Trajectories of emotional and behavioral problems from childhood to early adult life

Health service utilization among autistic youth in Aotearoa New Zealand: A nationwide cross-sectional study

Many autistic youth have complex healthcare needs, resulting in high rates of health service utilization. However, many characteristics of this health service utilization remain unknown. Using whole-of-population data, this study aimed to quantify and compare rates of psychiatric and non-psychiatric health service utilization among autistic and non-autistic youth, with and without co-occurring intellectual disability. A national retrospective cohort study was employed using linked individual-level administrative data for Aotearoa New Zealand youth (aged 0-24 years). Health service utilization outcomes included 11 psychiatric and non-psychiatric domains. Propensity score matching on a range of sociodemographic measures compared groups across health service utilization outcomes. Data were obtained for 19,479 autistic youth, 29% of whom had a co-occurring intellectual disability and 1,561,278 non-autistic youth. Results demonstrated higher rates of mental health service utilization among autistic compared with non-autistic youth, including inpatient (prevalence ratio 5.85; 95% confidence interval 4.93-6.94) and outpatient (prevalence ratio 4.96; 95% confidence interval 4.75-5.18) service use and psychotropic medication dispensing (prevalence ratio 6.83; 95% confidence interval 6.65-7.02), particularly among autistic youth without intellectual disability. Rates of non-psychiatric hospital admissions (prevalence ratio 1.93; 95% confidence interval 1.85-2.01), potentially avoidable hospitalizations (prevalence ratio 1.91; 95% confidence interval 1.82-2.00) and outpatient visits (prevalence ratio 1.99; 95% confidence interval 1.95-2.01) were also higher among autistic youth. Research implications for delivery of healthcare services are discussed.Lay abstractAutistic youth generally use healthcare services more often than non-autistic youth. However, we know very little about the factors that can affect health service use and the types of services that are used, and this has not been explored in Aotearoa New Zealand. We analysed data from New Zealand to compare health service use among autistic and non-autistic youth (0 to 24-year-olds). Data were available for 19,479 autistic youth and 1,561,278 non-autistic youth. We compared hospitalizations, specialist visits, emergency department visits and use of different types of medications. In this study, autistic youth were found to have been hospitalized for medical and mental health reasons, more often than non-autistic youth. Autistic youth were also more likely to have attended specialist appointments and to have been given medication. These differences were particularly large for medications commonly used for mental health conditions (e.g. anxiety, depression, attention deficit hyperactivity disorder) or associated symptoms. Autistic youth who also had an intellectual disability were more likely to use healthcare services for physical health conditions, but were less likely to use mental health services, when compared with autistic youth who did not have an intellectual disability. These findings, along with other research, suggest that the healthcare needs of autistic youth are not always being met. Further work is needed to enhance our understanding of co-occurring conditions among autistic youth, including those that result in high rates of health service use, in order to inform the development of healthcare services and training for healthcare professionals to better cater to the needs of autistic youth.

Study protocol for a randomized controlled trial of Regulating Together (RT), a group therapy for emotion dysregulation in school-age autistic youth and their caregivers

BACKGROUND

Emotion dysregulation is a common concern in autistic youth. Growing evidence suggests emotion dysregulation underlies multiple co-occurring issues in autism, including externalizing (e.g., aggression, irritability) and internalizing (e.g., anxiety, depression) disorders, and thus may serve as a key transdiagnostic treatment target. Emotion dysregulation during middle childhood (8-12 years) is concurrently and longitudinally associated with social difficulties and poorer quality of life for autistic individuals, highlighting a key window for intervention. There is an urgent need for treatments for emotion dysregulation in school-age autistic youth that involve caregivers to maximize skill generalization. To address this need, our group developed Regulating Together, an intensive outpatient group program targeting emotion dysregulation in 8- to 12-year-old autistic youth that integrates strategies from cognitive behavioral therapy, mindfulness and acceptance-based therapies, and parent training programs. Building on our previous non-randomized trials of Regulating Together, we document the study protocol for our first, and ongoing, randomized controlled trial comparing Regulating Together to an active control condition.

METHODS

This is a five-year randomized controlled trial comparing Regulating Together to Achieving Independence and Mastery in School (AIMS), an active control condition targeting executive functioning difficulties, in an outpatient hospital setting. Enrollment is ongoing and the study is expected to be completed in late Fall of 2026. Participants will be 144 autistic youth (8-12 years; IQ ≥ 65) randomized to either 5-week treatment condition. A comprehensive assessment battery integrating self-, caregiver-, and clinician-report information, functional outcomes (i.e., number of psychiatric hospitalizations), objective outcomes (probabilistic reversal learning task), and biobehavioral measures (heart rate variability) will be collected and compared between baseline (Week 0), post-treatment (Week 7), post-generalization (Week 16), and at long-term follow-up (Week 29).

DISCUSSION

This is the first comparison of the Regulating Together program to an active treatment condition. Findings from this study will build on previous piloted iterations of Regulating Together by characterizing its efficacy in relation to active treatment, testing moderators of treatment response, and identifying barriers and facilitators to treatment access, impact, and sustainability. Following completion of this study, we will pursue implementation studies (e.g., testing program implementation and effectiveness in community settings). Dissemination and external provider training efforts are ongoing.

TRIAL REGISTRATION

Trial registration took place through ClinicalTrials.gov (NCT05803369) on March 14th, 2023.

Effects of early-life antibiotic use on emotional and behavioral development trajectories in preschool children

BACKGROUND

Limited research exists on the link between antibiotic use and emotion and behavior, particularly the lack of continuous emotional and behavioral assessment. Emotions and behaviors reflect key modifiable dimensions of brain function and evolve during childhood growth and development. This paper aimed to examine the antibiotic use (yes/no), categories and duration in association with preschool children's emotional and behavioral development trajectory.

METHODS

Based on Ma'anshan-Anhui Birth Cohort, 1147 mother-child pairs were included in the study. Parents or guardians reported the children's antibiotic use before age 3, including whether antibiotics were used and the types and duration of antibiotics use. The trajectories of children's emotional and behavioral development were fitted using scores from the Strengths and Difficulties Questionnaire (SDQ) at 48, 60, and 72 months.

RESULTS

A total of 23.3 % (268/1147) of children had used antibiotics in the past three months. Children's antibiotic use significantly related with high level of hyperactivity. The use of β-lactam antibiotics, especially non-penicillin, was associated with the risk of high level hyperactivity at a dose-response pattern in duration. Children's combined use of β-lactam and macrolides was related with increased risk of high level hyperactivity, total difficulties and emotional symptoms.

CONCLUSIONS

Children's antibiotic use before age 3 is observed to be associated with hyperactivity development, especially using β-lactam antibiotics with a relatively long duration. The combined use of β-lactam and macrolides may increase the development of hyperactivity, total difficulties and emotional symptoms.

Expanding Research on Contextual Factors in Autism Research: What Took Us So Long?

Although autism is a childhood-onset neurodevelopmental disorder, its features change across the life course due to a combination of individual and contextual influences. However, the influence of contextual factors on development during childhood and beyond is less frequently studied than individual factors such as genetic variants that increase autism risk, IQ, language, and autistic features. Potentially important contexts include the family environment and socioeconomic status, social networks, school, work, services, neighborhood characteristics, environmental events, and sociocultural factors. Here, we articulate the benefit of studying contextual factors, and we offer selected examples of published longitudinal autism studies that have focused on how individuals develop within context. Expanding the autism research agenda to include the broader context in which autism emerges and changes across the life course can enhance understanding of how contexts influence the heterogeneity of autism, support strengths and resilience, or amplify disabilities. We describe challenges and opportunities for future research on contextual influences and provide a list of digital resources that can be integrated into autism data sets. It is important to conceptualize contextual influences on autism development as main exposures, not only as descriptive variables or factors needing statistical control.

Characteristics of geographic environments that support the health and wellbeing of young people with disability: A scoping review

PURPOSE

We aimed to: 1) identify key characteristics of geographic environments relating to the health and wellbeing of young people with disability that have been published in the literature, and 2) determine the coverage of evidence examining these characteristics and current gaps in knowledge of the ways geographic environments support health and wellbeing outcomes for young people with disability.

METHODS

This scoping review followed Arksey and O'Malley's methodological framework and established reporting guidelines (PRISMA-ScR Checklist). We searched the following databases: Web of Science (Core Collection), PubMed (Medline), Scopus, Proquest Central.

RESULTS

We identified 35 studies meeting inclusion criteria, which were mostly from high-income, English-speaking countries. Studies were grouped into ten major themes, which broadly align with place-based social determinants of health (e.g., access to transport, neighbourhood built environments). The largest body of evidence coalesced around neighbourhood social cohesion and related concepts. Notable gaps included a lack of evidence from the Global South, and limited investigation of local employment availability, access to healthcare, leisure and recreation, neighbourhood safety, and transitions into independent living.

CONCLUSIONS

This scoping review characterised the existing evidence around the key characteristics of geographic environments that support (or hinder) the health and wellbeing of young people with disability, and identified several important gaps and opportunities for future research. This includes developing a better understanding of the place-based experiences, geographic scales, and environmental exposures that are most relevant for young people with disability, including through participatory methods (e.g., participatory mapping).

Measurement issues in longitudinal studies of mental health problems in children with neurodevelopmental disorders

PURPOSE

To develop and test an approach for assessing the risk of bias in four measurement-related domains key to the study of mental health problem trajectories in children with neurodevelopmental disorders (NDD): (1) conceptual overlap between mental health problems and NDD diagnostic criteria, (2) over-reliance on a single informant, (3) unwarranted omission of the child's perspective, and (4) the use of instruments not designed for or adapted to the population.

METHODS

Building upon a previous systematic review, this study established supplementary criteria for assessing the risk of bias domains. Following this, the criteria were applied to measures used in 49 longitudinal studies of mental health problems in children with NDD.

RESULTS

The general risk of bias across domains was rated as high in 57.1% of the 49 included studies. The highest risk of bias was seen in domain four (rated as high in 87.8% of studies) and the lowest in domain three (24.5%).

CONCLUSIONS

The risk of bias items enhance our understanding of the quality of the evidence about mental health problem trajectories in children with NDD. The methodological quality of future research can be increased by selecting conceptually clear scales developed for the population - preferably in the form of cognitively accessible self-report scales - and adopting a multi-informant approach.

Trajectories of positive affect in autistic individuals during the transition to adulthood

LAY ABSTRACT

Recent research has revealed informative patterns about health, mental health, self-help skills, autism symptoms, and social skills during the transition to adulthood for autistic individuals. This study expands on these findings by examining how positive affect (e.g. excited) changes from age 15 to 30 years using a group of individuals first referred for autism at an early age. We also examined the agreement between caregiver-report and self-report on positive affect. We found different patterns of stability and change in positive affect across the transition to adulthood that related to differences in autism severity, cognitive abilities, self-help skills, as well as social and work participation in adulthood. The agreement between caregiver-report and self-report was strong in adolescence but became much weaker after the individuals were 23 years. These results have implications for how we measure happiness, positive emotions, or other internal experiences of autistic individuals.

Childhood risk factors and clinical and service outcomes in adulthood in people with intellectual disabilities

BACKGROUND

Adults with intellectual disability experience increased rates of mental health disorders and adverse mental health outcomes.

AIM

Explore childhood risk factors associated with adverse mental health outcomes during adulthood as defined by high cost of care, use of psychotropic medication without a severe mental illness and psychiatric hospital admissions.

METHOD

Data on 137 adults with intellectual disability were collected through an intellectual disability community service in an inner London borough. Childhood modifiable and non-modifiable risk factors were extracted from records to map onto variables identified as potential risk factors. Logistic and linear regression models were employed to analyse their associations with adverse outcomes.

RESULTS

We showed that the co-occurrence of intellectual disability with autism spectrum disorder and/or attention-deficit hyperactivity disorder (ADHD) were associated with psychotropic medication use and high-cost care packages. However, when challenging behaviour during childhood was added, ADHD and autism spectrum disorder were no longer significant and challenging behaviour better explained medication prescribing and higher cost care. In addition, the severity of intellectual disability was associated with higher cost care packages. Ethnicity (Black and mixed) also predicted higher cost of care.

CONCLUSIONS

Challenging behaviour during childhood emerged as a critical variable affecting outcomes in young adulthood and mediated the association between adult adverse mental health outcomes and co-occurring neurodevelopmental conditions, that is, ADHD and autism. These findings emphasise the need for effective early intervention strategies to address challenging behaviour during childhood. Such interventions for challenging behaviour will need to take into consideration autism and ADHD.

Autistic Characteristics, Cognitive Impairment, and Sex as Predictors of Anxiety and Depression among Autistic Youth

Although it is well established that autistic youth are at high risk for anxiety and depression, factors associated with heightened risk within this population are poorly understood. The purpose of this study was to evaluate whether autistic characteristics and cognitive impairment interact to predict anxiety and depression symptoms, and whether the impacts of autistic characteristics and cognitive impairment on anxiety and depression differ for male and female children. Participants comprised 7989 youth (M = 11.23 years) enrolled in SPARK, a national cohort of autistic individuals. Autistic characteristics were assessed via the Social Communication Questionnaire. Anxiety and depression were assessed via the Child Behavior Checklist. Linear regressions were conducted to examine associations between autistic characteristics, cognitive impairment, and symptoms and to test for interactions. The effect of parent-reported autistic characteristics on anxiety was stronger for males than for females, while the effect of cognitive impairment on anxiety was stronger for females than for males. A different pattern was observed for depression. The effect of autistic characteristics on depression was the same for males and females, while cognitive impairment was not associated with depression per parent report. Findings indicate that both male and female children with high levels of autistic characteristics are susceptible to experiencing anxiety and depression, and that autistic female children with intact cognitive abilities are uniquely vulnerable to experiencing anxiety based on parent report. Results have implications for the prevention of internalizing problems in autistic youth, and highlight future directions for longitudinal work examining mechanisms of comorbidity.

The effects of two types of neighborhood factors on trajectory of internalizing and externalizing symptoms from early childhood to adolescence

Although a robust body of previous empirical studies investigated the long-term trend of child behavior problems, limited research discussed the influences of various types of neighborhood factors on such trajectory (e.g., neighborhood structural characteristics and collective efficacy). Using a nationally representative longitudinal dataset the Fragile Families and Child Wellbeing Study (FFCWS), with six waves from 1998 to 2017, this study captures the longitudinal effects of two types of early childhood neighborhood factors on the co-development of internalizing and externalizing symptoms. Data was collected at the focal child's age 3, age 5, age 9, age 15 (N = 2,385), and the parallel-process growth curve models were applied. Results suggest that the trajectories of both internalization and externalizing symptoms showed U-shape and bidirectional relationships among internalizing and externalizing problems. The long-term effects of neighborhood social cohesion and economic disadvantages were significantly associated with children's internalizing and externalizing symptoms. The implication of this study was further discussed.

Trajectory research in children with an autism diagnosis: A scoping review

LAY ABSTRACT

The types of outcomes studied in children on the autism spectrum include clinical characteristics, such as social functioning, communication, language, or autism symptoms. Research that measures these outcomes at multiple timepoints is useful to improve our understanding of what to expect as children develop. In trajectory studies, researchers assess outcomes at three or more timepoints. This method has advantages over two-timepoint studies because it allows researchers to describe changes in the speed of development, such as accelerations, plateaus, or slowdowns. We identified and reviewed 103 published trajectory studies in children (to age 18 years) with an autism diagnosis. Importantly, we did not include studies of treatments or their effects, nor did we summarize the results of studies. Instead, this review summarizes the characteristics of the available published research, including the methods used, the many different outcomes that have been studied over time and the ages over which they have been studied. This summary may be of interest to autistic people and caregivers (parents) who want to know about the existence of research that provides answers about what to expect during an autistic child's development. We have recommended that future trajectory research efforts try to make up for the lack of studies from low- and middle-income countries; that more attention is given to the following outcomes that are meaningful to caregivers and autistic people; and to try to fill in the age gaps where more outcome-specific data are needed.

Parental Expressed Emotion and Behavioural Outcomes in Autistic Children and Adolescents: A Systematic Review

Growing interest in the links between parent-child relationships and child behavioural presentations in families of autistic children has led to an increased use of the Five Minute Speech Sample (FMSS) measure of parental expressed emotion (EE) in autism research. This review focuses on studies exploring the relationships between parental EE and behavioural outcomes in autistic children. Electronic searches of six databases and grey literature wielded eight studies that met eligibility criteria. Study designs were a mixture of cross-sectional and longitudinal and quality of studies was variable. Parental criticism was largely positively related to, and showed some predictive value for, child behaviour problems. Warmth was mostly negatively related to, and showed some predictive value for, child behaviour problems. Preliminary evidence from one study showed paternal warmth to be significantly related to child behaviours, whilst child behaviours were also significantly related to paternal warmth, suggesting a bidirectional relationship. Analysis of additional EE components produced variable results, however parental stress and depressive symptoms were consistently related to child behaviour, and preliminary evidence suggests a possible role of maternal education level and family cohesion. Outcomes were variable across FMSS coding systems and greater consistency in their application is needed in future research. The current findings suggest that parental EE has an important relationship with child behaviour and future intervention efforts may benefit from aiming to reduced EE in order to improve child outcomes.

A longitudinal comparison of emotional, behavioral and attention problems in autistic and typically developing children

BACKGROUND

Mental health problems are elevated in autistic individuals but there is limited evidence on the developmental course of problems across childhood. We compare the level and growth of anxious-depressed, behavioral and attention problems in an autistic and typically developing (TD) cohort.

METHODS

Latent growth curve models were applied to repeated parent-report Child Behavior Checklist data from age 2-10 years in an inception cohort of autistic children (Pathways, N = 397; 84% boys) and a general population TD cohort (Wirral Child Health and Development Study; WCHADS; N = 884, 49% boys). Percentile plots were generated to quantify the differences between autistic and TD children.

RESULTS

Autistic children showed elevated levels of mental health problems, but this was substantially reduced by accounting for IQ and sex differences between the autistic and TD samples. There was small differences in growth patterns; anxious-depressed problems were particularly elevated at preschool and attention problems at late childhood. Higher family income predicted lower base-level on all three dimensions, but steeper increase of anxious-depressed problems. Higher IQ predicted lower level of attention problems and faster decline over childhood. Female sex predicted higher level of anxious-depressed and faster decline in behavioral problems. Social-affect autism symptom severity predicted elevated level of attention problems. Autistic girls' problems were particularly elevated relative to their same-sex non-autistic peers.

CONCLUSIONS

Autistic children, and especially girls, show elevated mental health problems compared to TD children and there are some differences in predictors. Assessment of mental health should be integrated into clinical practice for autistic children.

Autism through midlife: trajectories of symptoms, behavioral functioning, and health

BACKGROUND

This study describes change in autism symptoms, behavioral functioning, and health measured prospectively over 22 years. Most studies tracking developmental trajectories have focused on autism during childhood, although adulthood is the longest stage of the life course. A robust understanding of how autistic people change through midlife and into older age has yet to be obtained.

METHODS

Using an accelerated longitudinal design with 9 waves of data, developmental trajectories were estimated from adolescence through midlife and into early old age in a community-based cohort (n = 406). The overall aim was to determine whether there were age-related increases or decreases, whether the change was linear or curvilinear, and whether these trajectories differed between those who have ID and those who have average or above-average intellectual functioning. Subsequently, the slopes of the trajectories were evaluated to determine if they differed depending on age when the study began, with the goal of identifying possible cohort effects.

RESULTS

There were significant trajectories of age-related change for all but one of the measures, although different measures manifested different patterns. Most autism symptoms improved through adulthood, while health worsened. An inverted U-shaped curve best described change for repetitive behavior symptoms, activities of daily living, maladaptive behaviors, and social interaction. For these measures, improved functioning was evident from adolescence until midlife. Then change leveled off, with worsening functioning from later midlife into early older age. Additionally, differences between autistic individuals with and without ID were evident. Although those who have ID had poorer levels of functioning, there were some indications that those without ID had accelerating challenges in their aging years that were not evident in those with ID - increases in medications for physical health problems and worsening repetitive behaviors.

CONCLUSIONS

Meeting the needs of the increasingly large population of autistic adults in midlife and old age requires a nuanced understanding of life course trajectories across the long stretch of adulthood and across multiple domains. Given the heterogeneity of autism, it will be important not to generalize across sub-groups, for example those who are minimally verbal and those who have above-average intellectual functioning.

Psychiatric conditions in autistic adolescents: longitudinal stability from childhood and associated risk factors

Autistic people experience high rates of co-occurring psychiatric diagnoses. Current prevalence estimates vary considerably due to an over-reliance on clinical cohorts and the longitudinal stability of diagnoses from childhood into adolescence is poorly understood. This study aims to provide prevalence rates of co-occurring DSM-5 psychiatric diagnosis for autistic adolescence and investigate, for the first time, the stability of diagnoses from childhood. Using a longitudinal stratified sample of autistic youth (N = 77; 13-17 years; 60% male), selected from a larger community-derived sample of those with pre-existing autism diagnoses (N = 277) weighted prevalence estimates of emotional (anxiety, depression), behavioural (oppositional and conduct disorders) and ADHD diagnoses were calculated based on semi-structured psychiatric interview. Prediction of adolescent psychiatric diagnosis based on childhood diagnostic status, sex, childhood IQ (both assessed at age 4-10 years) was tested. Emotional and behavioural disorders in adolescence were particularly prevalent, and significantly predicted by childhood disorder status. Attention-deficit/hyperactivity-disorder (ADHD) was prevalent but not predicted by childhood ADHD diagnosis. Neither sex nor childhood IQ predicted diagnostic outcomes. Autistic youth have high levels of co-occurring psychiatric conditions, which are broadly persistent across childhood and adolescence. Emotional disorders are particularly prevalent and remain persistent from childhood to adolescence. Greater diagnostic variability was found for ADHD with more adolescents moving across diagnostic thresholds.

Mental health challenges faced by autistic people

Mental health challenges impede the well-being of autistic people. This Review outlines contributing neurodevelopmental and physical health conditions, rates and developmental trajectories of mental health challenges experienced by autistic people, as well as unique clinical presentations. A framework is proposed to consider four contributing themes to aid personalized formulation: social-contextual determinants, adverse life experiences, autistic cognitive features, and shared genetic and early environmental predispositions. Current evidence-based and clinical-knowledge-informed intervention guidance and ongoing development of support are highlighted for specific mental health areas. Tailored mental health support for autistic people should be neurodivergence-informed, which is fundamentally humanistic and compatible with the prevailing bio-psycho-social frameworks. The personalized formulation should be holistic, considering physical health and transdiagnostic neurodevelopmental factors, intellectual and communication abilities, and contextual-experiential determinants and their interplay with autistic cognition and biology, alongside resilience. Supporting family well-being is integral. Mutual empathic understanding is fundamental to creating societies in which people across neurotypes are all empowered to thrive.

Aggression Is Associated With Social Adaptive Functioning in Children With ASD and Anxiety

Social adaptive functioning is notably compromised and may be further impaired by aggressive behavior in children with autism spectrum disorder (ASD). This study examined the association between aggressive behavior and social adaptive skills in children with ASD and the contribution of aggressive behavior to social adaptive skills in a combined sample of children with and without ASD. Participants consisted of children, ages 8 to 15 years, with ASD (n = 52) and who were typically developing (n = 29). Results indicate that aggressive behavior is negatively associated with social adaptive skills in children with ASD and that it contributes to reduced social adaptive functioning above and beyond ASD diagnosis. Findings underscore the importance of considering the role of aggressive behavior when evaluating and promoting social functioning in children with ASD.

Regulating Together: Emotion Dysregulation Group Treatment for ASD Youth and Their Caregivers

Individuals with autism spectrum disorder (ASD) experience behavioral and emotional symptoms hypothesized to arise from emotion dysregulation (ED), difficulty modulating emotional experience, expression, and intensity in an acceptable and contextually appropriate manner. We developed Regulating Together (RT)-an intensive-outpatient, caregiver-assisted group program to meet the ASD + ED intervention critical need. A within-subjects trial was conducted (5-week-control lead-in period, 5-week-treatment, and 5-and 10-weeks-post-treatment follow-ups). Forty-four youth with ASD + ED (25 8-12, 19 13-18 yr-olds, 88% male, mean FSIQ of 96) participated. Improvements were found in reactivity, emotion regulation knowledge, and flexibility post-treatment and 10-weeks post-treatment. A reduction in inpatient hospitalization rates by 16% from the 12 months pre-RT to 12 months post-RT was observed. RT shows promise to reduce ED in ASD.

Factors influencing the mental health of autistic children and teenagers: Parents' observations and experiences

LAY ABSTRACT

Autistic people are more likely to experience mental health difficulties compared to neurotypical people. It is very important that we understand what increases the risk for mental health difficulties, and what helps to protect against them. So far, research on this for children and young people has only investigated a small number of factors and these have been chosen by researchers and clinicians. This study took a different approach in which parents' expertise in their children was recognised. Parents were asked to tell the story of their autistic teenagers' mental health from diagnosis in early childhood through to the present, and to explain the 'theories' they developed about what affected their child's mental health - positively and negatively - and how. Parents believed a wide range of factors played a role. These include: (1) aspects of their child (e.g. their autistic traits, intelligence); (2) aspects of their surroundings (e.g. the efforts parents make to prevent and respond to their child's difficulties, features of the school they attend, availability of social activities); (3) changes their child experienced growing up (e.g. puberty, awareness of being autistic); and (4) life events involving loss and separation. Many of the factors parents identified as important have received little or no research attention to date. The findings suggest issues that should be considered in future research and reveal ways that support for parents and autistic children and teenagers can be improved.

Exploring developmental trajectories throughout adolescence of children with autism spectrum disorder without intellectual disability

Characterizing the developmental trajectories of children with autism spectrum disorder (ASD) throughout adolescence and across different domains of functioning offers opportunities to improve long-term outcomes. This prospective study explored, for the first time, the evolution of children with ASD-without intellectual disability (ID) in terms of socio-adaptative skills, learning behaviors, executive functioning (EF), and internalizing/externalizing problems, compared to typically developing (TD) peers. Forty-five children with ASD-without ID and 37 matched TD children (aged 7-11) were assessed at baseline and after 5 years. Parents and teachers completed measures on theory of mind (ToM), socialization, daily living skills, learning style, EF, and emotional/behavioural difficulties at both time points. On all the domains assessed, the ASD group performed significantly worse than the TD group, both in childhood and adolescence. Specific changes were noted between baseline and follow-up assessment on adaptive skills, prosocial behavior, emotional control, inhibit, working memory and monitoring. Group membership (ASD/TD) was influenced by peer relationships and inhibit EF variables. These findings have implications for clinical and school settings.

Is language ability associated with behaviors of concern in autism? A systematic review

This review systematically synthesized evidence on the association between structural language ability and behaviors of concern (BoC) in autism. Four databases were searched for studies that included >10 autistic participants, measures of structural language (content and/or form of language) and BoC, and an analysis of their association. BoCs included self-injurious behavior (SIB), aggression, tantrums, and externalizing behavior. Methodological quality of studies were assessed using the Newcastle Ottawa Scale. Forty-five publications (n = 11,961) were included. Forty studies were cross-sectional and five were prospective cohort studies. Over 70% of the studies investigating expressive language and SIB (n = 10), aggression (n = 5), tantrums (n = 3), and externalizing behavior (n = 17) reported an inverse association, where lower expressive language ability was associated with increased BoC. Eleven out of sixteen studies of combined expressive and receptive language reported an inverse relationship with SIB or aggression. All outcomes were rated as moderate to very low certainty of evidence. This review highlights evidence showing an inverse association between expressive or combined language ability and SIB, and externalizing behavior in autism. However, further high-quality studies that use standardized, consistent measures of language and behavior and investigate longitudinal associations are needed. Early detection and support for reduced structural language difficulties have substantial potential to assist in reducing BoC.

How do autistic people fare in adult life and can we predict it from childhood?

This study describes social, mental health, and quality of life outcomes in early adulthood, and examines childhood predictors in the Special Needs and Autism Project (SNAP), a longitudinal population-based cohort. Young autistic adults face variable but often substantial challenges across many areas of life. Prediction of outcomes is important to set expectations and could lead to the development of targeted early intervention. Autistic children were enrolled at age 12 and parents reported outcomes 11 years later when their children were age 23 (n = 121). Thirty six percent of autistic adults were in competitive employment or education and 54% had frequent contact with friends. Only 5% of autistic adults were living independently, and 37% required overnight care. Moderate or severe anxiety and depression symptoms were found for 11% and 12% of young adults, respectively. Subjective quality of life was similar to UK averages except for social relationships. Using childhood IQ, autism traits and adaptive functioning meaningful predictions can be made of living situation, employment and education and physical health. Prediction was poor for friendships, mental health outcomes and other aspects of quality of life. Our results suggest that although young autistic adults face challenges across normative, social outcomes, they may be faring better in regard to mental health or quality of life. Childhood IQ, autism traits and adaptive functioning are most useful for predicting outcomes. After accounting for these factors, childhood measurements of behavioral and emotional problems and language offered little improvement in prediction of adult outcomes.

Parent, Teacher and Observational Reports of Emotional and Behavioral Problems in Young Autistic Children

Emotional and behavioral problems (EBPs) frequently occur in young autistic children. Discrepancies between parents and other informants are common but can lead to uncertainty in formulation, diagnosis and care planning. This study aimed to explore child and informant characteristics are associated with reported child EBPs across settings. Participants were 83 4-8-year-old autistic children and their parents and teachers in the Autism Spectrum Treatment and Resilience (ASTAR) study. Questionnaires of child EBPs were completed by parents and teachers, and self-reported parenting stress and wellbeing measures were obtained. An observation of parent-child/researcher-child interaction was also completed. Parents reported more EBPs than teachers and parent-teacher agreement was low, particularly for emotional problems. Greater parenting stress and being verbal was associated with more parent- but not teacher-reported EBPs. More observed behaviors that challenge were displayed by minimally verbal children. More parenting stress could be associated with the presence of more EBPs in the home; alternatively, parenting stress may confound reports. It is essential for assessments of EBPs in autistic children to take a multi-informant approach. Better understanding of the associations between informant characteristics and informant discrepancies of EBPs is needed.

Teacher- and parent-reported trajectories of maladaptive behaviors among individuals with autism and non-spectrum delays

People with autism spectrum disorder (ASD) and non-spectrum developmental delays frequently exhibit maladaptive behaviors throughout the lifespan, which can have pervasive effects on quality of life. Maladaptive behaviors have been shown to change over time as a function of various individual-level factors (e.g., cognitive ability), yet research is primarily limited to parent-reported measures. To expand upon this work, the present study aimed to examine trajectories of teacher- and parent-reported maladaptive behaviors (i.e., hyperactivity, irritability, social withdrawal) and to test whether individual-level predictors (e.g., autism features, verbal intelligence quotient) and school-related predictors (e.g., teacher type, student-adult ratio, personal aide, school type) impact these trajectories among 165 individuals with ASD or non-spectrum delays from ages 9 to 18. Multilevel models revealed that, according to both teacher and parent report, participants showed the greatest improvement in hyperactivity, less but still notable improvement in irritability, and stable levels of social withdrawal over time. Higher verbal ability and fewer ASD features, in addition to mainstream school placement, emerged as important individual- and school-related differences associated with fewer maladaptive behaviors over time. The multi-informant perspective and longitudinal design provide novel insight into the manifestations of these maladaptive behaviors across different contexts and across time. Findings highlight the consistency of teacher- and parent-reported trajectories over time and further emphasize the importance of targeting maladaptive behaviors using a multisystem intervention approach in both school and home contexts.

Homotypic and Heterotypic Continuity in Psychiatric Symptoms From Childhood to Adolescence in Autistic Youth

OBJECTIVE

Despite the high prevalence of mental health difficulties in autistic youth, little is known about the patterns of developmental continuity and change in psychiatric symptoms between childhood and adolescence. Using a stratified community-derived sample of autistic youth (n = 101; 57 males, 44 females), within (homotypic) and between (heterotypic) domain associations between psychiatric symptoms in childhood to adolescence were tested as well as whether any continuities were moderated by sex, IQ, autism symptom severity, social economic status, or parental mental health.

METHOD

Autistic youth were assessed for emotional, behavioral, and attention-deficit/hyperactivity disorder (ADHD) symptoms in childhood (age 4-9 years) and adolescence (age 13-17 years) using parental diagnostic interview. Unadjusted and adjusted (accounting for the co-occurrence of psychiatric symptoms in childhood) weighted models tested homotypic and heterotypic associations between symptoms in childhood and adolescence. Moderation of significant pathways was tested using multigroup analysis.

RESULTS

Adolescent psychiatric symptoms all were predicted by symptoms of their childhood counterparts (emotional symptoms incidence rate ratio [IRR] = 1.06, 95% CI = 1.02-1.10, p < .01; behavioral symptoms IRR = 1.38, 95% CI = 1.21-1.59, p < .01; ADHD symptoms IRR = 1.11, 95% CI = 1.05-1.19, p < .01); the only heterotypic pathway that remained significant in adjusted analyses was from childhood emotional symptoms to adolescent ADHD symptoms (IRR = 1.04, 95% CI = 1.01-1.07, p = .02). Sex moderated the homotypic ADHD symptoms pathway; associations were significant in female participants only. Child IQ moderated the homotypic behavioral symptoms pathway; the association was stronger in youth with IQ <70.

CONCLUSION

Results from this community-based sample suggest that psychiatric symptoms in autistic youth exhibit substantial developmental continuity and thus highlight the importance of early screening and intervention. Sex and IQ may be important factors to consider when predicting likelihood of stability of ADHD and behavioral symptoms.

Mental health and social difficulties of late-diagnosed autistic children, across childhood and adolescence

BACKGROUND

Autism can be diagnosed from 2 years of age, although most autistic people receive their diagnosis later than this after they have started education. Research is required to understand why some autistic children are diagnosed late, and the level and nature of unmet need prior to diagnosis for late-diagnosed children.

METHODS

We examined trajectories of emotional, behavioural and social difficulties (EBSDs) across childhood and adolescence, comparing 'earlier-diagnosed' (diagnosed 7 years or younger) with 'late-diagnosed' (diagnosed between 8 and 14 years) autistic children. Data were from the Millennium Cohort Study, a population-based UK birth cohort. EBSDs were measured using the parent-report Strengths and Difficulties Questionnaire, at 3, 5, 7, 11 and 14 years. We used Growth Curve Modelling to investigate levels and rates of change in these difficulties, and to compare earlier- (n = 146) and late-diagnosed (n = 284) autistic children.

RESULTS

Aged 5, earlier-diagnosed autistic children had more emotional (i.e., internalising), conduct, hyperactivity and social difficulties; although clinical difficulties in these areas were nevertheless common in late-diagnosed children. There was a faster annual increase in scores for all domains for late-diagnosed children, and by age 14 years, they had higher levels of EBSDs. These results persisted when we ran adjusted models, to account for the late-diagnosed group having higher rates of late-diagnosed attention deficit/hyperactivity disorder, higher IQ, a higher proportion of females and older and more educated mothers.

CONCLUSIONS

Emotional, behavioural and social difficulties are associated with, and may influence, the timing of autism diagnosis. Late-diagnosed autistic children often have high levels of mental health and social difficulties prior to their autism diagnosis, and tend to develop even more severe problems as they enter adolescence.

Sibling Influences on Trajectories of Maladaptive Behaviors in Autism

Siblings play an important role in the behavioral trajectories of individuals with autism spectrum disorder (ASD). While having siblings has been associated with positive outcomes in ASD, including stronger adaptive functioning, social and non-verbal communication, and theory of mind, little is known about the impact of siblings on more negative outcomes, such as maladaptive behaviors. To address this gap, the present longitudinal study tested sibling predictors of trajectories of maladaptive behaviors (e.g., teacher- and parent-reported hyperactivity, irritability, and social withdrawal) from childhood through early adulthood among individuals with ASD and non-spectrum delays. Multilevel models revealed that, while the mere presence of a sibling did not impact maladaptive behavior trajectories apart from teacher-reported hyperactivity, the diagnostic profile of the sibling (e.g., emotional/behavioral disorder, ASD, medical condition) emerged as an important predictor. Specifically, although findings varied across teacher and parent reports, more hyperactivity and irritability across time was identified when the sibling had diagnoses of an emotional/behavioral disorder, ASD, and/or a medical condition. Overall, this study provides novel insight into the broader family-level factors that influence the presentation of maladaptive behaviors across time and across contexts.

Understanding the heterogeneity of anxiety in autistic youth: A person-centered approach

The present study aimed to examine anxiety profiles among children and adolescents on the autism spectrum. It further aimed to characterize the association between the identified anxiety profiles and key clinical and developmental variables. The Spence Children's Anxiety Scale-Parent Version (SCAS-P) data from a large international pooled sample of 870 caregivers of autistic children and adolescents (M_age  = 11.6 years, SD_age  = 2.77; 107 females) was used. Latent profile analysis identified a three-anxiety profile solution exhibiting high entropy (0.80) and high latent profile probabilities, with good classification accuracy. Identified profiles fell along the severity spectrum and were named as the mild (n = 498), moderate (n = 272) and severe (n = 100) anxiety profiles. There were no statistically significant differences between the three anxiety profiles in terms of sex distribution. Participants in the mild profile were significantly younger than those in the severe profile, had significantly fewer social communication difficulties than youth in the moderate anxiety profile group and had significantly fewer restricted and repetitive behaviors and lower cognitive functioning scores compared to participants in moderate and severe anxiety profiles. This is the first study to move beyond identifying associations and group-level differences to exploring and identifying characteristics of anxiety-based subgroups at an individual level that differ on key clinical and developmental variables. The subgroups identified in this study are a preliminary, yet important, first step towards informing future assessment and individualized interventions aiming to support young people on the autism spectrum to reduce and manage anxiety. LAY SUMMARY: This study tried to understand if there are subgroups of autistic young people who may have similar anxiety profiles. We found that we could meaningfully group young people into three groups based on how severe the anxiety symptoms their caregivers reported were: a group with low levels of anxiety, those with moderate anxiety, and those with more severe anxiety. We also found that the young people in the mild group were younger, had fewer autism traits and lower levels of intellectual functioning than young people in the other two groups.

Citalopram Did Not Significantly Improve Anxiety in Children with Autism Spectrum Disorder Undergoing Treatment for Core Symptoms: Secondary Analysis of a Trial to Reduce Repetitive Behaviors

Objective: Anxiety disorders are among the most common co-occurring conditions in autism spectrum disorder (ASD). Despite their prevalence and impact, there are no randomized controlled trials (RCTs) aimed at evaluating the efficacy of selective serotonin reuptake inhibitors (SSRIs) for anxiolysis in this population, who may have a different biological basis for anxiety. Methods: Secondary analyses of the STAART double-blind, placebo-controlled RCT of citalopram in children with ASD examined whether citalopram reduced anxiety measured on the parent-reported Child and Adolescent Symptom Inventory-4 (CASI-4) as the primary outcome. An intention-to-treat analysis involving all 149 participants used multiple imputations for missing data and included baseline stratification factors of age group and site, among others. We prespecified as clinically significant a 33% reduction in anxiety in citalopram versus placebo, coinciding with 80% power. We tested whether communicative ability on the Vineland Communication score moderated treatment effect and explored whether initial anxiety was associated with greater adverse events, which could impact on dose titration and achieving optimal dose. Results: Both groups showed substantial reduction in anxiety. Citalopram was associated with a nonsignificant 16.5% greater reduction (observed coefficient = -0.181, bootstrap standard error = 0.126, p = 0.151, confidence interval = -0.428 to 0.066). Anxiety reports were significantly lower in children with reduced communicative ability, but communicative ability did not moderate the treatment effect (interaction p = 0.294). Initial anxiety levels were not associated with increased adverse effects (interaction ps 0.162-0.954). Conclusion: Citalopram did not statistically significantly improve anxiety in children with ASD. Clinicians should be cautious in their use of SSRIs for this indication. There remains a need for well-powered clinical trials testing the efficacy of SSRIs among autistic children with anxiety disorders.

Rethinking Autism Intervention Science: A Dynamic Perspective

Recent advances in longitudinal methodologies for observational studies have contributed to a better understanding of Autism as a neurodevelopmental condition characterized by within-person and between-person variability over time across behavioral domains. However, this finer-grained approach to the study of developmental variability has yet to be applied to Autism intervention science. The widely adopted experimental designs in the field-randomized control trials and quasi-experimental designs-hold value for inferring treatment effects; at the same time, they are limited in elucidating what works for whom, why, and when, given the idiosyncrasies of neurodevelopmental disorders where predictors and outcomes are often dynamic in nature. This perspective paper aims to serve as a primer for Autism intervention scientists to rethink the way we approach predictors of treatment response and treatment-related change using a dynamic lens. We discuss several empirical gaps, and potential methodological challenges and opportunities pertaining to: (1) capturing finer-grained treatment effects in specific behavioral domains as indexed by micro-level within-person changes during and beyond intervention; and (2) examining and modeling dynamic prediction of treatment response. Addressing these issues can contribute to enhanced study designs and methodologies that generate evidence to inform the development of more personalized interventions and stepped care approaches for individuals on the heterogeneous spectrum of Autism with changing needs across development.

Oxytocin receptor gene (OXTR) polymorphisms and social, emotional and behavioral functioning in children and adolescents: a systematic narrative review

This study systematically reviewed available evidence regarding associations between polymorphisms of the oxytocin receptor (OXTR) gene and socio-emotional and behavioral functioning in children and adolescents. The search yielded 69 articles, which were grouped into nine categories: depression, anxiety, and internalizing symptoms, alcohol abuse, borderline personality disorder, conduct disorder symptoms or diagnosis, autism spectrum disorder, Attention deficit hyperactivity disorder, early childhood attachment and behavior, pro-social skills, and resilience. Direct and/or gene x environment interactions were identified in over half of the studies. ASD and conduct disorder (including callous unemotional traits) were the diagnoses that were most studied and for which there was the strongest evidence of direct links with OXTR polymorphisms. In most studies identifying gene x environment interactions, the candidate OXTR polymorphism was rs53576. Results suggest that OXTR polymorphisms are associated with social, emotional or behavioural functioning in children and adolescents. The mixed findings do, however, highlight the need for further research.

Early development in autism: How developmental cascades help us understand the emergence of developmental differences

Many theories of autism spectrum disorder (ASD) focus on a single system or factor as an explanatory mechanism for autism symptoms and behavior. However, there is growing recognition that ASD is a complex, multisystem neurodevelopmental condition with origins in prenatal life. Researchers therefore need a conceptual framework that allows examination of the interplay between multiple interacting domains and systems and the ways in which they extend their influence beyond the individual into the surrounding environment. The developmental cascades perspective suggests that even relatively small perturbations in early emerging behaviors in domains that are not traditionally linked may influence subsequent achievements across these areas. In this chapter, we illustrate how a developmental cascades framework can be used to inform the study of developmental differences. The developmental cascades perspective provides us with conceptual and methodological tools for considering how variation in children's real time behavior can provide new insights into sources of variation in their developmental trajectories and outcomes. It also suggests approaches for intervention that leverage targeted skills in novel ways, creating opportunities to support development in other domains and fine-tune caregiver behavior to create powerful moments for infant learning.

Adults with Autism: Changes in Understanding Since DSM-111

Over the past four decades there have been significant advances in our understanding of autism, yet services for autistic adults continue to lag far behind those for children, and prospects for employment and independent living remain poor. Adult outcomes also vary widely and while cognitive and language abilities are important prognostic indicators, the influence of social, emotional, familial and many other factors remains uncertain. For this special issue marking the 40th anniversary of DSM-III, the present paper describes the changing perspectives of autism in adulthood that have occurred over this period, explores individual and wider environmental factors related to outcome, and suggests ways in which services need to be changed to improve the future for adults living with autism.

Declining Trajectories of Co-occurring Psychopathology Symptoms in Attention-Deficit/Hyperactivity Disorder and Autism Spectrum Disorder: A 10-Year Longitudinal Study

Objective: Our objective was to examine developmental trajectories of co-occurring psychopathology symptoms from childhood to young adulthood in individuals with Attention-Deficit/Hyperactivity Disorder (ADHD), individuals with Autism Spectrum Disorder (ASD), and typically developing (TD) individuals. Method: We assessed co-occurring psychopathology symptoms in 61 individuals with ADHD, 26 with ASD, and 40 TD individuals at baseline (T1; Mage = 11.72, 64% boys), 2-year follow up (T2; Mage = 13.77), and 10-year follow up (T3; Mage = 21.35). We analyzed trajectories of internalizing behaviors, externalizing behaviors, and total problems with linear mixed models. Results: From T1 to T3, the ADHD group displayed a small decline in internalizing behaviors (d = -0.49) and large declines in externalizing behaviors (d = -0.78) and total problems (d = -0.71). The ASD group displayed large declines in internalizing behaviors (d = -0.79), externalizing behaviors (d = -0.80), and total problems (d = -0.89). From T1 to T2, the decline in externalizing behaviors and total problems were significantly smaller in the ADHD group compared with the ASD group. The ADHD and the ASD group displayed more co-occurring symptoms compared with the TD group at T3. Conclusion: Individuals with ADHD and ASD, respectively, displayed declines in co-occurring symptoms from childhood to young adulthood. Individuals with ASD displayed an earlier decline compared with individuals with ADHD. Compared with TD individuals, individuals with ADHD and ASD, respectively, continued to display elevated levels of co-occurring symptoms in young adulthood.

Exploring the impact of adolescent cognitive inflexibility on emotional and behavioural problems experienced by autistic adults

LAY ABSTRACT

Autistic people experience high levels of co-occurring mental health difficulties. To develop more effective treatments, a greater understanding of the thinking processes that may lead to these difficulties is needed. Cognitive inflexibility, defined as a rigid pattern of thoughts and subsequently behaviours, is one possible thinking trait which has previously been associated with both co-occurring mental health difficulties but also other features of autism such as restricted and repetitive behaviours. Restricted and repetitive behaviours include repetitive movements, ritualistic behaviours, and/or highly focused interests. This study investigates the relationship between, cognitive inflexibility, measured using neuropsychological tasks, and emotional and behavioural problems across adolescence and early adulthood. Eighty-one autistic people who were recruited to be representative of the wider autism population were assessed at 16 and 23 years on measures of emotional and behavioural problems, with cognitive inflexibility, restricted and repetitive behaviours and verbal intelligence measured at 16 years. We used statistical modelling to investigate the relationship between cognitive inflexibility and emotional and behavioural symptoms at both timepoints while accounting for the possible relationship with restricted and repetitive behaviours and verbal intelligence quotient. Our results suggest that cognitive inflexibility may be an important factor associated with emotional difficulties across adolescence and early adulthood. This suggests that developing intervention approaches targeting cognitive inflexibility may be an important step in improving the mental health of those with autism.

The association of adverse life events and parental mental health with emotional and behavioral outcomes in young adults with autism spectrum disorder

People with autism spectrum disorder (ASD) are at increased risk of developing co-occurring mental health difficulties across the lifespan. Exposure to adverse life events and parental mental health difficulties are known risk factors for developing a range of mental health difficulties. This study investigates the association of adverse life events, parental stress and mental health with emotional and behavioral problems in young adults with ASD. One hundred and fifteen young adults with ASD derived from a population-based longitudinal study were assessed at three time-points (12-, 16-, and 23-year) on questionnaire measures of emotional and behavioral problems. Parent-reported exposure to adverse life events and parental stress/mental health were measured at age 23. We used structural equation modeling to investigate the stability of emotional and behavioral problems over time, and the association between adverse life events and parental stress and mental health and emotional and behavioral outcomes at 23-year. Our results indicate that exposure to adverse life events was significantly associated with increased emotional and behavioral problems in young adults with ASD, while controlling for symptoms in childhood and adolescence. Higher reported parental stress and mental health difficulties were associated with a higher frequency of behavioral, but not emotional problems, and did not mediate the impact of adverse life events. These results suggest that child and adolescent emotional and behavioral problems, exposure to life events and parent stress and mental health are independently associated, to differing degrees, with emotional or behavioral outcomes in early adulthood. LAY SUMMARY: People with autism experience high rates of mental health difficulties throughout childhood and into adult life. Adverse life events and parental stress and mental health may contribute to poor mental health in adulthood. We used data at three time points (12-, 16-, and 23-year) to understand how these factors relate to symptoms at 23-year. We found that emotional and behavioral problems in childhood, adverse life events and parent mental health were all associated with increased emotional and behavioral problems in adulthood.

Drug development for Autism Spectrum Disorder (ASD): Progress, challenges, and future directions

In 2017, facing lack of progress and failures encountered in targeted drug development for Autism Spectrum Disorder (ASD) and related neurodevelopmental disorders, the ISCTM with the ECNP created the ASD Working Group charged to identify barriers to progress and recommending research strategies for the field to gain traction. Working Group international academic, regulatory and industry representatives held multiple in-person meetings, teleconferences, and subgroup communications to gather a wide range of perspectives on lessons learned from extant studies, current challenges, and paths for fundamental advances in ASD therapeutics. This overview delineates the barriers identified, and outlines major goals for next generation biomedical intervention development in ASD. Current challenges for ASD research are many: heterogeneity, lack of validated biomarkers, need for improved endpoints, prioritizing molecular targets, comorbidities, and more. The Working Group emphasized cautious but unwavering optimism for therapeutic progress for ASD core features given advances in the basic neuroscience of ASD and related disorders. Leveraging genetic data, intermediate phenotypes, digital phenotyping, big database discovery, refined endpoints, and earlier intervention, the prospects for breakthrough treatments are substantial. Recommendations include new priorities for expanded research funding to overcome challenges in translational clinical ASD therapeutic research.

Functioning assessment short test (FAST): validity and reliability in adults with Autism Spectrum Disorder

BACKGROUND

The assessment of functional impairment is crucial both for the diagnosis and the therapeutic approach to autism spectrum disorder (ASD). The purpose of the present study was to evaluate whether the FAST is a reliable and valid tool to assess functional impairment in adults with Level 1 ASD and to study the differences in psychosocial functioning between younger and older adults with ASD.

METHODS

A case-control study was carried out in a sample of 150 participants, 71 adults with Level 1 ASD, and 79 adults without psychiatric history records.

RESULTS

Results showed good psychometric properties in terms of validity and reliability. Cronbach's alpha for the total scale was .91 and the area under the curve was .98. The study also showed that adults with ASD present different profiles of functional impairment depending on their age: while younger patients present greater impairment in autonomy, older patients show more difficulties in interpersonal relationships.

CONCLUSIONS

Our results support the use of the FAST in the evaluation of adaptive functioning in adults with Level 1 ASD.

Age differences in broader autism phenotype traits from young adulthood to older adulthood

Much of past research has been dedicated to refining the operationalization and correlates of the broader autism phenotype (BAP) and less on how the BAP differs by socio-demographic characteristics, like age-particularly after midlife. This gap is important because other nonclinical trait-like characteristics (e.g., personality) have shown considerable age differences, leading to work assessing the malleability of psychological characteristics and improving outcomes for individuals and their significant others. In the current study, we examined cross-sectional age differences in the BAP in a large sample of adults ranging in age from 18 to 85. We recruited a sample of 2966 adults ranging in age from 18 to 85 (M_age = 36.53, SD = 12.61; 58.9% Female; 1.1% with an ASD diagnosis) recruited from an online survey service. We found that total BAP scores were higher in younger adults and lower among older adults. These differences were particularly true for pragmatic language difficulties, with this component of the BAP showing the most dramatic age differences. Aloofness showed similar negative associations with age, albeit much smaller. Rigidity was not significantly associated with age. The results are consistent with other research showing an abatement of symptoms among individuals with autism spectrum disorders (ASDs) across early life and theories predicting changes in other psychological characteristics (e.g., personality). The results are discussed in the context of the malleability of ASD and BAP traits across life, the clinical implications of these changes, and the origins and consequences for lifespan differences in BAP. LAY SUMMARY: Little is known about how subclinical autistic-like traits among middle-aged and older adults compare to younger adults. We found that these subclinical traits were highest in young adults and lowest in older adults. Knowing how these traits differ by age can provide researchers and clinicians with a sense of how much these traits might change across life, if the traits might be sensitive to interventions, and when in development it might be best to intervene.

Predicting Uncertain Multi-Dimensional Adulthood Outcomes From Childhood and Adolescent Data in People Referred to Autism Services

Introduction

Autism spectrum disorder is a highly heterogeneous diagnosis. When a child is referred to autism services or receives a diagnosis of autism spectrum disorder it is not known what their potential adult outcomes could be. We consider the challenge of making predictions of an individual child’s long-term multi-facetted adult outcome, focussing on which aspects are predictable and which are not.

Methods

We used data from 123 adults participating in the Autism Early Diagnosis Cohort. Participants were recruited from age 2 and followed up repeatedly through childhood and adolescence to adulthood. We predicted 14 adult outcome measures including cognitive, behavioral and well-being measures. Continuous outcomes were modeled using lasso regression and ordinal outcomes were modeled using proportional odds regression. Optimism corrected predictive performance was calculated using cross-validation or bootstrap. We also illustrated the prediction of an overall composite formed by weighting outcome measures by priorities elicited from parents.

Results

We found good predictive performance from age 9 for verbal and non-verbal IQ, and daily living skills. Predictions for symptom severity, hyperactivity and irritability improved with inclusion of behavioral data collected in adolescence but remained modest. For other outcomes covering well-being, depression, and positive and negative affect we found no ability to predict adult outcomes at any age. Predictions of composites based on parental priorities differed in magnitude and precision depending on which parts of the adult outcome were given more weight.

Conclusion

Verbal and non-verbal IQ, and daily living skills can be predicted well from assessments made in childhood. For other adult outcomes, it is challenging to make meaningful predictions from assessments made in childhood and adolescence using the measures employed in this study. Future work should replicate and validate the present findings in different samples, investigate whether the availability of different measures in childhood and adolescence can improve predictions, and consider systematic differences in priorities.

Emotional Availability and Play in Mother-Child Dyads with ASD: Changes during a Parental Based Intervention

(1) Background: Parental involvement during intervention with children with Autism Spectrum Disorder (ASD) has been demonstrated to be fundamental for children’s developmental outcomes. However, most research focused on child gains especially considering cognitive functioning and symptoms severity, whereas parental and dyadic changes during intervention need further investigation. (2) Methods: 29 mothers in interaction with their preschool children with ASD were analyzed through two standardized behavioral and observational measures to evaluate the dyadic Emotional Availability (EA) and play skills before (T1) and after (T2) a parental-based intervention. (3) Results: Results revealed mothers increased affective quality and major awareness in understanding the signals produced by the child, that in turn was more responsive, involving also using more complex play strategies. Interestingly, the role of specific factors able to predict parental characteristics was investigated, pointing out the important contribution of mothers’ perceptions of having a difficult child and child language communicative abilities. (4) Conclusions: the study enhances knowledge about child and caregiver variables that impact on dyadic outcomes, identifying important target areas to be addressed during intervention. Further, our results suggest that a parental-based intervention supports and facilitates improvements in both children’s and caregivers’ affective quality and cognitive abilities.

Trajectories of co-occurring psychopathology symptoms in autism from late childhood to adulthood

Given high rates of co-occurring conditions in youth and adults with autism spectrum disorder (ASD), it is critical to examine the developmental trajectories of these symptoms of psychopathology. Using data from a cohort of participants (n = 194), most of whom were first assessed for ASD in very early childhood, we investigated the trajectories of co-occurring depressive, anxiety, and attention-deficit hyperactivity disorder (ADHD) symptoms from late childhood to adulthood. Additionally, childhood predictors and adult outcomes associated with these symptom trajectories were examined. Using group-based trajectory modeling, we found two distinct classes of individuals exhibiting each of these co-occurring symptom patterns: one class exhibited fairly low symptoms across time, and one class with elevated symptoms with varied fluctuation across time (ADHD symptoms starting high but decreasing, anxiety symptoms high and stable, and depressive symptoms fluctuating but peaking at clinically significant levels in young adulthood). All high trajectory classes were associated with age 9 adaptive skills; verbal IQ predicted higher anxiety and depressive symptom classes. After accounting for verbal IQ, all high symptom trajectory classes were negative predictors of objective adult outcomes. These findings call for wide-ranging considerations of the needs of individuals across ability levels, autism symptoms, and behavioral and emotional challenges.

Defining Positive Outcomes in More and Less Cognitively Able Autistic Adults

Identifying positive outcomes for a wide range of intellectual abilities in autism spectrum disorder (ASD) remains a challenge. Several past studies of autistic adults have used outcome definitions that do not reflect the experiences of less cognitively able adults. The aim of the current study was to (1) define three domains of outcomes: autonomy, social relationships, and purpose, and (2) examine how these outcomes relate to concurrent aspects of adult functioning. Using data from a longitudinal sample of 126 adults (85% diagnosed with ASD at some point), mean age 26, who first entered the study in early childhood, we generated distinct outcomes for less (daily living skills above an 8-year-old level, having regular activities outside the home, and social contacts outside the family) and more cognitively able adults (living independently, having paid employment, and at least one true friend). Verbal IQ, assessed in adulthood, was a significant predictor of more outcomes achieved for individuals within more and less cognitively able groups. For less cognitively able adults, having ever received a formal ASD diagnosis (in contrast to current Autism Diagnostic Observation Schedule [ADOS] CSS scores) was associated with lower odds of positive outcomes. For more cognitively able adults, living skills and happiness measures were positively associated with number of outcomes met; higher ADOS CSS, internalizing and externalizing symptoms, being racially diverse, and having caregiver education below college graduation were all negatively associated with the number of positive outcomes. Tailoring outcomes to ability levels may lead to better identification of goals and service needs. LAY SUMMARY: This article describes the outcomes of autistic adults who are more and less cognitively able. For less cognitively able individuals, an earlier autism diagnosis was negatively related to outcomes. Several factors that were associated with positive outcomes for more cognitively able individuals, including daily living skills, fewer mental health problems, family demographics, and subjective measures of happiness. Our study identifies several important factors for families, individuals, and service providers to consider and discuss when planning the transition to adulthood. Autism Res 2020, 13: 1548-1560. © 2020 International Society for Autism Research, Wiley Periodicals, Inc.