Vineland Adaptive Behavior Scale scores as a function of age and initial IQ in 210 autistic children

Neurophysiological measures of auditory sensory processing are associated with adaptive behavior in children with Autism Spectrum Disorder

BACKGROUND

Atypical auditory cortical processing is consistently found in scalp electrophysiological and magnetoencephalographic studies of Autism Spectrum Disorder (ASD), and may provide a marker of neuropathological brain development. However, the relationship between atypical cortical processing of auditory information and adaptive behavior in ASD is not yet well understood.

METHODS

We sought to test the hypothesis that early (100-175 ms) auditory processing in ASD is related to everyday adaptive behavior through the examination of auditory event-related potentials (AEPs) in response to simple tones and Vineland Adaptive Behavior Scales in a large cohort of children with ASD (N = 84), aged 6-17, and in age- and IQ- matched neurotypically (NT) developing controls (N = 132).

RESULTS

Statistical analyses revealed significant group differences in early AEPs over temporal scalp regions (150-175 ms), and the expected rightward lateralization of the AEP (100-125 ms and 150-175 ms) to tonal stimuli in both groups. Lateralization of the AEP (150-175 ms) was significantly associated with adaptive functioning in the socialization domain.

CONCLUSIONS

These results lend support to the hypothesis that atypical processing of sensory information is related to everyday adaptive behavior in autism.

Neurodiversity and Intelligence: Evaluating the Flynn Effect in Children with Autism Spectrum Disorder

The Flynn Effect (FE) among child and adolescent populations indicates that intelligence scores improve by about three points per decade. Using nine years of data from the National Database for Autism Research, this study examined whether general intelligence changed significantly for nine cohorts with autism spectrum disorder (ASD; N = 671). Analyses demonstrated a downward trend such that Cohen's d from 1998 to 2006 was - 0.27. The mean IQ is 92.74 for years 1-3, 91.54 for years 4-6, and 87.34 for years 7-9, indicating a reverse FE of 5.4 points per decade. A linear regression revealed a significant negative FE comparable to the positive effect of age on IQ among those with ASD. Implications for research, practice, and law are discussed.

Towards Robot-Assisted Therapy for Children With Autism—The Ontological Knowledge Models and Reinforcement Learning-Based Algorithms

Robots are more and more present in our lives, particularly in the health sector. In therapeutic centers, some therapists are beginning to explore various tools like video games, Internet exchanges, and robot-assisted therapy. These tools will be at the disposal of these professionals as additional resources that can support them to assist their patients intuitively and remotely. The humanoid robot can capture young children’s attention and then attract the attention of researchers. It can be considered as a play partner and can directly interact with children or without a third party’s presence. It can equally perform repetitive tasks that humans cannot achieve in the same way. Moreover, humanoid robots can assist a therapist by allowing him to teleoperated and interact from a distance. In this context, our research focuses on robot-assisted therapy and introduces a humanoid social robot in a pediatric hospital care unit. That will be performed by analyzing many aspects of the child’s behavior, such as verbal interactions, gestures and facial expressions, etc. Consequently, the robot can reproduce consistent experiences and actions for children with communication capacity restrictions. This work is done by applying a novel approach based on deep learning and reinforcement learning algorithms supported by an ontological knowledge base that contains relevant information and knowledge about patients, screening tests, and therapies. In this study, we realized a humanoid robot that will assist a therapist by equipping the robot NAO: 1) to detect whether a child is autistic or not using a convolutional neural network, 2) to recommend a set of therapies based on a selection algorithm using a correspondence matrix between screening test and therapies, and 2) to assist and monitor autistic children by executing tasks that require those therapies.

Influence of siblings on adaptive behavior trajectories in autism spectrum disorder

LAY ABSTRACT

Siblings have the potential to shape the developmental trajectories of individuals with autism spectrum disorder. Having siblings has been associated with better social communication skills, less severe non-verbal communication deficits, and improved theory of mind abilities in autism spectrum disorder. This study examined the influence of the presence of a sibling, participant's position in the birth order, gender of the closest-age sibling, and gender match of the sibling dyad on the rate of growth in adaptive skills from ages 9 to 26 years among individuals with autism spectrum disorder and individuals with a history of non-spectrum developmental disorders. While all participants showed consistent gains in adaptive skill development as a function of age, there was variability in rates of growth based on sibling constellation group membership. Participants with at least one sibling, regardless of other sibling constellation factors, experienced greater rates of growth in adaptive behavior trajectories from childhood to adulthood than participants with no siblings across both Black and White participants, although differences were magnified in Black participants. Furthermore, among participants with siblings, those with male closest-age siblings and those with gender-matched siblings, irrespective of birth order position, demonstrated the steepest growth patterns in adaptive functioning within their respective groups over the 17-year period. Results suggest that siblings may serve an important role in improving the adaptive functioning trajectories and overall outcomes of individuals with autism spectrum disorder.

Use of the Vineland-3, a measure of adaptive functioning, in CLN3

Progressive vision loss and neurocognitive impairment are early and frequent presentations in CLN3 disease. This highlights neurodevelopmental functioning as critical to the disease, but limits the neuropsychological test repertoire. We evaluated the convergent validity of the Vineland Adaptive Behavior Scales as a potential outcome measure. In a prospective observational study of 22 individuals (female:male 11:11; 6-20 years-old) with a molecular diagnosis of CLN3, we used generalized linear models and Spearman correlations to quantify the relationship of the adaptive behavior composite (ABC) standard score with established outcomes of verbal IQ (VIQ) and disease severity (Unified Batten Disease Rating Scale, UBDRS) scores. We analyzed ABC changes in 1-year follow-up data in a subset of the same cohort (n = 17). The ABC and VIQ, both standard scores, exhibited a strong positive correlation in cross-sectional data (r = 0.81). ABC and UBDRS scores were strongly and positively correlated in cross-sectional data (r_range  = 0.87-0.93). Participants' ABC scores decreased slightly over the 1-year follow-up period (mean change, 95% CI: -5.23, -2.16). The convergent validity of the Vineland-3 for use in CLN3 is supported by its relationships with the established outcomes of VIQ and UBDRS. Future longitudinal research, including replication in other cohorts and evaluation of sensitivity to change, will be important to establish utility of the Vineland-3 for monitoring change in CLN3.

Crowdsourced privacy-preserved feature tagging of short home videos for machine learning ASD detection

Standard medical diagnosis of mental health conditions requires licensed experts who are increasingly outnumbered by those at risk, limiting reach. We test the hypothesis that a trustworthy crowd of non-experts can efficiently annotate behavioral features needed for accurate machine learning detection of the common childhood developmental disorder Autism Spectrum Disorder (ASD) for children under 8 years old. We implement a novel process for identifying and certifying a trustworthy distributed workforce for video feature extraction, selecting a workforce of 102 workers from a pool of 1,107. Two previously validated ASD logistic regression classifiers, evaluated against parent-reported diagnoses, were used to assess the accuracy of the trusted crowd's ratings of unstructured home videos. A representative balanced sample (N = 50 videos) of videos were evaluated with and without face box and pitch shift privacy alterations, with AUROC and AUPRC scores > 0.98. With both privacy-preserving modifications, sensitivity is preserved (96.0%) while maintaining specificity (80.0%) and accuracy (88.0%) at levels comparable to prior classification methods without alterations. We find that machine learning classification from features extracted by a certified nonexpert crowd achieves high performance for ASD detection from natural home videos of the child at risk and maintains high sensitivity when privacy-preserving mechanisms are applied. These results suggest that privacy-safeguarded crowdsourced analysis of short home videos can help enable rapid and mobile machine-learning detection of developmental delays in children.

Genome, Environment, Microbiome and Metabolome in Autism (GEMMA) Study Design: Biomarkers Identification for Precision Treatment and Primary Prevention of Autism Spectrum Disorders by an Integrated Multi-Omics Systems Biology Approach

Autism Spectrum Disorder (ASD) affects approximately 1 child in 54, with a 35-fold increase since 1960. Selected studies suggest that part of the recent increase in prevalence is likely attributable to an improved awareness and recognition, and changes in clinical practice or service availability. However, this is not sufficient to explain this epidemiological phenomenon. Research points to a possible link between ASD and intestinal microbiota because many children with ASD display gastro-intestinal problems. Current large-scale datasets of ASD are limited in their ability to provide mechanistic insight into ASD because they are predominantly cross-sectional studies that do not allow evaluation of perspective associations between early life microbiota composition/function and later ASD diagnoses. Here we describe GEMMA (Genome, Environment, Microbiome and Metabolome in Autism), a prospective study supported by the European Commission, that follows at-risk infants from birth to identify potential biomarker predictors of ASD development followed by validation on large multi-omics datasets. The project includes clinical (observational and interventional trials) and pre-clinical studies in humanized murine models (fecal transfer from ASD probands) and in vitro colon models. This will support the progress of a microbiome-wide association study (of human participants) to identify prognostic microbiome signatures and metabolic pathways underlying mechanisms for ASD progression and severity and potential treatment response.

Correlates of daily functioning in older adults with autism spectrum disorder

Objectives: Studies of adults with autism spectrum disorder (ASD) have demonstrated poor outcomes related to independence and everyday living skills compared to the general population. In a sample of 74 adults with ASD who require a high level of support we sought to identify correlates of daily functioning.Methods: We administered questionnaires to residential staff and identified participants' independence level in basic and instrumental activities of daily living.Results: There was no association of age with daily functioning. Higher daily functioning was associated with a better general medical health rating. Functional independence was greater in participants with IQ range of 55 to 65 compared to those with IQ below 55. Language difficulties and behavioral disturbances were not significantly correlated with independence in daily living skills. In this sample, individual had held a median of three different types of jobs in supported employment.Conclusion: Daily functioning in adults with autism generally does not decline with age, but because this was cross-sectional data, this requires further confirmation. Community programs designed for adults with ASD who require a high level of support should focus on overall medical health and promotion of daily living skill building.

Relationship Between the Performance of Self-Care and Visual Perception Among Young Children With Autism Spectrum Disorder and Typical Developing Children

Studies investigating the performance of self-care and visual perception in young children with autism spectrum disorder (ASD) are limited. The relationship between self-care performance and visual perception ability in young children with ASD is not yet clearly understood. Here, self-care performance was evaluated by the caregivers and therapists of children with ASD. The differences in self-care performance and visual perception ability were investigated in 66 children with ASD and 66 typically developing (TD) children between the ages of 48-83 months. The relationships between self-care and visual perception were tested in both two groups. The Assessment of Motor and Process Skills (AMPS) and the Chinese version of the Pediatric Evaluation of Disability Inventory (PEDI-C) were used to assess the children's self-care performance. The Test of Visual Perceptual Skills-Third Edition (TVPS-3) and the Developmental Test of Visual Perception-Third Edition (DTVP-3) were used to evaluate visual perception ability. Young children with ASD obtained significantly lower scores for self-care performance (AMPS and PEDI-C) and visual perception ability (TVPS-3 and DTVP) compared with TD children. Additionally, positive correlations were found between self-care performance and visual perception ability in young children with ASD. The results provide a valuable contribution to our understanding about self-care and visual perception performance of young children with ASD. The findings of this research highlight the need for pediatric practitioners to include self-care and visual-motor integration evaluations for young children with ASD. LAY SUMMARY: Young children with ASD obtained significantly lower scores for self-care performance and visual perception ability compared with TD children. Positive correlations were found between self-care performance and visual perception ability in young children with ASD. The results provide a valuable contribution to our understanding about self-care and visual perception performance of young children with ASD.

Developmental Trajectories of Adaptive Behavior From Toddlerhood to Middle Childhood in Autism Spectrum Disorder

Longitudinal growth modeling was utilized to examine adaptive behavior over eight years across the three time points (i.e., ages 2-10). Seventy-six parents completed the Vineland Adaptive Behavior Scales interviews of adaptive behavior. Child participants completed standardized developmental testing and an executive function task in toddlerhood and the Autism Diagnostic Observation Schedule across all time points. Growth models were specified for communication, daily living skills, and socialization domains of adaptive behavior. Mental age in toddlerhood was a significant predictor of trajectories of communication, daily living skills, and socialization. Executive function and autism severity were significant predictors of socialization. Findings suggest executive function as a potential target for promoting the growth of adaptive behavior skills in addition to autism symptomology.

Examining Trajectories of Daily Living Skills over the Preschool Years for Children with Autism Spectrum Disorder

Preschool children with autism spectrum disorder (ASD) experience slower development of daily living skills (DLS) that are essential for independent functioning compared to typically developing children. Few studies have examined the trajectories of DLS in preschoolers with ASD and the existing literature has reported conflicting results. This study examined DLS trajectories and potential covariates for preschoolers with ASD from a multi-site longitudinal study following children from diagnosis to the end of grade 1. Multi-level modeling was conducted with DLS domain scores from the Vineland Adaptive Behavior Scales-2. The results demonstrated a positive trajectory of increasing scores over time, associations of age of diagnosis, developmental level, stereotypy, and language skills with the mean score at T4 or age 6 years, whereas rate of change was only associated with ASD symptom severity, such that an improvement in DLS trajectory was associated with lower and improving ASD symptom severity.

Early Adaptive Functioning Trajectories in Preschoolers With Autism Spectrum Disorders

Background

In preschoolers with autism spectrum disorder (ASD) symptom, severity has a negative impact on the development of adaptive functioning, with critical consequences on the quality of life of those children. Developmental features such as reduced social interest or the presence of behavioral problems can further impede daily life learning experiences.

Objectives

The first aim of this study is to confirm the negative impact of high symptom severity on adaptive functioning trajectories in preschoolers with ASD. The second objective intends to explore whether reduced social interest and severe behavioral problems negatively affect developmental trajectories of adaptive functioning in young children with ASD.

Methods

In total, 68 children with ASD and 48 age and gender-matched children with typical development (TD) between 1.6 and 6 years were included in our study, and longitudinal data on adaptive functioning were collected (mean length of the longitudinal data collection was 1.4 years ± 0.6). Baseline measures of symptom severity, social interest, and behavioral problems were also obtained.

Results

We confirmed that children with ASD show parallel developmental trajectories but a significantly lower performance of adaptive functioning compared with children with TD. Furthermore, analyses within ASD children demonstrated that those with higher symptom severity, reduced social interest, and higher scores of behavioral problems exhibited especially lower or faster declining trajectories of adaptive functioning.

Conclusions

These findings bolster the idea that social interest and behavioral problems are crucial for the early adaptive functioning development of children with autism. The current study has clinical implications in pointing out early intervention targets in children with ASD.

Developmental trajectories of adaptive behavior in autism spectrum disorder: a high-risk sibling cohort

BACKGROUND

Children with autism spectrum disorder (ASD) often experience impairments in adaptive behavior.

METHODS

Developmental trajectories of adaptive behavior in ASD were examined in children from high-risk (siblings of children diagnosed with ASD, n = 403) and low-risk (no family history of ASD, n = 163) families. Children were assessed prospectively at 12, 18, 24, and 36 months of age using the Vineland Adaptive Behavior Scales and underwent a blind independent diagnostic assessment for ASD at 36 months of age.

RESULTS

The semi-parametric group-based modeling approach using standard scores on the Adaptive Behavior Composite revealed three distinct developmental trajectories: (a) Group 1 (21.2% of sample) showed average performance at 12 months and a declining trajectory; (b) Group 2 (52.8% of the sample) showed average performance at 12 months with a slightly declining trajectory; and (c) Group 3 (26.0% of the sample) showed a higher level of adaptive behavior at 12 months and a stable trajectory. The Mullen Scales of Early Learning Early Learning Composite and the Autism Observation Scale for Infants total score at 6 and 12 months predicted trajectory membership.

CONCLUSIONS

The results emphasize heterogeneous development associated with ASD and the need for interventions tailored to individual presentations.

Validation of the Simplified Chinese Psychoeducational Profile Third Edition in Mainland China

The Psychoeducational Profile 3rd Edition (PEP-3) is a comprehensive assessment tool designed for children with autism spectrum disorder (ASD). Although its original English version has been validated, few validation studies have been conducted on translated versions including Chinese ones. Based on 554 Chinese children with ASD and 311 typically developing Chinese children as the control group, this study investigated the psychometric properties of a simplified Chinese PEP-3 (sCPEP-3) in China mainland. Psychometric evaluation of the sCPEP-3 showed satisfactory internal consistency, test–retest reliability, inter-rater reliability, convergent validity, construct validity, and factorial validity. The findings have several implications such as utilizing the sCPEP-3 in mainland China for customized educational program planning, early identification, and evaluating the treatment effects for children with ASD.

Growth mixture models of adaptive behavior in adolescents with autism spectrum disorder

This study examined growth trajectories of teacher-reported adaptive behavior in a diverse sample of adolescents with autism spectrum disorder. The participants were 244 adolescents between the ages of 14 and 21 years who were assessed at up to four time points across two and a half years of high school. Demographic variables (age, sex, race, maternal education), phenotypic characteristics (intelligence quotient, autism severity) and school factors (location of the school, school quality) were collected. Growth mixture modeling was used to identify distinct classes of growth trajectories in communication, daily living skills, and socialization domains of adaptive behavior. Two distinct classes were identified for each domain. The first class had moderately low adaptive behavior scores and demonstrated growth of adaptive behavior over time and the second class had low adaptive behavior scores and did not demonstrate change over time. Adolescents within the moderately low adaptive behavior classes were younger at enrollment in the study, had higher IQs, and lower autism symptom severity. Logistic regressions were performed, and aspects of school quality predicted the likelihood of being in the moderately low classes above and beyond autism symptoms.

Sensory features as predictors of adaptive behaviors: A comparative longitudinal study of children with autism spectrum disorder and other developmental disabilities

BACKGROUND

Children with autism spectrum disorder (ASD) and other developmental disabilities (DD) exhibit sensory features that differ from their typically developing peers. Prior cross-sectional research has demonstrated significant associations between elevated sensory features and lower adaptive behavior scores, yet there is limited prospective research examining longitudinal associations.

AIMS

To examine the longitudinal prediction of early sensory response patterns (i.e., hyperresponsiveness, hyporesponsiveness, and sensory interests, repetitions, and seeking behaviors) to later adaptive behavior outcomes in children with ASD and DD.

METHODS AND PROCEDURES

Children with ASD (n = 51) and DD (n = 30) were seen at two time points (Time 1: M(SD) = 5.6(2.5) years; Time 2: M(SD) = 9.0(2.2) years). We used a series of regression models with both observational and parent-report measures of sensory response patterns, and including group interactions.

OUTCOMES AND RESULTS

All three sensory response patterns significantly predicted aspects of adaptive behaviors, with some differences based on assessment format and diagnostic group. Across groups and sensory patterns, we found some evidence that elevated sensory features early in childhood predicted lower adaptive behavior skills later in childhood.

CONCLUSIONS AND IMPLICATIONS

Sensory features may interfere with development of adaptive behaviors, suggesting a need for effective interventions addressing sensory features early in development.

Adaptive trajectories and early risk factors in the autism spectrum: A 15-year prospective study

Little is known about long-term outcomes. We investigate the adaptive trajectories and their risk factors in ASD. Data were obtained from 281 children prospectively followed untill adulthood. The final sample consisted of 106 individuals. Vineland scores were collected at baseline (T1), 3 (T2), 10 (T3), and 15 (T4) years later. A group-based method was used to identify homogeneous patterns of adaptive skills trajectories. Results show that among the children initially categorized as autistic, 82.6% remained over the ADOS diagnostic threshold, 11.9% converted to atypical autism, and 5.4% fell under the ADOS threshold. Most atypical autism diagnoses were unstable. Most (81.7%) autistic participants had an ID at inclusion. At T1, 59.3% were nonverbal, but only 39% at T4. Most changes occurred between 4 and 8 years of age. Approximately 25% of participants exhibited a "high" growth trajectory, in which progress continues throughout adolescence, and 75% a "low" growth trajectory, characterized by greater autistic symptoms, intellectual disability, and lower language abilities reflected by high CARS scores, low apparent DQ, and speech difficulties, which mostly, but not always, predicted low trajectories. Our findings suggest that the adaptive prognosis of autism is mostly poor in this cohort, biased toward intellectual disability. However, changes in diagnostic, speech, and adaptive status are not uncommon, even for indivduals with low measured intelligence or apparent intellectual disability, and are sometimes difficult to predict. Autism Research 2018, 11: 1455-1467. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Most autism diagnoses given before 5 years of age are stable to adulthood, but one-fifth of individuals are no longer considered to be autistic, even in a cohort biased toward apparent intellectual disability. Conversely, atypical autism diagnoses are mostly unstable. One-third of children who are nonverbal at 5 years are verbal within 15 years, mostly before 8 years of age. Concerning adaptive behavior outcomes, only one-fourth of children exhibit a high-growth trajectory through at least 15 years.

Long-term outcome of children with autism who received different forms of early intervention during their preschool years: a pilot study of 15 young adults

Background:

Studies on early intervention have reported significant gains for many children with autism. Knowledge on how these children fare in adulthood is limited.

Objective:

To examine long-term outcome of children with autism who received different forms of early intervention.

Method:

Participants were 15 young people who had all been diagnosed with ICD-10 childhood autism during the preschool years. Five received intervention based on the UCLA model for early intensive behavioral intervention, and 10 received eclectic treatment. Participants were followed from their first autism diagnosis during the preschool years (time 1) to the age of six years (time 2). The participants are now in their twenties (time 3), and at this point in time, information on autism symptoms, co-occurring disorders, quality of life, functioning, participation, adaptive behavior, and overall outcome was gathered from parents. Six of the participants answered questionnaires on quality of life, functioning, and participation.

Results:

The groups were comparable on all measures at time 1. Reassessment at time 2 showed that the early intensive behavioral intervention group had made significant gains in IQ, and that autism symptoms had decreased significantly, whereas such changes were not found for the eclectic treatment group. At time 3, most participants had considerable autism symptoms. Approximately half of them had received diagnosis of a co-occurring condition. Their quality of life and adaptive behavior was less favorable than that of the general population, but only a third had “poor” overall outcome. However, at time 3, hardly any differences were found between the groups.

Conclusions:

To maintain gains made during the preschool years, appropriate intervention and services may need to be extended into adulthood. These services should take into account the perceived needs of the individual, as expressed by himself/herself and his/her family.

The Emergence of Effortful Control in Young Boys With Fragile X Syndrome

Effortful control, or the ability to suppress a dominant response to perform a subdominant response, is an early-emerging temperament trait that is linked with positive social-emotional development. Fragile X syndrome (FXS) is a single-gene disorder characterized by hallmark regulatory impairments, suggesting diminished effortful control. This study compared the development of effortful control in preschool boys with FXS ( n = 97) and typical development ( n = 32). Unlike their typical peers, the boys with FXS did not exhibit growth in effortful control over time, which could not be accounted for by adaptive impairments, FMR1 molecular measures, or autism symptoms. These results contribute to our understanding of the childhood phenotype of FXS that may be linked to the poor social-emotional outcomes seen in this group.

The Application of Adaptive Behaviour Models: A Systematic Review

Adaptive behaviour has been viewed broadly as an individual's ability to meet the standards of social responsibilities and independence; however, this definition has been a source of debate amongst researchers and clinicians. Based on the rich history and the importance of the construct of adaptive behaviour, the current study aimed to provide a comprehensive overview of the application of adaptive behaviour models to assessment tools, through a systematic review. A plethora of assessment measures for adaptive behaviour have been developed in order to adequately assess the construct; however, it appears that the only definition on which authors seem to agree is that adaptive behaviour is what adaptive behaviour scales measure. The importance of the construct for diagnosis, intervention and planning has been highlighted throughout the literature. It is recommended that researchers and clinicians critically review what measures of adaptive behaviour they are utilising and it is suggested that the definition and theory is revisited.

Relationships between atypical sensory processing patterns, maladaptive behaviour and maternal stress in Spanish children with autism spectrum disorder

BACKGROUND

This study investigated sensory processing in a sample of Spanish children with autism spectrum disorder (ASD). Specifically, the study aimed to explore (1) the prevalence and distribution of atypical sensory processing patterns, (2) the relationship between adaptive and maladaptive behaviour with atypical sensory processing and (3) the possible relationship between sensory subtype and maternal stress.

METHODS

The short sensory profile 2 (Dunn 2014) and the vineland adaptive behavior scale (Sparrow et al. 1984) were administered to examine the sensory processing difficulties and maladaptive behaviours of 45 children with ASD aged 3 to 14; their mothers also completed the parenting stress index-short form (Abidin 1995).

RESULTS

Atypical sensory features were found in 86.7% of the children; avoider and sensor being the two most common patterns. No significant relationship was found between atypical sensory processing and adaptive behaviour. However, the analysis showed a strong relationship between sensory processing and maladaptive behaviour. Both maladaptive behaviour and sensory processing difficulties correlated significantly with maternal stress although maternal stress was predicted only by the sensory variable, and in particular by the avoider pattern.

CONCLUSIONS

The findings suggest that sensory features in ASD may be driving the high prevalence of parental stress in carers. They also suggest that the effect on parental stress that has been attributed traditionally to maladaptive behaviours may be driven by sensory difficulties. The implications of these findings are discussed in relation to the development of interventions and the need to explore contextual and cultural variables as possible sources of variability.

Behaviorally-determined sleep phenotypes are robustly associated with adaptive functioning in individuals with low functioning autism

Despite sleep disturbance being a common complaint in individuals with autism, specific sleep phenotypes and their relationship to adaptive functioning have yet to be identified. This study used cluster analysis to find distinct sleep patterns and relate them to independent measures of adaptive functioning in individuals with autism. Approximately 50,000 nights of care-giver sleep/wake logs were collected on school-days for 106 individuals with low functioning autism (87 boys, 14.77 ± 3.11 years) for 0.5-6 years (2.2 ± 1.5 years) from two residential schools. Using hierarchical cluster analysis, performed on summary statistics of each individual across their recording duration, two clusters of individuals with clearly distinguishable sleep phenotypes were found. The groups were summarized as 'unstable' sleepers (cluster 1, n = 41) and 'stable' sleepers (cluster 2, n = 65), with the former exhibiting reduced sleep duration, earlier sleep offset, and less stability in sleep timing. The sleep clusters displayed significant differences in properties that were not used for clustering, such as intellectual functioning, communication, and socialization, demonstrating that sleep phenotypes are associated with symptom severity in individuals with autism. This study provides foundational evidence for profiling and targeting sleep as a standard part of therapeutic intervention in individuals with autism.

Vineland Adaptive Behavior Scales: II Profile of Young Children with Autism Spectrum Disorder

Adaptive behaviour is a crucial area of assessment for individuals with Autism Spectrum Disorder (ASD). This study examined the adaptive behaviour profile of 77 young children with ASD using the Vineland-II, and analysed factors associated with adaptive functioning. Consistent with previous research with the original Vineland a distinct autism profile of Vineland-II age equivalent scores, but not standard scores, was found. Highest scores were in motor skills and lowest scores were in socialisation. The addition of the Autism Diagnostic Observation Schedule calibrated severity score did not contribute significant variance to Vineland-II scores beyond that accounted for by age and nonverbal ability. Limitations, future directions, and implications are discussed.

Social skills characteristics of students with autism spectrum disorder

Objectives: This study examines differences in social skills among children with autism spectrum disorder (ASD). In order to investigate these differences, social skills were associated with variables like gender, age, intellectual disability, language development, and school type. Methods: For the purposes of the study a total of 63 students with ASD attending primary and secondary special education units were selected in Northern Greece. A structured questionnaire was filled in by their teachers. Results: The results showed major differences between children with ASD and intellectual disability and those without. Likewise, verbal children obtained higher scores than non-verbal. These higher scores indicate better social skills. Age, gender, and school type differentiated the scores of the groups only in a few factors of the questionnaire. Conclusion: Intellectual disability and language are variables that clearly influence the socialization of children with ASD.

Age and Adaptive Functioning in Children and Adolescents with ASD: The Effects of Intellectual Functioning and ASD Symptom Severity

The present study examined the moderating effects of intellectual functioning and ASD symptom severity on the relation between age and adaptive functioning in 220 youth with autism spectrum disorder (ASD). Regression analysis indicated that intellectual functioning and ASD symptom severity moderated the relation between age and adaptive functioning. For younger children with lower intellectual functioning, higher ASD symptom severity was associated with better adaptive functioning than that of those with lower ASD symptom severity. Similarly, for older children with higher intellectual functioning, higher ASD symptom severity was associated with better adaptive functioning than that of those with lower ASD symptom severity. Analyses by subscales suggest that this pattern is driven by the Conceptual subscale. Clinical and research implications are discussed.

The Preschool Confusion Assessment Method for the ICU: Valid and Reliable Delirium Monitoring for Critically Ill Infants and Children

OBJECTIVES

Delirium assessments in critically ill infants and young children pose unique challenges due to evolution of cognitive and language skills. The objectives of this study were to determine the validity and reliability of a fundamentally objective and developmentally appropriate delirium assessment tool for critically ill infants and preschool-aged children and to determine delirium prevalence.

DESIGN AND SETTING

Prospective, observational cohort validation study of the PreSchool Confusion Assessment Method for the ICU in a tertiary medical center PICU.

PATIENTS

Participants aged 6 months to 5 years and admitted to the PICU regardless of admission diagnosis were enrolled.

MEASUREMENTS AND MAIN RESULTS

An interdisciplinary team created the PreSchool Confusion Assessment Method for the ICU for pediatric delirium monitoring. To assess validity, patients were independently assessed for delirium daily by the research team using the PreSchool Confusion Assessment Method for the ICU and by a child psychiatrist using the Diagnostic and Statistical Manual of Mental Disorders criteria. Reliability was assessed using blinded, concurrent PreSchool Confusion Assessment Method for the ICU evaluations by research staff. A total of 530-paired delirium assessments were completed among 300 patients, with a median age of 20 months (interquartile range, 11-37) and 43% requiring mechanical ventilation. The PreSchool Confusion Assessment Method for the ICU demonstrated a specificity of 91% (95% CI, 90-93), sensitivity of 75% (95% CI, 72-78), negative predictive value of 86% (95% CI, 84-88), positive predictive value of 84% (95% CI, 81-87), and a reliability κ-statistic of 0.79 (0.76-0.83). Delirium prevalence was 44% using the PreSchool Confusion Assessment Method for the ICU and 47% by the reference rater. The rates of delirium were 53% versus 56% in patients younger than 2 years old and 33% versus 35% in patients 2-5 years old using the PreSchool Confusion Assessment Method for the ICU and reference rater, respectively. The short-form PreSchool Confusion Assessment Method for the ICU maintained a high specificity (87%) and sensitivity (78%) in post hoc analysis.

CONCLUSIONS

The PreSchool Confusion Assessment Method for the ICU is a highly valid and reliable delirium instrument for critically ill infants and preschool-aged children, in whom delirium is extremely prevalent.

The relationship between expressive language level and psychological development in children with autism 5 years of age

The age of detection of autism varies and may be linked to differences in the severity of disturbance and any associated retardation. Symptom intensity, overall language level, age of recognition of first disturbances and level of psychological development were examined in 222 children with pervasive developmental disorder with a mean age of 5 years. Results showed a positive correlation between language level and psychological development as well as between language level and intensity of symptoms. The central position of language in psychological development is discussed.

Quantitative assessment of autistic symptomatology in preschoolers

Given a growing emphasis on early intervention for children with autism, valid quantitative tools for measuring treatment response are needed. The Social Responsiveness Scale (SRS) is a brief (15–20 minute) quantitative measure of autistic traits in 4-to 18-year-olds, for which a version for 3-year-olds was recently developed. We obtained serial SRS measurements on 73 preschool children with ( n = 51) and without ( n = 22) autism spectrum conditions. Inter-rater reliability (mothers and teachers) and test–retest reliability were of the order of 0.75 (Pearson's r). There was substantial agreement between SRS scores and (1) the Vineland Adaptive Behavior Composite (Pearson's r = –0.86) and (2) scores for social impairment on the Autism Diagnostic Interview–Revised ( r = 0.63). Overall, quantitative autistic trait scores tended to improve over time in preschoolers, irrespective of treatment conditions. We conclude that it is possible to obtain reliable quantitative measurements of autistic social impairment in preschoolers, suitable for assessing treatment response.

Longitudinal Examination of Adaptive Behavior in Autism Spectrum Disorders: Influence of Executive Function

This study characterizes longitudinal change in adaptive behavior in 64 children and adolescents with autism spectrum disorder (ASD) without intellectual disability evaluated on multiple occasions, and examines whether prior estimate of executive function (EF) problems predicts future adaptive behavior scores. Compared to standardized estimates for their developmental stage, adaptive behavior in most participants was impaired and did not improve over time. Prior EF predicted later adaptive behavior in daily living skills and socialization domains after controlling for age and IQ. Self-monitoring behaviors robustly predicted later adaptive behavior in all domains (d = 0.60-0.94). Results support targeting treatment of adaptive skills in ASD, as well as the importance of assessing for EF problems that may contribute to adaptive behavior difficulties.

Brief Report: Adaptive Functioning in Children with ASD, ADHD and ASD + ADHD

Autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) often co-occur. Children with ASD and ADHD demonstrate deficits in adaptive functioning, yet pure and comorbid groups have not been directly compared. Vineland Adaptive Behaviour Scales (VABS-II) data were examined in boys with ASD (n = 17), ADHD (n = 31) and ASD + ADHD (n = 38). Results demonstrated lower socialisation and composite scores and greater discrepancy between cognitive and adaptive abilities in the ASD + ADHD group compared to the ADHD-only group. Significant associations were shown between reduced adaptive functioning and autism symptoms, but not ADHD symptoms. Children with ASD + ADHD present with exacerbated impairments in adaptive functioning relative to children with ADHD, associated with ASD symptoms. Disentangling variation in adaptive skills may aid the assessment of complex cases.

A randomized, placebo-controlled trial of D-cycloserine for the enhancement of social skills training in autism spectrum disorders

BACKGROUND

Researchers have demonstrated that d-cycloserine (DCS) can enhance the effects of behavioral interventions in adults with anxiety and enhances prosocial behavior in animal models of autism spectrum disorders (ASD). This study extended upon this background by combining DCS with behavioral social skills therapy in youth with ASD to assess its impact on the core social deficits of ASD. We hypothesized that DCS used in combination with social skills training would enhance the acquisition of social skills in children with ASD.

METHODS

A 10-week, double-blind, placebo-controlled trial of DCS (50 mg) given 30 min prior to weekly group social skills training was conducted at two sites. Children with ASD were randomized to receive 10 weeks (10 doses) of DCS or placebo in a 1:1 ratio.

RESULTS

No statistically significant difference attributable to drug treatment was observed in the change scores for the primary outcome measure, the Social Responsiveness Scale (SRS), total score (p = 0.45), or on secondary outcome measures.

CONCLUSIONS

The results of this trial demonstrated no drug-related short-term improvement on the primary outcome measure, or any of the secondary outcome measures. However, an overall significant improvement in SRS total raw score was observed from baseline to end of treatment for the entire group of children with ASD. This suggests a need to further study the efficacy of the social skills training protocol. Limitations to the current study and areas for future research are discussed.

TRIAL REGISTRATION

ClinicalTrials.govNCT01086475.

Implicit and explicit motor learning: Application to children with Autism Spectrum Disorder (ASD)

AIMS AND OBJECTIVES

This study aims to determine whether children with Autism Spectrum Disorder (ASD) are capable of learning a motor skill both implicitly and explicitly.

METHODS

In the present study, 30 boys with ASD, aged 7-11 with IQ average of 81.2, were compared with 32 typical IQ- and age-matched boys on their performance on a serial reaction time task (SRTT). Children were grouped by ASD and typical children and by implicit and explicit learning groups for the SRTT.

RESULTS

Implicit motor learning occurred in both children with ASD (p=.02) and typical children (p=.01). There were no significant differences between groups (p=.39). However, explicit motor learning was only observed in typical children (p=.01) not children with ASD (p=.40). There was a significant difference between groups for explicit learning (p=.01).

DISCUSSION

The results of our study showed that implicit motor learning is not affected in children with ASD. Implications for implicit and explicit learning are applied to the CO-OP approach of motor learning with children with ASD.

Adaptive profiles in autism and other neurodevelopmental disorders

We investigated the influence of specific autism spectrum disorder (ASD) deficits in learning adaptive behaviour, besides intelligence quotient (IQ). Participated 217 school-aged: ASD (N = 115), and other neurodevelopmental disorders (OND) groups (N = 102) matched by Full-Scale IQ. We compared standard scores of Vineland Adaptive Behaviour Scale (VABS) in communication, daily living skills, socialization and adaptive behaviour composite. Pearson-correlation analysis was performed between each domain of VABS and Full-Scale, Verbal and Performance IQ, and chronological age (CA). Results indicated that impairment in adaptive behaviour within the domain of socialization skills remains a distinctive factor of ASD versus OND, independently of intellectual disability (ID). Co-occurring ID result in further debilitating effects on overall functioning, especially in ASD. CA is negatively associated with VABS scores.

Daily living skills in individuals with autism spectrum disorder from 2 to 21 years of age

Daily living skills (DLS), such as personal hygiene, meal preparation, and money management, are important to independent living. Research suggests that many individuals with autism spectrum disorder exhibit impairments in daily living skills relative to their cognitive skills. This study examined predictors of daily living skills attainment and trajectories of daily living skills in a longitudinal sample referred for possible autism spectrum disorder and followed from 2 to 21 years of age. Consistent with previous studies, participants with autism spectrum disorder and nonspectrum diagnoses showed continual development of daily living skills throughout childhood and adolescence. Early childhood nonverbal mental age was the strongest predictor of daily living skills attainment for both diagnostic groups. Group-based modeling suggested two distinct trajectories of daily living skills development for participants with autism spectrum disorder. Skill levels for both groups of young adults with autism spectrum disorder remained considerably below age level expectations. Whereas the "High-DLS" group gained approximately 12 years in daily living skills from T2 to T21, the "Low-DLS" group's daily living skills improved 3-4 years over the 16- to 19-year study period. Nonverbal mental age, receptive language, and social-communication impairment at 2 years predicted High- versus Low-DLS group membership. Receiving greater than 20 h of parent-implemented intervention before age 3 was also associated with daily living skills trajectory. Results suggest that daily living skills should be a focus of treatment plans for individuals with autism spectrum disorder, particularly adolescents transitioning to young adulthood.

Predictors and course of daily living skills development in toddlers with autism spectrum disorders

Self-sufficiency is central to child and family well-being. This report focuses on predictors of adaptive daily living skills (DLS) development in young children with ASD and whether DLS gains predict decreases in parenting stress. Participants were 162 toddlers with ASD and their parents, assessed at 3 annual timepoints. Hierarchical Linear Models showed that age, DQ, and autism symptom severity uniquely predicted initial DLS and DLS growth. Child problem behaviors predicted initial DLS only. DLS was associated with change in parenting stress above and beyond DQ, autism symptom severity, and problem behaviors. Children with lower IQ and more severe symptoms showed slower DLS gains. Given its relation to parenting stress, DLS are an important intervention target in young children with ASD.

Follow-up at mid-school age (9-13 years) of children assessed for autism spectrum disorder before the age of four

BACKGROUND

Studies of diagnosis and outcome in mid-school age children (9-13 years) referred early in life for a suspected autism spectrum disorder (ASD) are scarce.

AIMS

This study aimed to describe outcome, developmental change and the stability of the early diagnosis in mid-school age.

METHODS

Children consecutively referred to a specialized autism unit at a regional psychiatric diagnostic centre in Denmark before the age of 4 were contacted in mid-school age (9-13 years). 14 children with ASD and 9 children diagnosed outside the spectrum were included. Current clinical diagnosis, autism characteristics, intellectual abilities and adaptive functioning were assessed at follow-up, and investigated in relation to early measures of intellectual abilities and difficulties in social and communicative situations.

RESULTS

The stability of an early ASD diagnosis was confirmed. However, a high degree of change into the autism spectrum was found for children who were initially diagnosed with another developmental disorder. A positive change with regard to IQ level was evident at the individual level. At group level, there was a tendency for lower functioning in the children diagnosed early with ASD. Early measures of intellectual abilities, and of social and communicative difficulties, predicted between 16% and 50% of the variance in intellectual abilities and adaptive functioning.

CONCLUSIONS

The findings are in line with follow-up studies in preschool and early school age but highlight the need to monitor early diagnostic decisions, and the need for more nuanced baseline and outcome measures that may help increase our prognostic understanding.

Translation and validation of the Children's Communication Checklist to evaluate pragmatic language impairment in Thai children

BACKGROUND

The Children's Communication Checklist (CCC) was developed to provide an assessment of domains of language impairment in children, particularly the pragmatic domain. This study examined the effectiveness of the CCC-Thai version in discriminating children with autism spectrum disorders (ASD) from typically developing children.

METHODS

The parents of two groups of 50 children aged 4-6 years, one with clinically ascertained ASD, and one with typical development, completed the CCC-Thai version.

RESULTS

The mean pragmatic composite score was significantly lower in the ASD group (124.6) than in the typical development group (142). The optimal receiver operating characteristic curve cut-off score was found to be identical to the original English version (132). Corresponding sensitivity and specificity were 94% and 86%, respectively. The positive predictive value and the negative predictive value were 87% and 93%, respectively. The corresponding area under the curve was 0.95 (95% confidence interval: 0.91-0.99).

CONCLUSION

The CCC-Thai version is a promising instrument to assess pragmatic language impairment in Thai children.

Adaptive behaviors in high-functioning Taiwanese children with autism spectrum disorders: an investigation of the mediating roles of symptom severity and cognitive ability

We investigated the relationship among cognitive level, autistic severity and adaptive function in a Taiwanese sample of 94 high-functioning children with autism spectrum disorders (ASD) (mean full scale intelligent quotients FSIQ = 84.8). Parents and teachers both completed the Adaptive Behavior Assessment System-II and the Social Responsiveness Scale. Correlational and regression analyses were used to explore the relationships among the constructs of cognitive, symptomatic and adaptive domains. Results revealed that average General Adaptive Composites of these children (home: 74.0; school: 74.6) was below average FSIQ. Profile analysis revealed that Social domain was the weakness among the adaptive abilities assessed at school and home. Cognitive abilities had positive relationship with adaptive function, while autistic severity had a weak negative relationship with adaptive function. Also, the younger the age the child got diagnosed, the less severe the current symptoms of autism were. The implication for emphasizing adaptive skills intervention was discussed.

An open-label pilot study of a formulation containing the anti-inflammatory flavonoid luteolin and its effects on behavior in children with autism spectrum disorders

BACKGROUND

Accumulating evidence suggests an association between autism spectrum disorders (ASD) and inflammation in brain regions related to cognitive function. The natural flavonoid luteolin has antioxidant, anti-inflammatory, mast cell-blocking, and neuroprotective effects. It was shown to improve cognitive performance in a mouse model of ASD, but its effect in humans has not been adequately studied.

OBJECTIVES

The goal of this study was to assess the effectiveness and tolerability in white children with ASD of a dietary supplement containing 2 flavonoids (>95% pure), luteolin (100 mg/capsule, from chamomile) and quercetin (70 mg/capsule), and the quercetin glycoside rutin (30 mg/capsule) from the Sophora japonica leaf, formulated in olive kernel oil to increase oral absorption.

METHODS

Fifty children (4-10 years old; 42 boys and 8 girls) with ASD were enrolled in a 26-week, prospective, open-label trial at the 2nd University Department of Psychiatry at "Attikon" General Hospital, Athens, Greece. Children were referred for the study by their respective physicians or came from the practice of the senior author. ASD diagnosis by clinical assessment was based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, symptom list and corroborated by using the Autism Diagnostic Observation Schedule. The dose of the study formulation used was 1 capsule per 10 kg weight per day with food. The primary outcome measures were the age-equivalent scores in the Vineland Adaptive Behavior Scales domains. Secondary outcomes included the Aberrant Behavior Checklist, the Autism Treatment Evaluation Checklist, and the Clinical Global Impression-Improvement score. Data were measured at baseline, week 18, and week 26. Parents were interviewed for any possible improvements they noticed and instructed to report any unusual adverse events.

RESULTS

A total of 40 children completed the protocol. There was a significant improvement in adaptive functioning as measured by using the VABS age-equivalent scores (8.43 months in the communication domain, 7.17 months in daily living skills, and 8 months in the social domain; P < 0.005), as well as in overall behavior as indicated by the reduction (26.6%-34.8%) in Aberrant Behavior Checklist subscale scores. Age, sex, and history of allergies had no effect on the results, whereas the initial level of functioning or difficulty did predict the final outcome in most of the measures used. There was a transient (1-8 weeks) increased irritability in 27 of the 50 participants.

CONCLUSIONS

These results are encouraging in that the combination of the flavonoids luteolin and quercetin seemed to be effective in reducing ASD symptoms, with no major adverse effects. ClinicalTrials.gov identifier: NCT01847521.

Head circumferences in twins with and without Autism Spectrum Disorders

To determine the genetic relationship between head circumference (HC) and Autism Spectrum Disorders (ASDs). Twin pairs with at least one twin with an ASD were assessed. HCs in affected and unaffected individuals were compared, as were HC correlations in monozygotic and dizygotic pairs. 404 subjects, ages 4-18, were included. 20 % of males and 27 % of females with an ASD had macrocephaly. Unaffected co-twins showed similar rates (16 % of males and 22 % of females). Statistical analysis revealed no significant difference in HCs between affected and unaffected twins. Twins with ASDs and unaffected co-twins have similar HCs and increased rates of macrocephaly. Correlations demonstrated partial inheritance of HCs. Thus, macrocephaly may represent an endophenotype in ASDs.

Pediatric delirium: monitoring and management in the pediatric intensive care unit

This review article updates the pediatric medical community on the current literature regarding diagnosis and treatment of delirium in critically ill children. This information will be of value to pediatricians, intensivists, and anesthesiologists in developing delirium monitoring and management protocols in their pediatric critical care units.

Developmental trajectories in adolescents and adults with autism: the case of daily living skills

OBJECTIVE

This study aimed to investigate the longitudinal course of daily living skills in a large, community-based sample of adolescents and adults with autism spectrum disorders (ASD) over a 10-year period.

METHOD

Adolescents and adults with ASD (n = 397) were drawn from an ongoing, longitudinal study of individuals with ASD and their families. A comparison group of 167 individuals with Down syndrome (DS) were drawn from a linked longitudinal study. The Waisman Activities of Daily Living Scale was administered four times over a 10-year period.

RESULTS

We used latent growth curve modeling to examine change in daily living skills. Daily living skills improved for the individuals with ASD during adolescence and their early 20s, but plateaued during their late 20s. Having an intellectual disability was associated with lower initial levels of daily living skills and a slower change over time. Individuals with DS likewise gained daily living skills over time, but there was no significant curvature in the change.

CONCLUSIONS

Future research should explore what environmental factors and interventions may be associated with continued gains in daily living skills for adults with ASD.

WISC-IV profile in high-functioning autism spectrum disorders: impaired processing speed is associated with increased autism communication symptoms and decreased adaptive communication abilities

Changes in the Wechsler Intelligence Scales for Children-IV (WISC-IV) may affect the IQ profile characteristic of autism spectrum disorders (ASD). Moreover, the association of particular component cognitive abilities (unlike overall IQ) with symptomatology and adaptive functioning in ASD remains unclear. This archival study characterizes the WISC-IV IQ profile among 56 high-functioning (IQ > 70) children with ASD and correlates WISC-IV performance with ASD and ADHD symptomatology and adaptive functioning. The ASD WISC-IV profile included strengths on Matrix Reasoning and Similarities, weaknesses on Comprehension (which correlated negatively with social symptoms) and the subtests comprising the Processing Speed Index (Coding, Symbol Search). Processing speed task performance correlated negatively with communication symptoms and positively with communication abilities, indicating its importance to functional outcomes in ASD.

Characteristics of autism spectrum disorders in a sample of egyptian and saudi patients: transcultural cross sectional study

BACKGROUND

Autism is a biological disorder with clearly defined phenomenology. Studies from the Middle East on this topic have been particularly rare. Little is known about the influence of culture on clinical features, presentations and management of autism. The current study was done to compare characteristics of autism in two groups of Egyptian as well as Saudi children.

METHODS

The sample included 48 children with Autism Spectrum Disorder. They were recruited from the Okasha Institute of Psychiatry, Ain Shams University, Cairo, Egypt and Al-Amal Complex for Mental Health, Dammam, Kingdom of Saudi Arabia. They were grouped into an Egyptian group (n = 20) and a Saudi group (n = 28). They were assessed both clinically and psychometrically using the GARS, the Vineland adaptive behavioral scale, and the Stanford Binnet IQ test.

RESULTS

Typical autism was more prevalent than atypical autism in both groups. There were no statistically significant differences in clinical variables like regression, hyperactivity, epilepsy or mental retardation. Delayed language development was significantly higher in the Egyptian group while delay in all developmental milestones was more significant in the Saudi group. The Vineland communication subscale showed more significant severe and profound communication defects in the Saudi group while the Gilliam developmental subscale showed significantly more average scores in the Egyptian group. Both groups differed significantly such that the age of noticing abnormality was younger in the Saudi group. The age at diagnosis and at the commencement of intervention was lower in the Egyptian group. The Saudi group showed a higher percentage of missing examinations, older birth order and significantly higher preference to drug treatment, while the Egyptian group showed a high preference to behavioral and phoniatric therapies, higher paternal and maternal education, higher employment among parents and higher family concern.

CONCLUSION

Cultural context may significantly influence the age of noticing abnormality, the age of starting intervention, developmental and perinatal problems, family concerns about managing the problem as well as familial tendency for neurodevelopmental disorders, all of which have important impact on clinical symptomatology and severity of autism. Culture also influences significantly the ways of investigating and treating autism.