Autism Diagnostic Observation Schedule (ADOS) scores in males and females diagnosed with autism: a naturalistic study

A comparison of the presentations of males and females with autism spectrum disorder and those narrowly below the diagnostic threshold

LAY ABSTRACT

Most research about autism spectrum disorder (ASD) in females has looked at autistic features in people who have already received diagnoses. Because our understanding of ASD has been shaped by the difficulties of males, females may experience different difficulties and may not meet the criteria for diagnosis because of a skewed concept of ASD. We extracted detailed information from the assessment reports of 222 children who were either diagnosed with ASD (156 children) or not diagnosed despite many ASD traits (78 children). Females were less likely to have restricted interests, especially females who did not receive an ASD diagnosis. Females who did not receive an ASD diagnosis tended to show more ability in social and emotional reciprocity than what would qualify them for a diagnosis. We also found sex-/gender-specific profiles of body use and speech mannerisms. Many behaviours were more closely linked with an ASD diagnosis for males and others for females, suggesting that behaviours may be interpreted differently depending on the child's sex/gender. We discuss implications for assessing females for ASD in the context of this evidence.

Sex Differences on the ADOS-2

The sex difference in the prevalence of autism spectrum disorder (ASD) may be magnified by sex differences on diagnostic measures. The current study compared autistic males and females on items on the gold-standard diagnostic measure, the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2). In a sample of 8-to-17-year old autistic individuals from research (n = 229) and clinical settings (n = 238), females were less likely to show atypicalities on most items related to social-communication behaviors and on total and subscale scores. When controlling for overall intensity of symptomatology, no sex differences survived statistical corrections. Diagnostic criteria and/or gold-standard assessments may be less sensitive to female presentations of ASD and/or autistic females may exhibit fewer or less intense behaviors characteristic of ASD.

Binocular rivalry in autistic and socially anxious adults

Background

Social anxiousness is a pervasive symptom in both social anxiety disorder and autism spectrum conditions. Binocular rivalry, which occurs when different images are presented to each eye, has been used to explore how visual and cognitive processing differs across various clinical diagnoses. Previous studies have separately explored whether individuals with autism or anxiety experience binocular rivalry in ways that are different from neurotypical individuals.

Methods

We applied rivalry paradigms that are similar to those used in previous studies of autism and general anxiety to individuals experiencing symptoms of social anxiousness at clinical or subclinical levels. We also incorporated rivalrous stimuli featuring neutral and emotional facial valances to explore potential overlap of social processing components in social anxiety and autism.

Results

We hypothesized that higher levels of social anxiousness would increase binocular rivalry switch rates and that higher levels of autistic traits would decrease switch rates. However, stimulus condition did not affect switch rates in either diagnostic group, and switch rate was not significantly predictive of dimensional measures of either autism or social anxiety.

Discussion

This may suggest a common mechanism for atypical visual cognition styles previously associated with social anxiety and autism. Alternatively, differences in switch rates may only emerge at higher trait levels than reported by the participants in our studies. Furthermore, these findings may be influenced by sex differences in our unique sample.

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.

Gender and age differences in the presentation of at-risk or probable Developmental Coordination Disorder in adults

BACKGROUND

Developmental Coordination Disorder (DCD), also called Dyspraxia, is a common Neurodevelopmental Disorder (NDD) that affects motor coordination with a marked impact on both academic and day-to-day living activities. It is increasingly clear that NDDs such as Attention-Deficit/Hyperactivity Disorder and Autism Spectrum Disorder may present differently in males and females, resulting in underdiagnoses of women and girls.

AIMS

To consider age and gender differences in the presentation of at-risk and probable DCD.

METHODS AND PROCEDURES

A sample of 1,476 adults aged 16-60 years were surveyed online using the Adult DCD Checklist.

OUTCOMES AND RESULTS

Women with at-risk (n = 1 8 6, 1 6. 6 %) or probable DCD (n = 6 4 3, 5 6. 6 %) reported significantly greater gross motor and non-motor difficulties and significantly greater impact on activities and participation, whereas men with at-risk (n = 58,16.3 %) or probable (n = 177,49.9 %), DCD reported significantly greater fine motor difficulties. Emerging adults (aged 16-25 years) with at-risk (n = 65,14.3 %) or probable (293,64.3 %) DCD reported significantly greater non-motor difficulty than adults (aged 26-60+ years) with at-risk (n = 179,17.5 %) or probable (n = 518, 50.8 %) DCD.

CONCLUSIONS AND IMPLICATIONS

Both age and gender differences were found in the presentation of at-risk and probable DCD in adults. This may have implications for the development of future DCD assessment tools and for the training of front-line staff who may encounter individuals with DCD throughout their lives, including teachers, doctors and employers' Human Resources and Occupational Health staff.

Evaluation of sex differences in preschool children with and without autism spectrum disorder enrolled in the study to explore early development

BACKGROUND AND AIMS

Research in school-aged children, adolescents, and adults with autism spectrum disorder (ASD) has found sex-based differences in behavioral, developmental, and diagnostic outcomes. These findings have not been consistently replicated in preschool-aged children. We examined sex-based differences in a large sample of 2-5-year-old children with ASD symptoms in a multi-site community-based study.

METHODS AND PROCEDURES

Based on a comprehensive evaluation, children were classified as having ASD (n = 1480, 81.55 % male) or subthreshold ASD characteristics (n = 593, 70.15 % male). Outcomes were behavior problems, developmental abilities, performance on ASD screening and diagnostic tests, and parent-reported developmental conditions diagnosed before study enrollment.

OUTCOMES AND RESULTS

We found no statistically significant sex differences in behavioral functioning, developmental functioning, performance on an ASD screening test, and developmental conditions diagnosed before study enrollment among children with ASD or subthreshold ASD characteristics. Males in both study groups had more parent reported restricted interests and repetitive behaviors than females, but these differences were small in magnitude and not clinically meaningful.

CONCLUSIONS AND IMPLICATIONS

Preschool males and females who showed risk for ASD were more similar than different in the outcomes assessed in our study. Future research could examine sex-based differences in ASD phenotypes as children age.

Diagnostic Tools for Autism Spectrum Disorders by Gender: Analysis of Current Status and Future Lines

Studies on the prevalence of autism spectrum disorders have shown gender disproportion. In recent years, there has been an increasing interest in this investigation area. There are two main research lines; the first is focused mostly on gender-related biological reasons that could account for low ASD prevalence in women (i.e., related to some protective factors related to hormones or the immune system, among others), and the second research line studies possible diagnostic biases. In the present study, a review of the latter line of research is made based on two main objectives: (a) analysis of possible biases in diagnostic tools and (b) other nonbiological ASD prevalence explained by gender differences. As a result of our theoretical review, we found that the articles reviewed showed contradictory results and possible diagnostic biases, not only in their design but also in their assessment standards. We concluded that specific or complementary diagnostic tools and procedures differentiated by gender should be developed in order to reduce these biases.

Unique deficit in embodied simulation in autism: An fMRI study comparing autism and developmental coordination disorder

A deficit in pre‐cognitively mirroring other people's actions and experiences may be related to the social impairments observed in autism spectrum disorder (ASD). However, it is unclear whether such embodied simulation deficits are unique to ASD or instead are related to motor impairment, which is commonly comorbid with ASD. Here we aim to disentangle how, neurologically, motor impairments contribute to simulation deficits and identify unique neural signatures of ASD. We compare children with ASD (N = 30) to children with Developmental Coordination Disorder (DCD; N = 23) as well as a typically developing group (N = 33) during fMRI tasks in which children observe, imitate, and mentalize about other people's actions. Results indicate a unique neural signature in ASD: during action observation, only the ASD group shows hypoactivity in a region important for simulation (inferior frontal gyrus, pars opercularis, IFGop). However, during a motor production task (imitation), the IFGop is hypoactive for both ASD and DCD groups. For all tasks, we find correlations across groups with motor ability, even after controlling for age, IQ, and social impairment. Conversely, across groups, mentalizing ability is correlated with activity in the dorsomedial prefrontal cortex when controlling for motor ability. These findings help identify the unique neurobiological basis of ASD for aspects of social processing. Furthermore, as no previous fMRI studies correlated brain activity with motor impairment in ASD, these findings help explain prior conflicting reports in these simulation networks.

Social Communication and Structural Language of Girls With High-Functioning Autism Spectrum Disorder

Purpose The purpose of this study was to characterize social communication and structural language of school-age girls with high-functioning autism spectrum disorder (HF-ASD) compared to a matched group of girls who are typically developing (TD). Method Participants were 37 girls between 7;5 and 15;2 (years;months)-18 HF-ASD and 19 TD. Children completed the Test of Pragmatic Language-Second Edition (TOPL-2) and Clinical Evaluation of Language Fundamentals-Fifth Edition. Parents completed the Children's Communication Checklist-2 United States Edition (CCC-2) and Receptive and Expressive Communication subdomains of the Vineland Adaptive Behavior Scales-Second Edition. Results In the area of social communication, girls with HF-ASD earned significantly lower scores and were more often classified as having an impairment on the TOPL-2 and the CCC-2. However, 28% and 33% earned average scores on the TOPL-2 and the CCC-2, respectively. In the area of structural language, no significant differences were found between groups on Clinical Evaluation of Language Fundamentals-Fifth Edition indexes. In contrast, girls with HF-ASD earned significantly lower scores and were more often classified as having an impairment on the Vineland Adaptive Behavior Scales-Second Edition. Sixty-one percent and 83% scored below average on the Receptive and Expressive Communication subdomains, respectively. Conclusions It has been argued that girls with HF-ASD, when compared to boys with HF-ASD, may have advantages for social communication and structural language that mask their impairments. However, when compared to girls who are TD, girls with HF-ASD demonstrated impaired social communication and structural language. Clinicians should include and carefully examine multiple sources of information when assessing girls with HF-ASD.

Gender Differences and Similarities: Autism Symptomatology and Developmental Functioning in Young Children

A growing body of research suggests that symptoms of autism spectrum disorder (ASD) may present differently in males and females. This study examined gender differences in ASD symptoms and developmental functioning, using the Baby and Infant Screen for Children with aUtism Traits, Part 1 (BISCUIT-Part 1) and the Battelle Developmental Inventory, 2nd Edition (BDI-2), amongst children aged 17-37 months meeting ASD diagnostic criteria (n = 1317). No gender differences were found in regards to overall symptom severity or symptom domains on the BISCUIT-Part 1 when gender groups were matched by cognitive ability. Females with ASD had greater motor deficits and less communication impairment compared to their male counterparts as measured by the BDI-2. Secondary analyses examining item endorsement patterns were also conducted. Implications of the findings are discussed.

Understanding and recognising the female phenotype of autism spectrum disorder and the “camouflage” hypothesis: a systematic PRISMA review

Purpose

Females with autism spectrum disorder (ASD) may display superficial social skills which may mask their ASD symptomology impacting on the identification of the disorder – known as the “camouflage” hypothesis. Compared to males with ASD, it is increasingly recognised that females with ASD have a stronger ability to imitate behaviour which is socially acceptable, particularly those females who have higher cognitive abilities (i.e. intelligence considered to be within the normal range) (Ehlers and Gillberg, 1993). The paper aims to discuss this issue.

Design/methodology/approach

This paper will explore the literature on camouflaging or masking behaviour in females with ASD. A systematic PRISMA review was conducted.

Findings

The capacity to “camouflage” social difficulties in social situations is considered to be one of the main features of the female phenotype of ASD (e.g. Kenyon, 2014). Social imitation or camouflaging enables some level of success and coping, which results in some females never receiving a diagnosis of ASD. They typically may not exhibit any observable functional impairments. However, under the surface of the camouflage, females may experience high levels of subjective stress, anxiety and exhaustion and a need to re-charge or recuperate by withdrawing from any social interaction.

Research limitations/implications

There is relatively little understanding and knowledge of the female phenotype of ASD. This lack of understanding and knowledge impacts significantly on the ability to identify females with ASD (Laiet al., 2015; Bargielaet al., 2016), which can have a number of negative consequence (Adamouet al., 2018; National Collaborating Centre for Mental Health (UK), 2012).

Practical implications

There is a need for the development of a camouflaging measure.

Originality/value

There is a real need for further research exploring the positive and negative impact of the phenomenon of “camouflaging”, or “pretending to be normal” in females with ASD.

Autism spectrum disorders in high secure psychiatric care: a review of literature, future research and clinical directions

Purpose

The purpose of this paper is to review available literature targeting the assessment and management of individuals with an autism spectrum disorder (ASD) admitted to high secure psychiatric care (HSPC). Key areas of examination include the prevalence of ASD in HSPC, how individuals with an ASD differ from other patient groups in clinical and cognitive characteristics, the views of staff regarding patients with an ASD, an exploration of the experiences and quality of life of patients with an ASD, as well as treatment and interventions.

Design/methodology/approach

A review of the published literature.

Findings

Although individuals with an ASD comprise a relatively small proportion of the total HSPC cohort, they appear to be over represented relative to the general population prevalence. Several research projects suggest that individuals with an ASD present with difficulties and needs different to other patient groups, as well as being viewed by staff as potentially vulnerable and requiring a different care approach. Individuals with an ASD report both positive and negative aspects to life in HSPC.

Practical implications

Suggestions are made with regard to how individuals with an ASD might be better managed in HSPC. Following the spirit of various pieces of government legislation such as the Autism Act (2009) and the Equalities Act (2010) the role of a specialist ASD HSPC service is proposed.

Originality/value

This paper provides a detailed review of the research to date exploring the assessment and management of individuals with an ASD detained in HSPC. It outlines key research findings, highlights limitations with it and provides a personal perspective on future research and clinical targets.