Verbal Ability and Psychiatric Symptoms in Clinically Referred Inpatient and Outpatient Youth with ASD

Exploring the clinical features of minimally verbal autistic children

Introduction

It is recognized that around 25-30% of autistic children do not develop functional speech and remain minimally verbal beyond the age of 5. However, little is known about the clinical characteristics of this group.

Methods

We retrospectively examined a sample of 189 autistic children and adolescents classified as minimally verbal (mean age: 7.37 ± 1.51; 152 males, 37 females) and compared them with a group of 184 verbal autistic children and adolescents (mean age: 7.71 ± 2.52; 160 males, 24 females). We considered intellectual functioning, severity of autism, emotional and behavioural problems, and parenting stress.

Results

Children in the minimally verbal group exhibited significantly lower nonverbal Intelligent Quotient and an increase in restricted repetitive behaviours compared to the verbal group. Exploring potential differences in emotional and behavioural problems, the verbally group showed higher levels of anxiety symptoms. In addition, minimally verbal group showed high score of parenting stress.

Discussion

This study highlights the importance of accurately characterizing minimally verbal autistic children and adolescents to facilitate the identification of specific and individualized interventions based on individual functioning profiles.

Concurrent predictors of behavioral inflexibility in minimally verbal and verbal autistic children

Behavioral inflexibility (BI) refers to the rigid and inflexible patterns of behaviors that are a core aspect of autism. Few studies have investigated BI in autism separately from other restricted and repetitive behaviors (RRBs). The present study used a relatively new measure, the behavioral inflexibility scale (BIS; Lecavalier, L., Bodfish, J., Harrop, C., Whitten, A., Jones, D., Pritchett, J., Faldowski, R., & Boyd, B. (2020). Autism Research, 13(3), 489-499), to examine the relationship of BI and variables that are both core symptoms in autism as well as symptoms associated with cooccurring mental health conditions, atypical sensory experiences, and adaptive functioning in a sample of 87 children with autism. Additionally, we aimed to understand how these relationships may be related to autistic individuals' verbal status: minimally verbal (MV) or verbal. Results revealed that anxiety, attention deficit/hyperactive, depressive, oppositional defiance problems, and sensory differences were all significantly correlated with BI in the MV group. In contrast, only anxiety, depressive, and oppositional defiance problems were significantly correlated with BI in the verbal group. Linear regression analyses showed that oppositional defiance problems and atypical sensory experiences explained a significant proportion of the variance of BI in the MV group, whereas only depressive problems were significant in the verbal group after accounting for other mental health conditions. Overall, our findings demonstrate that multiple aspects of psychopathology are significantly related to BI and can have broader implications for interventions and mental health care in autistic children.

Executive function deficits in attention-deficit/hyperactivity disorder and autism spectrum disorder

Executive function deficits have been reported in both autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD). However, little is known regarding which, if any, of these impairments are unique vs. shared in children with ADHD versus ASD. In this Review, we provide an overview of the current literature with a critical eye toward diagnostic, measurement, and third-variable considerations that should be leveraged to provide more definitive answers. We conclude that the field's understanding of ASD and ADHD executive function profiles is highly limited because most research on one disorder has failed to account for their co-occurrence and the presence of symptoms of the other disorder; a vast majority of studies have relied on traditional neuropsychological tests and/or informant-rated executive function scales that have poor specificity and construct validity; and most studies have been unable to account for the well-documented between-person heterogeneity within and across disorders. Currently, the most parsimonious conclusion is that children with ADHD and/or ASD tend to perform moderately worse than neurotypical children on a broad range of neuropsychological tests. However, the extent to which these difficulties are unique vs. shared, or attributable to impairments in specific executive functions subcomponents, remains largely unknown. We end with focused recommendations for future research that we believe will advance this important line of inquiry.

The importance of social relationships in depression in autistic adolescents: a narrative-review

Objective

The impact of social relationships on autistic adolescents has been recently studied. However, the link between social relationships and depression in autistic adolescents seem underrepresented in the scientific literature. Especially no specific assessment tool has been developed to evaluate depression in autistic adolescents. The aim of this narrative review is to raise the impact of social relationships on depression in autistic adolescents. We aim to propose lines of thought on the creation of a sensitive tool for identifying depression in this population.

Methods

We conducted two types of searches for articles and reviews on PubMed, Embase, and Cochrane. First, regarding social relationships, we searched the following terms: [("adolesc*" OR "youth") AND ("ASD" OR "autis*") AND ("social communication" OR "peer relationship") AND ("depress*")]. Secondly, regarding assessment tool, we searched the following terms: [("tool" OR "assess*") AND ("depress*") AND ("ASD" OR "Autis*)"].

Results

Social impact, verbal skills, and good social motivation are risk factors of depression in autistic adolescents. Social impairment during childhood is related to peer victimization and is a risk factor for depression. There is no specific tool to measure depression in autistic adolescents.

Conclusion

No specific tool based on social relationships was developed to evaluate depression in autistic adolescents. Depression in autistic adolescents needs to be assessed considering the social and pragmatic specificities of autism. Social communication and difficulties in peer relationships may be evaluated in specific assessment tools based on social relationships for depression in autistic adolescents.

The Predictive Relationship Between Sensory Reactivity and Depressive Symptoms in Young Autistic Children with Few to No Words

Depression and sensory reactivity are both common in autism. However, there is little understanding of the predictive relationship between these factors, or the nature of this relationship in autistic children who speak few to no words. This study set out to explore the longitudinal relationship between sensory reactivity and depressive symptoms in 33 young autistic children who speak few to no words. We found positive correlations between depressive symptoms and hyper-reactivity and sensory seeking at both timepoints, and across timepoints. We further found a bidirectional predictive relationship between depressive symptoms and sensory seeking. These results implicate sensory seeking in the development of depressive symptoms in young autistic children who use few to no words. Our findings have important implications for preventative mental health interventions, especially for those with a developmental language delay.

The Autism Spectrum: Behavioral, Psychiatric and Genetic Associations

Autism spectrum disorder (ASD) consists of a group of heterogeneous genetic neurobehavioral disorders associated with developmental impairments in social communication skills and stereotypic, rigid or repetitive behaviors. We review common behavioral, psychiatric and genetic associations related to ASD. Autism affects about 2% of children with 4:1 male-to-female ratio and a heritability estimate between 70 and 90%. The etiology of ASD involves a complex interplay between inheritance and environmental factors influenced by epigenetics. Over 800 genes and dozens of genetic syndromes are associated with ASD. Novel gene–protein interactions with pathway and molecular function analyses have identified at least three functional pathways including chromatin modeling, Wnt, Notch and other signaling pathways and metabolic disturbances involving neuronal growth and dendritic spine profiles. An estimated 50% of individuals with ASD are diagnosed with chromosome deletions or duplications (e.g., 15q11.2, BP1-BP2, 16p11.2 and 15q13.3), identified syndromes (e.g., Williams, Phelan-McDermid and Shprintzen velocardiofacial) or single gene disorders. Behavioral and psychiatric conditions in autism impacted by genetics influence clinical evaluations, counseling, diagnoses, therapeutic interventions and treatment approaches. Pharmacogenetics testing is now possible to help guide the selection of psychotropic medications to treat challenging behaviors or co-occurring psychiatric conditions commonly seen in ASD. In this review of the autism spectrum disorder, behavioral, psychiatric and genetic observations and associations relevant to the evaluation and treatment of individuals with ASD are discussed.

Clinical Characteristics of Youth with Autism or Developmental Disability during Inpatient Psychiatric Admission

Children with autism spectrum disorder and developmental disabilities (ASD/DD) often experience severe co-occurring psychological and behavioral challenges, which can warrant inpatient psychiatric care. However, very little is known about the characteristics and clinical care of children with ASD/DD within the context of inpatient psychiatric settings. In this paper, we describe factors unique to inpatients with ASD or DD, by drawing on electronic health records from over 2300 children and adolescents ages 4–17 years admitted to a pediatric psychiatric inpatient unit over a 3-year period. Patients with ASD/DD accounted for approximately 16% of inpatients and 21% of admissions, were younger, more likely to be readmitted, more likely to be male, and more likely to have Medicaid insurance, as compared to patients without ASD/DD. Clinically, those with ASD/DD more frequently had externalizing concerns documented in their records, in contrast to more frequent internalizing concerns among other patients. Within the ASD/DD group, we identified effects of patient age, sex, and race/ethnicity on multiple dimensions of clinical care, including length of stay, use of physical restraint, and patterns of medication use. Results suggest the need for psychiatric screening tools that are appropriate for ASD/DD populations, and intentional integration of anti-racist practices into inpatient care, particularly with regard to use of physical restraint among youth.

Comparison of Verbal Performance of Children with Autism Spectrum Disorder on the WISC-V

Children with autism spectrum disorder (ASD) display variable verbal cognitive profiles despite a historical requirement for a language delay in autistic disorder. This study compared the Verbal Comprehension Index (VCI) to the newly created ancillary index score, the Verbal Expanded Crystallized Index (VECI) of the Wechsler Intelligence Scale for Children, Fifth Edition (WISC-V) in a group of children with ASD. Using the ASD sample from the standardization data of the WISC-V, results indicated the VCI and VECI were significantly different for the ASD group but not for the matched controls. Follow up analysis of the ASD group revealed the VCI and VECI were significantly different for those with language impairment but not for those without language impairment. Psychologists should consider administering all verbal subtests of the WISC-V to children with ASD given the VECI may better capture the language impairment seen in this population.

The relationship between sensory reactivity differences and mental health symptoms in preschool-age autistic children

There is growing evidence for an association between sensory reactivity and mental health in autism. This study set out to explore the relationship between sensory reactivity and mental health in preschool-aged autistic children. In total 54 preschool-aged children with an Autism Spectrum Condition took part. Sensory and mental health symptoms were obtained from the Sensory Processing Scale Inventory, Sensory Assessment of Neurodevelopmental Differences and the Behavioral Assessment System for Children-3. Correlational analyses showed a relationship between sensory reactivity and mental health symptoms in autistic preschool-aged children. Results also indicate divergence in sensory-mental health profiles between autistic preschool-aged children who are verbal and those who use few to no words. For the first time this study has revealed a relationship between sensory hyper-reactivity, as well as sensory seeking, and mental health symptoms outside of anxiety in autism. Of note, this relationship between sensory hyper-reactivity and internalizing symptoms appears to be driven by those with few to no words. This has implications for both research and clinical interventions, in particular for our understanding of the factors underlying mental health symptoms in different autistic phenotypes, as well as the possible role of functional communication in mitigating the development of mental health symptoms. LAY SUMMARY: The present study found that in autistic preschoolers, externalizing mental health symptoms, such as hyperactivity, are related to sensory seeking (seeking out or being fascinated with sensory stimuli), and internalizing mental health symptoms, such as depression, are related to sensory hyper-reactivity (sensitivity to sensory stimuli). Our results also show that whilst the relationships between externalizing symptoms and sensory seeking is seen across participants, the relationship between internalizing symptoms and sensory hyper-reactivity was only seen in autistic preschoolers who used few to no words. This has important implications for the assessment of sensory differences as part of more rigorous mental health assessments, especially in autistic people who use few to no words.

Neural Evidence for Speech Processing Deficits During a Cocktail Party Scenario in Minimally and Low Verbal Adolescents and Young Adults with Autism

As demonstrated by the Cocktail Party Effect, a person's attention is grabbed when they hear their name in a multispeaker setting. However, individuals with autism (ASD) are commonly challenged in multispeaker settings and often do not respond to salient speech, including one's own name (OON). It is unknown whether neural responses during this Cocktail Party scenario differ in those with ASD and whether such differences are associated with expressive language or auditory filtering abilities. We measured neural responses to hearing OON in quiet and multispeaker settings using electroencephalography in 20 minimally or low verbal ASD (ASD-MLV), 27 verbally fluent ASD (ASD-V), and 27 neurotypical (TD) participants, ages 13-22. First, we determined whether TD's neural responses to OON relative to other names could be quantified with early frontal mismatch responses (MMRs) and late, slow shift parietal and frontal responses (LPPs/FNs). Second, we compared the strength of MMRs and LPPs/FNs across the three groups. Third, we tested whether participants with poorer auditory filtering abilities exhibited particularly weak neural responses to OON heard in a multispeaker setting. Our primary finding was that TDs and ASD-Vs, but not ASD-MLVs, had significant MMRs to OON in a multispeaker setting, and strength of LPPs positively correlated with auditory filtering abilities in those with ASD. These findings reveal electrophysiological correlates of auditory filtering disruption within a clinical population that has severe language and communication impairments and offer a novel neuroimaging approach to studying the Cocktail Party effect in neurotypical and clinical populations. Autism Res 2020, 13: 1828-1842. © 2020 International Society for Autism Research and Wiley Periodicals LLC. LAY SUMMARY: We found that minimally and low verbal adolescents and young adults with autism exhibit decreased neural responses to one's own name when heard in a multispeaker setting. In addition, decreased strength of neural responses in those with autism correlated with decreased auditory filtering abilities. We propose that these neural deficits may reflect the ineffective processing of salient speech in noisy settings and contribute to language and communication deficits observed in autism.

Defining Positive Outcomes in More and Less Cognitively Able Autistic Adults

Identifying positive outcomes for a wide range of intellectual abilities in autism spectrum disorder (ASD) remains a challenge. Several past studies of autistic adults have used outcome definitions that do not reflect the experiences of less cognitively able adults. The aim of the current study was to (1) define three domains of outcomes: autonomy, social relationships, and purpose, and (2) examine how these outcomes relate to concurrent aspects of adult functioning. Using data from a longitudinal sample of 126 adults (85% diagnosed with ASD at some point), mean age 26, who first entered the study in early childhood, we generated distinct outcomes for less (daily living skills above an 8-year-old level, having regular activities outside the home, and social contacts outside the family) and more cognitively able adults (living independently, having paid employment, and at least one true friend). Verbal IQ, assessed in adulthood, was a significant predictor of more outcomes achieved for individuals within more and less cognitively able groups. For less cognitively able adults, having ever received a formal ASD diagnosis (in contrast to current Autism Diagnostic Observation Schedule [ADOS] CSS scores) was associated with lower odds of positive outcomes. For more cognitively able adults, living skills and happiness measures were positively associated with number of outcomes met; higher ADOS CSS, internalizing and externalizing symptoms, being racially diverse, and having caregiver education below college graduation were all negatively associated with the number of positive outcomes. Tailoring outcomes to ability levels may lead to better identification of goals and service needs. LAY SUMMARY: This article describes the outcomes of autistic adults who are more and less cognitively able. For less cognitively able individuals, an earlier autism diagnosis was negatively related to outcomes. Several factors that were associated with positive outcomes for more cognitively able individuals, including daily living skills, fewer mental health problems, family demographics, and subjective measures of happiness. Our study identifies several important factors for families, individuals, and service providers to consider and discuss when planning the transition to adulthood. Autism Res 2020, 13: 1548-1560. © 2020 International Society for Autism Research, Wiley Periodicals, Inc.

Gender Differences in Emotion Dysregulation in an Autism Inpatient Psychiatric Sample

There is a wide range of emotion regulation (ER)-related impairment observed in autism spectrum disorder (ASD), which is associated with both internalizing and externalizing problems. Although the importance of ER is widely acknowledged in the ASD literature, little is known about factors associated with variability in ER impairment. Given the identified gender differences in ASD, gender may be a potential contributor to ER. This study examined gender differences in ER in an ASD inpatient psychiatric sample (n = 722; 146 females) aged 4-20 years, collected as part of the Autism Inpatient Collection. In addition, the study investigated whether age, nonverbal intelligence quotient (NVIQ), or verbal ability moderate the association between ER and gender. While both male and female inpatients with ASD presented with clinically elevated emotion dysregulation compared to general population norms, results suggest that female psychiatric inpatients have more severe dysregulation, including higher reactivity and dysphoria, than inpatient males. NVIQ and verbal ability did not moderate the association between gender and ER. Age moderated the association between gender and ER, with greater gender difference seen in older individuals, but only for dysphoria. However, overall, these effects were small. Improved understanding of ER presentation in males and females with ASD is critical, as these symptoms may differentially impact individuals with ASD and may warrant a different treatment emphasis. LAY SUMMARY: Previous research has identified several gender differences in presentation of autism spectrum disorder (ASD) symptoms, as well as difficulties with emotion regulation in individuals with ASD. In order to better understand the factors that may contribute to emotion regulation in ASD, this study examined whether psychiatrically hospitalized males and females with ASD differed in emotion regulation and what factors influenced the differences. Results suggest that females with ASD have slightly but significantly more difficulty with emotion regulation compared to males. Autism Res 2020, 13: 1343-1348. © 2020 International Society for Autism Research, Wiley Periodicals, Inc.

Felt but not seen: Observed restricted repetitive behaviors are associated with self-report-but not parent-report-obsessive-compulsive disorder symptoms in youth with autism spectrum disorder

LAY ABSTRACT

Youth with autism spectrum disorder often exhibit symptoms of obsessive-compulsive disorder; however, it can be difficult for parents and clinicians to tell the difference between the restricted and repetitive behaviors often seen in autism spectrum disorder and symptoms of obsessive-compulsive disorder. This difficulty in distinguishing symptoms may arise from the fact that these symptoms appear the same to observers but are typically differentiated based on whether the motivation for the behavior is to reduce stress (restricted and repetitive behaviors) or whether the behavior itself is stressful (obsessive-compulsive disorder). It is important to know the difference between these two symptoms as it may impact the treatment prescribed. The goal of this study was to better determine the difference between restricted and repetitive behaviors and symptoms of obsessive-compulsive disorder in youth with autism spectrum disorder. It was found that although parents and clinicians had trouble differentiating between the two, the children were able to provide insight as to their own motivations for behavior, and thus whether they were restricted and repetitive behaviors or symptoms of obsessive-compulsive disorder. It was also found that children may actually have subjective negative experiences when engaging in restricted and repetitive behaviors, which complicates their classification. These results provide guidance for better understanding, distinguishing, and ultimately treating obsessive-compulsive disorder behavior in youth with autism spectrum disorder.

The role of emotion regulation and core autism symptoms in the experience of anxiety in autism

LAY ABSTRACT

Many children with autism spectrum disorder have problems with managing their emotions (emotion regulation) and anxiety. In this study, over 1000 parents completed an online survey which showed that emotion regulation and anxiety are closely linked. Although emotion regulation and anxiety are inter-connected, the results also show that autism symptoms play an important role in anxiety in autism spectrum disorder. Emotion regulation problems may be an important target for the treatment of anxiety in autism.

Differences in profiles of emotional behavioral problems across instruments in verbal versus minimally verbal children with autism spectrum disorder

There has been increasing attention to the assessment of minimally verbal (MV) children with autism spectrum disorder (ASD). Previous research has begun to examine the relationship between verbal abilities and emotional and behavioral problems (EBP). The current study compared parent-reported EBP in children of differing language levels on two instruments commonly used in ASD research and clinical practice, the Child Behavior Checklist (CBCL) and Aberrant Behavior Checklist (ABC). The study consisted of 1,937 6-18 years old children with ASD from the Simons Simplex Collection. Children were divided into three language groups, by ADOS module (Module 1 = MV, 2 = phrase speech (PS), and 3 = verbally fluent (VF)) and then compared on CBCL and ABC subscales. The ABC and CBCL showed different patterns of elevations across the language groups. MV children were reported to have more impairment than VF children on the ABC irritability, lethargy, and hyperactivity scales. Children with less language (MV and PS) exhibited less impairment on the CBCL internalizing domain than VF children, but did not differ on the externalizing domain. Post hoc comparisons showed that internalizing differences were driven by fewer children with less language exhibiting clinically elevated anxious/depressed scores compared to VF children. The present study underscores the significance of considering language when assessing EBP. Results have implications for the psychiatric screening of children with ASD, particularly those with language impairments. Researchers should exercise caution when applying EBP instruments designed for use with different populations and purposes to broad samples of children. Autism Res 2019, 12: 1367-1375. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Some emotional and behavioral problem (EBP) scales include items that may be inappropriate for children with ASD and limited language. The present study found that there was a tendency for children with language impairment to have lower internalizing scores on the Child Behavior Checklist, but higher scores lethargy and irritability scores on the Aberrant Behavior Checklist, relative to verbally fluent children. This suggests that each of these instruments may underestimate EBPs in certain subsets of children.

Prevalence and Correlates of Psychiatric Symptoms in Minimally Verbal Children and Adolescents With ASD

Despite many studies documenting the prevalence of various co-occurring psychiatric symptoms in children and adults with ASD, less is known about how these symptoms relate to subtypes defined by particular phenotypic features within the ASD population. We examined the severity and prevalence of comorbid symptoms of psychopathology, emotion dysregulation, and maladaptive behaviors, as well as adaptive functioning, in a group of 65 minimally verbal children (n = 33) and adolescents (n = 32) with ASD. On the Child and Adolescent Symptom Inventory (CASI-5), for all the symptom classifications except oppositional defiant disorder and conduct disorder, more participants in our sample showed elevated or clinically concerning severity scores relative to the general population. On the Emotion Dysregulation Inventory (EDI), the mean scores for Reactivity and Dysphoria factors in our sample were lower than in the autism calibration sample, which included a large number of inpatient youth with ASD. Overall, few differences were found between the children and adolescents within this severely impaired group of ASD individuals based on clinical cutoff scores on the CASI-5 and EDI factor scores. Psychiatric comorbidities and emotion dysregulation measures were not correlated with autism symptom severity or with measures of adaptive functioning, and were largely unrelated to IQ in our sample. The number of clinically significant psychiatric symptoms on the CASI-5 emerged as the main predictor of maladaptive behaviors. Findings suggest a wide range of co-occurring psychopathology and high degree of maladaptive behavior among minimally verbal children and adolescents with ASD, which are not directly attributable to autism symptom severity, intellectual disability or limitations in adaptive functioning.

The Severe End of the Spectrum: Insights and Opportunities from the Autism Inpatient Collection (AIC)

Research on individuals severely affected by autism, including those who are minimally verbal, have intellectual disability or challenging behaviors, has become less common. The Autism Inpatient Collection (AIC) was initiated so data on this group is available to the research community. Ten studies utilizing phenotypic data from the first 350 AIC participants are presented. Greater autism severity, sleep disturbance, and psychiatric disorders are risks for hospitalization; fluently verbal youth experience more depression and oppositional symptoms; lower adaptive/coping skills are associated with increased problem behaviors; lower IQ is a risk for SIB; post-traumatic and suicidal symptoms are common; and challenging behaviors improve with specialized inpatient treatment. A new measure of emotion regulation and prescribing practices are described and future research discussed.

Co-occurring psychiatric conditions in autism spectrum disorder

Individuals with autism spectrum disorder (ASD) are at increased risk for experiencing one or more co-occurring psychiatric conditions. When present, these conditions are associated with additional impairment and distress. It is therefore crucial that clinicians and researchers adequately understand and address these challenges. However, due to symptom overlap, diagnostic overshadowing, and ambiguous symptom presentation in ASD, the assessment of co-occurring conditions in ASD is complex and challenging. Likewise, individual difference factors, such as age, intellectual functioning, and gender, may influence the presentation of co-occurring symptoms. Relatedly, a transdiagnostic framework may offer utility in assessing and treating co-occurring conditions. However, with the exception of anxiety disorders, treatment research for co-occurring psychiatric conditions in ASD is relatively limited. Therefore, the present paper aims to summarize and review available research on the most common co-occurring psychiatric disorders in ASD, with a focus on estimated population-based prevalence rates, diagnostic challenges, the influence of individual differences, and assessment guidelines. The utility of a transdiagnostic framework for conceptualizing co-occurring disorders in ASD is discussed, and the state of treatment research for co-occurring disorders is summarized. This study concludes with a summary of the extant literature, as well as recommendations for future research.