Making Research Possible: Barriers and Solutions For Those With ASD and ID

Exercise Interventions for Autistic People: An Integrative Review of Evidence from Clinical Trials

PURPOSE OF REVIEW

This review integrates recent findings from randomized controlled clinical trial (RCT) research examining the impacts of physical exercise activities on various aspects and areas of functioning for autistic individuals.

RECENT FINDINGS

Recent meta-analytic and clinical trials research indicates physical exercise intervention programs improve social and communication skills for autistic children and adolescents, improve executive functioning skills for autistic children, improve sleep-related behavior for autistic children and adolescents, and may be helpful for improving physical health for autistic children. There is very limited RCT research evidence on exercise intervention approaches or impacts for autistic adults, for autistic girls or women, for autistic people with co-occurring intellectual disability, and for reducing negative emotional symptoms (e.g., anxiety, depression) for any autistic population. The extant clinical trials research provides convincing, consistent evidence for positive impacts of physical exercise programs on multiple areas of functioning for autistic children and adolescents. Additional research is needed to determine and ensure potential impacts of physical exercise activity programs for important autistic sub-populations, including adults.

What Factors Have Been the Most Helpful and Harmful and When? Identifying Key Impacts on Psychosocial Development According to Autistic Adults and Caregivers

Few studies have asked autistic adults and caregivers directly about what has most positively and negatively impacted their lives. This study sought to: (a) identify positive and negative factors experienced by autistic adults and caregivers; (b) test for within-subject differences in endorsement of promotive factors reported specific to four stages of development; and (c) test for differences in factors between adults with varying cognitive ability (i.e., less cognitively able [LCA; verbal IQ < 70] and more cognitively able [MCA; verbal IQ ≥ 70]). Participants included 91 autistic adults and caregivers. Autistic adults' VIQs ranged from 4 to 139. Participants completed a modified version of the Social/Emotional Functioning Interview which consists of open-ended questions about positive and negative factors experienced across development. Autistic adults and caregivers, regardless of cognitive abilities, frequently reported people supports as more helpful than specific services, aspects of education, or generative activities from early childhood through adulthood. For both cognitive groups, generative activities were increasingly important after childhood. Services were more frequently identified as helpful by LCA caregivers in adulthood, while education was reported more by MCA caregivers and autistic adults. Differences by cognitive ability in negative factors included that more LCA caregivers reported poorly prepared professionals/caregivers as disruptive, while more MCA caregivers and autistic adults reported family conflict and bullying. Positive and negative factors identified through interviews of lived experiences can inform targeted care based on strengths and needs across cognitive abilities and life stages.

Toward improved understanding and treatment of self-injurious behaviors in autistic individuals with profound intellectual disability

Self-injurious behaviors (SIB) commonly occur in autism spectrum disorder (ASD) and span diverse topographies of self-inflicted behaviors ranging from head banging to hitting oneself against hard objects. Despite the high rates of SIB in autistic individuals, relatively little research has focused on psychological factors associated with the development and maintenance of SIB in individuals with autism and moderate-profound intellectual disability (ID). This commentary synthesizes existing literature on SIB and highlights the need for more research focused on psychological correlates and mechanisms in autistic individuals with moderate-profound ID. We highlight the key role of difficulties in emotion regulation (ER) and co-occurring internalizing symptoms in the manifestation of self-harm behaviors in clinical samples and autism. Furthermore, this commentary proposes a framework for understanding the interplay between poor ER and internalizing symptoms in the development and maintenance of SIB in autistic individuals with moderate-profound ID. Specifically, we explore the emergence of SIB in the context of precipitating cues that trigger strong emotions, ER processes and strategy deployment, and co-occurring internalizing symptoms. Future directions and implications for longitudinal research, measurement development, and clinical treatments are discussed.

Breaking barriers: a commentary on research gaps in cancer and depression among individuals with intellectual disabilities

The European Commission's Strategy for the Rights of Persons with Disabilities 2021-2030 aims to ensure equal opportunities and rights for all individuals, including those with intellectual disabilities. People with intellectual disabilities are often underrepresented in cancer prevention and screening policies, leading to disparities in health outcomes and early mortality. The intersection of intellectual disability, cancer, and depression represents an underexplored area in healthcare research. Individuals with intellectual disability diagnosed with both cancer and depression face compounded challenges impacting their quality of life, proper access to medical care, and treatment outcomes. To address these gaps in the systems globally, a focused effort is indispensable to understand their unique needs and better tailor care strategies for this target group. Therefore, this commentary outlines the challenges in researching individuals with intellectual disabilities who have a dual diagnosis of cancer and depression. Challenges include providing informed consent, ethical researcher-participant relationships, and maintaining confidentiality and autonomy. Strategies for improvement include creating accessible procedures, raising awareness, and involving individuals with intellectual disabilities in research ethics committees.

Autism Early Intervention - Progress, Steps Backward, and the Reconciliation of Conflicting Narratives

PURPOSE OF REVIEW

We review recent research on interventions, services and supports for children on the autism spectrum, examining both advancements and setbacks.

RECENT FINDINGS

Progress has included an increase in quantity and rigor of intervention science, as well as a broadening of disciplines and perspectives engaged in the examination of early interventions, including their effectiveness, social validity and the contextual determinants of implementation outcomes. Setbacks have included the decrease in research involving children on the autism spectrum who have co-occurring profound intellectual disability, minimal or no spoken language, and who require constant assistance with daily living activities. This trend is alarming because it contributes to the marginalization and unmet needs of children who need intervention the most. Additionally, access to early intervention services is unequal and complicated by the misalignment of policy with the evolving evidence base in the field. The recent growth in the depth and breadth of knowledge related to autism early intervention means that policies, practices, advocacy efforts and research directions can be grounded on a more comprehensive evidence base and societal appraisal of autism. Nevertheless, these indisputable markers of success co-exist with conflicting narratives that hinder the establishment of a cohesive agenda to tackle inequities experienced by marginalized subgroups. Reconciliation of conflicting narratives requires a nuanced and compassionate appraisal of sources of tensions and heterogeneity of needs within the autism spectrum.

Prediction by Young Autistic Children from Visual and Spoken Input

Recent theoretical accounts suggest that differences in the processing of probabilistic events underlie the core and associated traits of autism spectrum disorder (ASD). These theories hypothesize that autistic individuals are differentially impacted by disruptions in probabilistic input relative to neurotypical peers. According to this view, autistic individuals assign disproportionate weight to prediction errors such that novel input is overweighted relative to the aggregation of prior input; this is referred to as 'hyperplasticity' of learning. Prediction among autistic individuals has primarily been examined in nonverbal, visual contexts with older children and adults. The present study examined 32 autistic and 32 cognitively-matched neurotypical (NT) children's ability to generate predictions and adjust to changes in predictive relationships in auditory stimuli using two eye gaze tasks. In both studies, children were trained and tested on an auditory-visual cue which predicted the location of a reward stimulus. In Experiment 1 the cue was non-linguistic (instrumental sound) whereas in Experiment 2 the cue was linguistically-relevant (speaker gender). In both experiments, the cue-reward contingency was switched after the first block of trials, and predictive behavior was evaluated across a second block of trials. Analyses of children's looking behavior revealed similar performance in both groups on the non-linguistic task (Exp. 1). In the linguistically-relevant task (Exp. 2), predictive looking was less disrupted by the contingency switch for autistic children than NT children. Results suggest that autistic children may demonstrate hyperplastic learning in linguistically-relevant contexts, relative to NT peers.

"There is No Help:" Caregiver Perspectives on Service Needs for Adolescents and Adults with Profound Autism

The underrepresentation of individuals with profound autism (who require 24/7 access to care) in autism research has resulted in limited knowledge about their service needs and a lack of evidence-based practices tailored to those needs. This study explored caregiver perspectives on service needs, barriers to accessing care, and treatment priorities to guide treatment development and improvement of service delivery. A sequential mixed-methods design integrated quantitative survey data (n = 423; Mage = 18.89 years; 26.7% female) with qualitative interviews (n = 20) with caregivers of adolescents and adults with profound autism. Quantitative findings indicated regular socialization opportunities were the most frequently endorsed unmet service need (60.3% of caregivers), followed by primary health care with autism-trained staff (59.3%), social skills instruction (55.8%), life skills instruction (51.3%), and behavioral support (47.3%). Higher likelihood of needing social activity groups was associated with elevated emotional reactivity, higher language level, minoritized ethnicity, and lower household income. Greater need for specialized primary health care was associated with lower income, while the need for social and life skills instruction was associated with increased age and elevated dysphoria. Qualitative analysis identified 10 themes that converged and expanded quantitative findings by highlighting a pervasive shortage of individualized, goal-oriented services, common barriers to care, and the priority of developing centralized treatment settings that coordinate care throughout adulthood. This study identified pressing service needs for adolescents and adults with profound autism in the United States. These insights are crucial for improving the accessibility and quality of clinical care.

Moving from Disorder to Difference: A Systematic Review of Recent Language Use in Autism Research

Background

The neurodiversity paradigm positions autism as a neurological difference that is disabling in the societal context, shifting away from the traditional medical view of a disorder. Several recent publications recommend use of alternative neuro-affirming language (ANL) instead of traditional medical language (TML) with the aim to increase acceptance of autistic people and reduce prejudice. Examining language use within recent autism literature, including by journal and study characteristics, may offer insight into the influence of these recommendations and current disability discourse.

Methods

A systematic review was conducted using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines in autism research from 2021 (n = 2322 articles; 394 journals). Articles were coded according to topic, participants, and use of self-report. Journals were coded by topic, geographic region, and language guidelines. Terminology use was extracted using QDA Miner software.

Results

Many articles primarily used TML with a smaller subset primarily using ANL. There was a positive correlation between ANL use and publication date. More ANL was associated with articles on topics of autistic traits, diversity, equity, and inclusion (DEI), or lifespan and that included autistic adults or autistic self-report. More ANL was also found in journals from Australasia or Europe or those that had identify-first language (IFL) guidelines. Less ANL (more TML) was associated with articles on biology/causes or treatment and that included autistic or non-autistic parents, autistic youth, siblings, or other clinical groups, and were published in medical journals.

Conclusion

TML continues to largely dominate language choices in autism research, with an emerging shift toward ANL in recent literature. Increased ANL may be facilitated by journal and article language recommendations. Neuro-affirming language was also more likely in articles on topics prioritized by the autistic community, that included autistic adults, and may also be driven by cultural differences. Researchers and practitioners should consider the potential for their language use to impact individual and societal views of autistic people.

Special considerations for assessing and caring for autism in girls and women

PURPOSE OF REVIEW

As the specificities of autistic women are increasingly recognized, this review aims to highlight emerging areas of research. These areas primarily focus on measurement bias of diagnostic tools, the physical and mental health of autistic women, and the unique aspects of the lives of autistic women, both personally and professionally across all life stages.

RECENT FINDINGS

Conventional diagnostic tools struggle to capture the specificities of autism in females, but more sensitive instruments like the GQ-ASC (Girls' Questionnaire for Autism Spectrum Conditions), later also referred to as Q-ASC (Questionnaire for Autism Spectrum Conditions) in the scientific literature, show better performances. Autistic women face particular challenges, including an increased risk of physical and mental health problems throughout their lives as women (puberty, motherhood, menopause). Autistic women also encounter specific difficulties in their employment that require greater consideration.

SUMMARY

The findings of this review identify research areas that need to be developed to better understand and support autistic girls and women and to enhance clinical practice for them.

Patient-advocate-led global coalition adapting fit-for-purpose outcomes measures to assure meaningful inclusion of DEEs in clinical trials

Existing clinical tools that measure non-seizure outcomes lack the range and granularity needed to capture skills in developmental and epileptic encephalopathy (DEE)-affected individuals who also fall in the severe to profound range of intellectual disability. This effectively excludes those with severe impairments from clinical trials, impeding the ability of sponsors to evaluate disease-modifying therapies (DMTs). The Inchstone Project, an international, patient advocate-led collaboration, brings together leading researchers, clinicians, pharmaceutical companies, and advocates to develop an adapted, validated assessment battery within 5 years. The goal is to support trials of DMTs for the DEEs by providing sufficiently sensitive measurement tools to demonstrate therapeutic efficacy. An initial pilot study administered 7 established assessments to 10 individuals affected by SCN2A-DEE, identifying specific limitations of existing measures and areas for improvement. It was clear that most tools do not account for challenges throughout the DEE population, including vision impairments, significant motor impairments and profound intellectual disability, which need to be accounted for in creating a 'fit-for-purpose' battery for the DEE population. Several novel assessments, including two measures of responsivity developed for use in monitoring recovery after acquired brain injury as well as individualized Goal Attainment Scaling, showed promise in this group. The team also completed a DEE-wide survey with over 270 caregivers documenting their children's abilities and priorities for their improvement from new treatments. The Inchstone team is using this information to evaluate how existing tools might be updated to better capture what is most important to families and measure their child's small but important improvements over time. These efforts are building a coherent picture across multiple DEEs of what domains, or concepts of interest, have the greatest impact on most patients and families. The Inchstone team is on course to adapt non-seizure outcome measures that are (1) sufficiently sensitive to measure small increments of meaningful change ('Inchstones') and (2) applicable to multiple DEE conditions.

Teaching receptive vocabulary to two autistic children: A replicated, clinic-based, single case experimental design

Background and aims

This study was conducted in a clinical setting with the aim of replicating previously used procedures for teaching receptive vocabulary. Researchers increased the number of vocabulary words and maintained use of match-to-sample (MtS), prompting, and reinforcement procedures. Researchers were also interested in the efficacy of the intervention from caregivers' perspectives.

Methods

Using a concurrent multiple baseline design, two autistic preschoolers with receptive language impairment were taught to identify 30 common objects. MtS, prompting, and reinforcement procedures were individualized to support each child. Maintenance checks and generalization probes were completed after a predetermined number of intervention sessions (i.e. three or four clinic sessions). A social validity questionnaire was completed by parents following the final maintenance check.

Results

Receptive object identification improved significantly for both participants. Despite exposure to vocabulary targets for only three or four sessions, they generalized the vocabulary targets to non-identical pictures and maintained words at maintenance checks. Participants were most successful when researchers individualized prompting and reinforcement.

Conclusion

MtS, prompting, and reinforcement were effective procedures for improving object identification, even with a limited number of intervention sessions. To support varying learner profiles, modifying prompting and reinforcement procedures was necessary. Caregivers of both participants reported positive improvements in areas such as communication, attention, and behaviors.

Implications

This replicated study provides support for MtS, prompting, and reinforcement as means of teaching receptive vocabulary to autistic preschoolers in a clinical setting. The materials used were simple and cost-effective. Overall, this study outlines and supports a flexible and effective evidence-based practice to teach receptive language to autistic children.

Teaching Receptive Vocabulary to Minimally Verbal Preschoolers With Autism Spectrum Disorder: A Single-Case Multiple Baseline Design

PURPOSE

The purpose of this multiple probe design was (a) to investigate whether the use of the match-to-sample (MtS) procedure would result in independent identification of objects and (b) to examine whether the participants could generalize to matching objects and nonidentical pictures.

METHOD

Using a nonconcurrent multiple baseline design, three minimally verbal preschoolers with autism spectrum disorder and receptive language impairment were taught to identify common objects using a MtS procedure and physical prompts. Participants were taught to match identical objects to identical pictures. Maintenance checks were completed following mastery of vocabulary for a total of 22 words. Generalization probes were conducted with the objects and nonidentical pictures. Intervention was completed by a speech-language pathologist during typical speech-language pathology sessions.

RESULTS

Results illustrated that all of the participants learned to match and generalize the pictures. All were able to independently identify the objects at 1-month follow-up.

CONCLUSIONS

MtS and prompting appear to be effective procedures for teaching receptive vocabulary and can be easily implemented by education professionals. Learner profiles varied for the participants in this study and are an important aspect when teaching students with autism spectrum disorder and co-occurring receptive language impairment.

The Work Ahead for Intellectual and Developmental Disabilities Research

In "Toward Equity in Research on Intellectual and Developmental Disabilities," we sought to make entrenched assumptions and practices of intellectual and developmental disabilities research visible by explicitly describing the status quo in terms of models of disability, participant and researcher identities, research priorities, and biases in measurement and treatment approaches. We then curated individual- and systems-level actions drawn from disability justice and broader social justice lenses to offer a way forward. We focused on three major areas (i.e., intersectionality and person-centered approaches, participatory research, and interprofessional collaboration), depicting influences, methods, and actions in a framework of disability, identity, and culture. In this Author Response, we address five commentaries that critique and extend that synthesis.

Commentary: Best practices and processes for assessment of autism spectrum disorder - the intended role of standardized diagnostic instruments

Development of standardized diagnostic instruments has facilitated the systematic characterization of individuals with autism spectrum disorders (ASD) in clinical and research settings. However, overemphasis on scores from specific instruments has significantly detracted from the original purpose of these tools. Rather than provide a definitive "answer," or even a confirmation of diagnosis, standardized diagnostic instruments were designed to aid clinicians in the process of gathering information about social communication, play, and repetitive and sensory behaviors relevant to diagnosis and treatment planning. Importantly, many autism diagnostic instruments are not validated for certain patient populations, including those with severe vision, hearing, motor, and/or cognitive impairments, and they cannot be administered via a translator. In addition, certain circumstances, such as the need to wear personal protective equipment (PPE), or behavioral factors (e.g., selective mutism) may interfere with standardized administration or scoring procedures, rendering scores invalid. Thus, understanding the uses and limitations of specific tools within specific clinical or research populations, as well as similarities or differences between these populations and the instrument validation samples, is paramount. Accordingly, payers and other systems must not mandate the use of specific tools in cases when their use would be inappropriate. To ensure equitable access to appropriate assessment and treatment services, it is imperative that diagnosticians be trained in best practice methods for the assessment of autism, including if, how, and when to appropriately employ standardized diagnostic instruments.

Sex and gender in neurodevelopmental conditions

Health-related conditions often differ qualitatively or quantitatively between individuals of different birth-assigned sexes and gender identities, and/or with different gendered experiences, requiring tailored care. Studying the moderating and mediating effects of sex-related and gender-related factors on impairment, disability, wellbeing and health is of paramount importance especially for neurodivergent individuals, who are diagnosed with neurodevelopmental conditions with uneven sex/gender distributions. Researchers have become aware of the myriad influences that sex-related and gender-related variables have on the manifestations of neurodevelopmental conditions, and contemporary work has begun to investigate the mechanisms through which these effects are mediated. Here we describe topical concepts of sex and gender science, summarize current knowledge, and discuss research and clinical challenges related to autism, attention-deficit/hyperactivity disorder and other neurodevelopmental conditions. We consider sex and gender in the context of epidemiology, behavioural phenotypes, neurobiology, genetics, endocrinology and neighbouring disciplines. The available evidence supports the view that sex and gender are important contributors to the biological and behavioural variability in neurodevelopmental conditions. Methodological caveats such as frequent conflation of sex and gender constructs, inappropriate measurement of these constructs and under-representation of specific demographic groups (for example, female and gender minority individuals and people with intellectual disabilities) limit the translational potential of research so far. Future research and clinical implementation should integrate sex and gender into next-generation diagnostics, mechanistic investigations and support practices.

A full semantic toolbox is essential for autism research and practice to thrive

Individuals diagnosed with autism spectrum disorder (ASD) present with a highly diverse set of challenges, disabilities, impairments and strengths. Recently, it has been suggested that researchers and practitioners avoid using certain words to describe the difficulties and impairments experienced by individuals with ASD to reduce stigma. The proposed limitations on terminology were developed by only a subset of the autism community, and the recommendations are already causing negative consequences that may be harmful to future scientific and clinical endeavors and, ultimately, to people with ASD. No one should have the power to censor language to exclude the observable realities of autism. Scientists and clinicians must be able to use any scientifically accurate terms necessary to describe the wide range of autistic people they study and support, without fear of censure or retribution.