Measurement properties of screening and diagnostic tools for autism spectrum adults of mean normal intelligence: A systematic review

Sex Differences in Adult Autism Screening: A Comparison of Current Self-Report and Retrospective Parent-Report Measures

This study investigated sex differences in adult autism screening by comparing self-reports on current traits (Autism Spectrum Quotient; AQ) and parent-reports on childhood traits (Relatives Questionnaire; RQ). The aim was to examine the differential contribution of these distinct measures to diagnostic classification in both sexes. The study compared 102 clinically diagnosed autistic adults (30 females) and 152 non-autistic adults (60 females), aged 17-35 years. Participants completed the AQ, while their parents completed the RQ. Multivariate analysis of variance and sex-stratified discriminant analyses were employed to evaluate measurement patterns in males and in females. Significant main effects were found for diagnostic group on both measures and for sex on the RQ only. Group × sex interactions were significant for both measures. Within the autistic group, males and females showed no significant difference in AQ scores, but females scored significantly lower than males on the RQ. Discriminant analyses revealed high classification accuracies for both males (95.1%) and females (96.7%), with different weighting patterns between males (AQ = 0.597 [CI: 0.413-0.720], RQ = 0.712 [CI: 0.553-0.789]) and females (AQ = 0.763 [CI: 0.637-0.898], RQ = 0.478 [CI: 0.191-0.616]). The findings suggest that current self-report may be more central for identifying autism in females, while a more balanced combination of current-self and past-parent reports may be optimal for males. These sex-specific patterns highlight the importance of considering both current self-reported traits and developmental history in adult autism screening, with potential implications for improving diagnostic accuracy across sexes.

Critical Examination of Autism Screening Tools: A Reply to Øien

We thank Dr. Øien for his comments on the relevance and implications of our cluster randomized controlled trial (RCT) in his editorial, "Editorial: The Critical Examination of Autism Screening Tools: A Call for Addressing False Negatives."1.

Autism spectrum disorder and anorexia nervosa: Investigating the behavioural and neurocognitive overlap

Autism spectrum disorder (autism) and anorexia nervosa (AN) share many clinical features. Two key neurocognitive correlates of the autistic dyad, specifically, mentalising (social impairment) and set-shifting (restricted and repetitive behaviours/interests [RRBI]) were investigated in a sample of 327 adult participants with autism (n = 100; 50 females, 50 male), AN (n = 82; 54 females, 28 male), autism and AN (n = 45; 36 females, 9 male), and 100 (50 female, 50 male) control participants from the general population. A battery of self-report (Autism Spectrum Quotient, Eating Disorder Examination Questionnaire, Reflective Function Questionnaire, and Repetitive Behaviour Questionnaire 2 - Adult version) and performance-based (Wisconsin Card Sort Task [WCST] and Penn Emotion Recognition Test [ER-40]) measures were administered online. Clinical participants reported greater mentalising difficulty, more repetitive behaviour, and displayed worse mentalising ability compared to controls, with no difference between the clinical groups. Eating disorder psychopathology predicted error (total and perseverative) rates on the WCST, while lower levels of autistic traits were positively associated with ER-40 accuracy. We provide evidence that clinical features of autism and AN might have specific neurocognitive relevance. Improved understanding of the mechanisms underlying the overlapping features of autism and AN can have critical implications for early detection and improved and tailored intervention.

Self-identification of autism: Why some autistic adults lack a clinical diagnosis and why this matters for inclusion

LAY ABSTRACT

Most autism research and services focus on individuals with formal autism diagnoses. However, autism activists and self-advocates have raised awareness about the challenges that can prevent individuals from seeking or getting an autism diagnosis. We interviewed 65 queer and transgender adults who either self-identified as autistic without a formal diagnosis or who had a formal autism diagnosis. We found that participants made meaning of their autistic diagnosis and/or identity and found affirmation in this, faced significant barriers and deterrents to getting diagnosed, and experienced invalidation as both a barrier to and product of diagnosis. Due to the challenges that individuals face in getting a diagnosis, we recommend that researchers and advocates consider including self-identified autistic individuals in research and services.

The Prevalence of Autistic Traits in a Sample of Young Adults Referred to a Generalized Mental Health Outpatient Clinic

BACKGROUND/OBJECTIVES

The diagnosis of Autism Spectrum Disorders (ASD) is undergoing significant revisions, impacting prevalence estimates in the general population. Moreover, the rise of a dimensional perspective on psychopathology has broadened our understanding of autism, recognizing that subthreshold autistic features extend throughout the general population. However, there remains a limited understanding of the prevalence of ASD traits in individuals with psychiatric disorders, particularly in young adults, who are at an age where several mental health conditions emerge. The aim of this study was to evaluate the prevalence of ASD traits in a sample of young adults (18-24 years old) attending a generalized mental health outpatient clinic.

METHODS

A total of 259 young adult patients completed the self-report screening questionnaires Autism Quotient (AQ) and Ritvo Autism and Asperger Diagnostic Scale-Revised (RAADS-R).

RESULTS

A total of 16.2% of our sample scored above the cut-off in both scales; this percentage decreased to 13.13% when restricting the RAADS-R cut-off to >119, as suggested for clinical samples. The association with sociodemographic features is discussed.

CONCLUSIONS

We argue that screening for autistic traits should be integrated into the assessment of young adults presenting with nonspecific psychiatric symptoms or psychological distress. Although there is ongoing debate over the use of self-report screening tools, a positive result on both the AQ and RAADS-R should prompt clinicians to pursue a comprehensive diagnostic evaluation using structured or semi-structured interviews.

French Validation of the Camouflaging Autistic Traits Questionnaire (CAT-Q)

PURPOSE

Autistic camouflaging is a collection of strategies used to hide autistic characteristics. It can have serious consequences on autistic people's mental health and needs to be addressed and measured in clinical practice. The purpose of this study is to evaluate the psychometric properties of the French adaptation of the Camouflaging Autistic Traits Questionnaire.

METHODS

1227 participants (744 autistic, 483 non-autistic) answered the French version of the CAT-Q in an online survey or on paper. Confirmatory factor analysis, measurement invariance testing, internal consistency analysis (McDonald's ω), and convergent validity with the DASS-21 depression subscale were conducted. Test-rest reliability was assessed on a sample of 22 autistic volunteers using intraclass correlation coefficient.

RESULTS

A good fit was found for the original three-factor structure as well as a good internal consistency, excellent test-retest reliability and highly significant convergent validity. Measurement invariance testing indicates however that the meaning behind items is different for autistic vs. non-autistic people.

CONCLUSION

The French version of the CAT-Q can be used in clinical settings to assess camouflaging behaviors and intent to camouflage. Further research is needed to clarify the camouflage construct and whether reported measurement noninvariance are due to cultural differences or a true difference in what camouflaging might mean for non-autistic people.

Protocol for a systematic review evaluating psychometric properties and gender-related measurement (non)invariance of self-report assessment tools for autism in adults

BACKGROUND

Given the recent evidence on gender differences in the presentation of autism, there is an increasing concern that current tools for autism do not adequately capture traits more often found in women. If tools for autism measure autistic traits differently based on gender alone, their validity may be compromised as they may not be measuring the same construct across genders. Measurement invariance investigations of autism measures can help assess the validity of autism constructs for different genders. The aim of this systematic review is to identify and critically appraise the psychometric properties of all self-report tools for autism in adults that meet two criteria: (a) they have been published since or included in the NICE (2014) recommendations, and (b) they have undergone gender-related measurement invariance investigations as part of their validation process.

METHODS

A search of electronic databases will be conducted from 2014 until the present using MEDLINE, Embase, and PsycINFO using predefined search terms to identify eligible studies. The search for grey literature will include sources such as OpenGrey, APA PsycEXTRA, and Scopus. Two reviewers will independently screen titles, abstracts, and full texts for eligibility. The references of included studies will be searched for additional records. The methodological quality of the studies will be evaluated using the COSMIN Risk of Bias checklist, while psychometric quality of findings will be assessed based on criteria for good measurement properties and ConPsy checklist. The quality of the total body of evidence will be appraised using the approach outlined in the modified GRADE guidelines.

DISCUSSION

This systematic review will be among the first to assess the psychometric properties and gender-related measurement invariance of self-reported measures for autism in adults that were published since (or included in) NICE (2014) guidelines. The review will provide recommendations for the most suitable tool to assess for autism without gender bias. If no such measure is found, it will identify existing tools with promising psychometric properties that require further testing, or suggest developing a new measure.

SYSTEMATIC REVIEW REGISTRATION

The protocol has been registered at the International Prospective Register of Systematic Reviews (PROSPERO). The registration number is CRD42023429350.

Alexithymia in Adult Autism Clinic Service-Users: Relationships with Sensory Processing Differences and Mental Health

Mental health difficulties commonly co-occur with autism, especially in autistic people accessing clinic services, impacting substantially on quality-of-life. Alexithymia (difficulty describing/identifying feelings) and sensory processing differences are prevalent traits in autism that have been associated with depression/anxiety in autistic community samples. However, it is important to better understand interrelationships between these traits in clinical populations to improve identification of service-user needs. In this study, 190 autistic adults (65.3% male), seen in a tertiary autism clinic, completed self-report measures of alexithymia (20-item Toronto Alexithymia Scale), sensory processing differences (Adolescent/Adult Sensory Profile) and depression/anxiety (Hospital Anxiety and Depression Scale). Multiple linear regression models and mediation analyses were used to examine associations between alexithymia, sensory processing differences, and depression/anxiety severity. Across the sample, 66.3% of individuals (N = 126) were classified as alexithymic (score ≥ 61). Total alexithymia and difficulty describing/identifying feelings were significantly associated with depression severity (β = 0.30-0.38, highest p < 0.002), and difficulty identifying feelings was significantly associated with anxiety severity (β = 0.36, p < 0.001). Sensory processing differences were also significantly associated with depression severity (β = 0.29, p = 0.002) and anxiety severity across all models (β = 0.34-0.48, highest p < 0.001) Finally, difficulty describing/identifying feelings partially mediated the relationships between sensory processing differences and both depression/anxiety severity. Overall, these results highlight that interventions adapted for and targeting emotional awareness and sensory-related uncertainty may improve mental health outcomes in autistic service-users.

Development and Initial Validation of the Russian Version of the RAADS-14: A Self-Report Questionnaire to Assess Autistic Traits

Autism is a relatively common neurodevelopmental condition that affects social communication and behavior, affecting the overall quality of life. The prevalence of autism is constantly increasing, but timely diagnosis allows for effective treatment. The aim of our research was to construct a Russian version of the RAADS-14, a brief self-report questionnaire originally designed for autism screening, and to perform its initial validation to provide a reference point in developing autism self-assessment tools for the Russian-speaking population. Psychometric properties of the RAADS-14 Rus were evaluated on a sample of 1724 participants, including a general sample of non-psychiatric young adults (n = 794) and adults with clinically established ASD (n = 49); a brief Russian inventory assessing Big Five personality traits (FFQ) was administered to a part of the sample (n = 364) to provide the first assessment of criterion validity. Confirmatory factor analysis of the RAADS-14 Rus confirmed the factor structure of the original Swedish version yielding acceptable fit indices. The discriminating properties were substantially worse than in the original study. The correlations between the RAADS-14 Rus domain scores and the Big Five factors were similar to previously obtained findings. Overall, the results suggest that the RAADS-14 Rus can be used as a screening tool for ASD in adults with proper caution and considering its discriminating properties.

Comprehensive Assessments of Theory of Mind Abilities for School-Age Children: A Systematic Review

PURPOSE

Theory of mind involves perceiving both the thoughts and emotions of others. Theory of mind skills continue to develop in school-age individuals. For children at risk for social communication difficulties, evaluating theory of mind is warranted to determine whether theory of mind should be a target of intervention. There are hundreds of tasks designed to evaluate theory of mind, but many evaluate a single facet of the construct and have uneven psychometric properties. Comprehensive assessments evaluate both cognitive and affective aspects of theory of mind. The purpose of this systematic review was to identify comprehensive theory of mind assessments for school-age individuals and to critically appraise their measurement properties.

METHOD

Four databases were searched to identify 27 included records describing the measurement properties of comprehensive theory of mind assessments for 5- to 21-year-olds. Assessments appearing in at least three records were included. The methodological quality of the studies and the sufficiency of assessments' measurement properties were evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN).

RESULTS

Nine assessments were evaluated, and four met COSMIN standards for sufficient content validity and internal consistency to be recommended for clinical use.

CONCLUSIONS

Comprehensive assessments enable examiners to develop a profile of children's theory of mind strengths and needs. Strengths of the identified assessments include sufficient convergent validity and internal consistency. Further research is required to develop higher quality evidence for the content validity, structural validity, and reliability of the included assessments.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.23817495.

Autistic Traits and College Adjustment

This study evaluated the association of autistic traits (RAADS-14) with academic and social outcomes among college students using data from an online survey (N = 2,736). In the academic domain, the total trait score and all subscale scores (mentalizing deficits, social anxiety, sensory reactivity) were associated with course failure and academic difficulties independent of an autism diagnosis; the total score and mentalizing deficits also predicted lower grade point average (GPA). In the social domain, the total trait score and subscale scores were associated with lower odds of having a confidant, lower friendship quality, and higher odds of social exclusion. Subgroup analyses revealed that autistic traits had more consistently negative associations with social outcomes for students without an autism diagnosis than for students with a diagnosis. Associations were also more often significant for women than men. These results support the development of programs and services for students with autistic traits regardless of diagnostic status.

From neurodevelopmental to neurodegenerative disorders: Investigating symptoms of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) in patients with dementia

Dementia is characterized by a progressive cognitive decline that could be caused by several disorders. Autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) are two prevalent neurodevelopmental disorders that might overlap with dementia symptoms. Hence, this study aimed to evaluate the ASD and ADHD symptoms in dementia patients referred to a memory clinic in Iran. We recruited 65 dementia patients and instructed them to fill out the autism quotient (AQ) and the Conners' Adult ADHD Rating Scales (CAARS) questionnaires. Considering the cutoff points of AQ and CAARS questionnaires, 18.5% of participants were at higher risk of ASD, and 35.4% were at higher risk of ADHD. The results indicated that ADHD and ASD symptoms might be common comorbidities in patients with dementia which can increase the disease burden. Specialized ADHD and ASD screening tools in the elderly population with dementia are needed to prevent misdiagnoses due to symptom overlaps.

Autism spectrum disorders in adults and the autonomic nervous system: Heart rate variability markers in the diagnostic procedure

The diagnostic assessment of autism spectrum disorders (ASD) in adults is a challenging and time-consuming procedure. In order to address the lack of specialised health-care professionals and improve the waiting time, we aimed to identify specific electrocardiogram (ECG) derived Heart Rate Variability (HRV) parameters that could be used for diagnostic purposes. 152 patients were diagnosed based on a standardised clinical procedure and assigned to one of three groups: ASD (n = 56), any other psychiatric disorder (OD) (n = 72), and patients with no diagnosis (ND) (n = 24). Groups were compared using ANOVA. Discriminative power of biological parameters and the clinical assessment were compared using receiver operating characteristic curves (ROCs). Patients with ASD showed reduced parasympathetic and increased sympathetic activity compared to ND. The accuracy determined by the area under the curve (AUC) of the biological parameters for discrimination between ASD vs. pooled OD/ND was 0.736 (95% CI = 0.652-0.820), compared to .856 (95% CI = 0.795-0.917) for the extensive clinical assessment. Our results confirmed the dysregulation of the autonomic nervous system in ASD with reduced parasympathetic and increased sympathetic activity as compared to ND. The discriminative power of biological markers including HRV was considerable and could supplement less sophisticated clinical assessments.

“I Always Knew I Was Different”: Experiences of Receiving a Diagnosis of Autistic Spectrum Disorder in Adulthood—a Meta-Ethnographic Systematic Review

A broadening of diagnostic criteria and increased awareness of autism has led to a large number of individuals whose difficulties remained undetected until adulthood. This systematic review aimed to synthesise empirical evidence of the experience of individuals who received their diagnosis of autism in adulthood. Eight studies met the inclusion criteria. A meta-ethnographic approach was used to synthesise the findings. Analysis revealed two meta-themes: feeling “like an alien” and the “not guilty” verdict, each with three associated subthemes. The findings indicate the need for timely diagnosis and provision of post-diagnostic support to alleviate the mental health implications of not having a framework to understand one’s experiences and to support the process of adjustment to the diagnosis.

Does learning you are autistic at a younger age lead to better adult outcomes? A participatory exploration of the perspectives of autistic university students

LAY ABSTRACT

People learn they are autistic at different ages. We wanted to know if telling kids they are autistic earlier helps them feel better about their lives when they grow up. We are a team of autistic and non-autistic students and professors. Seventy-eight autistic university students did our online survey. They shared how they found out they were autistic and how they felt about being autistic. They also shared how they feel about their lives now. Around the same number of students learned they were autistic from doctors and parents. Students who learned they were autistic when they were younger felt happier about their lives than people who learned they were autistic when they were older. Students who learned they were autistic when they were older felt happier about being autistic when they first found out than people who did not have to wait as long. Our study shows that it is probably best to tell people they are autistic as soon as possible. The students who did our study did not think it was a good idea to wait until children are adults to tell them they are autistic. They said that parents should tell their children they are autistic in ways that help them understand and feel good about who they are.

Identification of autism in cognitively able adults with epilepsy: A narrative review and discussion of available screening and diagnostic tools

The recent NICE epilepsy Guideline (NG217; 2022) recommends that epilepsy professionals need to be alert to autism when considering mental health presentations, behavioural difficulties and as a marker for referral for whole genome sequencing for those patients with epilepsy of unknown cause. However, this relies upon the existence of valid autism screens for people with epilepsy (PWE). We found few studies of autism in cognitively able PWE. This represents an important gap in the literature. We describe different autism screening and diagnostic tools; two screening tools have been used specifically for adult PWE who are cognitively able (AQ, SRS-AS). The AQ is more psychometrically robust, but there may be an overlap between these screening questions and questions relevant to some psychiatric disorders. Formal gold-standard diagnostic tools (module 4 of ADOS-2, ADI-R or 3Di or 3Di-Adult) would benefit from studies of their application to cognitively able PWE. More research is needed to understand the characteristics of autism in cognitively able PWE and to ascertain the appropriate screening and diagnostic tools for this cohort.

The Autism-Spectrum Quotient-Hebrew version: Psychometric properties of a full and a short form, adapted for DSM-5

LAY ABSTRACT

Despite the attempt to diagnose autism at an early age, there are still many individuals who would only get an autism diagnosis in adulthood. For these adults, a questionnaire that could assist in highlighting their need to seek diagnostic assessment is needed. The Autism-Spectrum Quotient is a self-report scale used to assess autistic traits. It was tested cross-culturally, and a short version was recommended to help identify adults who should be referred for an autism assessment. However, its relevance for the up-to-date diagnostic criteria, according to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.), has not been tested. This study aimed to examine the psychometric properties of the Hebrew version of the Autism-Spectrum Quotient and to create a short version of the Hebrew Autism-Spectrum Quotient, based on items which map on to Diagnostic and Statistical Manual of Mental Disorders (5th ed.) criteria. Ninety-three autistic adults (24 females), aged 18-51, clinically diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (5th ed.), and 147 comparable controls (34 females) filled out the Hebrew version of the Autism-Spectrum Quotient. Ten clinicians who specialize in diagnosing autism in adults classified the Autism-Spectrum Quotient's items according to Diagnostic and Statistical Manual of Mental Disorders (5th ed.) criteria. The short version of the Hebrew Autism-Spectrum Quotient comprised items that best differentiated between adults with and without autism, five items representing each of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) diagnostic domains. The overall probability for participants to be correctly classified as autistic or neurotypical was 86% for the Hebrew version of the Autism-Spectrum Quotient and 88% for the short version of the Hebrew Autism-Spectrum Quotient. We conclude that both versions are reliable and sensitive instruments that can help referring adults for autism assessment.

Burnt Out and Dropping Out: A Comparison of the Experiences of Autistic and Non-autistic Students During the COVID-19 Pandemic

Autistic students are more likely to drop out of university, while facing both challenges and opportunities within university environments. This study compared the experiences of autistic and non-autistic current United Kingdom students, in terms of thoughts about dropping out, burnout, mental health and coping, during the COVID-19 pandemic. Burnout was of particular interest as this is a relatively unexamined phenomenon for autistic students. Seventy autistic and 315 non-autistic students, completed a mixed methods questionnaire with standardized measures of burnout (personal and academic), mental health (depression, stress, and anxiety), and coping styles (adaptive and maladaptive). We also included qualitative questions about dropping out and COVID-19 experiences. We found autistic participants experienced higher rates of burnout and mental health symptoms and were more likely to have thought about dropping out. Reasons given for thinking about dropping out, for both groups, focused on poor mental well-being, doubts about university, and academic challenges. For autistic participants, further analyses did not identify specific predictors of thinking about dropping out, but for non-autistic participants, this was predicted by maladaptive coping styles and academic burnout. Academic and personal burnout predicted one another for autistic students, and age, maladaptive coping, autistic characteristics, stress, and anxiety additionally predicted burnout for non-autistic students. Similarities in experiences during the pandemic were noted, with both groups experiencing negative social implications, difficulties adjusting to emergency online learning, and poorer psychological well-being. Moving forward from COVID-19, universities must find ways to enhance both academic and social support, to enable equal opportunity within Higher Education for autistic students.

Improving control over euthanasia of persons with psychiatric illness: Lessons from the first Belgian criminal court case concerning euthanasia

BACKGROUND

Belgium is one of very few countries that legally allow euthanasia for suffering caused by psychiatric illness. In the first criminal trial in Belgium of physicians involved in euthanasia, three physicians recently faced the accusation of "murder by poisoning," for allegedly having failed to comply with several requirements of the Belgian Euthanasia Law in granting the euthanasia request a woman suffering from psychiatric illness. Although all three physicians were acquitted, the case generated much debate among policy makers, medical professionals, and the general public.

METHOD

We use this trial as the starting point for a critical analysis of the adequacy of the three-level control system established in the Euthanasia Law, as it is applied in the evaluation of euthanasia requests from persons who suffer unbearably from a psychiatric illness. This analysis is based on information presented during the criminal trial as well as information on the euthanasia that was published in the press.

RESULTS

Our analysis highlights substantial problems in the assessment and granting of the euthanasia request. The patient was euthanized without it having been substantiated that her psychiatric illness had no prospect of improvement and that her suffering could not be alleviated. The three-step control system enshrined in the Law and promoted by the Federal Control and Evaluation Commission for Euthanasia appears to have failed at each level.

CONCLUSION

To evaluate requests for euthanasia for mental suffering caused by psychiatric illness, the requirements of the Belgian Euthanasia Law should be complemented by mandating the advice of two psychiatrists, and face-to-face discussions between all physicians involved. In parallel with the process of evaluating the euthanasia request, a treatment track should be guaranteed where reasonable evidence-based treatments and recovery-oriented options are tried.

Understanding the Diversity of Pharmacotherapeutic Management of ADHD With Co-occurring Autism: An Australian Cross-Sectional Survey

OBJECTIVES

Attention deficit hyperactivity disorder (ADHD) frequently co-occurs with other neurodevelopmental diagnoses, such as autism spectrum disorder (autism), which can make clinical decision making around symptom management challenging for clinicians. There is a paucity of research examining pharmacotherapeutic management of children who have ADHD with co-occurring diagnoses. We aimed to report on the co-occurring diagnoses and symptom profile of children, and report on medication use, stratified by ADHD, autism and ADHD + autism diagnoses.

METHODS AND MATERIALS

Caregivers of 505 children (2-18 years) with ADHD (n = 239), autism (n = 117), and co-occurring ADHD + autism (n = 149) completed a questionnaire on current medication use and clinical rating scales about their child's symptoms, as part of a broader project investigating diagnosis and management of symptoms in children with ADHD or autism.

RESULTS

The parents of the ADHD group reported a higher proportion of their children had learning disorders (17.15%) and speech and language disorders (4.60%) compared to the parents of the autism and ADHD + autism groups. Parents of the ADHD + autism group reported higher proportions of intellectual disability (5.37%), oppositional defiant disorder (20.13%), anxiety (38.93%), depression (6.71%) and genetic conditions (3.36%) in their children, in comparison to the parents of the ADHD and autism groups. Children with ADHD were reported to be taking a higher proportion of psychotropic medication (90%), followed by ADHD + autism (86%) and autism (39%). The parents of children with ADHD + autism reported a higher proportion of non-stimulant ADHD medication (25.5%), antipsychotic (18.79%), antidepressant (22.15%) and melatonin (31.54%) use by their children, compared to the parents of the ADHD and autism groups.

CONCLUSIONS

A similar proportion of children with ADHD + autism and ADHD were reported to be taking medication. However, the types of medication taken were different, as expected with reported co-occurring diagnoses. The complexity of symptoms and diagnoses in ADHD + autism warrants targeted research to optimize management and therapeutic outcomes.

Atypically slow processing of faces and non-faces in older autistic adults

Face recognition is a fundamental function that requires holistic processing. Differences in face processing have been consistently identified in autistic children, but it is unknown whether these differences persist across the adult lifespan. Using event-related functional magnetic resonance imaging, we measured holistic face processing with a rapid Mooney faces task in 50 autistic and 49 non-autistic participants (30–74 years). Behavioral tasks included a self-paced version of the same paradigm and a global–local processing task (Navon). Reduced detection rates for faces, but not non-faces, were found in autistic adults, including slower responses on all conditions. Without time constraints, differences in accuracy disappeared between groups, although reaction times in correctly identifying faces remained higher in autistic adults. The functional magnetic resonance imaging results showed lower activation in the left and right superior frontal gyrus in the autism group but no age-related differences. Overall, our findings point toward slower information processing speed rather than a face recognition deficit in autistic adults. This suggests that face-processing differences are not a core feature of autism across the adult lifespan.

Satisfaction and experience with colorectal cancer screening: a systematic review of validated patient reported outcome measures

BACKGROUND

Patient satisfaction or experience with colorectal cancer screening can determine adherence to screening programs. An evaluation of validated patient reported outcome measures (PROMs) for measuring experience or satisfaction with colorectal cancer screening does not exist. Our objective was to identify and critically appraise validated questionnaires for measuring patient satisfaction or experience with colorectal cancer screening.

METHODS

We conducted a systematic review following the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology. We conducted searches on MEDLINE, EMBASE, PsychINFO, CINAHL and BiblioPRO and assessed the methodological quality of studies and measurement properties of questionnaires according to the COSMIN guidelines for systematic reviews of PROMs. PROSPERO registration number: CRD42019118527.

RESULTS

We included 80 studies that used 75 questionnaires, of which only 5 were validated. Four questionnaires measured satisfaction with endoscopy: two in the context of colorectal cancer screening (for colonoscopy and sigmoidoscopy) and two for non-screening endoscopy. One questionnaire measured satisfaction with bowel preparation. The methodological quality of studies was variable. The questionnaires with evidence for sufficient content validity and internal consistency were: the CSSQP questionnaire, which measures safety and satisfaction with screening colonoscopy, and the Post-Procedure questionnaire which measures satisfaction with non-screening endoscopic procedures.

CONCLUSIONS

This systematic review shows that a minority of existing PROMs for measuring patient satisfaction with colorectal cancer screening are validated. We identified two questionnaires with high potential for further use (CSSQP and the Post-Procedure questionnaire).

Exploring the Career Motivations, Strengths, and Challenges of Autistic and Non-autistic University Students: Insights From a Participatory Study

Supports for the growing number of autistic university students often focus on helping them succeed in university. However, even educated autistic people experience discrimination and other challenges which can make it very difficult for them to obtain meaningful jobs. Little remains known about how universities can better support their autistic students and alumni in overcoming barriers to meaningful employment. In this participatory study, a team of autistic and non-autistic researchers asked autistic (n = 92) and non-autistic (n = 774) university students about their career aspirations, strengths they believe will help them succeed in their "dream jobs," and obstacles they expect to encounter. Autistic participants' top goal in attending college was to improve their career prospects. However, relatively few autistic students reported learning career-specific skills at university. Autistic students were more likely to seek an academic job and less likely to seek a career in healthcare than non-autistic students. Autistic students highlighted writing skills and detail orientation as strengths that could help them succeed in their dream jobs more often than non-autistic students. However, they were also more likely to expect discrimination, social, and psychological difficulties to stand in the way of their dream jobs. These findings suggest that universities should prioritize experiential learning opportunities to help autistic (and non-autistic) students develop employment-related skills while providing mental health supports. Universities should demonstrate their commitment to supporting diverse learners by seeking out and hiring autistic professionals and by teaching their own staff and employers how to appreciate and support autistic colleagues.

Factors associated with age at autism diagnosis in a community sample of Australian adults

Autism diagnosis in adulthood has become increasingly common due to a range of factors including changes in awareness, diagnostic criteria, and professional practices. Past research identified a range of demographic and autism-related factors associated with autism diagnosis age in children. However, it is unclear whether these apply to autistic adults. This study aimed to examine predictors of autism diagnosis age in adults while controlling for current age and autistic traits. We used a cross-sectional sample of 657 adults aged 15-80 from three self and carer-report studies: the Australian Longitudinal Study of Autism in Adulthood (ALSAA), Study of Australian School-Leavers with Autism (SASLA) and Pathways, Predictors and Impact of Receiving an Autism Spectrum Diagnosis in Adulthood (Pathways). Using hierarchical multiplicative heteroscedastic regression, we found that older current age and higher self-reported autistic traits predicted older diagnosis age, and that female gender, lack of intellectual disability, language other than English, family history of autism, lifetime depression, and no obsessive-compulsive disorder predicted older diagnosis age beyond current age and autistic traits. The paradoxical relationship between high autistic traits and older diagnosis age requires further investigation. Based on these findings, we recommended strategies to improve autism recognition in women and people from non-English-speaking backgrounds. Future studies could extend the findings by examining the effects of childhood and adulthood socioeconomic status on adult diagnosis age.

AAA screening in adults with ASD: a retrospective cohort study

Purpose

The Adult Asperger Assessment (AAA), comprising the Autism Questionnaire, the Empathy Quiotient and the Relatives Questionnaire is a commonly used screening tool designed to identify adults who may benefit from a further clinical assessment for autism spectrum disorder. The purpose of this paper is to investigate the usefulness of this screening measure in a clinical setting.

Design/methodology/approach

This retrospective cohort study comprised of 192 service users referred for diagnostic assessment of Autism by a specialist service of the National Health Service. The authors evaluated the diagnostic accuracy of the AAA by investigating if the Autism Questionnaire, the Empathy Quiotient and the Relatives Questionnaire were able to predict the diagnostic outcome of Autism in a clinical setting.

Findings

Scores from the Relatives Questionnaire can accurately predict diagnostic outcome. No evidence of accuracy for the Autism Questionnaire or the Empathy Quotient was apparent. Based on the findings, the authors recommend clinicians are cautious when interpreting results of the AAA.

Research limitations/implications

It should be acknowledged that the results may not be generalisable to whole populations. Also, the authors used the full item versions of the scales; therefore, the findings are most applicable to studies which did similar.

Originality/value

This study highlights the need for investigation into the lack of validation of commonly used screening measures in autistic populations.

Development and validation of the suicidal behaviours questionnaire - autism spectrum conditions in a community sample of autistic, possibly autistic and non-autistic adults

BACKGROUND

Autistic people and those with high autistic traits are at high risk of experiencing suicidality. Yet, there are no suicidality assessment tools developed or validated for these groups.

METHODS

A widely used and validated suicidality assessment tool developed for the general population (SBQ-R), was adapted using feedback from autistic adults, to create the Suicidal Behaviours Questionnaire-Autism Spectrum Conditions (SBQ-ASC). The adapted tool was refined through nine interviews, and an online survey with 251 autistic adults, to establish clarity and relevance of the items. Subsequently, 308 autistic, 113 possibly autistic, and 268 non-autistic adults completed the adapted tool online, alongside self-report measures of autistic traits (AQ), camouflaging autistic traits (CAT-Q), depression (PHQ-9), anxiety (ASA-A), thwarted belongingness and perceived burdensomeness (INQ-15), lifetime non-suicidal self-injury, and the original version of the suicidality assessment tool (SBQ-R). Analyses explored the appropriateness and measurement properties of the adapted tool between the groups.

RESULTS

There was evidence in support of content validity, structural validity, internal consistency, convergent and divergent validity, test-retest validity, sensitivity and specificity (for distinguishing those with or without lifetime experience of suicide attempt), and hypothesis testing of the adapted tool (SBQ-ASC) in each group. The structure of the SBQ-ASC was equivalent between autistic and possibly autistic adults, regardless of gender, or use of visual aids to help quantify abstract rating scales.

LIMITATIONS

The samples involved in the development and validation of the adapted tool were largely female, and largely diagnosed as autistic in adulthood, which limits the generalisability of results to the wider autistic population. The SBQ-ASC has been developed for use in research and is not recommended to assess risk of future suicide attempts and/or self-harm. The SBQ-ASC has been designed with and for autistic and possibly autistic adults, and is not appropriate to compare to non-autistic adults given measurement differences between these groups.

CONCLUSIONS

The SBQ-ASC is a brief self-report suicidality assessment tool, developed and validated with and for autistic adults, without co-occurring intellectual disability. The SBQ-ASC is appropriate for use in research to identify suicidal thoughts and behaviours in autistic and possibly autistic people, and model associations with risk and protective factors.

The Relationship of Age with the Autism-Spectrum Quotient Scale in a Large Sample of Adults

Background: The historical focus on autism as a childhood disorder means that evidence regarding autism in adulthood lags significantly behind research in other age groups. Emerging studies on the relationship of age with autism characteristics do not target older adult samples, which presents a barrier to studying the important variability that exists in life span developmental research. This study aims to further our understanding of the relationship between the Autism-Spectrum Quotient Scale and age in a large adult sample. Methods: The present study examines the relationship of Autism-Spectrum Quotient Scale (AQ) scores with age in 1139 adults, ages 18-97 years. Participants came from three distinct samples-a sample of primarily students, a sample of MTurk participants, and a sample of primarily community dwelling older adults. The majority of the participants did not self-report an autism diagnosis (91%), were female (67%), and identified as White (81%). Participants completed the AQ primarily via online surveys. Researchers scored the AQ following six common scoring practices. Results: Results of preregistered analyses indicate that autism characteristics measured by the AQ are not strongly associated with age (r values from -0.01 to -0.11). Further findings indicate that the measurement of autism characteristics is consistent across age into late life using both multiple groups and local structural equation modeling approaches to measurement invariance (comparative fit indices = 0.82-0.83, root mean square error = 0.06) as well as reliability analysis. Finally, demographic and autism-related variables (sex, race, self-identified autism spectrum disorder diagnosis, and degree of autism characteristics) did not moderate the relationship between age and autism characteristics. Conclusion: These results suggest that self-reports of autism characteristics using the AQ do not vary strongly by age in this large age-representative sample. Findings suggest that the AQ can potentially serve as a useful tool for future research on autism across the life span. Important limitations on what we can learn from these findings point toward critical avenues for future research in this area.

Lay summary

Why was this study done?: Self-report questionnaires of autism characteristics are a potentially important resource for studying autism in adulthood. This study sought to provide additional information about one of the most commonly used self-report questionnaires, the Autism-Spectrum Quotient Scale (AQ), across adulthood.What was the purpose of this study?: This study intended to determine if there is a relationship between scores on the AQ and age. Researchers also worked to identify which of the multiple different ways of scoring the AQ worked best across adulthood.What did the researchers do?: Researchers collected data from over a thousand participants aged 18-97 years. Participants from three different age groups completed online surveys to self-report their levels of autism characteristics on the AQ. Researchers tested the relationship between AQ scores and age with six different commonly used ways to calculate AQ scores. Researchers used multiple statistical techniques to evaluate various measurement properties of the AQ.What were the results of the study?: The results indicate that autism characteristics measured by the AQ are not strongly associated with age. Along with that, there is evidence that certain approaches to measuring of autism characteristics are consistent across age into late life and do not vary with demographic and autism-related factors.What do these findings add to what was already known?: These results add to the growing evidence that self-reports of autism characteristics using the AQ in general samples are not strongly associated with age across adulthood. These findings also provide guidance about ways of scoring the AQ that work well through late life.What are potential weaknesses in the study?: While the AQ has a degree of relationship with autism diagnoses, this is far from perfect and has not been evaluated in the context of aging research. Therefore, findings from the present research must be carefully interpreted to be about autism characteristics not diagnoses. The sample was also limited in a number of other ways. As in any studies including a broad age range of individuals, the oldest participants are likely quite healthy, engaged individuals. This may particularly be the case given the higher mortality rates and health challenges seen with autism. Similarly, as with any self-report research, this research is limited to those individuals who could answer questions about their autism characteristics. The sample was also predominantly White and nonautistic. Finally, the research was limited to one point in time and so cannot tell us about how autism characteristics may change across adulthood.How will these findings help autistic adults now or in the future?: These findings support the potential for the AQ to be a useful tool for future research on autism in adulthood. For example, researchers can use measures such as the AQ to study how autism characteristics change over time or are associated with aging-related issues such as changes in physical health and memory. Such research may be able to provide a better understanding of how to support autistic individuals across adulthood.

Autistic traits are associated with faster pace of aging: Evidence from the Dunedin study at age 45

Growing evidence indicates that the defining characteristics of autism spectrum disorder (ASD) are distributed throughout the general population; hence, understanding the correlates of aging in people with high autistic traits could shed light on ASD and aging. 915 members of the Dunedin longitudinal birth cohort completed a measure of autistic traits at age 45. A composite measure of the "pace of aging" was derived by tracking the decline in 19 biomarkers across ages 26, 32, 38, and 45 years. Facial age was also assessed. Reports of perceived health were collected from participants themselves, informants, and interviewers. Higher self-reported autistic traits significantly correlated with a faster pace of aging, older facial age, and poorer self-, informant-, and interviewer-rated health. After control for sex, SES and IQ, autistic traits were significantly associated with each variable: pace of aging (β = 0.09), facial age (β = 0.08), self- (β = -0.15), informant (β = -0.12), and interviewer-rated (β = -0.17) health. Autistic traits measured at age 45 are associated with faster aging. Participants with high autistic traits appear to be more vulnerable to poor health outcomes, as previously reported for those clinically diagnosed with ASD. Therefore, autistic traits may have important health implications. Replicating these findings in samples of autistic people is needed to identify the mechanism of their effect on aging and physical health to improve outcomes for those with ASD diagnoses or high autistic traits. LAY SUMMARY: The role that autistic traits have in relation to health outcomes has not been investigated. We looked at how physical health and aging (measured with self-reported questions and decline in multiple biological measures) were related to autistic traits (measured with a questionnaire, at age 45). We found that higher autistic traits were associated with poorer reports of physical health, and a faster pace of aging. This suggests that both those with autism and those with higher autistic traits may be more likely to experience poorer health outcomes.

Measurement Properties of Social Communication Assessments for Transition-Age Adolescents: A Systematic Review

Purpose An important role of social communication assessment is to support intervention planning as adolescents with disabilities transition to workplaces and other adult settings. Adoption of evidence-based assessment practices would align professionals with legal and ethical mandates for schools and other settings. There is, however, limited adoption of evidence-based assessment selection. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) provide a structured approach to identifying assessments with sufficient validity and reliability backed by strong evidence. The purpose of this review was to identify directly administered social communication assessments for adolescents and to apply the COSMIN framework to evaluate their measurement properties. Method A systematic search identified 13 assessments designed for 14- to 21-year-olds with developmental disabilities putting them at risk for social communication deficits. Measurement properties were extracted from included studies and rated for sufficiency. The quality of evidence supporting the findings was graded using COSMIN guidelines. Results Five social communication assessments were recommended as having sufficient evidence of content validity and internal consistency. Remaining assessments could be recommended as gaps in the evidence for their measurement properties are filled. Conclusions The application of the COSMIN standards has the potential to advance evidence-based assessment for social communication. There were important gaps in the independent replication of measurement properties and methodological shortcomings in the evaluation of reliability, measurement error, and structural validity.

Thalamic and prefrontal GABA concentrations but not GABAA receptor densities are altered in high-functioning adults with autism spectrum disorder

The gamma aminobutyric acid (GABA) neurotransmission system has been implicated in autism spectrum disorder (ASD). Molecular neuroimaging studies incorporating simultaneous acquisitions of GABA concentrations and GABAA receptor densities can identify objective molecular markers in ASD. We measured both total GABAA receptor densities by using [18F]flumazenil positron emission tomography ([18F]FMZ-PET) and GABA concentrations by using proton magnetic resonance spectroscopy (1H-MRS) in 28 adults with ASD and 29 age-matched typically developing (TD) individuals. Focusing on the bilateral thalami and the left dorsolateral prefrontal cortex (DLPFC) as our regions of interest, we found no differences in GABAA receptor densities between ASD and TD groups. However, 1H-MRS measurements revealed significantly higher GABA/Water (GABA normalized by water signal) in the left DLPFC of individuals with ASD than that of TD controls. Furthermore, a significant gender effect was observed in the thalami, with higher GABA/Water in males than in females. Hypothesizing that thalamic GABA correlates with ASD symptom severity in gender-specific ways, we stratified by diagnosis and investigated the interaction between gender and thalamic GABA/Water in predicting Autism-Spectrum Quotient (AQ) and Ritvo Autism Asperger's Diagnostic Scale-Revised (RAADS-R) total scores. We found that gender is a significant effect modifier of thalamic GABA/Water's relationship with AQ and RAADS-R scores for individuals with ASD, but not for TD controls. When we separated the ASD participants by gender, a negative correlation between thalamic GABA/Water and AQ was observed in male ASD participants. Remarkably, in female ASD participants, a positive correlation between thalamic GABA/Water and AQ was found.

Psychometric properties of a screening tool for autism in the community-The Indian Autism Screening Questionnaire (IASQ)

INTRODUCTION

Currently available screening questionnaires for Autism spectrum disorders were tested in developed countries, but many require additional training and many are unsuitable for older individuals, thus reducing their utility in lower/ middle- income countries. We aimed to derive a simplified questionnaire that could be used to screen persons in India.

METHODS

We have previously validated Indian Scale for Assessment of Autism (ISAA), that is now mandated for disability assessment by the Government of India. This detailed tool requires intensive training and it is time consuming. It was used to derive a new screening questionnaire: 1) items most frequently scored as positive by participants with autism in original ISAA validation study were modified for binary scoring following expert review. 2) In a new sample, clinically diagnosed individuals with/without autism were administered the screening tool and ISAA following written informed consent. Its psychometric properties were determined.

RESULTS

A 10-item scale named Indian Autism Screening Questionnaire (IASQ) was prepared in Hindi and English. Thereafter 145 parents/caregivers of participants (autism, n = 90, other psychiatric disorders, n = 55) (ages 3-18), were administered IASQ and ISAA (parents/caregivers plus observation) by separate interviewers, blind to each other and to diagnosis. At a cutoff of 1, sensitivity was 99%, specificity 62%, Positive Predictive Value 81%, and Negative Predictive Value 95%. Test-retest reliability was r = 0.767 (CI = 0.62-0.86) and interrater reliability- Krippendorff"s-alpha was 0.872. The area under Receiver Operating Characteristic Curve (ROC) was 95%. There was a significant difference on IASQ-scores between participants with and without a clinical diagnosis of Autism (t = 14.57, p<0.0001).

DISCUSSION

The IASQ is a simple, easy to use screening tool with satisfactory reliability and validity, that can be administered to caregivers in 15 minutes and provides information about DSM 5 criteria for autism. It may be applicable outside India, following additional adaptation, for community-based studies.

The French Version of the Revised Ritvo Autism and Asperger Diagnostic Scale: A Psychometric Validation and Diagnostic Accuracy Study

The early recognition of ASD in adults is challenging, in particular due to the lack of appropriate and robust diagnostic tools. We performed a psychometric validation and diagnostic accuracy study of the French version of the RAADS-R on a sample of 305 adults: 105 with ASD without ID, 99 with psychiatric disorders, and 103 non-psychiatric control groups. The French version of the RAADS-R demonstrates good reliability and diagnostic validity, suggesting that it can help clinicians during the diagnostic process in adults with ASD without ID. However, the finding that a two-factor structure better fits the results requires further validation. This study point out the need of further study of RAADS in psychiatric disorders group due to the relatively high false positive rate (55.6%) of ASD.

Real-World Experiences in Autistic Adult Diagnostic Services and Post-diagnostic Support and Alignment with Services Guidelines: Results from the ASDEU Study

Research providing an evidence-base for autistic adult services is sparse. The Autism Spectrum Disorders in the European Union (ASDEU) network implemented an on-line survey to determine gaps in autistic adult diagnostic evaluation and post-diagnostic support services. More than 55% in all groups experienced most of the recommended features for diagnostic evaluation for autistic adults. In contrast, < 2% of adults or carers, and < 21% of professionals experienced each of the recommended features for post-diagnostic support. In contrast to 61% of professionals, only about 30% of autistic adults and carers had knowledge of good local services models for autism diagnosis in adulthood. There are major differences between good practice guidelines for diagnostic and post-diagnostic care for autistic adults, and what is actually experienced by services users and professionals.

Is Camouflaging Autistic Traits Associated with Suicidal Thoughts and Behaviours? Expanding the Interpersonal Psychological Theory of Suicide in an Undergraduate Student Sample

The current study explored whether people who camouflage autistic traits are more likely to experience thwarted belongingness and suicidality, as predicted by the Interpersonal Psychological Theory of Suicide (IPTS). 160 undergraduate students (86.9% female, 18–23 years) completed a cross-sectional online survey from 8th February to 30th May 2019 including self-report measures of thwarted belongingness and perceived burdensomeness, autistic traits, depression, anxiety, camouflaging autistic traits, and lifetime suicidality. Results suggest that camouflaging autistic traits is associated with increased risk of experiencing thwarted belongingness and lifetime suicidality. It is important for suicide theories such as the IPTS to include variables relevant to the broader autism phenotype, to increase applicability of models to both autistic and non-autistic people.

Risk Factors for Sexual Offending in Self-Referred Men With Pedophilic Disorder: A Swedish Case-Control Study

Background

The risk of child sexual abuse among non-forensic, non-correctional patients with Pedophilic Disorder (PD) is largely unknown.

Methods

We recruited a consecutive sample of 55 help-seeking, non-correctional adult men diagnosed with DSM-5 PD at a university-affiliated sexual medicine outpatient unit in Sweden. PD participants were compared with 57 age-matched, non-clinical control men on four literature-based dynamic risk domains and self-rated child sexual abuse risk.

Results

PD participants scored higher than controls on all tested domains (0-3 points); expectedly so for pedophilic attraction (2.5 vs. 0.0, Cohen's d = 2.40, 95% confidence interval (CI): [1.91-2.89]), but also for sexual preoccupation (1.6 vs. 1.0, d = 1.11, 95% CI: [0.71-1.51]), impaired self-regulation (1.4 vs. 1.0, d = 0.44, 95% CI: [0.06 to 0.81]), impaired cognitive empathy and antisocial traits (0.9 vs. 0.1, d = 1.18, 95% CI: [0.78-1.59]), and self-rated child sexual abuse risk (1.0 vs. 0.0, d = 1.56, 95% CI: [1.13-1.98]). When summarizing all five domains into a pre-specified composite score (0-15 points), PD subjects scored substantially higher than matched control men (7.5 vs. 2.1, d = 2.12, 95% CI: [1.65-2.59]). Five (9%) PD participants self-reported any previous conviction for a contact child sexual offense and eight (15%) for possession of child sexual abuse material or non-contact sexual offending (adult or child victim). Eighteen subjects (34%) acknowledged past week, child-related sexual behaviors.

Conclusion

Self-referred, help-seeking men with PD scored higher (small to very large effect sizes) than non-clinical control men on psychiatric measures of dynamic risk of child sexual abuse suggested in prior research with correctional samples diagnosed with PD. Our findings, including the composite risk measure, might inform clinical practice, but needs validation against actual sexual offending behavior.

An Exploratory Study of a Dimensional Assessment of the Diagnostic Criteria for Autism

Prevalence rates of autism based upon child samples have shown a consistent increase over the past three decades, suggesting that many autistic adults are undiagnosed. Adult diagnostic pathways typically are initiated with measures of autistic-like traits. Whilst autistic-like traits represent a continuous dimension across the general population, autism is a categorical diagnosis and the relationship between the two is unclear. A self-report dimensional reflection upon the two diagnostic criteria for autism was developed and reflected upon by 1076 participants embedded within two online surveys. Those with an informal (self) diagnosis of autism self-reported comparable social difficulties but fewer restricted and repetitive behaviour difficulties than those with a formal diagnosis of autism. The new items also significantly correlated with autistic-like traits.

Diagnosis of autism in adulthood: A scoping review

LAY ABSTRACT

More adults are getting assessed for possible autism. Here, we give an overview on what is already known about autism diagnosis in adulthood and find areas that need more research. We divided results from the studies we found into six topics of (1) rates of autism in different groups; (2) the process of getting an autism diagnosis in adulthood; (3) gender; (4) personality traits, abilities and behaviours of diagnosed adults; (5) mental and physical health conditions that occur together with autism; and (6) how adults think and feel about being assessed and diagnosed. We found that adults often have strong emotions after being diagnosed, the process of getting a diagnosis can be unclear and different for everyone, and not many support services are available for adults. More research on diagnosing adults with intellectual disability, differences between early and late-diagnosed adults, and support after diagnosis would be useful.

Self-Reported Autistic Traits Using the AQ: A Comparison between Individuals with ASD, Psychosis, and Non-Clinical Controls

The term "autism" was originally coined by Eugen Bleuler to describe one of the core symptoms of schizophrenia. Even if autism spectrum disorder (ASD) and schizophrenia spectrum disorders (SSD) are now considered two distinct conditions, they share some clinical features. The present study aimed to investigate self-reported autistic traits in individuals with ASD, SSD, and non-clinical controls (NCC), using the Autism-Spectrum Quotient (AQ), a 50-item questionnaire. The study was conducted in the Psychiatry Unit of Policlinico "G. Rodolico", Catania, Italy. The AQ was administered to 35 adults with ASD, 64 with SSD, and 198 NCC. Overall, our data showed that the ASD sample scored significantly higher than NCC. However, no significant differences were detected between individuals with ASD and SSD. Notably, the three groups scored similarly in the subscale "attention to detail". AQ showed good accuracy in differentiating ASD from NCC (AUC = 0.84), while discriminant ability was poor in the clinical sample (AUC = 0.63). Finally, AQ did not correlate with clinician-rated ADOS-2 scores in the ASD sample. Our study confirms that symptoms are partially overlapping in adults with ASD and psychosis. Moreover, they raise concerns regarding the usefulness of AQ as a screening tool in clinical populations.

Screening Tools for Autism Spectrum Disorder in Primary Care: A Systematic Evidence Review

CONTEXT

Recommendations conflict regarding universal application of formal screening instruments in primary care (PC) and PC-like settings for autism spectrum disorder (ASD).

OBJECTIVES

We systematically reviewed evidence for universal screening of children for ASD in PC.

DATA SOURCES

We searched Medline, PsychInfo, Educational Resources Informational Clearinghouse, and Cumulative Index of Nursing and Allied Health Literature.

STUDY SELECTION

We included studies in which researchers report psychometric properties of screening tools in unselected populations across PC and PC-like settings.

DATA EXTRACTION

At least 2 authors reviewed each study, extracted data, checked accuracy, and assigned quality ratings using predefined criteria.

RESULTS

We found evidence for moderate to high positive predictive values for ASD screening tools to identify children aged 16 to 40 months and 1 study for ≥48 months in PC and PC-like settings. Limited evidence evaluating sensitivity, specificity, and negative predictive value of instruments was available. No studies directly evaluated the impact of screening on treatment or harm.

LIMITATIONS

Potential limitations include publication bias, selective reporting within studies, and a constrained search.

CONCLUSIONS

ASD screening tools can be used to accurately identify percentages of unselected populations of young children for ASD in PC and PC-like settings. The scope of challenges associated with establishing direct linkage suggests that clinical and policy groups will likely continue to guide screening practices. ASD is a common neurodevelopmental disorder associated with significant life span costs.^1,2 Growing evidence supports functional gains and improved outcomes for young children receiving intensive intervention, so early identification on a population level is a pressing public health challenge.^3,4.

Autism Identity and the "Lost Generation": Structural Validation of the Autism Spectrum Identity Scale (ASIS) and Comparison of Diagnosed and Self-Diagnosed Adults on the Autism Spectrum

Background

A population segment of autistic adults are under-identified due, in part, to historic changes in criteria for diagnosing autism and diagnostic biases related to gender, socioeconomic status, and other individual characteristics such as intellectual functioning. Some of these individuals, described as the "lost generation", may choose to self-diagnose. Although little is known about this population, it is possible that they share similar self-conceptualizations or internalized stigma as their diagnosed counterparts. This study reports on the structural validity of the Autism Spectrum Identity Scale (ASIS) with individuals diagnosed and self-diagnosed with autism and compares the demographic characteristics, stigma, self-concept, and quality of life of these two groups.

Methods

Over 1000 adults diagnosed (n = 893) or self-diagnosed (n = 245) with autism were recruited through organizations serving the autism community to participate in a nationally distributed online survey that included demographic questions and measures for stigma, self-concept, quality of life, and wellbeing. The diagnosed dataset was randomly split with exploratory factor analysis performed on a training dataset. Split-half cross-validation was used to predict the factor structure of the holdout dataset. Then, the full diagnosed dataset structure was used to determine the generalizability of the factor structure to the self-diagnosed dataset. The diagnosed and self-diagnosed were also compared for differences in gender, age, employment status, diagnostic term preference, and factors of self-concept (autism identity and self-esteem), stigma, and quality of life.

Results

Factor analysis of diagnosed participants yielded a four-factor structure, consistent with previous research, with strong split-sample cross-validation and good internal consistency. Factor predictions of the self-diagnosed dataset from the diagnosed dataset ranged from .97 - 1.00 with similar internal consistency. Self-diagnosed participants were more likely to be older, women, or employed and less likely to be students or prefer the term "autism" than those with an autism diagnosis. The groups were remarkably similar in reported stigma, self-esteem, quality of life and in ASIS factors; both groups reported lower quality of life than the general population.

Conclusions

The ASIS demonstrated the same internal structure with both the diagnosed and self-diagnosed. The profile of self-diagnosed participants matches the profile hypothesized for the "lost generation" and others at risk of being under-identified for autism. Both populations appear to be similarly struggling with employment, stigma, and quality of life. Future research should examine whether self-diagnosed individuals meet criteria for autism or could benefit from interventions, programs, or services serving autism communities.

Is There a Relationship Between Cyber-Dependent Crime, Autistic-Like Traits and Autism?

International law enforcement agencies have reported an apparent preponderance of autistic individuals amongst perpetrators of cyber-dependent crimes, such as hacking or spreading malware (Ledingham and Mills in Adv Autism 1:1–10, 2015). However, no empirical evidence exists to support such a relationship. This is the first study to empirically explore potential relationships between cyber-dependent crime and autism, autistic-like traits, explicit social cognition and perceived interpersonal support. Participants were 290 internet users, 23 of whom self-reported being autistic, who completed an anonymous online survey. Increased risk of committing cyber-dependent crime was associated with higher autistic-like traits. A diagnosis of autism was associated with a decreased risk of committing cyber-dependent crime. Around 40% of the association between autistic-like traits and cyber-dependent crime was mediated by advanced digital skills.

Autistic traits influence the strategic diversity of information sampling: Insights from two-stage decision models

Information sampling can reduce uncertainty in future decisions but is often costly. To maximize reward, people need to balance sampling cost and information gain. Here we aimed to understand how autistic traits influence the optimality of information sampling and to identify the particularly affected cognitive processes. Healthy human adults with different levels of autistic traits performed a probabilistic inference task, where they could sequentially sample information to increase their likelihood of correct inference and may choose to stop at any moment. We manipulated the cost and evidence associated with each sample and compared participants’ performance to strategies that maximize expected gain. We found that participants were overall close to optimal but also showed autistic-trait-related differences. Participants with higher autistic traits had a higher efficiency of winning rewards when the sampling cost was zero but a lower efficiency when the cost was high and the evidence was more ambiguous. Computational modeling of participants’ sampling choices and decision times revealed a two-stage decision process, with the second stage being an optional second thought. Participants may consider cost in the first stage and evidence in the second stage, or in the reverse order. The probability of choosing to stop sampling at a specific stage increases with increasing cost or increasing evidence. Surprisingly, autistic traits did not influence the decision in either stage. However, participants with higher autistic traits inclined to consider cost first, while those with lower autistic traits considered cost or evidence first in a more balanced way. This would lead to the observed autistic-trait-related advantages or disadvantages in sampling optimality, depending on whether the optimal sampling strategy is determined only by cost or jointly by cost and evidence.

Children with autism can spend hours practicing lining up toys or learning all about cars or lighthouses. This kind of behaviors, we think, may reflect suboptimal information sampling strategies, that is, a failure to balance the gain of information with the cost (time, energy, or money) of information sampling. We hypothesized that suboptimal information sampling is a general characteristic of people with autism or high level of autistic traits. In our experiment, we tested how participants may adjust their sampling strategies with the change of sampling cost and information gain in the environment. Though all participants were healthy young adults who had similar IQs, higher autistic traits were associated with higher or lower efficiency of winning rewards under different conditions. Counterintuitively, participants with different levels of autistic traits did not differ in the general tendency of oversampling or undersampling, or in the decision they would reach when a specific set of sampling cost or information gain was considered. Instead, participants with higher autistic traits consistently considered sampling cost first and only weighed information gain during a second thought, while those with lower autistic traits had more diverse sampling strategies that consequently better balanced sampling cost and information gain.

[ADI-R and ADOS and the differential diagnosis of autism spectrum disorders: Interests, limits and openings]

INTRODUCTION

Current developments in international public health are leading qualified authorities to release clinical practice guidelines for Autism Spectrum Disorders (ASD) assessment and diagnosis. Such documents incorporate procedures that rely on the Autism Diagnostic Interview-Revised (ADI-R) and the Autism Diagnostic Observation Schedule (ADOS) which are considered to be the "gold standard" assessment measures in the evaluation of ASD. Although these tools do prove their effectiveness in the evaluation of autistic symptomatology, they nevertheless stumble whenever the situation becomes more complex and reveal differential diagnostic issues in infantile and adult autism cases. This differential diagnostic issue remains significant in the clinical practice of daily life and has strong implications for the course of therapeutic treatment.

OBJECTIVES

Our objective is to underline and nuance the metrological qualities of the ADI-R and the ADOS in the differential diagnosis of autistic disorders by presenting a synthesis of recent studies, thus supporting the interest of maintaining an open debate on diagnostic practices.

METHODS

Our selective review of the recent literature focuses on studies that confront the ADI-R and the ADOS - used either independently or in a combination - with various differential issues in adulthood and childhood autism in order to highlight their qualities and limits.

RESULTS

The ADI-R is a semi-structured interview applied by trained examiners and applied to relatives and/or caregivers who collect developmental information about the patient's first years of life on a variety of behaviors and skills. It is therefore relatively dependent on the availability and personal bias of the interviewed third parties. Metric features highlighted by the reviewed studies straightforwardly reveal a certain effectiveness of the tool and a good discrimination of childhood disorders. At the same time, the tool's discriminatory capacity seems insufficient when applied to toddlers, very young children, and adults alike. The latter seems particularly true when it comes to differentiating between autistic and schizophrenic spectrum disorders. The ADOS is a semi-structured standardized observation assessment tool that has experienced several successive developments, such as optimizations concerning the sensitivity of its cutoffs. Many works have contributed to building such a tool with reliable and solid metric qualities which nevertheless retain important biases such as the subjectivity of the caregiver or the evaluator during the scoring process. For assessments of autistic children the tool still has a good diagnostic validity but seems to retain cases of incorrect diagnosis of ASD (false positives). In other words, disorders or developmental disabilities of some children and adolescents could not be distinguished from ASD when relying on this test alone. The ADOS Module 4, designed for the diagnosis of adolescents and adults with fluent speech, has undergone less updating. This revisited algorithm has metrological qualities useful for clinicians and remains one of the few available tools for this population. Unfortunately, its diagnostic accuracy is lower when applied to women, the elderly, people with personality disorders or higher intellectual abilities, or for the discrimination between ASD and schizophrenia. Overall, scores from these two instruments bring strong evidence of their usefulness in the diagnostic process of ASD, provided that they are used with caution and a critical clinical perspective, and only as a secondary technical support. Their use in combination is effective since they are complementary and compensate for each other's limitations. However, their globalized hegemony as "gold-standard" tools constitutes a setback insofar as it constrains the diagnosis of ASD to a set of stereotyped items. The latter in turn sets a normative model of autism that excludes other phenotypic forms, especially in the case of women and the elderly. Finally, the discrimination between autism and psychosis for children seems to remain an insoluble task even for the ADI-R/ADOS combination.

CONCLUSIONS

The problematics of differential diagnosis remain critical for clinical approaches to autism. Therefore, formalizations of the diagnostic procedures must be able to remain open-minded and accompanied by a creative clinical approach, especially in the case of complex situations that are not soluble by means of conventional diagnostic tools. One possibility may lie in the deepening of the phenomenological approach to autism as an attempt to model the subjective phenomena of autistic subjects and thus operationalize elements that serve the diagnostic process. In the same way, a psychodynamic epistemology could help clinicians to go beyond the consideration of observable behaviors and scores, introducing a psychoanalytic point of view that interfaces objective behaviors with the individual's dynamic intrapsychic functioning. This project could be articulated with projective methodologies - notably the Rorschach test - which respects the needs for standardization and quantification of conventionally used diagnostic tools.

Syllogistic reasoning reveals reduced bias in people with higher autistic-like traits from the general population

Recent theories of autism have emphasised the cognitive strengths and weaknesses in those with autism, which are also seen to some degree in non-clinical samples with higher autistic-like traits. The dual process theory of autism proposes that people with autism and non-clinical people with a higher degree of autistic-like traits have a propensity to show reduced intuitive processing (automatic and typically faster) alongside enhanced propensity towards deliberative processing (dependent on general cognitive ability and typically slower). This study aimed to further test the dual process theory of autism by investigating syllogistic reasoning (whether a conclusion can be logically deduced from two propositions) in addition to the cognitive reflection test (correct responses to which reflect deliberative processing over-riding intuitive processing) with respect to the degree of autistic-like traits and general cognitive ability in a non-clinical sample of 189 adults. Results showed that higher levels of autistic-like traits were related to lower levels of intuitive processing and higher levels of deliberative processing, which was found across both the syllogistic reasoning and cognitive reflection test measures - over and above the effect of general cognitive ability. The findings are consistent with the dual process theory of autism, and implications for autism are discussed.