Systematic review and meta-analysis of the association of Autism Spectrum Disorder in visually or hearing impaired children

Parental and Child Sleep: Children with Vision Impairment, Autistic Children, and Children with Comorbid Vision Impairment and Autism

BACKGROUND

Parents report associations between children's sleep disturbances and behaviors. Children with neurodevelopmental conditions (e.g., Williams Syndrome and autism) are consistently reported to experience increased sleeping problems. Sleep in children with vision impairment and children with a dual diagnosis of vision impairment and autism remains understudied.

METHODS

Our exploratory study compared sleep profiles in 52 children (aged 4-12 years) and their parents (n = 37), across four groups: children with vision impairment (VI; n = 9), autism (n = 10), comorbid vision impairment + autism (n = 6), and typically developing children (n = 27). Childhood sleep was measured using the parental report Childhood Sleep Habits Questionnaire and sleep diaries. Children's cognitive functioning was measured using digit span, semantic, and phonemic verbal fluency measures. Parental sleep was measured via the Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale.

RESULTS

Clinically disordered sleep was reported in all child groups (p ≤ 0.001), particularly children with VI + autism. Age, not sleep quality/quantity, predicted cognitive task performance in TD and autistic groups, but not in VI and VI + autism groups. The child's diagnosis affected parental sleep, particularly in children with a dual diagnosis of VI + autism.

CONCLUSIONS

All participants experienced problematic sleep to varying degrees. Those most affected were children and parents in the VI + autism group, suggesting that autism may be the main driver of sleep problems in our sample.

The prevalence of autism among children with albinism

BACKGROUND

The association between Autism spectrum disorders (ASD) and visual impairment has been mentioned in the literature. The aim of our study was to investigate the prevalence of autism among children with albinism compared to the prevalence of ASD in children with visual impairment secondary to other causes.

METHODS

Retrospective study of children with albinism from January 2015 to December 2020. A control group was created with children with early onset visual impairment of similar visual range and age, secondary to diagnosis other than albinism. Patients with associated Autism were identified in both groups.

RESULTS

Seven hundred and eight children aged 1-18 years with visual impairment were included in the study. 401 children had a diagnosis of albinism, of whom 14 were also diagnosed with ASD. In the control group, composed of 307 patients, only 3 had ASD (p: 0·03).

CONCLUSIONS

The prevalence of ASD in patients with albinism was 1 in 28, while in children with visual impairment from other causes was 1 in 102. We aim to raise awareness of the higher prevalence of autism in children diagnosed with albinism in order to reach earlier diagnosis and support.

A systematic review of the impact of childhood vision impairment on reading and literacy in education

PURPOSE

This systematic review evaluates current literature on the impact vision impairment has on reading and literacy levels within education.

METHODS

Six databases were searched with inclusion criteria of trials or studies involving children who are blind or vision impaired, and impact on academic or school performance - including reading and literacy. 1262 articles were identified, with 61 papers undergoing full screening. Quality appraisal was performed using Critical Appraisal Skills Program (CASP) and seven articles deemed eligible for inclusion.

RESULTS

Included articles achieved a quality score of over 70 % using the CASP checklists. Direct comparison of articles was not possible due to methodological differences in assessing reading and literacy levels. All seven studies investigated aspects of reading speed, with additional measures of reading performance, such as reading reserve, comprehension, and reading accuracy.

DISCUSSION

Underlying trends highlighted students with a vision impairment do not perform at same level as their normally sighted peers with respect to reading performance - in terms of speed, but not ability. Additionally, early intervention to enhance literacy skills may help improve educational outcomes. Future direction should be aimed at identifying specific obstacles to learning these students face and providing interventions to improve academic outcomes.

Diagnosis and Assessment of Autism Spectrum Disorder in South Korea

Autism spectrum disorder (ASD) is diagnosed by the clinical decision of a trained professional based on the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition or International Classification of Diseases 11th Revision diagnostic criteria. To obtain information for diagnostic formulation, professionals should explore detailed developmental history, and can use structured or semi-structured assessment tools to observe interaction between the child and parents or strangers. Diagnostic assessment should include a profile of the strength and weaknesses of the individual and should be conducted using an optimal approach by a multidisciplinary team with appropriate techniques and experience. Assessment of language, cognitive, neuropsychological, and adaptive functioning should be conducted in ASD individuals prior to establishing an individualized treatment plan. Genetic testing, brain magnetic resonance imaging or electroencephalogram testing can be considered for identification of underlying causes.

Association between Autism Spectrum Disorder (ASD) and vision problems. A systematic review and meta-analysis

AIM

To conduct a systematic review and meta-analysis assessing whether vision and/or eye disorders are associated with Autism Spectrum Disorder (ASD).

METHOD

Based on a pre-registered protocol (PROSPERO: CRD42022328485), we searched PubMed, Web of Knowledge/Science, Ovid Medline, Embase and APA PsycINFO up to 5th February 2022, with no language/type of document restrictions. We included observational studies 1) reporting at least one measure of vision in people of any age with a diagnosis of ASD based on DSM or ICD criteria, or ADOS; or 2) reporting the prevalence of ASD in people with and without vision disorders. Study quality was assessed with the Appraisal tool for Cross-Sectional Studies (AXIS). Random-effects meta-analyses were used for data synthesis.

RESULTS

We included 49 studies in the narrative synthesis and 46 studies in the meta-analyses (15,629,159 individuals distributed across multiple different measures). We found meta-analytic evidence of increased prevalence of strabismus (OR = 4.72 [95% CI: 4.60, 4.85]) in people with versus those without ASD (non-significant heterogeneity: Q = 1.0545, p = 0.7881). We also found evidence of increased accommodation deficits (Hedge's g = 0.68 [CI: 0.28, 1.08]) (non-significant heterogeneity: Q = 6.9331, p = 0.0741), reduced peripheral vision (-0.82 [CI: -1.32, -0.33]) (non-significant heterogeneity: Q = 4.8075, p = 0.4398), reduced stereoacuity (0.73 [CI: -1.14, -0.31]) (non-significant heterogeneity: Q = 0.8974, p = 0.3435), increased color discrimination difficulties (0.69 [CI: 0.27,1.10]) (non-significant heterogeneity: Q = 9.9928, p = 0.1890), reduced contrast sensitivity (0.45 [CI: -0.60, -0.30]) (non-significant heterogeneity: Q = 9.9928, p = 0.1890) and increased retinal thickness (=0.29 [CI: 0.07, 0.51]) (non-significant heterogeneity: Q = 0.8113, p = 0.9918) in ASD.

DISCUSSION

ASD is associated with some self-reported and objectively measured functional vision problems, and structural alterations of the eye, even though we observed several methodological limitations in the individual studies included in our meta-analyses. Further research should clarify the causal relationship, if any, between ASD and problems of vision during early life.

PROSPERO REGISTRATION

CRD42022328485.

Visual acuity and reading print size requirements in children with vision impairment

CLINICAL RELEVANCE

The support of students with a vision impairment throughout education could be enhanced by assessing the functional reading ability of the individual. This visual assessment could inform educators of individualised student needs and potentially improve the academic achievement for these students.

BACKGROUND

Support for children with a vision impairment within a classroom is typically based on clinical findings of distance visual acuity and visual fields. Therefore, determining optimal print size for reading is essential to ensure best academic outcomes. Secondary aims were to investigate the possible impact of underlying pathology on reading ability.

METHODS

Forty-seven participants were recruited from a state-wide support service for children with a vision impairment in South Australia. Three visual acuity groups were formed based on World Health Organisation definitions of mild, moderate, and severe vision impairment. Correlation between clinical measures of distance visual acuity using the Freiburg Visual Acuity Test, were compared with reading acuity and critical print size (smallest font before reading speed reduced) using Minnesota low vision reading chart (MNREAD).

RESULTS

No significant correlations were found for mild (0.20-0.49 logMAR) and severe (1.00-1.52 logMAR) vision impairment groups between distance visual acuity and reading acuity read (p = .64, CI [-.585, .395]/p = .82, CI [-.48, .58]) or critical print size (p = .78, CI [-.57, .45]/p = .43, CI [-.34, .68]. A significant correlation was found for the moderate vision impairment group: 0.50-0.99 logMAR for minimum reading acuity (p < .001, CI [.44, .91]) and critical print size (p = .03, CI [.05, .80]).

CONCLUSIONS

Standard clinical measures of distance visual acuity are an unpredictable estimate of reading ability in children with mild and severe vision impairment. Additional measures of functional near reading ability could provide a more meaningful indicator of reading ability and help provide optimum support to students through education.

Attention-deficit/hyperactivity disorder in children with hearing loss

OBJECTIVE

To evaluate rates of Attention-Deficit/Hyperactivity Disorder (AD/HD) diagnosis among pediatric patients with normal hearing (NH) and hearing loss (HL) with and without comorbidities.

STUDY DESIGN

Retrospective cohort study of NH and HL patients following chart review of all pediatric patients with a history of tympanostomy tube placement treated at the Cleveland Clinic Foundation between 2019 and 2022.

METHODS

Patient demographic information, hearing status (type of HL, laterality, severity), and comorbidities including prematurity, genetic syndromes, disorders with neurological impairment, and autism spectrum disorder (ASD) were collected. Rate of AD/HD amongst HL and NH cohorts with and without comorbidities were compared using Fisher's exact test. Covariate-adjusted analysis was also completed (sex, current age, age at tube placement, and OSA). The primary outcome of interest was rates of AD/HD among children with NH and HL, and the secondary outcome of interest was the impact of comorbidities on rates of AD/HD diagnosis in these cohorts.

RESULTS

Of the 919 screened patients between 2019 and 2022, there were 778 NH patients and 141 HL patients (80 bilateral, 61 unilateral). HL ranged from mild (n = 110) to moderate (n = 21) to severe/profound (n = 9). Overall, the rate of AD/HD was significantly higher in HL children (12.1% HL vs 3.6% NH, p < 0.001). Of the 919 patients, 157 had comorbidities. In children without comorbidities, HL children still had significantly higher rates of AD/HD compared to NH children (8.0% vs 1.9%, p = 0.02), but there was loss of significance after covariate adjustment (p = 0.72).

CONCLUSION

The rate of AD/HD among children with HL (12.1%) is higher than the rate of AD/HD in NH children (3.6%), consistent with previous findings. After excluding patients with comorbidities and adjusting for covariates, there are similar rates of AD/HD between HL and NH patients. Given high rates of comorbidities and AD/HD in HL patients and potential for augmented developmental challenges, clinicians should have a low threshold to refer children with HL for neurocognitive testing, particularly those with any of the comorbidities or covariates described in this study.

Associations between autistic traits and early ear and upper respiratory signs: a prospective observational study of the Avon Longitudinal Study of Parents and Children (ALSPAC) geographically defined childhood population

OBJECTIVE

To determine whether early ear and upper respiratory signs are associated with the development of high levels of autistic traits or diagnosed autism.

DESIGN

Longitudinal birth cohort: Avon Longitudinal Study of Parents and Children (ALSPAC).

SETTING

Area centred on the city of Bristol in Southwest England. Eligible pregnant women resident in the area with expected date of delivery between April 1991 and December 1992 inclusive.

PARTICIPANTS

10 000+ young children followed throughout their first 4 years. Their mothers completed three questionnaires between 18-42 months recording the frequency of nine different signs and symptoms relating to the upper respiratory system, as well as ear and hearing problems.

OUTCOME MEASURES

Primary-high levels of autism traits (social communication, coherent speech, sociability, and repetitive behaviour); secondary-diagnosed autism.

RESULTS

Early evidence of mouth breathing, snoring, pulling/poking ears, ears going red, hearing worse during a cold, and rarely listening were associated with high scores on each autism trait and with a diagnosis of autism. There was also evidence of associations of pus or sticky mucus discharge from ears, especially with autism and with poor coherent speech. Adjustment for 10 environmental characteristics made little difference to the results, and substantially more adjusted associations were at p<0.001 than expected by chance (41 observed; 0.01 expected). For example, for discharge of pus or sticky mucus from ears the adjusted odds ratio (aOR) for autism at 30 months was 3.29 (95% CI 1.85 to 5.86, p<0.001), and for impaired hearing during a cold the aOR was 2.18 (95% CI 1.43 to 3.31, p<0.001).

CONCLUSIONS

Very young children exhibiting common ear and upper respiratory signs appear to have an increased risk of a subsequent diagnosis of autism or demonstrated high levels of autism traits. Results suggest the need for identification and management of ear, nose and throat conditions in autistic children and may provide possible indicators of causal mechanisms.

Visual Autism

Autism spectrum disorder (ASD) is a lifelong neurodevelopmental disorder characterized by deficits in social communication and restricted, repetitive behaviors. It affects approximately 2.2% of children. Both genetic and environmental risk factors have been identified for ASD. Visual comorbidities are relatively common among children with ASD. Between 20 and 44% of ASD children have visually significant refractive error, on-third have strabismus, and one-fifth have amblyopia. In addition, ASD is 30 times more common in children with congenital blindness. It is unknown whether the association of ASD with visual morbidity is causal, comorbid, or contributing. Structural and functional abnormalities have been identified in MRIs of ASD children, and ASD children have been noted to have aberrant eye tracking. ASD children with visually significant refractive errors and poor spectacle compliance (present in 30% of ASD children) offer the opportunity for investigation into how improved visual acuity influences ASD behaviors. In this review, we focus on what is known of the visual system, refractive surgery, and ASD.

Auditory Pitch Perception in Autism Spectrum Disorder: A Systematic Review and Meta-Analysis

PURPOSE

Pitch plays an important role in auditory perception of music and language. This study provides a systematic review with meta-analysis to investigate whether individuals with autism spectrum disorder (ASD) have enhanced pitch processing ability and to identify the potential factors associated with processing differences between ASD and neurotypicals.

METHOD

We conducted a systematic search through six major electronic databases focusing on the studies that used nonspeech stimuli to provide a qualitative and quantitative assessment across existing studies on pitch perception in autism. We identified potential participant- and methodology-related moderators and conducted metaregression analyses using mixed-effects models.

RESULTS

On the basis of 22 studies with a total of 464 participants with ASD, we obtained a small-to-medium positive effect size (g = 0.26) in support of enhanced pitch perception in ASD. Moreover, the mean age and nonverbal IQ of participants were found to significantly moderate the between-studies heterogeneity.

CONCLUSIONS

Our study provides the first meta-analysis on auditory pitch perception in ASD and demonstrates the existence of different developmental trajectories between autistic individuals and neurotypicals. In addition to age, nonverbal ability is found to be a significant contributor to the lower level/local processing bias in ASD. We highlight the need for further investigation of pitch perception in ASD under challenging listening conditions. Future neurophysiological and brain imaging studies with a longitudinal design are also needed to better understand the underlying neural mechanisms of atypical pitch processing in ASD and to help guide auditory-based interventions for improving language and social functioning.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21614271.

Peripheral Auditory Nerve Impairment in a Mouse Model of Syndromic Autism

Dysfunction of the peripheral auditory nerve (AN) contributes to dynamic changes throughout the central auditory system, resulting in abnormal auditory processing, including hypersensitivity. Altered sound sensitivity is frequently observed in autism spectrum disorder (ASD), suggesting that AN deficits and changes in auditory information processing may contribute to ASD-associated symptoms, including social communication deficits and hyperacusis. The MEF2C transcription factor is associated with risk for several neurodevelopmental disorders, and mutations or deletions of MEF2C produce a haploinsufficiency syndrome characterized by ASD, language, and cognitive deficits. A mouse model of this syndromic ASD (Mef2c-Het) recapitulates many of the MEF2C haploinsufficiency syndrome-linked behaviors, including communication deficits. We show here that Mef2c-Het mice of both sexes exhibit functional impairment of the peripheral AN and a modest reduction in hearing sensitivity. We find that MEF2C is expressed during development in multiple AN and cochlear cell types; and in Mef2c-Het mice, we observe multiple cellular and molecular alterations associated with the AN, including abnormal myelination, neuronal degeneration, neuronal mitochondria dysfunction, and increased macrophage activation and cochlear inflammation. These results reveal the importance of MEF2C function in inner ear development and function and the engagement of immune cells and other non-neuronal cells, which suggests that microglia/macrophages and other non-neuronal cells might contribute, directly or indirectly, to AN dysfunction and ASD-related phenotypes. Finally, our study establishes a comprehensive approach for characterizing AN function at the physiological, cellular, and molecular levels in mice, which can be applied to animal models with a wide range of human auditory processing impairments.SIGNIFICANCE STATEMENT This is the first report of peripheral auditory nerve (AN) impairment in a mouse model of human MEF2C haploinsufficiency syndrome that has well-characterized ASD-related behaviors, including communication deficits, hyperactivity, repetitive behavior, and social deficits. We identify multiple underlying cellular, subcellular, and molecular abnormalities that may contribute to peripheral AN impairment. Our findings also highlight the important roles of immune cells (e.g., cochlear macrophages) and other non-neuronal elements (e.g., glial cells and cells in the stria vascularis) in auditory impairment in ASD. The methodological significance of the study is the establishment of a comprehensive approach for evaluating peripheral AN function and impact of peripheral AN deficits with minimal hearing loss.

What can a national patient registry tell us about psychiatric disorders and reasons for referral to outpatient services in youth with hearing loss?

BACKGROUND

Studies of reasons for referral to the Child and Adolescent Mental Health Services (CAMHS) and subsequent psychiatric disorders are missing in youth with Hearing loss (HL).

AIMS

To examine the referral reasons to CAMHS and the clinically diagnosed psychiatric disorders in youth with HL among the nationally representative population.

METHODS

The study population was a youth with HL referred to CAMHS and registered in the national Norwegian Patient Registry (NPR) during the years 2011-2016. The results were also compared with some data published from CAMHS for the General Youth Population (GenPop).

RESULTS

Among youth with HL, 18.1% had also been referred to CAMHS compared to about 5% in GenPop, at mean age 9.1 years, >70% before age 13 years vs. 46% in the GenPop. Boys with HL comprised 57% and were referred about two years earlier than girls with HL. Compared to the GenPop, youth with HL were referred more frequently for suspected neurodevelopmental- and disruptive disorders, and less frequently for suspected emotional disorders. Girls with HL were referred for suspected Attention-Deficit/Hyperactivity Disorder (ADHD) at about the same rate as boys with HL in the 7-12 year age group. The most frequently registered psychiatric disorders were ADHD: 29.8%, anxiety disorders: 20.4%, and autism spectrum disorders: 11.0%, while disruptive disorders constituted about 5.0%.

CONCLUSIONS

Youth with HL were referred to CAMHS more often, but earlier than the GenPop, mostly due to ADHD disorders. Although more rarely referred for suspected anxiety disorders, these were frequently diagnosed, suggesting that anxiety was not recognized at referral in youth with HL.

Considerations for the identification of autism spectrum disorder in children with vision or hearing impairment: A critical review of the literature and recommendations for practice

OBJECTIVE

There is higher risk for autism spectrum disorder (ASD) across many pediatric neurological conditions characterized by vision impairment or hearing loss. Early and accurate identification of ASD is imperative in promoting access to appropriate and early evidenced-based intervention; however, differential diagnosis can be particularly challenging in children with sensory impairment given the heterogeneity of ASD combined with the impact of vision impairment or hearing loss/deafness on development and behavior. A neuropsychologist's unique expertise and appreciation of the interplay between sensory and behavioral manifestations can be valuable for making an early and accurate ASD diagnosis in children who are blind/visually impaired or deaf/hard-of-hearing. This article highlights clinical considerations when identifying ASD within the context of vision impairment or hearing loss/deafness.

METHOD

We discuss clinical considerations for the early identification of ASD in children who are blind/visually impaired and deaf/hard-of-hearing. Information presented in the article is based on a critical review of the literature and the expertise of the author group.

CONCLUSION

Ongoing development of clinical expertise and evidence-based assessment methods are important when informing the early differential diagnosis of ASD in individuals with sensory impairment. Accurate identification is also vital for the development of targeted interventions across the lifespan.

Appraising the need for audiological assessment before autism spectrum disorder referral

Objectives

Mandatory audiological testing before autism spectrum disorder (ASD) assessment is common practice. Hearing impairment (HI) in the general paediatric population is estimated at 3%; however, hearing impairment prevalence among children with ASD is poorly established. Our objective was to determine which children referred for ASD assessment require preliminary audiological assessment.

Methods

Retrospective chart review of children (n=4,173; 0 to 19 years) referred to British Columbia's Autism Assessment Network (2010 to 2014). We analyzed HI rate, risk factors, and timing of HI diagnosis relative to ASD referral.

Results

ASD was diagnosed in 53.4%. HI rates among ASD referrals was 3.3% and not significantly higher in children with ASD (ASD+; 3.5%) versus No-ASD (3.0%). No significant differences in HI severity or type were found, but more ASD+ females (5.5%) than ASD+ males (3.1%) had HI (P<0.05). Six HI risk factors were significant (problems with intellect, language, vision/eye, ear, genetic abnormalities, and prematurity) and HI was associated with more risk factors (P<0.01). Only 12 children (8.9%) were diagnosed with HI after ASD referral; all males 6 years or younger and only one had no risk factors. ASD+ children with HI were older at ASD referral than No-ASD (P<0.05).

Conclusions

Children with ASD have similar hearing impairment rates to those without ASD. HI may delay referral for ASD assessment. As most children were diagnosed with HI before ASD referral or had at least one risk factor, we suggest that routine testing for HI among ASD referrals should only be required for children with risk factors.

Hearing Loss in Neurological Disorders

Sensorineural hearing loss (SNHL) affects approximately 466 million people worldwide, which is projected to reach 900 million by 2050. Its histological characteristics are lesions in cochlear hair cells, supporting cells, and auditory nerve endings. Neurological disorders cover a wide range of diseases affecting the nervous system, including Alzheimer's disease (AD), Parkinson's disease (PD), Huntington's disease (HD), autism spectrum disorder (ASD), etc. Many studies have revealed that neurological disorders manifest with hearing loss, in addition to typical nervous symptoms. The prevalence, manifestations, and neuropathological mechanisms underlying vary among different diseases. In this review, we discuss the relevant literature, from clinical trials to research mice models, to provide an overview of auditory dysfunctions in the most common neurological disorders, particularly those associated with hearing loss, and to explain their underlying pathological and molecular mechanisms.

Hearing impairment and diverse health outcomes : An umbrella review of meta-analyses of observational studies

BACKGROUND

Globally, it is estimated that approximately 1.3 billion people live with some form of hearing impairment. Major causes of hearing loss include infection/disease, age-related factors, and occupational factors. Numerous systematic reviews and meta-analyses have attempted to synthesise literature on these topics. To date there has not been a systematic evaluation of the relationships between hearing impairment and diverse physical, mental, and social outcomes.

OBJECTIVE

We performed an umbrella review of systematic reviews of observational studies with meta-analyses for any physical disease, biomarkers of disease, mental health or cognitive outcomes, and/or modifiable risk factors associated with hearing impairment.

METHODS

For each meta-analytic association, random effects summary effect size, 95% confidence intervals, heterogeneity, evidence for small-study effect, excess significance bias and 95% prediction intervals were calculated, and risk of bias was assessed via the AMSTAR2 tool. These were used to grade significant evidence (p < 0.05) from I to IV, using the recommendations from the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria.

RESULTS

From 3747 studies, 21 were included covering 54 outcomes. Overall, 44/54 outcomes (82%) yielded significant results. Of the highest quality evidence, age-related hearing loss and non-specific hearing impairment were negatively associated with several types of cognitive impairments; pediatric bilateral hearing loss was negatively associated with quality of life, sensorineural hearing loss was positively associated with rheumatoid arthritis and tinnitus was positively associated with temporomandibular disorders.

CONCLUSION AND RELEVANCE

Results show moderate quality evidence for associations between several types of hearing impairments and cognitive difficulties, quality of life and systemic diseases such as rheumatoid arthritis. Practitioners and public health policies should note these findings when developing relevant healthcare policies.

Mother-infant interactions with infants with congenital visual impairment and associations with longitudinal outcomes in cognition and language

BACKGROUND

This study investigated mother-infant interactions, including maternal maintaining of infant attentional focus and sensitivity, with infants with congenital severe and profound visual impairment (VI) and the association with developmental trajectories from one to three years.

METHOD

Fifty-five infants and mothers were video-recorded playing together with a standard set of toys at Time 1 (T1) mean age 12.95 months (8.13-17.05 months). Maintain was categorized as the mother following and maintaining the child's focus, and Sensitivity, the mother's responsiveness and contingency to infant behaviour. Vision level was measured using the Near Detection Scale. Cognition and language were measured at T1, 12 months later (T2) and 24 months later (T3) using the Reynell-Zinkin Scales.

RESULTS

Cross-sectional analyses showed that mothers of infants with severe VI (basic form vision) produced higher rates of Maintain compared to those with children with profound VI (light perception at best). Linear mixed-effects models examining developmental progression from T1 to T3 (controlling for vision level) showed an average increase of 5 DQ points (CI 95%: 1.03-9.08) in verbal comprehension for higher Sensitivity. No significant findings were found for Maintain.

CONCLUSIONS

The findings suggest that mother-infant interactions (maternal Maintain) are associated with level of vision at infancy, but only maternal Sensitivity has a long-term positive association with advances in verbal comprehension from infancy to about three years. They highlight the need for incorporating strategies related to parent-infant interactions, including increased sensitivity, into early intervention for children with visual impairment.

LEBER CONGENITAL AMAUROSIS DUE TO CEP290 MUTATIONS-SEVERE VISION IMPAIRMENT WITH A HIGH UNMET MEDICAL NEED: A Review

PURPOSE

Leber congenital amaurosis due to CEP290 mutations (LCA10) is an inherited retinal disease that often results in severe visual impairment or blindness in early childhood. Currently, there are no approved treatments, highlighting the considerable unmet medical need associated with LCA10. We aimed to review the clinical characteristics of LCA10, its impact on patients and society, and the investigational treatment strategies currently in development.

METHODS

Review of the current literature.

RESULTS

LCA10 is an autosomal recessive ciliopathy, for which the CEP290 intronic variant c.2991+1655A>G (p.Cys998X) is the most common mutation. Usually diagnosed in early childhood, most patients with LCA10 have severe visual impairment during their first decade of life, which significantly affects the quality of life and development. LCA10 also has a significant societal burden (direct and indirect costs). RNA editing using antisense oligonucleotides or Staphylococcus aureus CRISPR-associated protein-9 nuclease is currently under investigation for treatment of p.Cys998X LCA10. Specifically, the antisense oligonucleotide therapy QR-110 (sepofarsen) has demonstrated encouraging safety and efficacy data in a first-in-human trial; a phase 3 clinical trial is ongoing.

CONCLUSION

Interventions that can preserve or improve vision in patients with LCA10 have considerable potential to improve the patient quality of life and reduce burden of disease.

Umbrella systematic review of systematic reviews and meta-analyses on comorbid physical conditions in people with autism spectrum disorder

BACKGROUND

Comorbid physical conditions may be more common in people with autism spectrum disorder (ASD) than other people.

AIMS

To identify what is and what is not known about comorbid physical conditions in people with ASD.

METHOD

We undertook an umbrella systematic review of systematic reviews and meta-analyses on comorbid physical conditions in people with ASD. Five databases were searched. There were strict inclusion/exclusion criteria. We undertook double reviewing for eligibility, systematic data extraction and quality assessment. Prospective PROSPERO registration: CRD42015020896.

RESULTS

In total, 24 of 5552 retrieved articles were included, 15 on children, 1 on adults, and 8 both on children and adults. Although the quality of included reviews was good, most reported several limitations in the studies they included and considerable heterogeneity. Comorbid physical conditions are common, and some are more prevalent than in the general population: sleep problems, epilepsy, sensory impairments, atopy, autoimmune disorders and obesity. Asthma is not. However, there are substantial gaps in the evidence base. Fewer studies have been undertaken on other conditions and some findings are inconsistent.

CONCLUSIONS

Comorbid physical conditions occur more commonly in people with ASD, but the evidence base is slim and more research is needed. Some comorbidities compound care if clinicians are unaware, for example sensory impairments, given the communication needs of people with ASD. Others, such as obesity, can lead to an array of other conditions, disadvantages and early mortality. It is essential that potentially modifiable physical conditions are identified to ensure people with ASD achieve their best outcomes. Heightening clinicians' awareness is important to aid in assessments and differential diagnoses, and to improve healthcare.

Vision Screening among Children with Autism Spectrum Disorder

SIGNIFICANCE

Vision problems occur at higher rates in children with autism spectrum disorder (ASD) than in the general population. Some professional organizations recommend that children with neurodevelopmental disorders need comprehensive assessment by eye care professionals rather than vision screening.

METHODS

Data from the 2011 to 2012 National Survey of Children's Health (NSCH) were accessed. Logistic regression was used to evaluate differences between vision screening rates in eye care professionals' offices and other screening locations among children with and without ASD.

RESULTS

Overall, 82.21% (95% confidence interval [CI], 78.35 to 86.06%) of children with ASD were reported to have had a vision screening as defined by the NSCH criteria. Among children younger than 5 years with ASD, 8.87% (95% CI, 1.27 to 16.5%) had a vision screening at a pediatrician's office, 41.1% (95% CI, 20.54 to 61.70%) were screened at school, and 37.62% (95% CI, 9.80 to 55.45%) were examined by an eye care professionals. Among children with ASD older than 5 years, 24.84% (95% CI, 18.42 to 31.26%) were screened at school, 22.24% (95% CI, 17.26 to 27.21%) were screened at the pediatricians' office, and 50.15% (95% CI, 44.22 to 56.08%) were examined by eye care professionals. Based on estimates from NSCH, no children in the U.S. population younger than 5 years with ASD screened in a pediatrician's office were also seen by an eye care provider.

CONCLUSIONS

If the public health goal is to have all children with ASD assessed in an eye care professional's office, data from the NSCH indicate that we as a nation are falling far short of that target.

Association between MTHFR C677T/A1298C and susceptibility to autism spectrum disorders: a meta-analysis

Background

Autism spectrum disorder (ASD) is becoming increasingly prevalent of late. Methylenetetrahydrofolate reductase (MTHFR) has a significant role in folate metabolism. Owing to the inconsistencies and inconclusiveness on the association between MTHFR single nucleotide polymorphism (SNP) and ASD susceptibilities, a meta-analysis was conducted to settle the inconsistencies.

Methods

For this meta-analysis, a total of 15 manuscripts published up to January 26, 2020, were selected from PubMed, Google Scholar, Medline, WangFang, and CNKI databases using search terms “MTHFR” OR “methylenetetrahydrofolate reductase” AND “ASD” OR “Autism Spectrum Disorders” OR “Autism” AND “polymorphism” OR “susceptibility” OR “C677T” OR “A1298C”.

Results

The findings of the meta-analysis indicated that MTHFR C677T polymorphism is remarkably associated with ASD in the five genetic models, viz., allelic, dominant, recessive, heterozygote, and homozygote. However, the MTHFR A1298C polymorphism was not found to be significantly related to ASD in the five genetic models. Subgroup analyses revealed significant associations of ASD with the MTHFR (C677T and A1298C) polymorphism. Sensitivity analysis showed that this meta-analysis was stable and reliable. No publication bias was identified in the associations between MTHFRC677T polymorphisms and ASD in the five genetic models, except for the one with regard to the associations between MTHFRA1298C polymorphisms and ASD in the five genetic models.

Conclusion

This meta-analysis showed that MTHFR C677T polymorphism is a susceptibility factor for ASD, and MTHFR A1298C polymorphism is not associated with ASD susceptibility.

Autistic-Like Features in Visually Impaired Children: A Review of Literature and Directions for Future Research

There remains great interest in understanding the relationship between visual impairment (VI) and autism spectrum disorder (ASD) due to the extraordinarily high prevalence of ASD in blind and visually impaired children. The broad variability across individuals and assessment methodologies have made it difficult to understand whether autistic-like symptoms shown by some children with VI might reflect the influence of the visual deficit, or represent a primary neurodevelopmental condition that occurs independently of the VI itself. In the absence of a valid methodology adapted for the visually impaired population, diagnosis of ASD in children with VI is often based on non-objective clinical impression, with inconclusive prevalence data. In this review, we discuss the current state of knowledge and suggest directions for future research.

The development of vision between nature and nurture: clinical implications from visual neuroscience

BACKGROUND

Vision is an adaptive function and should be considered a prerequisite for neurodevelopment because it permits the organization and the comprehension of the sensory data collected by the visual system during daily life. For this reason, the influence of visual functions on neuromotor, cognitive, and emotional development has been investigated by several studies that have highlighted how visual functions can drive the organization and maturation of human behavior. Recent studies on animals and human models have indicated that visual functions mature gradually during post-natal life, and its development is closely linked to environment and experience.

DISCUSSION

The role of vision in early brain development and some of the neuroplasticity mechanisms that have been described in the presence of cerebral damage during childhood are analyzed in this review, according to a neurorehabilitation prospective.

Genes Positively Selected in Domesticated Mammals Are Significantly Dysregulated in the Blood of Individuals with Autism Spectrum Disorders

Human self-domestication (i.e., the presence of traits in our species that are commonly found in domesticated animals) has been hypothesized to have contributed to the emergence of many human-specific features, including aspects of our cognition and behavior. Signs of self-domestication have been claimed to be attenuated in individuals with autism spectrum disorders (ASD), this conceivably accounting for facets of their distinctive cognitive and behavioral profile, although this possibility needs to be properly tested. In this study, we have found that candidate genes for mammal domestication, but not for neural crest development and function, are significantly dysregulated in the blood of subjects with ASD. The set of differentially expressed genes (DEGs) is enriched in biological and molecular processes, as well as in pathological phenotypes, of relevance for the etiology of ASD, like lipid metabolism, cell apoptosis, the activity of the insulin-like growth factor, gene expression regulation, skin/hair anomalies, musculoskeletal abnormalities, and hearing impairment. Moreover, among the DEGs, there are known candidates for ASD and/or genes involved in biological processes known to be affected in ASD. Our findings give support to the view that one important aspect of the etiopathogenesis of ASD is the abnormal manifestation of features of human self-domestication.

Profiling Children With Cerebral Visual Impairment Using Multiple Methods of Assessment to Aid in Differential Diagnosis

Cerebral (cortical) visual impairment (CVI), the primary cause of visual impairment in children in high-income countries, is increasing globally due to improved life-saving measures for premature and full-term infants. Yet the consequences of this condition are only beginning to be understood and addressed. According to the topography, site, and the extent of the pathology, the deficit may variably concern central visual functions, visual field, perception of movement, visual analysis, visual exploration, attention, or visual memory, as well as visual guidance of movement. Each affected child has a unique clinical picture, which needs to be identified and individually profiled. This is probably the underlying reason that CVI is commonly underdiagnosed or misdiagnosed, especially in children, and, as a consequence, the full range of potential behavioral outcomes are not identified and adequately addressed. The present paper shows how the use of multiple methods of assessment can improve understanding of children with CVI.

Autism in Children With Cerebral and Peripheral Visual Impairment: Fact or Artifact?

The aim of this study was to evaluate the occurrence and clinical characteristics of autism spectrum disorder in visually impaired children. In total, 273 participants, 214 with cerebral causes of vision impairment and 59 with peripheral causes, were assessed using multiple assessment methods and adapted for individuals with vision loss. We found that autism spectrum disorder was more prevalent in the visually impaired compared to general population, and that the prevalence varied according to the type of visual disorder (2.8% for cerebral and 8.4% for peripheral visual impairment). In subjects with cerebral visual impairment, the presence of autistic symptoms was consistent with the diagnosis of autism spectrum disorder. In children with peripheral visual impairment, certain symptoms related to visual loss overlapped with the clinical features of autism spectrum disorder, thus making clinical diagnosis more challenging. The development of assessment tools that take into account the type and level of visual impairment and validation testing in a larger population sample are needed in order to confirm these initial findings regarding the diagnosis of autism spectrum disorder in visually impaired children.

Use of the LENA Autism Screen with Children who are Deaf or Hard of Hearing

Background and Objectives: This systematic review reports the evidence from the literature concerning the potential for using an automated vocal analysis, the Language ENvironment Analysis (LENA, LENA Research Foundation, Boulder, CO, USA) in the screening process for children at risk for autism spectrum disorder (ASD) and deaf or hard of hearing (D/HH). ASD and D/HH have increased comorbidity, but current behavioral diagnostic and screening tools have limitations. The LENA Language Autism Screen (LLAS) may offer an additional tool to disambiguate ASD from D/HH in young children. Materials and Methods: We examine empirical reports that use automatic vocal analysis methods to differentiate disordered from typically developing children. Results: Consensus across the sampled scientific literature shows support for use of automatic methods for screening and disambiguation of children with ASD and D/HH. There is some evidence of vocal differentiation between ASD, D/HH, and typically-developing children warranting use of the LLAS, but additional empirical evidence is needed to better understand the strengths and weaknesses of the tool. Conclusions: The findings reported here warrant further, more substantive, methodologically-sound research that is fully powered to show a reliable difference. Findings may be useful for both clinicians and researchers in better identification and understanding of communication disorders.

Effect size of search superiority in autism spectrum disorder

This review of the literature in visual search superiority in autism was intended to quantify the effect size of visual search performance in autism. Not all studies have found an advantage within the autistic population. Early findings on search superiority have led to different proposed mechanisms for the observed results. A review of feature search found that the effect size was low across 15 included studies (Cohen's d 0.089 [-0.150 to 0.293]). However, the effect size was larger for more complex search paradigms using a conjunctive search strategy with Cohen's d showing a moderate effect of 0.223 (0.087 to 0.293). The majority of studies were limited to a small sample size and biased toward the high-functioning end of the autistic spectrum. The overall results indicate that within the autism spectrum disorder population there is a low to moderate search advantage compared to typically developing individuals.

Environmental risk factors and biomarkers for autism spectrum disorder: an umbrella review of the evidence

BACKGROUND

Numerous studies have identified potential risk factors and biomarkers for autism spectrum disorder. We aimed to study the strength and validity of the suggested environmental risk factors or biomarkers of autism spectrum disorder.

METHODS

We did an umbrella review and systematically appraised the relevant meta-analyses of observational studies. We searched PubMed, Embase, and the Cochrane Database of Systematic Reviews for papers published between database inception and Oct 17, 2018, and screened the reference list of relevant articles. We obtained the summary effect, 95% CI, heterogeneity, and 95% prediction intervals. We examined small study effects and excess significance. We did analyses under credibility ceilings. This review is registered with PROSPERO, number CRD42018091704.

FINDINGS

46 eligible articles yielded data on 67 environmental risk factors (544 212 cases, 81 708 787 individuals) and 52 biomarkers (15 614 cases, 15 433 controls). Evidence of association was convincing for maternal age of 35 years or over (relative risk [RR] 1·31, 95% CI 1·18-1·45), maternal chronic hypertension (odds ratio [OR] 1·48, 1·29-1·70), maternal gestational hypertension (OR 1·37, 1·21-1·54), maternal overweight before or during pregnancy (RR 1·28, 1·19-1·36), pre-eclampsia (RR 1·32, 1·20-1·45), prepregnancy maternal antidepressant use (RR 1·48, 1·29-1·71), and maternal selective serotonin reuptake inhibitor (SSRI) use during pregnancy (OR 1·84, 1·60-2·11). Only two associations, maternal overweight before or during pregnancy and SSRI use during pregnancy, retained their high level of evidence under subset sensitivity analyses. Evidence from biomarkers was scarce, being supported by p values close to the significance threshold and too few cases.

INTERPRETATION

Convincing evidence suggests that maternal factors, such as age and features of metabolic syndrome, are associated with risk of autism spectrum disorder. Although SSRI use during pregnancy was also associated with such risk when exposed and non-exposed groups were compared, this association could be affected by other confounding factors, considering that prepregnancy maternal antidepressant use was also convincingly associated with higher risk of autism spectrum disorder. Findings from previous studies suggest that one possible confounding factor is underlying maternal psychiatric disorders.

FUNDING

None.

Updated View on the Relation of the Pineal Gland to Autism Spectrum Disorders

Identification of the biological features of autism is essential for designing an efficient treatment and for prevention of the disorder. Though the subject of extensive research, the neurophysiological features of autism remain unclear. One of the proposed biological causes of autism is malfunction of the pineal gland and deficiency of its principal hormone, melatonin. The main function of melatonin is to link and synchronize the body's homeostasis processes to the circadian and seasonal rhythms, and to regulate the sleep-wake cycle. Therefore, pineal dysfunction has been implicated based on the common observation of low melatonin levels and sleep disorders associated with autism. In this perspective, we highlight several recent findings that support the hypothesis of pineal gland/melatonin involvement in autism. Another common symptom of autism is abnormal neuroplasticity, such as cortical overgrowth and dendritic spine dysgenesis. Here, we synthesize recent information and speculate on the possibility that this abnormal neuroplasticity is caused by hyperactivity of endogenous N,N-dimethyltryptamine (DMT). The pineal gland was proposed as the source of DMT in the brain and therefore, our assumption is that besides melatonin deficiency, pineal dysfunction might also play a part in the development of autism through abnormal metabolism of DMT. We hope that this manuscript will encourage future research of the DMT hypothesis and reexamination of several observations that were previously attributed to other factors, to see if they could be related to pineal gland/melatonin malfunction. Such research could contribute to the development of autism treatment by exogenous melatonin and monitored light exposure.

Alteration of gut microbiota-associated epitopes in children with autism spectrum disorders

BACKGROUND

Autism spectrum disorder (ASD) affects 1% of children and has no cure. Gastrointestinal (GI) problems are common in children with ASD, and although gut microbiota is known to play an important role in ASD through the gut-brain axis, the specific mechanism is unknown. Recent evidence suggests that gut microbiota may participate in the pathogenesis of ASD through immune- and inflammation-mediated pathways. Here, we identified potentially immunogenic epitopes derived from gut microbiota in stool samples from ASD children with and without GI problems and typically developing (TD) children.

METHODS

Candidate gut microbiota-associated epitopes (MEs) were identified by blast shotgun metagenomic sequencing of fecal samples from 43 ASD children (19 with and 24 without GI involvement) and 31 sex- and age-matched typically developing (TD) children. Potentially immunogenic epitopes were screened against a predictive human Immune Epitope Database. The composition and abundance of candidate MEs were compared between the three groups of children.

RESULTS

MEs identified in ASD children with GI problems were significantly more diverse than those in TD children. ME composition could discriminate between the three groups of children. We identified 34 MEs that were significantly more or less abundant in ASD children than TD children, most (29/34) of the differences in MEs were reduced in ASD and associated with abnormal gut IgA level and altered gut microbiota composition, these MEs were limited effected by clinical factors such as age, gender, and GI problems, of which eleven MEs were pathogenic microorganisms peptides with strong T or B cell response, nine MEs showed high homology to peptides from human self proteins associated with autoimmune disease occurrence, eliciting immune attack against hematopoietic stem cells and inhibition antigen binding. We also found that the abundance of five MEs were increased in ASD, including three human self proteins, gap junction alpha-1 (GJA1), paired box protein Pax-3 (PAX3) and eyes absent homolog 1 isoform 4 (EYA1) which associated with cancer, and a ME with homology to a Listeriolysin O peptide from the pathogenic bacterium Listeria monocytogenes was significantly increased in ASD children compared with TD children.

CONCLUSIONS

Our findings demonstrate the abnormal of MEs composition in the gut of children with ASD, moreover, the abnormality in MEs composition was associated with abnormal gut IgA levels and altered gut microbiota composition, this abnormality also suggests that there may be abnormalities in intestinal immunity in children with ASD; In all, thirty-four MEs identified were potential biomarker of ASD, and alterations in MEs may contribute to abnormalities in gut immunity and/or homeostasis in ASD children. Further study of the MEs identified here may advance our understanding of the pathogenesis of ASD.

Development of Infants With Congenital Zika Syndrome: What Do We Know and What Can We Expect?

The association between Zika virus infection during pregnancy and severe birth defects in infants has led to worldwide attention focused on the mechanisms of the disease and the prevention of future exposure. Surveillance efforts around the world continue with the goal of identifying and monitoring all potentially exposed women and their newborns. For infants who were born with congenital Zika syndrome (CZS) and their families, an uncertain future awaits. As infants who were born with CZS during the most recent outbreak enter their second year of life, new developments in the outcomes of the condition continue to unfold, providing some insight into the likely long-term sequalae. In this article, I review the literature on emerging findings regarding the impact of CZS on the developing infant and provide some predictions regarding the long-term outcomes and lifetime needs of these children and their families.

Vision in children with autism spectrum disorder: a critical review

Autism spectrum disorder (ASD) is a common neurodevelopmental condition with approximately 1-2 per cent prevalence in the population. The condition has lifelong effects for the individual and family, and early intervention and management helps maximise quality of life and outcomes. Many studies of vision in ASD have attempted to link the behavioural and sensory deficits in ASD with underlying visual processing. From this work, it is clear that individuals with ASD 'see' and process the world differently, but there remain gaps in our understanding. This review will summarise our current knowledge of key aspects of visual functions and the optometric profile of ASD. This includes findings regarding visual acuity and contrast sensitivity, refractive error, eye movements, binocular vision, near visual functions and retinal structure in ASD. From this, a pattern of knowledge emerges for children with ASD: we should expect normal visual acuity; there will likely be atypical eye movements and susceptibility for subtle visuo-motor deficits, there is an increased prevalence of strabismus; an increased likelihood of astigmatism and possibly other refractive errors; attention, crowding and task complexity will likely be problematic; and retinal structure and function may be compromised. Bringing this together, these findings highlight that further work is necessary, not only to understand how higher-level functions link to behaviours, but also to ensure there is a sound understanding of the building-blocks of vision to fully grasp the profile of visual processing as a whole in ASD. This review will give a translational viewpoint for clinicians, and underline the benefits of comprehensive vision care in ASD.