of externalising problem investigations and longitudinal studies) to further advance our understanding of the role of SPDs in the aetiology, development, and treatment of internalising/externalising problems in autism.

A Comprehensive Investigation of Social Anxiety and Social Evaluative Stress in Autistic Children and Adolescents and Specific Learning Disorders

The aim was to investigate trait social anxiety and social evaluative stress in autistic children and adolescents and Specific Learning Disorders (SLD). This was done by evaluating behavioral, subjective, and autonomic responses to the Trier Social Stress Test (TSST). Study 1 included 280 children and adolescents: 60 autistic without intellectual disability (ID), 70 SLD, and 150 non-diagnosed (ND) peers. Study 2 involved 55 participants: 15 autistic without ID, 15 SLD, and 20 ND. The sample was predominantly male. In Study 1, behavioral (quality of public speech) and subjective (valence, arousal, perceived competence, and worries) aspects of social stress were examined. Study 2 expands upon the first study, as physiological responses to social stress were also measured. Trait social anxiety was investigated using both parents' and children's reports in the two studies. Parents of autistic participants and with SLD reported higher trait social anxiety in their children than the parents of ND. No differences emerged from the participants' self-reports, though those autistic and with SLD were assigned lower scores in the public speech quality than ND. Autistic children and adolescents reported lower arousal and higher perceived competence than ND, while those with SLD reported a lower perception of competence. Autistic participants had a decreased cardiac reactivity across the TSST when compared to SLD and ND. Our findings show unique patterns of responses within each group, confirming that the combined investigation of trait anxiety and social stress responses could be a valuable insight in research and clinical practice.

Probing heterogeneity to identify individualized treatment approaches in autism: Specific clusters of executive function challenges link to distinct co-occurring mental health problems

LAY ABSTRACT

Many autistic people struggle with mental health problems like anxiety, depression, inattention, and aggression, which can be challenging to treat. Executive function challenges, which impact many autistic individuals, may serve as a risk factor for mental health problems or make treating mental health conditions more difficult. While some people respond well to medication or therapy, others do not. This study tried to understand if there are different subgroups of autistic young people who may have similar patterns of executive function strengths and challenges-like flexibility, planning, self-monitoring, and emotion regulation. Then, we investigated whether executive function subgroups were related to mental health problems in autistic youth. We found three different types of executive function subgroups in autistic youth, each with different patterns of mental health problems. This helps us identify specific profiles of executive function strengths and challenges that may be helpful with identifying personalized supports, services, and treatment strategies for mental health conditions.

Influence of the functional intervention on the development of essential social skills in children with life-limiting conditions

Life-limiting conditions often cause children to be overlooked as participants in everyday activities. For parents child development should lead to independence in daily living activity. For parents of children who are disabled, independence is a step to a better quality of a child's life. The aim of the study was to examine the effectiveness of functional intervention of self-service activities in children with life-limiting conditions at the age of 3-6 years of life. 32 children aged 3-6 years (N = 32, girls and boys) were followed for two years. The Progress Assessment Chart of Personal and Social Development (PPAC) H.C Gunzburg according to Witkowski inventory was used to assess. After two years of functional intervention, statistically significant improvement in everyday activities was observed in examining group. The control group showed less progress than the study group, even though the children in the control group were older. Functional intervention allows for effective work with a patient with life-limited conditions. Better progress was observed in the younger group, subjected to therapy for the existence of developmental potential occurring in children with limitations in intellectual development.

Refining our Understanding of Anxiety in Autistic Youth: Examining the Role of Behavioral Inflexibility

Prior research has demonstrated that cognitive inflexibility is associated with anxiety in autistic individuals. Everyday patterns of behavioral inflexibility (e.g. observable inflexible behavior in the context of the need to change or adapt and that is manifested in real-world everyday settings) is common in autism and can be distinguished from performance on discrete cognitive tasks that tap flexible attention, learning, or decision-making. The purpose of this study was to extend this prior work on inflexibility in autism but with measures specifically developed with input from stakeholders (caregivers and clinicians) for autistic youth designed to measure everyday behavioral inflexibility (BI). We characterized anxiety in a large sample of autistic (N = 145) and non-autistic youth (N = 91), ages 3 to 17 years, using the Parent Rated Anxiety Scale for Autism Spectrum Disorder (PRAS-ASD). Further, we sought to understand how BI, measured via the Behavioral Inflexibility Scale (BIS), predicted anxiety compared to other variables known to increase anxiety in youth (chronological age, IQ, autism diagnosis, assigned sex at birth). Autistic youth had higher parent-related anxiety and BI compared to non-autistic youth. BI was the strongest predictor of anxiety scores, irrespective of diagnosis. Overall, our findings highlight the importance of BI to the understanding of anxiety in autistic youth.

Exploring the association between social camouflaging and self- versus caregiver-report discrepancies in anxiety and depressive symptoms in autistic and non-autistic socially anxious adolescents

LAY ABSTRACT

Social camouflaging or masking refers to strategies autistic individuals adopt to hide their autism persona when trying to fit in. It is unclear whether camouflaging is only applicable to social differences unique to autism, or more generally to any types of social difference, such as experiences of mental health difficulties. We asked 43 autistic and 39 non-autistic adolescents (aged 14-19 years, all of whom showed similarly high levels of social anxiety) and their primary caregivers to complete questionnaires about their mental health (anxiety and depression) and autistic traits, and adolescents self-reported camouflaging behaviours. We wondered if camouflaging may be used to hide mental health difficulties reported by young people and affect caregiver report on symptom severity. We found that adolescents who self-reported greater levels of autistic traits, anxiety and depression symptoms compared with their caregivers reported greater camouflaging. Adolescents who agreed on having high levels of autistic traits and anxiety symptoms with their caregivers reported greater camouflaging behaviours. We discuss how having high levels of autistic traits and anxiety may increase adolescents' camouflaging behaviours to hide social differences, which may contribute towards poor mental health outcomes. We think it is important to talk with adolescents about how camouflaging social and mental health difference can have negative impacts for mental health as well as possible positive social gains.

Prevalence, Symptom Profiles, and Correlates of Mixed Anxiety-Depression in Male and Female Autistic Youth

Relatively little attention has been given to mixed anxiety and depression in autistic youth, particularly how this differs between males and females. This study investigated sex-based differences in the prevalence and correlates of mixed anxiety and depression in a sample of 51 autistic males (M age = 10.16 yr, SD = 2.81 yr, and range = 6 yr to 17 yr) and 51 autistic females (M age = - 10.07 yr, SD = 2.76 yr, and range = 6 yr to 17 yr), matched for age, IQ, and autism severity. Self-reports on generalised anxiety disorder and major depressive disorder, morning salivary cortisol, ADOS-2 scores, and WASI-II full-scale scores were collected from these autistic youth, and data on the ASD-related symptoms of these youth were collected from their parents. The data were analysed for total anxiety-depression score levels, for the underlying components of this scale, and for the individual items used in the scale. The results indicate no significant sex differences for the prevalence of mixed anxiety and depression total scores or the underlying components of anxiety and depression or for the individual items of the mixed anxiety-depression scale. There were sex differences in the significant correlates of mixed anxiety and depression: morning cortisol and ASD-related difficulties in social interaction for females, and ASD-related behaviour for males. Males' feelings of being restless or edgy were correlated with their social interaction and repetitive and restricted behaviour. Females' difficulties in social interaction were correlated with their concerns about their abilities and their sleeping problems. Females' sleeping problems, their tendency to talk about dying, and feeling worthless, were correlated with their morning cortisol. These findings suggest that, while mixed anxiety and depression is experienced similarly by autistic males and females at the global, component, and individual item levels, specific aspects of the symptomatology of mixed anxiety and depression are differently associated with aspects of their ASD-related symptomatology and their levels of chronic physiological stress for males and females.

Characterizing associations between emotion dysregulation, anxiety, and repetitive behaviors in autistic youth with intellectual disability

There is a paucity of research that explores associations between emotion dysregulation and the expression and severity of core and co-occurring characteristics of autism spectrum disorder (ASD), especially in autistic youth with co-occurring intellectual disability (ID). This study explored the interplay between developmental characteristics and emotion dysregulation, anxiety, and specific subtypes of RRBs that are elevated in autistic youth with co-occurring ID. Generalized additive models demonstrated that age, sex, language level, dysregulation, and anxiety showed unique patterns of association with subtypes of RRBs in a sample of 150 autistic youth with co-occurring ID who are non-speaking or minimally verbal. More specifically, higher anxiety levels were significantly associated with elevations in repetitive sensory motor behaviors (RSMB), self-injurious behaviors (SIB), insistence on sameness (IS), and unusual interests (UI). While emotion dysregulation was a significant predictor of UI, it demonstrated positive, albeit not significant, associations with the intensity of SIB and RSMB. Language level was a significant predictor of RSMB, such that the intensity of RSMB was higher for individuals who were non-speaking relative to those who spoke in single words. These findings provide preliminary insights into patterns of associations between emotion dysregulation, anxiety, and specific subdomains of RRBs in autistic youth with ID.

Autistic Characteristics, Cognitive Impairment, and Sex as Predictors of Anxiety and Depression among Autistic Youth

Although it is well established that autistic youth are at high risk for anxiety and depression, factors associated with heightened risk within this population are poorly understood. The purpose of this study was to evaluate whether autistic characteristics and cognitive impairment interact to predict anxiety and depression symptoms, and whether the impacts of autistic characteristics and cognitive impairment on anxiety and depression differ for male and female children. Participants comprised 7989 youth (M = 11.23 years) enrolled in SPARK, a national cohort of autistic individuals. Autistic characteristics were assessed via the Social Communication Questionnaire. Anxiety and depression were assessed via the Child Behavior Checklist. Linear regressions were conducted to examine associations between autistic characteristics, cognitive impairment, and symptoms and to test for interactions. The effect of parent-reported autistic characteristics on anxiety was stronger for males than for females, while the effect of cognitive impairment on anxiety was stronger for females than for males. A different pattern was observed for depression. The effect of autistic characteristics on depression was the same for males and females, while cognitive impairment was not associated with depression per parent report. Findings indicate that both male and female children with high levels of autistic characteristics are susceptible to experiencing anxiety and depression, and that autistic female children with intact cognitive abilities are uniquely vulnerable to experiencing anxiety based on parent report. Results have implications for the prevention of internalizing problems in autistic youth, and highlight future directions for longitudinal work examining mechanisms of comorbidity.

Examining the Relationship Between Anxiety Severity and Autism-Related Challenges During Cognitive Behavioral Therapy for Children with Autism

PURPOSE

Using data from a randomized clinical trial evaluating cognitive behavioral therapy (CBT) for children with autism and co-occurring anxiety, this study examined the relationship between autism features and anxiety symptoms throughout CBT.

METHODS

Two multilevel mediation analyses were run which examined the mediating role of changes in anxiety for changes in two core features of autism, (a) repetitive and restrictive behaviors (RRBs) and (b) social communication/interaction impairments, between pre- and post-treatment.

RESULTS

Indirect effects between time and autism characteristics were significant for both models, indicating that as anxiety changes, so do RRBs and social communication/interaction as the outcomes respectively.

CONCLUSION

Findings suggest a bidirectional relationship between anxiety and autism features. Implications of these findings are discussed.

Changes in the severity of autism symptom domains are related to mental health challenges during middle childhood

LAY ABSTRACT

For many autistic children, the severity of their autism symptoms changes during middle childhood. We studied whether these changes are associated with the emergence of other mental health challenges such as anxiety and attention-deficit hyperactivity disorder. Children who had increased social-communication challenges had more anxiety and attention-deficit hyperactivity disorder symptoms and disruptive behavior problems than other children. Children who decreased their restricted and repetitive behaviors, on the contrary, had more anxiety. We discuss why these changes in autism symptoms may lead to increases in other mental health concerns.

Emotion regulation and emotion dysregulation in children and adolescents with Autism Spectrum Disorder: A meta-analysis of evaluation and intervention studies

Children and adolescents with Autism Spectrum Disorder (ASD) often experience challenges in emotion regulation (ER) and emotion dysregulation (ED) which can interfere with their adaptive functioning. This study aimed to systematically review and meta-analyze the evidence on ER/ED in children and/or adolescents with ASD, examining its relationship with the following variables: internalizing and externalizing symptoms, cognitive function and social skills, and the effectiveness of non-pharmacological interventions addressing ER difficulties. Both electronic and manual searches were conducted to identify potential studies. Fifty-five studies were included in the meta-analysis. A statistically significant between-group difference was found, suggesting greater ER/ED challenges in the ASD group. Also, the ASD group showed more maladaptive ER strategies and fewer adaptive ER strategies compared to the non-ASD participants. Additionally, more severe ASD and poorer social skills were associated with greater ED and poorer ER skills, respectivelly. Furthermore, there was a significant correlation between internalizing symptomatology and both adaptive and maladaptive ER strategies. Studies of non-pharmacological interventions showed significant improvement in both ER and ED. These results imply that assessing ER/ED in children and adolescents with ASD should be part of the evaluation process, and it should also be a focal point for intervention in this population.

Intellectual development in young children with autism spectrum disorders: A longitudinal study

Intelligence profiles in autism have been characterized by great variability. The questions of how autistic children's intelligence changes over time, and what factors influence these changes deserve study as part of efforts to document child autism profiles, but also because the relationship between intellectual functioning and children's background characteristics is poorly understood, particularly in a longitudinal context. A total of 39 autistic children and 39 age-matched neurotypical children (5-9 years old) completed two IQ assessments at preschool age and up to 4 years later. Repeated-measures analyses assessed longitudinal changes in the children's verbal (VIQ), performance (PIQ), and full-scale IQ (FSIQ) at group level. We further sought to identify clusters with distinct profiles in each group by adopting an unsupervised K-means clustering approach, and detect possible between-subgroup differences in terms of children's socioeconomic status and autism severity. The largest cluster in the autistic group was composed of children whose PIQ significantly dropped at follow-up, while the second largest cluster improved in all quotients; the smallest cluster, wherein children had more highly educated mothers than the rest of the clusters, was characterized by large improvement in VIQ. For the neurotypical children, there was a two-cluster division; the majority of them improved in the three quotients, while very few dropped in PIQ at follow-up. The relation between socioeconomic status and IQ changes was significant for both groups. The findings demonstrate both the complexity of intelligence changes in autism and the need to view this complexity through the lens of the children's socioeconomic diversity.

Characterizing individual differences in children and adolescents with autism spectrum disorder: a descriptive study

Introduction

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by a higher prevalence in male than in female participants. Recent studies have hypothesized the presence of different phenotypes in male and female participants with ASD. The present study aims to assess possible sex differences in cognitive and adaptive functioning, symptomatology of ASD, and psychopathological comorbidities in a large sample of children and adolescents with ASD.

Methods

The study included a total of 2,146 children and adolescents diagnosed with ASD, comprising 1785 boys (mean age 7.12 ± 3.69 years) and 361 girls (mean age 6.25 ± 3.30 years). The age of the participants ranged from 1.35 to 19.05 years (mean age 9.98 ± 3.64). The study sought to include all children and adolescents diagnosed with Autism or ASD.

Results

Present results showed that girls with ASD had lower IQs than boys but similar adaptive functioning. The severity of symptoms of ASD was greater in boys than in girls, as were scores on psychopathological measures. With increasing age, boys with ASD showed greater impairment in social communication skills than girls and increased psychopathological comorbidities. Older girls showed fewer restricted and repetitive behaviors.

Discussion

Exploring phenotypic differences in children and adolescents with ASD fosters an understanding of subtle diagnostic facets that may go unrecognized, allowing for increasingly individualized and tailored interventions.

Behavioral and Molecular Characterization of Prenatal Stress Effects on the C57BL/6J Genetic Background for the Study of Autism Spectrum Disorder

Stress-inducing events during pregnancy are associated with aberrant neurodevelopment resulting in adverse psychiatric outcomes, including autism spectrum disorder (ASD). While numerous preclinical models for the study of ASD are frequently generated using C57BL/6J mice, few studies have investigated the effects of prenatal stress on this genetic background. In the current manuscript, we stressed C57BL/6 dams during gestation and examined numerous behavioral and molecular endophenotypes in the adult male and female offspring to characterize the resultant phenotype as compared with offspring born from nonstressed (NS) dams. Adult mice born from prenatal restraint stressed (PRS) dams demonstrated reduced sociability and reciprocal social interaction along with increased marble burying behaviors relative to mice born from nonstressed control dams. Differential expression of genes related to excitatory and inhibitory neurotransmission was evaluated in the medial prefrontal cortex, amygdala, hippocampus, nucleus accumbens and caudate putamen via qRT-PCR. The male PRS mouse behavioral phenotype coincided with aberrant expression of glutamate and GABA marker genes (e.g., Grin1, Grin2b, Gls, Gat1, Reln) in neural substrates of social behavior. Rescue of the male PRS sociability deficit by a known antipsychotic with epigenetic properties (i.e., clozapine (5 mg/kg) + 18 hr washout) indicated possible epigenetic regulation of genes that govern sociability. Clozapine treatment increased the expression levels of genes involved in DNA methylation, histone methylation, and histone acetylation in the nucleus accumbens. Identification of etiology-specific mechanisms underlying clinically relevant behavioral phenotypes may ultimately provide novel therapeutic interventions for the treatment of psychiatric disorders including ASD.

Associations between early trajectories of amygdala development and later school-age anxiety in two longitudinal samples

Amygdala function is implicated in the pathogenesis of autism spectrum disorder (ASD) and anxiety. We investigated associations between early trajectories of amygdala growth and anxiety and ASD outcomes at school age in two longitudinal studies: high- and low-familial likelihood for ASD, Infant Brain Imaging Study (IBIS, n = 257) and typically developing (TD) community sample, Early Brain Development Study (EBDS, n = 158). Infants underwent MRI scanning at up to 3 timepoints from neonate to 24 months. Anxiety was assessed at 6-12 years. Linear multilevel modeling tested whether amygdala volume growth was associated with anxiety symptoms at school age. In the IBIS sample, children with higher anxiety showed accelerated amygdala growth from 6 to 24 months. ASD diagnosis and ASD familial likelihood were not significant predictors. In the EBDS sample, amygdala growth from birth to 24 months was associated with anxiety. More anxious children had smaller amygdala volume and slower rates of amygdala growth. We explore reasons for the contrasting results between high-familial likelihood for ASD and TD samples, grounding results in the broader literature of variable associations between early amygdala volume and later anxiety. Results have the potential to identify mechanisms linking early amygdala growth to later anxiety in certain groups.

Autism Spectrum Disorder and Anxiety Among Transgender Youth: Use of the Social Communication Questionnaire (SCQ)

Autism spectrum disorder (ASD) and ASD symptoms are overrepresented among gender-diverse youth across studies. Gender-diverse and ASD youth are at risk for anxiety, but anxiety is unclear among gender-diverse youth with ASD. The Social Communication Questionnaire (SCQ) is a commonly used ASD screener, including in multidisciplinary gender-affirming programs, but scholars have disagreed on the most optimal cut-off score. To date, no study has investigated the sensitivity and specificity of its established cut-off score of 15 with a sample of transgender youth. Gaining more accurate information about the utility of ASD screening tools with gender diverse youth is critical in order to help refer youth to needed services. Among a sample of 325 transgender youth, this study sought to determine an optimal cut-off score for the SCQ, the prevalence of ASD and ASD symptoms, and the relationship between ASD and anxiety within this population. The current study found that a lower cut-off score of 11 yielded optimal sensitivity and specificity (i.e., the best balance of accurately identifying individuals with ASD based on the screener), and analyses found an overrepresentation of ASD (5.2%) and ASD traits (12.1%). Transgender youth with ASD or ASD symptoms had higher anxiety, and all youth perceived themselves as more anxious than their parents. Future research is needed to identify the needs of this population, with particular consideration for the lived experiences of gender diverse and transgender youth.

The effect of compression on repetitive behaviors and task participation in children with autism spectrum disorder

Compression clothes are marketed to relieve anxiety and decrease hyperactivity in children with autism. However, few studies have examined the impact of compression for individuals with autism spectrum disorder (ASD). In this study, nine children with autism were observed during Applied Behavioral Analysis therapy sessions while wearing compression clothing. The participants were randomly assigned to wear compression clothing for either their first five sessions or their last five sessions. Videos of the therapy sessions were reviewed and each child's "off task" behavior was identified in the following domains: motor, verbal, and visual. In addition, frequency of the child's repetitive behaviors and external visual stimuli were recorded. The compression clothes failed to increase task participation or reduce the participants' repetitive behavior suggesting that the clothing may not contribute to professional practice of ABA therapy.

Similar overall expression, but different profiles, of autistic traits, sensory processing, and mental health between young adult males and females

Recent trends suggest that autism is more common in females than traditionally held. Additionally, some argue that females express autistic traits differently than males. Dimensional views of autism could shed light on these issues, especially with regards to understudied behavioral areas, such as sensory processing. We examined autistic traits, sensory processing, anxiety, and related behaviors in a large sample of neurotypical young adult males and females (n = 1,122; 556 female; ages 19-26). Participants completed an online survey containing questionnaires related to the above. Between groups statistical analyses, as well as within groups correlations and mediation analyses containing these constructs were then computed. We also carried out a cluster analysis to establish groups with behavioral similarities and estimate within-cluster male/female ratios. Results showed modest differences in the overall expression of autistic traits and sensory processing, if any, between males and females. Conversely, more detailed examination of survey subtests and mediation analyses revealed differing profiles between these groups. Cluster analysis uncovered a group comprised of both males (69.8%) and females (30.2%) who exhibited elevated degrees of autism-related behaviors, suggesting a higher proportion of females than would be predicted by traditional ratios. Taken together, these findings suggest that males and females may not differ as much as previously thought in their general levels of autistic traits or sensory processing, but may present with distinct profiles of such behaviors. These novel results add to our understanding of autistic traits in females and have the potential to positively influence diagnostic and support practices.

Selective Mutism in Children With and Without an Autism Spectrum Disorder: The Role of Sensory Avoidance in Mediating Symptoms of Social Anxiety

The present study addressed the different contributors to social anxiety in children with Selective Mutism (SM), with and without co-occurring Autism Spectrum Disorder (ASD) (SM + ASD). Seventy-five parents completed an online composite questionnaire consisting of the symptoms of SM and ASD, anxiety and sensory measures. The results found the SM + ASD group showed significantly higher levels of social anxiety and sensory avoidance compared to the SM only group. However, a simple mediation model revealed sensory avoidance to be a mediator of this relationship between the diagnosis and social anxiety.. Therefore, higher levels of sensory avoidance may help to differentiate social anxiety between the groups and may also be a sign of ASD in children with SM who have and/or are yet to receive an ASD diagnosis.

'Playing a guessing game': Recognising and responding to anxiety in children with intellectual disability

BACKGROUND

Children with intellectual disability are at greater risk of developing anxiety than the general population. Limited research has examined the challenges associated with recognising and responding to anxiety in children with intellectual disability, and its perceived impact.

AIM

This study aimed to explore anxiety in children with intellectual disability, from the child and parent perspective to better understand how parents and children recognise and respond to anxiety.

METHOD AND PROCEDURES

Six children with an intellectual disability (age range: 12-17, four boys) and their mothers participated in a semi-structured interview online. Interviews were transcribed verbatim and interpreted using thematic analysis.

OUTCOME AND RESULTS

Mothers elaborated on the difficulties with recognising signs of anxiety due to the impact of the child's primary diagnosis and the overlap of symptoms with co-occurring conditions. Mothers and children discussed the 'contagious' effect of anxiety within the household and how this influenced mothers' approaches to managing their child's anxiety. They reported that anxiety limited the meaningful activities in which children and families could engage.

CONCLUSIONS AND IMPLICATIONS

These findings highlight the importance of supporting mothers to recognise their children's anxiety and to assist them with strategies on how best to respond and cope. These findings have implications for future research, and practitioners working in this field.

The relationshipbetween anxiety and social outcomes in autistic children and adolescents: A meta-analysis

Anxiety is one of the most frequently reported co-occurring conditions for autistic children and adolescents. The relationship between anxiety and social outcomes in autistic youth has been the focus of a range of studies, with mixed results. This meta-analysis aimed to identify the strength of the association between anxiety and a frequently researched social outcome (social competence) in autistic young people and whether that association is influenced by individual or research design factors. A previous preregistered systematic review was updated with a search of the same three databases (CINAHL, ERIC, and PsycINFO) as the original review. Through this, 20 studies with sufficient data on a neurotypically-defined measure of social competence and anxiety were identified. Results were synthesised using a mixed effects model. The meta-analysis on 2,321 participants (from 22 samples) highlighted wide heterogeneity in results. The findings show that anxiety has a significant, small negative impact on social competence (d = - 0.48; 95% CI = - 0.71, - 0.26), meaning that as scores on measures of anxiety increase, scores on measures of social competence decrease. This relationship between anxiety and social competence was moderated by age, becoming weaker as age increased. Whilst this is an important finding for supporting mental health and well-being of autistic young people, the large amount of variance left unexplained suggests that multiple factors, including the use of measures designed for neurotypical people and the potential impact of camouflaging on such measures, need to be considered in future designs.

Implementation of a Minimal Sedation Protocol for Patients With Developmental Disabilities and Needle Phobia

Objective Patients with intellectual and developmental disabilities (IDD) experience needle phobia at greater rates than individuals in the general population. Needle phobia deters patients with IDD from receiving routine medical procedures, which impacts their physical health outcomes. The aim of this quality improvement study was to assess the feasibility of a minimal sedation protocol in an outpatient care setting for patients with IDD and needle phobia. Methods The sample included 18 patients characterized as having a diagnosis of IDD only or IDD and needle phobia compared to patients with only a diagnosis of needle phobia. Reasons for referral to intervention included routine lab work, therapeutic drug monitoring, and routine vaccination. The minimal sedation intervention involved intranasal administration of a benzodiazepine (midazolam) by a registered nurse. Outcomes of interest were administration of the sedation and administration of medical orders. Results Nearly a third of patients were children (33.3%, n=6), and 39% of patients were female (n=7). Individuals with IDD (including those both with and without needle phobias) comprised 72.2% of patients (n=13). Half of intervention encounters were successful in both administering the sedation and performing the medical orders (n=9). Among individuals with IDD, 38.4% successfully completed the intervention (n=5). Conclusion This pilot study assessed the feasibility of implementing a minimal sedation protocol in primary care outpatient care settings. The preliminary results suggest that the minimal sedation protocol may improve the uptake of needle-related medical procedures for patients with IDD and/or needle phobia. The minimal sedation protocol should be studied in a larger sample and among multiple outpatient settings to establish effectiveness of the intervention.

The Needle Anxiety Program: A Patient-Centered Initiative for Individuals With Developmental Disabilities

Objective To describe the development process of a patient-centered initiative focused on improving primary care health outcomes of patients with intellectual and developmental disabilities (IDD) and needle-related anxiety using evidence-based practices and novel approaches that can be implemented in outpatient settings. The overall outcome of the program is to increase vaccine uptake and accessibility in the IDD population as well as improve needle-related procedures in primary care settings to be more humane and effective. Methods The development process occurred in the context of a large healthcare system serving a diverse patient population in the U.S. and was led by an expert committee made of an multidisciplinary team of physicians, psychologists, ambulatory and clinic nurses, pharmacists, and anesthesiologists committed to promoting quality healthcare for the IDD population. Committee members were recruited within the healthcare system based on their relevant expertise. The methodology included an iterative and collaborative process that took place over three development phases: ideation and design, literature review and synthesis, and expert engagement. The ideation and design phase included a series of planning meetings among the expert committee, in which committee members identified preliminary concerns based on their expertise in the field and background knowledge on the current procedures related to improving routine care for individuals with IDD and/or needle-related anxiety. The literature review and synthesis phase led to the development of an annotated bibliography of research and clinical guidelines that synthesized findings on needle anxiety in clinical care. The expert engagement phase included all Committee members meeting for a final discussion to establish a tiered approach to utilizing evidence-based strategies that could be implemented across clinics within the healthcare system.  Results The multidisciplinary team of experts developed a three-tier system, deployed sequentially as needed. The first tier focuses on training nurses in evidence-based behavioral modification strategies to implement as standard of care. The second tier uses the addition of a distraction device and topical analgesic to reduce anxiety in patients with slightly elevated procedural anxiety. The third tier involves a novel minimal sedation protocol using intranasal midazolam for patients with needle phobia that can be administered in an outpatient setting. Conclusion The Needle Anxiety Program eases the administration of needle-related medical procedures in the primary care setting for patients with IDD and needle-related anxiety. The use of evidence-based practices and a novel minimal sedation protocol for individuals with needle phobia assists in the completion of routine healthcare procedures, such as vaccinations and phlebotomy, in a patient-preferred setting. The purpose of delineating needle-related processes and procedures through the Needle Anxiety Program is to reduce health disparities for patients with IDD and promote uptake of the Needle Anxiety Program in similar healthcare settings.

Understanding the prevalence and manifestation of anxiety and other socio-emotional and behavioural difficulties in children with Developmental Language Disorder

BACKGROUND

It is well-documented that children with Developmental Language Disorder (DLD) have a higher likelihood of experiencing anxiety, as well as other socio-emotional and behavioural (SEB) difficulties. Despite this, there is little consensus as to how these difficulties manifest. This study aims to understand the prevalence of broader SEB difficulties and anxiety, informing intervention development by understanding the relationships between them.

METHODS

A mixed-methods, case-control study was conducted. First, an online survey was completed by 107 parents of either children with DLD ("DLD sample"; n = 57) or typically developing children ("typical sample"; n = 50), aged 6-12 years old. Binary SEB statements informed by previous qualitative work (e.g. "my child requires routine/sameness"; "my child has frequent tantrums") provided an insight into the prevalence of SEB difficulties in both DLD and typical samples. Validated measures of anxiety, emotion regulation, intolerance of uncertainty, insistence on sameness, family stress and coping mechanisms were also collected. Correlation and mediation analyses were run using these validated measures to understand the manifestation of anxiety in children with DLD in more detail. Qualitative interviews were then carried out with a select panel of survey respondents (n = 4).

RESULTS

The DLD sample scored significantly higher on all binary SEB statements than the typical sample: experiencing anxiety (80.7%, p < .05), requiring routine and sameness (75.4%, p < .001) and emotional dysregulation (75.4%; p < .001) were the most common difficulties reported for children with DLD. Using the validated scales, family stress and coping mechanisms were found to only correlate with the manifestation of anxiety in the typical group, not the DLD group. "Intolerance of uncertainty" and "insistence on sameness" were found to fully mediate the relationship between DLD diagnosis and symptoms of anxiety. Parent's interviews provided contextual support for the analysis, as well as highlighting sensory sensitivities as a focus for future research.

CONCLUSIONS

Parents of children with DLD appear to cope well with their children's complex SEB needs. Intervention focussing on intolerance of uncertainty may help the management of difficulties with anxiety. Behaviours such as insistence on sameness should be investigated further, as potential indicators for anxiety amongst children with DLD.

Occurrence and correlates of anxiety and depression in carers of autistic children across three nations

Purpose

Caring for an autistic child is associated with elevated stress, anxiety and depression. Although some data suggest that 'child' or 'carer' factors may moderate the severity of carer distress, relatively few international comparisons have been made, limiting the generalizability of previous findings. This study aimed to address this issue.

Method

A survey-based comparison was made of carers from three nations (Australia, Denmark, Greece), and the effects of demographic, child, and carer variables upon carer anxiety and depression were investigated.

Results

Only limited cross-nation consistency was found for nation, child, or carer variables and their effects upon carer anxiety or depression.

Conclusion

The application of universal treatment models for carer anxiety and depression may be of differing value across nations.

Anxiety and Depression Signs Among Adolescents in 26 Low- and Middle-Income Countries: Prevalence and Association With Functional Difficulties

PURPOSE

The aim of this study is to describe the occurrence of signs of depression and anxiety among adolescents from 26 low- and middle-income countries and explore the extent to which these are associated with difficulties across other functional domains.

METHODS

We analyzed randomly selected, nationally representative data from 26 countries with a total sample size of 123,975 adolescents aged 10-17 years. Data on functional difficulties, including signs of depression and anxiety, were collected by the Child Functioning Module, an instrument validated to identify the population of children with disabilities through household surveys. We estimated percentages and 95% confidence intervals of adolescents with difficulties across 11 domains of functioning, and of signs of depression and/or anxiety. We used multinomial regressions to estimate the association between difficulties in the different domains and having signs of depression only, signs of anxiety only, and signs of both depression and anxiety, relative to not presenting signs of depression or anxiety.

RESULTS

In total, 5.5% of adolescents were reported to have had signs of anxiety, 3.1% signs of depression, and 2.3% co-occurring signs of anxiety and depression. Compared to adolescents without functional difficulties, those with difficulties in one or more domains were three times more likely to have signs of depression and anxiety. The likelihood of presenting signs of depression only or signs of both depression and anxiety was significantly higher across all domains, and the highest among adolescent with difficulties to self-care and communicating. The likelihood of presenting signs of anxiety only was significantly higher across all domains except seeing and hearing, and the highest among adolescent with difficulties communicating and accepting changes.

DISCUSSION

Adolescents with functional difficulties in all domains analyzed, across different contexts, are more likely to experience depression and anxiety signs than those without such difficulties. Increasing the availability of population-level data on adolescent functional difficulties, including those related to depression and anxiety, is important in promoting inclusivity, participation, and the right of children to equal opportunities.

Friendship and Anxiety/Depression Symptoms in Boys With and Without Autism Spectrum Disorder

The transition to adolescence may be a challenging time for individuals with autism spectrum disorder (ASD). This developmental period is marked by increased social demands and increasing anxiety and depression symptoms for many individuals with autism. As both of these factors may compound social difficulties and impact friendship experiences, this study explored the relations among autism symptom severity, internalizing symptoms, and friendship experiences in boys with and without ASD (with IQ > 75). Results showed that internalizing symptoms predicted quantity of close friendships in the ASD group. Given the observed relationship between internalizing symptoms and friendship experiences, social skills intervention programs should address possible internalizing symptoms associated with establishing/maintaining social relationships and perceived friendship quality.

Prevalence and Phenomenology of Anxiety in Preschool-Aged Children with Autism Spectrum Disorder

Individuals with autism spectrum disorder (ASD) are at a higher risk for developing co-occurring anxiety symptoms and diagnosable anxiety disorders compared to children with neurotypical development (NTD). The objective of the current study was to characterize the prevalence and phenomenology of anxiety in preschool-aged children with ASD. Our sample consisted of preschoolers (M = 52.8 months, SD = 10.8 months) with ASD (n = 77, 66% with co-occurring intellectual disability, ID) and NTD (n = 55). We employed multi-method (questionnaire and semi-structured diagnostic interview) and multi-informant (parent- and teacher-report) assessments of anxiety. Children with ASD were significantly more likely to meet criteria for an anxiety disorder than children with NTD. Over 70% of our sample with ASD met DSM-5 criteria for an anxiety disorder, with Specific Phobia and Separation Anxiety Disorder being the most prevalent. A range of specific fears was endorsed in the group with ASD, many of which overlapped with ASD symptoms. Parents, but not teachers, also reported greater anxiety symptoms for children with ASD relative to the comparison sample. Prevalence and phenomenology of anxiety in our sample with ASD generally did not differ between those with and without co-occurring ID, with the exception of higher rates of generalized anxiety in those without ID. Results showed poor concordance between parent questionnaires and a semi-structured diagnostic interview in detecting clinically-elevated anxiety in children with ASD. Implications for clinical practice and research are discussed.

Ansiedad y trastornos del espectro del autismo: notas para la intervención psicoeducativa

Se analizan de forma narrativa las relaciones entre comportamiento sensorial atípico, intolerancia a la incertidumbre y regulación emocional como generadores de los trastornos de ansiedad en niños y niñas autistas. El objetivo es estudiar el origen de la ansiedad en los niños y niñas autistas con la finalidad de determinar cuál o cuáles pueden ser los procedimientos de intervención más adecuados. Se han revisado algunos de los programas de intervención cognitivo-conductuales más utilizados en niños y niñas autistas y las adaptaciones realizadas a los mismos. Se observa un divorcio entre los programas psicoeducativos escolares y los programas clínicos de intervención para el tratamiento de la ansiedad. Como conclusión, se recomienda que en los programas psicoeducativos escolares se incorporen acciones proactivas en forma de programas de intervención cognitivo-conductuales para evitar o aminorar los efectos negativos de la ansiedad en el aprendizaje e inclusión escolar de los niños y las niñas autistas.

Using percentiles in the interpretation of Patient-Reported Outcomes Measurement Information System scores: Guidelines for autism

The objectives of this study were to (1) demonstrate the application of percentiles to advance the interpretation of patient-reported outcomes and (2) establish autism-specific percentiles for four Patient-Reported Outcomes Measurement Information System (PROMIS) measures. PROMIS measures were completed by parents of autistic children and adolescents ages 5-17 years as part of two studies (n = 939 parents in the first study and n = 406 parents in the second study). Data from the first study were used to develop autism-specific percentiles for PROMIS parent-proxy sleep disturbance, sleep-related impairment, fatigue, and anxiety. Previously established United States general population percentiles were applied to interpret PROMIS scores in both studies. Results of logistic regression models showed that parent-reported material hardship was associated with scoring in the moderate-severe range (defined as ≥75th percentile in the general population) on all four PROMIS measures (odds ratios 1.7-2.2). In the second study, the percentage of children with severe scores (defined as ≥95th percentile in the general population) was 30% for anxiety, 25% for sleep disturbance, and 17% for sleep-related impairment, indicating a high burden of these problems among autistic children. Few children had scores at or above the autism-specific 95th percentile on these measures (3%-4%), indicating that their scores were similar to other autistic children. The general population and condition-specific percentiles provide two complementary reference points to aid interpretation of PROMIS scores, including corresponding severity categories that are comparable across different PROMIS measures.

Anxiety in Autism Spectrum Disorder: Clinical Characteristics and the Role of the Family

BACKGROUND

Anxiety Disorder (AD) is among the most common psychiatric comorbidity in children and adolescents with Autism Spectrum Disorder (ASD). Likewise, parental psychological distress (PPD) was linked to anxiety symptoms in children and adolescents with ASD. The aim of this study was to characterise, in a sample of children and adolescents with ASD, anxiety symptoms, the functional impairment associated and the presence of PPD.

METHODS

Participants were divided into three groups based on their diagnosis: children and adolescents with a diagnosis of ASD + AD, others with a diagnosis of AD but without a diagnosis of ASD, and others with a diagnosis of ASD but without a diagnosis of AD.

RESULTS

Group ASD + AD showed lower global functioning than Group ASD and Group AD. Generalised Anxiety Disorder, Separation Anxiety Disorder and Specific Phobias were more frequent in Group ASD + AD. Our findings also showed higher depressive symptoms in Group ASD + AD, both in the child and parent reports. Finally, parents of the Group ASD + AD revealed higher levels of PPD.

CONCLUSIONS

Our findings suggest that early assessment of AD with functional impairment associated with the role of PPD could define individualised treatments and consequently mean a better prognosis in children and adolescents with ASD and AD.

Experiences of equine assisted therapy for females with autism spectrum disorders

Purpose

This research indicates females with autism spectrum disorders (ASDs) have a diverse clinical presentation compared to males. Furthermore, females with ASD are often diagnosed later and typically experience greater levels of mental health difficulties. Evidence suggests that clinic-based verbal interventions for ASD have limited efficacy; therefore, alternative therapies, such as equine-assisted therapies (EATs), are gaining recognition. The purpose of this study was to directly explore the experiences of females with an ASD who have undertaken EAT.

Design/methodology/approach

Five female participants with a diagnosis of ASD were recruited from two equine therapy centres. Participants were aged between 15 and 30 years and undertook semi-structured interviews, which were analysed using interpretative phenomenological analysis.

Findings

Three superordinate themes emerged: the difficult experience of the social world, the process of EAT and the emotional impact of horses.

Originality/value

Directly exploring the experiences of females with ASD highlights benefits from engaging therapeutically with horses, building confidence and independence to transferring this into more effective social communication with other people. Offering emotion-focused therapeutic complementary interventions for females with ASD should be forefronted to help remediate the impact of difficult and sometimes traumatic earlier experiences in the social world. This requires increased funding for EAT, combined with larger-scale research projects to evaluate this.

Differentiation of autism spectrum disorder and mood or anxiety disorder

LAY ABSTRACT

Symptoms of mood and anxiety disorders overlap with symptoms of autism spectrum disorder, making the diagnostic process challenging. This study found that a combination of communicational deficits and unusual and/or inappropriate social overtures facilitates differentiation between autism spectrum disorder and mood and anxiety disorders. Furthermore, the results confirm the essential need of a behavioral observation with the Autism Diagnostic Observation Schedule in combination with a full Autism Diagnostic Interview-Revised to support diagnostic decisions.

The impact of COVID-19 measures on parent-reported restricted and repetitive behaviours in pre-school children with autism

Background

COVID-19 restrictive measures have had a considerable impact on daily life routines, which may be especially challenging for families of children with autism. In pre-schoolers with autism, it is likely that the disruption of routines mainly impacts the presence of restrictive and repetitive behaviours (RRBs). Furthermore, influence of comorbid conditions, secondary behavioural difficulties and home environment characteristics on RRBs was explored.

Method

A cross-sectional online survey design was used to collect parent-report data on 254 children with autism (2.5–6 years) during lockdown in the early months of the pandemic. RRBs were assessed using the Repetitive Behaviour Scale-Revised (RBS-R).

Results

Parents reported a significant increase in stereotypic, self-injurious, compulsive and ritualistic behaviour, and restricted interests after implementation of COVID-19 restrictions. The presence of a co-occurring condition, such as language impairments or intellectual disability, was associated with more self-injurious and stereotypic behaviour. However, there was no effect of home environment on RRBs. Further, most children showed increases in internalising and/or externalising behaviour. Increased inattentive behaviour was associated with more ritualistic and stereotypic behaviour, and restricted interests. Decreases in hyperactivity were related to more restricted interests. Importantly, in a subset of children, parents reported less behavioural difficulties during the lockdown.

Conclusions

Findings highlight the importance of flexible implementation and continuity of care for pre-schoolers with autism and support for parents. Further follow-up of children with autism and RRBs, and co-occurring behavioural difficulties is needed and could enhance our understanding of the long-term effects associated with sudden restrictive measures to daily routines.

A systematic review of risk for the development and persistence of self-injurious behavior in intellectual and developmental disabilities

Self-injurious behavior (SIB) by individuals with intellectual and developmental disabilities including autism (I/DD) is among the most clinically disturbing, socially costly, and scientifically challenging behavior disorders. Forty years of clinical research has produced a knowledge base supporting idiographic behavioral assessment and treatment approaches. Despite the treatment progress, from a public health and population perspective, we argue it is less clear that we have reduced the disorder's burden. The developmental course of the disorder is mostly unknown and empirically informed population-level models of risk are absent. In this review, we systematically examined the published scientific literature specific to risk for SIB in the I/DD population. We reviewed study methodology in detail intentionally informed by an epidemiological perspective with a set of questions intended to test the quality of the inferences about risk. Results are discussed in terms of conceptual, methodological, and translational issues with respect to what needs to be done to create credible and useful clinical models for SIB risk in the I/DD population.

Understanding the heterogeneity of anxiety in autistic youth: A person-centered approach

The present study aimed to examine anxiety profiles among children and adolescents on the autism spectrum. It further aimed to characterize the association between the identified anxiety profiles and key clinical and developmental variables. The Spence Children's Anxiety Scale-Parent Version (SCAS-P) data from a large international pooled sample of 870 caregivers of autistic children and adolescents (M_age  = 11.6 years, SD_age  = 2.77; 107 females) was used. Latent profile analysis identified a three-anxiety profile solution exhibiting high entropy (0.80) and high latent profile probabilities, with good classification accuracy. Identified profiles fell along the severity spectrum and were named as the mild (n = 498), moderate (n = 272) and severe (n = 100) anxiety profiles. There were no statistically significant differences between the three anxiety profiles in terms of sex distribution. Participants in the mild profile were significantly younger than those in the severe profile, had significantly fewer social communication difficulties than youth in the moderate anxiety profile group and had significantly fewer restricted and repetitive behaviors and lower cognitive functioning scores compared to participants in moderate and severe anxiety profiles. This is the first study to move beyond identifying associations and group-level differences to exploring and identifying characteristics of anxiety-based subgroups at an individual level that differ on key clinical and developmental variables. The subgroups identified in this study are a preliminary, yet important, first step towards informing future assessment and individualized interventions aiming to support young people on the autism spectrum to reduce and manage anxiety. LAY SUMMARY: This study tried to understand if there are subgroups of autistic young people who may have similar anxiety profiles. We found that we could meaningfully group young people into three groups based on how severe the anxiety symptoms their caregivers reported were: a group with low levels of anxiety, those with moderate anxiety, and those with more severe anxiety. We also found that the young people in the mild group were younger, had fewer autism traits and lower levels of intellectual functioning than young people in the other two groups.

Citalopram Did Not Significantly Improve Anxiety in Children with Autism Spectrum Disorder Undergoing Treatment for Core Symptoms: Secondary Analysis of a Trial to Reduce Repetitive Behaviors

Objective: Anxiety disorders are among the most common co-occurring conditions in autism spectrum disorder (ASD). Despite their prevalence and impact, there are no randomized controlled trials (RCTs) aimed at evaluating the efficacy of selective serotonin reuptake inhibitors (SSRIs) for anxiolysis in this population, who may have a different biological basis for anxiety. Methods: Secondary analyses of the STAART double-blind, placebo-controlled RCT of citalopram in children with ASD examined whether citalopram reduced anxiety measured on the parent-reported Child and Adolescent Symptom Inventory-4 (CASI-4) as the primary outcome. An intention-to-treat analysis involving all 149 participants used multiple imputations for missing data and included baseline stratification factors of age group and site, among others. We prespecified as clinically significant a 33% reduction in anxiety in citalopram versus placebo, coinciding with 80% power. We tested whether communicative ability on the Vineland Communication score moderated treatment effect and explored whether initial anxiety was associated with greater adverse events, which could impact on dose titration and achieving optimal dose. Results: Both groups showed substantial reduction in anxiety. Citalopram was associated with a nonsignificant 16.5% greater reduction (observed coefficient = -0.181, bootstrap standard error = 0.126, p = 0.151, confidence interval = -0.428 to 0.066). Anxiety reports were significantly lower in children with reduced communicative ability, but communicative ability did not moderate the treatment effect (interaction p = 0.294). Initial anxiety levels were not associated with increased adverse effects (interaction ps 0.162-0.954). Conclusion: Citalopram did not statistically significantly improve anxiety in children with ASD. Clinicians should be cautious in their use of SSRIs for this indication. There remains a need for well-powered clinical trials testing the efficacy of SSRIs among autistic children with anxiety disorders.

A randomized double-blind, placebo-controlled pilot trial of mirtazapine for anxiety in children and adolescents with autism spectrum disorder

This study was a 10-week double-blind, placebo-controlled pilot trial of mirtazapine for anxiety in youth with autism spectrum disorder (ASD). Participants were ages 5 to 17 years with ASD and clinically significant anxiety (Pediatric Anxiety Rating Scale [PARS] score ≥10). Thirty participants were randomized to mirtazapine (7.5-45 mg/day) or placebo in a 2:1 ratio. The co-primary outcome measures were the PARS and the Clinical Global Impressions-Improvement subscale (CGI-I). Mirtazapine resulted in a statistically significant within group decrease in anxiety on the PARS (ES 1.76, p < 0.001). The improvement in PARS score for mirtazapine versus placebo was clinically meaningful but not statistically significant (ES = 0.63, p = 0.64). Forty-seven percent of participants assigned to mirtazapine (95% CI 22%: 74%) and 20% assigned to placebo (95% CI 2%: 60%) were rated "much improved" (CGI-I = 2) or "very much improved" (CGI-I = 1) for anxiety, p = 0.46. No statistically significant differences in mean 10-week changes between mirtazapine and placebo occurred on any outcome measure. There were no statistically significant differences in adverse effect frequency between mirtazapine and placebo. The results are consistent with mirtazapine's safety and tolerability and meet three of four pre-specified indicators of efficacy (statistically significant change in total PARS score for mirtazapine, numerically greater reduction in total PARS score for mirtazapine than placebo, numerically higher number of responders to mirtazapine than placebo, but not greater than 50% of participants receiving mirtazapine rated as responders). Implementation of a larger randomized controlled trial of mirtazapine for the treatment of anxiety in this population is supported.Clinical trial registration information: Mirtazapine Treatment of Anxiety in Children and Adolescents with Pervasive Developmental Disorders; https://clinicaltrials.gov ; NCT01302964.

Phenotypic differences between female and male individuals with suspicion of autism spectrum disorder

BACKGROUND

Although autism spectrum disorder (ASD) is a common developmental disorder, our knowledge about a behavioral and neurobiological female phenotype is still scarce. As the conceptualization and understanding of ASD are mainly based on the investigation of male individuals, females with ASD may not be adequately identified by routine clinical diagnostics. The present machine learning approach aimed to identify diagnostic information from the Autism Diagnostic Observation Schedule (ADOS) that discriminates best between ASD and non-ASD in females and males.

METHODS

Random forests (RF) were used to discover patterns of symptoms in diagnostic data from the ADOS (modules 3 and 4) in 1057 participants with ASD (18.1% female) and 1230 participants with non-ASD (17.9% % female). Predictive performances of reduced feature models were explored and compared between females and males without intellectual disabilities.

RESULTS

Reduced feature models relied on considerably fewer features from the ADOS in females compared to males, while still yielding similar classification performance (e.g., sensitivity, specificity).

LIMITATIONS

As in previous studies, the current sample of females with ASD is smaller than the male sample and thus, females may still be underrepresented, limiting the statistical power to detect small to moderate effects.

CONCLUSION

Our results do not suggest the need for new or altered diagnostic algorithms for females with ASD. Although we identified some phenotypic differences between females and males, the existing diagnostic tools seem to sufficiently capture the core autistic features in both groups.

The Pediatric Autism Spectrum Therapy Observation System: Development, Psychometric Properties, and Sensitivity to Treatment

An observational coding system was developed to track clinical change in children with autism spectrum disorder (ASD) during psychotherapy. The Pediatric Autism Spectrum Therapy Observation System (PASTOS) consists of 23 items divided into 5 subscales and is used to rate child behaviors in individual psychotherapy sessions. Manual-based cognitive behavioral therapy session transcripts of 22 children diagnosed with ASD (IQ > 70) and a concurrent anxiety disorder (M = 9.41 years, SD = 1.56 years) enrolled in a randomized, controlled trial were coded. Results suggested that the PASTOS exhibited promising interrater reliability, internal consistency, convergent validity at post-treatment, and treatment sensitivity. The PASTOS may be a useful tool for studying process and outcome in psychotherapy research on children with ASD.

Autism-related dietary preferences mediate autism-gut microbiome associations

There is increasing interest in the potential contribution of the gut microbiome to autism spectrum disorder (ASD). However, previous studies have been underpowered and have not been designed to address potential confounding factors in a comprehensive way. We performed a large autism stool metagenomics study (n = 247) based on participants from the Australian Autism Biobank and the Queensland Twin Adolescent Brain project. We found negligible direct associations between ASD diagnosis and the gut microbiome. Instead, our data support a model whereby ASD-related restricted interests are associated with less-diverse diet, and in turn reduced microbial taxonomic diversity and looser stool consistency. In contrast to ASD diagnosis, our dataset was well powered to detect microbiome associations with traits such as age, dietary intake, and stool consistency. Overall, microbiome differences in ASD may reflect dietary preferences that relate to diagnostic features, and we caution against claims that the microbiome has a driving role in ASD.

Assessment and treatment of anxiety in children and adolescents with ASD: a systematic review

Purpose

The purpose of this study was to investigate the quality of current studies that assess and treat anxiety symptoms in children with autism spectrum disorder (ASD). More specifically the study aimed to answer the following questions: What are the qualities of the current studies using cognitive behavioral therapies (CBTs) to treat anxiety symptoms in children with ASD? Did studies make necessary modifications and adaptations to CBTs according to the evidence-based strategies and implement these versions of CBTs with precise fidelity? Were the selected measurements appropriate for assessing the anxiety symptoms in children with ASD?

Design/methodology/approach

A systematic review protocol was developed from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Moher et al., 2009). A rubric was adapted based on the CEC (Council for Exceptional Children; Cook, 2014) group comparison studies standards and the Evaluative Method for Determining EBP in Autism (Reichow et al., 2007). The 3-point Likert Scale (Chard et al., 2009) was adapted to score each study based on the rubric.

Findings

CBT is a first-line treatment with significant mixed results. Current studies use adapted versions of existing CBTs for children with ASD without reporting empirical evidence to these adaptations and changes. Reporting of the implementation fidelity is still an issue in the treatment of anxiety. Anxiety measurements that were designed for typically developing children failure to detect unusual anxiety symptoms in children with ASD.

Research limitations/implications

The first limitation of this study was including a variety of studies across CBT programs and types of anxiety symptoms. Types of anxiety and CBT treatments may require separate analyses with specific indicators. Due to the limited studies, reviews could not be analyzed across types of CBT programs. The second limitation was the types of studies. Most of the studies were pilot studies. Pilot studies might use various instruments and CBTs components for making selections to produce the best effects and results. The final limitation was the lack of examination of the data analysis process.

Originality/value

These findings are important because due to the variety of changes or adaptation to CBTs, inappropriate implementations and failure to detect unusual anxiety symptoms of children with ASD may cause significant differences in treatment responses and outcomes. The study demonstrated that the majority of the studies used adapted versions of existing CBTs without reporting empirical evidence for these adaptations and changes. The findings have shown that reporting of the implementation fidelity is still an issue. Moreover, the majority of studies had used anxiety measurements that were designed for typically developing children, not for children with ASD.

Clinically Significant Anxiety in Children with Autism Spectrum Disorder and Varied Intellectual Functioning

Objective: To evaluate how distinct presentations of anxiety symptoms and intellectual impairment influence the measurement and estimated rate of clinically significant anxiety in autism spectrum disorder (ASD).Method: The sample included 75 children (ages 9-13 years) with ASD and varied IQ and 52 typically developing (TD) controls and parents. Parents completed anxiety symptom scales and a diagnostic interview, designed to (1) differentiate anxiety and ASD and (2) examine DSM-specified and unspecified ("distinct") anxiety presentations in each child, including fears of change, special interests, idiosyncratic stimuli and social confusion rather than evaluation. Children completed standard intellectual and ASD diagnostic assessments.Results: 69% of those with ASD had clinically-significant anxiety, including 21% DSM-specified anxiety disorders, 17% distinct anxiety, and 31% both. Only 8% of TD children had clinically-significant anxiety, all DSM-specified. DSM-specified anxiety disorders in children with ASD and intellectual impairment (IQ<70) were predominantly specific phobias. DSM-specified anxiety other than specific phobia was significantly less common in children with, versus without, intellectual impairment; this was not the case for distinct anxiety. The sensitivities of anxiety scales were moderate to poor, particularly in cases with intellectual impairment.Conclusions: ASD is associated with more frequent and varied presentations of clinical anxiety, which may align with and differ from the specified anxiety disorders of the DSM. Standard parent report anxiety scales have reduced sensitivity to detect clinical anxiety in ASD, particularly in children with intellectual impairment.

Assessing and Treating Anxiety in Individuals with Autism

Anxiety is a cluster of responses that can involve both operant and respondent behavior, which can be both public and/or private in nature, and occurs when an upcoming aversive stimulus is signaled. Despite the reported high comorbidity of autism and anxiety, there has been very limited research on how to directly assess and treat anxiety, especially with individuals who have limited communication skills. In Study 1, anxiety was assessed in five individuals with autism, ranging in age from 10 to 19 years old. Anxiety was assessed by measuring behavior during (1) a baseline (with no putative anxiety-provoking stimuli present), (2) signals for an upcoming aversive event, and (3) exposure to that aversive event. Anxiety presented in several different ways, as both conditioned activation and suppression, and both with and without problem behavior during the aversive event. In Study 2, individualized treatments involving differential reinforcement of alternative responses and stimulus fading were used to successfully reduce anxious responding in all four participants who displayed anxiety. These studies demonstrated a potentially useful means of assessing anxiety in individuals with autism which may not only help to measure anxious behavior and identify anxiety-provoking events, but may also lead to effective treatment.

The relationship between social and academic outcomes and anxiety for children and adolescents on the autism spectrum: A systematic review

Anxiety is the most common co-occurring condition in children on the autism spectrum but the potential impacts of anxiety on social and academic outcomes of children on the autism spectrum have not been systematically examined. In this review, 50 studies were identified that explore the relationship between anxiety and scores on social or academic measures in children on the autism spectrum. Social competence was frequently measured, and the findings of these studies were mixed. While other social constructs have received little attention, associations were found between anxiety and victimisation, and anxiety and social relationships. Only three studies focused on the impact of anxiety on scores on academic measures, highlighting the need for further research in this area. Anxiety was most frequently measured using subscales from broader behavioural instruments, which may not capture the range of anxiety symptoms of children on the autism spectrum. Future studies that include multi-informant methodologies and proportional representation of females and children with intellectual disability will further knowledge of the impact of anxiety in children on the spectrum.

Interpersonal Trauma and Posttraumatic Stress in Autistic Adults

Background

Many autistic adults report interpersonal traumas (IPTs) such as physical or sexual assault, which are often associated with posttraumatic stress and dissociation. Factors such as gender might make autistic individuals particularly vulnerable to experiencing IPT and negative posttraumatic symptoms.

Methods

In this study, 687 self-identified autistic adults completed an online survey on their traumatic experiences and mental health symptoms.

Results

Seventy-two percent of participants reported experiencing sexual assault, other unwanted or uncomfortable sexual experiences, or physical assault. Forty-four percent of participants met the criteria for posttraumatic stress disorder (PTSD), including 50% of those who had experienced IPT and 28% of those who had not (odds ratio = 2.50; 95% confidence interval 1.74-3.60). IPT was also significantly associated with higher levels of psychoform (p < 0.001) and somatoform (p < 0.001) dissociation. Autistic cisgender women and gender minorities experienced a significantly higher number of traumas (p = 0.004) and were significantly more likely than cisgender men to experience sexual IPT (p < 0.001) and meet the criteria for PTSD (p < 0.001). There were no significant differences between autistic individuals with and without a professional autism spectrum disorder (ASD) diagnosis.

Conclusions

IPT is associated with potentially severe mental health outcomes for autistic adults. Autistic women and gender minorities may be particularly vulnerable to sexual IPT and adverse outcomes. Increased screening for a history of IPT and posttraumatic symptoms is recommended for all autistic adults regardless of ASD diagnosis status.

Lay summary

Why was this study done?: Many autistic people experience interpersonal traumas (IPTs) such as sexual or physical assault. These can lead to mental health challenges such as posttraumatic stress disorder (PTSD) or dissociation (a disconnection between individuals and aspects of their perceptions or sense of self). We wanted to better understand what might make autistic adults more likely to experience trauma and how it affects them.What was the purpose of this study?: The purpose was to understand what might make autistic people more at risk of experiencing IPT and PTSD. We also wanted to know if IPT is associated with a higher risk of PTSD or dissociation.What did the researchers do?: Six hundred eighty-seven autistic adults filled out an online survey about their traumatic experiences, PTSD symptoms, and dissociation symptoms. We analyzed their responses to see how often participants reported experiencing different types of trauma and whether they met the criteria for PTSD and clinical dissociation. We then compared trauma experiences and PTSD rates across genders and those with and without a professional autism spectrum disorder (ASD) diagnosis and compared PTSD rates and dissociation rates across participants who had versus had not experienced IPT.What were the results of the study?: Seventy-two percent of autistic adults in this study reported having experienced sexual assault, another unwanted sexual experience, or physical assault. Almost half (44%) met the criteria for PTSD. Most participants (93%) also reported high levels of mind-based dissociation, and 32% reported high levels of body-based dissociation (dissociation that causes negative emotions to be experienced as physical problems such as headaches or trouble moving). Participants who had experienced IPT were almost twice as likely to meet the criteria for PTSD and scored higher on both measures of dissociation. Cisgender women and gender minorities were more likely to experience IPT and meet the criteria for PTSD than cisgender men. Participants with and without a professional ASD diagnosis did not differ.What do these findings add to what was already known?: Most previous research on trauma and PTSD for autistic people was done on children and did not look at IPT specifically or compare people based on their gender or ASD diagnosis. As far as we know, this is the first study on posttraumatic dissociation in autistic adults.What are potential weaknesses in the study?: The findings of this study may not apply to autistic adults as a whole. People who could have participated may not have been interested in the topic, may not have seen study advertisements and so been unaware of the study, or may not have had the time or energy to participate. Findings might have been different if different groups of autistic people participated more.How will these findings help autistic adults now or in the future?: If professionals who help autistic people do not talk to them about trauma, traumatized autistic adults may not get the right support. This study could encourage professionals to screen more autistic people, especially women and gender minorities, for trauma.