A five to fifteen year follow-up study of infantile psychosis. II. Social and behavioural outcome

Enhanced interest in letters and numbers in autistic children

BACKGROUND

An intense and precocious interest in written material, together with a discrepancy between decoding and reading comprehension skills are defining criteria for hyperlexia, which is found in up to 20% of autistic individuals. It may represent the extreme end of a broader interest in written material in autism. This study examines the magnitude and nature of the interest in written material in a large population of autistic and non-autistic children.

METHODS

All 701 children (391 autistic, 310 non-autistic) under the age of 7 referred to an autism assessment clinic over a span of 4 years were included. Ordinal logistic regressions assessed the association between diagnosis and the level of interest in letters and numbers. A nested sample of parents of 138 autistic, 99 non-autistic clinical, and 76 typically developing (TD) children completed a detailed questionnaire. Cox proportional hazards models analyzed the age of emergence of these interests. Linear regressions evaluated the association between diagnosis and interest level. The frequency of each behaviour showing interest and competence with letters and numbers were compared.

RESULTS

In the two studies, 22 to 37% of autistic children had an intense or exclusive interest in letters. The odds of having a greater interest in letters was 2.78 times higher for autistic children than for non-autistic clinical children of the same age, and 3.49 times higher for the interest in numbers, even if 76% of autistic children were minimally or non-verbal. The age of emergence of these interests did not differ between autistic and TD children and did not depend on their level of oral language. Non-autistic children showed more interest in letters within a social context.

LIMITATIONS

The study holds limitations inherent to the use of a phone questionnaire with caregivers and missing sociodemographic information.

CONCLUSIONS

The emergence of the interest of autistic children toward written language is contemporaneous to the moment in their development where they display a strong deficit in oral language. Together with recent demonstrations of non-social development of oral language in some autistic children, precocious and intense interest in written material suggests that language acquisition in autism may follow an alternative developmental pathway.

Exome functional risk score and brain connectivity can predict social adaptability outcome of children with autism spectrum disorder in 4 years' follow up

Introduction

Autism Spectrum Disorder (ASD) is a common neurodevelopmental disorder emerging in early childhood, with heterogeneous clinical outcomes across individuals. This study aims to recognize neuroimaging genetic factors associated with outcomes of ASD after a 4-year follow-up.

Methods

A total of 104 ASD children were included in this study; they underwent clinical assessments, MRI data acquisition, and the whole exome sequencing (WES). Exome functional risk score (EFRS) was calculated based on WES; and two modalities of brain connectivity were constructed based on MRI data, that is functional connectivity (FC) for functional MRI (fMRI), and individual differential structural covariance network (IDSCN) for structural MRI (sMRI), to explore the neuroimaging genetic biomarker of outcomes of ASD children.

Results

Regression analysis found EFRS predicts social adaptability at the 4-year follow-up (Y = -0.013X + 9.29, p = 0.003). We identified 19 pairs of FC associated with autism symptoms severity at follow-up, 10 pairs of FC and 4 pairs of IDSCN associated with social adaptability at follow-up, and 10 pairs of FC associated with ASD EFRS by support vector regression (SVR). Related brain regions with prognostic predictive effects are mainly distributed in superior frontal gyrus, occipital cortex, temporal cortex, parietal cortex, paracentral lobule, pallidum, and amygdala for FC, and temporal cortex, thalamus, and hippocampus for IDSCN. Mediation model showed that ASD EFRS affects the social communication of ASD children through the mediation of FC between left middle occipital gyrus and left pallidum (RMSEA=0.126, CMIN=80.66, DF=42, p< 0.001, CFI=0.867, AIC=152).

Discussion

Our findings underscore that both EFRS and brain connectivity can predict social adaptability, and that brain connectivity serving as mediator in the relationship of EFRS and behaviors of ASD, suggesting the intervention targets in the future clinical application.

Child development, film evidence, and epidemiological sciences: Elwyn James Anthony and the 1957 Zurich International Congress of Psychiatry

In 1957, the British-Indian child psychiatrist Dr Elwyn James Anthony travelled to the Zurich International Congress of Psychiatry to show a film featuring 70 children with such complex symptomatology and behaviour that they betrayed the certainty of contemporary theories of developmental psychology and psychoanalysis. This article examines the significance of Anthony's film to the creation of new scientific models in international developmental psychology and psychiatric epidemiology. It marked a significant change in the use of filmed evidence that sought to create a truly global and universalist approach to atypical child development based purely on scientific observations. This new observational work was important in shaping new internationally ratified models to study the epidemiology of children's psychiatric conditions.

Appropriateness of psychopharmacological therapies to psychiatric diagnoses in persons with autism spectrum disorder with or without intellectual disabilities: a cross-sectional analytic study

BACKGROUND

Observational studies highlighted high rates of psychotropic medication in persons with autistic spectrum disorder (ASD) with or without intellectual disability, which seems to be associated with the management of problem behaviors more than co-occurrent psychiatric disorders. The purpose of the study is to investigate psychopharmacology use and diagnoses of co-occurrent psychiatric disorder (PD) in persons with ASD attending a public mental health service in Emilia Romagna, Italy.

METHODS

The present study is a multicenter, cross-sectional study.

RESULTS

275 persons out of 486 (56.5%) resulted to receive at least one psychotropic drug, compared to 74 persons (15.2%) that were diagnosed with a PD. 63.6% were on poly-pharmacotherapy (2-10 compounds), with 37.8% receiving 3 or more medications. Antipsychotics were the most frequently prescribed class of psychotropic drugs (89%), followed by antiepileptics/mood stabilizers/lithium (42.1%) and anxiolytics (BDZ) (38.5%). Most common psychiatric disorders were psychotic disorders (29.7%), followed by anxiety disorders (17.5%), bipolar disorders (12.2%), and depressive disorders (9.4%).

CONCLUSIONS

Our findings support earlier research showing that many individuals with ASD receive pharmacotherapy without being diagnosed with a co-occurring psychiatric disorder, indicating that the main reasons for prescription and the type of compound frequently have little to no link with specific psychopathology.

The importance of low IQ to early diagnosis of autism

Some individuals can flexibly adapt to life's changing demands while others, in particular those with Autism Spectrum Disorder (ASD), find it challenging. The origin of early individual differences in cognitive abilities, the putative tools with which to navigate novel information in life, including in infants later diagnosed with ASD remains unexplored. Moreover, the role of intelligence quotient (IQ) vis-à-vis core features of autism remains debated. We systematically investigate the contribution of early IQ in future autism outcomes in an extremely large, population-based study of 8000 newborns, infants, and toddlers from the US between 2 and 68 months with over 15,000 cross-sectional and longitudinal assessments, and for whom autism outcomes are ascertained or ruled out by about 2-4 years. This population is representative of subjects involved in the National Institutes of Health (NIH)-funded research, mainly on atypical development, in the US. Analyses using predetermined age bins showed that IQ scores are consistently lower in ASD relative to typically developing (TD) children at all ages (p < 0.001), and IQ significantly correlates with social, non-social, and total Calibrated Severity Scores (CSS) on the Autism Diagnostic Observation Schedule (ADOS) (p<0.01). Lower IQ is associated with greater autistic impairments. Note, verbal IQ (VIQ) is no better than the full-scale IQ to predict ASD cases. These findings raise new, compelling questions about potential atypical brain circuitry affecting performance in both verbal and nonverbal abilities and preceding an ASD diagnosis. This study is the first to establish prospectively that low early IQ is a major feature of ASD in early childhood. LAY SUMMARY: The role of IQ scores in autism remains debated. We systematically investigate the contribution of early IQ in an extremely large study of 8,000 children between 2 and 68 months with autism outcomes by about 2-4 years. We show that IQ scores are consistently lower in ASD relative to TD children. This study is the first to establish prospectively that low early IQ is a predictor for ASD diagnosis in early childhood.

Developmental disruption and restoration of brain synaptome architecture in the murine Pax6 neurodevelopmental disease model

Neurodevelopmental disorders of genetic origin delay the acquisition of normal abilities and cause disabling phenotypes. Nevertheless, spontaneous attenuation and even complete amelioration of symptoms in early childhood and adolescence can occur in many disorders, suggesting that brain circuits possess an intrinsic capacity to overcome the deficits arising from some germline mutations. We examined the molecular composition of almost a trillion excitatory synapses on a brain-wide scale between birth and adulthood in mice carrying a mutation in the homeobox transcription factor Pax6, a neurodevelopmental disorder model. Pax6 haploinsufficiency had no impact on total synapse number at any age. By contrast, the molecular composition of excitatory synapses, the postnatal expansion of synapse diversity and the acquisition of normal synaptome architecture were delayed in all brain regions, interfering with networks and electrophysiological simulations of cognitive functions. Specific excitatory synapse types and subtypes were affected in two key developmental age-windows. These phenotypes were reversed within 2-3 weeks of onset, restoring synapse diversity and synaptome architecture to the normal developmental trajectory. Synapse subtypes with rapid protein turnover mediated the synaptome remodeling. This brain-wide capacity for remodeling of synapse molecular composition to recover and maintain the developmental trajectory of synaptome architecture may help confer resilience to neurodevelopmental genetic disorders.

Exploring Growth in Expressive Communication of Infants and Toddlers With Autism Spectrum Disorder

One of the earliest indicators of autism spectrum disorder (ASD) is delay in language and social communication. Despite consensus on the benefits of earlier diagnosis and intervention, our understanding of the language growth of children with ASD during the first years of life remains limited. Therefore, this study compared communication growth patterns of infants and toddlers with ASD to growth benchmarks of a standardized language assessment. We conducted a retrospective analysis of growth on the Early Communication Indicator (ECI) of 23 infants and toddlers who received an ASD diagnosis in the future. At 42 months of age, children with ASD had significantly lower rates of gestures, single words, and multiple words, but significantly higher rates of nonword vocalizations. Children with ASD had significantly slower growth of single and multiple words, but their rate of vocalization growth was significantly greater than benchmark. Although more research is needed with larger samples, because the ECI was designed for practitioners to monitor children's response to intervention over time, these findings show promise for the ECI's use as a progress monitoring measure for young children with ASD. Limitations and the need for future research are discussed.

Echolalia from a transdiagnostic perspective

BACKGROUND & AIMS

Echolalia, the repetition of one's or others' utterances, is a behavior present in typical development, autism spectrum disorder, aphasias, Tourette's, and other clinical groups. Despite the broad range of conditions in which echolalia can occur, it is considered primarily through a disorder-specific lens, which limits a full understanding of the behavior.

METHOD

Empirical and review papers on echolalia across disciplines and etiologies were considered for this narrative review. Literatures were condensed into three primary sections, including echolalia presentations, neural mechanisms, and treatment approaches.

MAIN CONTRIBUTION

Echolalia, commonly observed in autism and other developmental conditions, is assessed, observed, and treated in a siloed fashion, which reduces our collective knowledge of this communication difference. Echolalia should be considered as a developmental, transdiagnostic, and communicative phenomenon. Echolalia is commonly considered as a communicative behavior, but little is known about its neural etiologies or efficacious treatments.

CONCLUSIONS

This review is the first to synthesize echolalia from a transdiagnostic perspective, which allows for the direct comparisons across and within clinical groups to inform assessment, treatment, conceptualization, and research recommendations.

IMPLICATIONS

Considering echolalia transdiagnostically highlights the lack of consensus on operationalization and measurement across and within disorders. Clinical and research future directions need to prioritize consistent definitions of echolalia, which can be used to derive accurate prevalence estimates. Echolalia should be considered as a communication strategy, used similarly across developmental and clinical groups, with recommended strategies of shaping to increase its effectiveness.

Repeating purposefully: Empowering educators with functional communication models of echolalia in Autism

BACKGROUND AND AIMS

Echolalia, the repetition of speech, is highly prevalent in school aged children with Autism. Prior research has found that individuals with echolalia use their repetitions to engage in communicatively functional speech, in the absence of self-generated speech. Educators are the natural audience for a wide vary of echoed utterances across environments and in differing contexts. The objectives of this paper were three-fold: (1) to systematically investigate how researchers identify and ascribe communicative function to echoed utterances; (2) to gather and evaluate the evidence that might assist teachers to identify and better understand echoed utterances as being communicatively purposeful; and (3) to provide teachers with evidence-informed response strategies they can use to assist their students on their journey towards more self-generated speech.

MAIN CONTRIBUTION

Prior research in the field of echolalia has generally been segmented into opposing viewpoints. A paucity of work in the echolalia field has meant that there is limited work that has sought to view how a communicative function to echolalia has been ascribed from across multiple disciplines and fields. As such, there is limited literature to guide the practice of classroom educators. This review combines communicative models from across various disciplines with the view to supporting classroom educators by providing guidance on how they might assist their students with echolalia. This review represents the first contribution to the research literature in this area.

CONCLUSIONS AND IMPLICATIONS

Research into echolalia did not originally emanate from the field of education; however, anecdotes from classroom educators were cited as the primary impetus for the creation of some of the communicatively functional models. We found that although there are many techniques that researchers have used to attribute a communicative function to echolalia, some of these can be easily employed by educators in their practice. By adopting these techniques, educators are placed in a position that may assist with the identification of communicative echolalia; subsequently they are better placed to acknowledge and respond to their students.

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.

Identifying Childhood Expressive Language Features That Best Predict Adult Language and Communication Outcome in Individuals With Autism Spectrum Disorder

Purpose Several studies have reported that "useful speech" at 5 years of age predicts outcomes in individuals with autism spectrum disorder (ASD), but this skill has been vaguely defined. This study investigates which specific aspects of expressive language in children with ASD best predict adult language and communication outcomes. Method Language samples from 29 children (ages 47-72 months) enrolled in a longitudinal project (e.g., Lord et al., 2006) were transcribed and coded for spoken language features. Hierarchical linear regression was used to compare the following childhood variables as predictors of adult language and communication outcomes: noun diversity, verb diversity, mean length of utterance, and proportion of utterances that were socially motivated. Results Childhood verb diversity was a value-added predictor of all four adult outcome measures (i.e., verbal IQ, Autism Diagnostic Observation Schedule Communication + Social Interaction Algorithm totals, Peabody Picture Vocabulary Test scores, and Vineland Adaptive Behavior Scales Communication Domain scores), while noun diversity and proportion of utterances that were socially motivated were not value-added predictors of any adult outcome measures. In a second set of regression analyses, mean length of utterance was substituted for verb diversity and was a value-added predictor of two out of four adult outcome measures (i.e., verbal IQ and Vineland Adaptive Behavior Scales Communication Domain scores). The pattern of findings for the other predictors remained the same as in the previous analyses. Conclusion These results have implications for our understanding of early language in ASD and for clinical decision making in early childhood.

Sensory Responsiveness Is Linked With Communication in Infant Siblings of Children With and Without Autism

Purpose Differences in communication development impact long-term outcomes of children with autism. Previous research has identified factors associated with communication in children with autism, but much of the variance in communication skill remains unexplained. It has been proposed that early differences in sensory responsiveness (i.e., hyporesponsiveness, hyperresponsiveness, and sensory seeking) may produce "cascading effects" on communication. Evidence for this theory is limited, however, as relations between sensory responsiveness and communication in the earliest stages of development have not been well established. The purpose of this study was to evaluate (a) whether infants with a heightened likelihood of autism diagnosis (i.e., infants with an older sibling with autism) differ from infants at general population-level likelihood of autism (i.e., infants with an older, nonautistic sibling) on patterns of sensory responsiveness, (b) whether early sensory responsiveness is correlated with concurrent communication, and (c) whether the aforementioned between-groups differences and associations are moderated by age. Method Participants were 40 infants (20 infants with an older sibling with autism, 20 infants with an older, nonautistic sibling) aged 12-18 months. A series of observational and parent report measures of sensory responsiveness and communication skill were administered. Results Group differences in sensory responsiveness across the 12- to 18-month period were limited (i.e., only observed for one measure of hyporesponsiveness), though selected differences in sensory responsiveness (i.e., parent-reported hyperresponsiveness and sensory seeking) emerged between groups over this developmental window. Parent-reported hyporesponsiveness was unconditionally, negatively associated with communication skills. Associations between expressive communication and (a) parent-reported sensory seeking and (b) an observational measure of hyperresponsiveness were moderated by age. Conclusions This study provides new insights into the nature of sensory responsiveness and theorized links with communication skill in infants at elevated and general population-level likelihood of autism diagnosis. Further work is needed to better characterize the effects of interest in a larger sample spanning a wider age range. Supplemental Material https://doi.org/10.23641/asha.14515542.

A Meta-analysis of Outcome Studies of Autistic Adults: Quantifying Effect Size, Quality, and Meta-regression

Longitudinal studies have generally reported poor outcomes in adulthood for the majority of individuals (c.50–60%) with autism. Several factors putatively predict outcome (e.g. IQ), but findings remain mixed. This paper presents an updated meta-analysis of autism outcome studies and extends previous findings with additional analyses (including meta-regression). A total of 4088 records was screened and 18 studies, involving 1199 individuals, were included in the quantitative analysis. Estimated percentages indicated that 20.0% of participants were rated as having a good outcome, 26.6% a fair outcome, and 49.3% a poor outcome. Meta-regression indicated that lower IQ in adulthood was predictive of poor outcome; other meta-regression models did not survive correction for multiple comparisons. Overall, outcomes for autistic people are on average poor, and higher IQ appears to be protective against having a poor outcome. The limitations of current constructs of outcome are discussed.

Affording autism an early brain development re-definition

The national priority to advance early detection and intervention for children with autism spectrum disorder (ASD) has not reduced the late age of ASD diagnosis in the US over several consecutive Centers for Disease Control and Prevention (CDC) surveillance cohorts, with traditionally under-served populations accessing diagnosis later still. In this review, we explore a potential perceptual barrier to this enterprise which views ASD in terms that are contradicted by current science, and which may have its origins in the current definition of the condition and in its historical associations. To address this perceptual barrier, we propose a re-definition of ASD in early brain development terms, with a view to revisit the world of opportunities afforded by current science to optimize children's outcomes despite the risks that they are born with. This view is presented here to counter outdated notions that potentially devastating disability is determined the moment a child is born, and that these burdens are inevitable, with opportunities for improvement being constrained to only alleviation of symptoms or limited improvements in adaptive skills. The impetus for this piece is the concern that such views of complex neurodevelopmental conditions, such as ASD, can become self-fulfilling science and policy, in ways that are diametrically opposed to what we currently know, and are learning every day, of how genetic risk becomes, or not, instantiated as lifetime disabilities.

Intervention Effects on Language in Children With Autism: A Project AIM Meta-Analysis

Purpose This study synthesized effects of interventions on language outcomes of young children (ages 0-8 years) with autism and evaluated the extent to which summary effects varied by intervention, participant, and outcome characteristics. Method A subset of effect sizes gathered for a larger meta-analysis (the Autism Intervention Meta-analysis or Project AIM) examining the effects of interventions for young children with autism, which were specific to language outcomes, was analyzed. Robust variance estimation and metaregression were used to calculate summary and moderated effects while controlling for intercorrelation among outcomes within studies. Results A total of 221 outcomes were gathered from 60 studies. The summary effect of intervention on language outcomes was small but significant. Summary effects were larger for expressive and composite language outcomes compared to receptive language outcomes. Interventions implemented by clinicians, or by clinicians and caregivers together, had summary effects that were significantly larger than interventions implemented by caregivers alone. Participants' pretreatment language age equivalent scores positively and significantly moderated intervention effects, such that effects were significantly larger on average when samples of children had higher pretreatment language levels. Effects were not moderated by cumulative intervention intensity, intervention type, autism symptomatology, chronological age, or the proximity or boundedness of outcomes. Study quality concerns were apparent for a majority of included outcomes. Conclusions We found evidence that intervention can facilitate improvements in language outcomes for young children with autism. Effects were largest for expressive and composite language outcomes, for children with initially higher language abilities, and for interventions implemented by clinicians or by caregivers and clinicians combined. However, quality concerns of included studies and borderline significance of some results temper our conclusions regarding intervention effectiveness and corresponding moderators.

Autism spectrum disorder

Autism spectrum disorder is a construct used to describe individuals with a specific combination of impairments in social communication and repetitive behaviours, highly restricted interests and/or sensory behaviours beginning early in life. The worldwide prevalence of autism is just under 1%, but estimates are higher in high-income countries. Although gross brain pathology is not characteristic of autism, subtle anatomical and functional differences have been observed in post-mortem, neuroimaging and electrophysiological studies. Initially, it was hoped that accurate measurement of behavioural phenotypes would lead to specific genetic subtypes, but genetic findings have mainly applied to heterogeneous groups that are not specific to autism. Psychosocial interventions in children can improve specific behaviours, such as joint attention, language and social engagement, that may affect further development and could reduce symptom severity. However, further research is necessary to identify the long-term needs of people with autism, and treatments and the mechanisms behind them that could result in improved independence and quality of life over time. Families are often the major source of support for people with autism throughout much of life and need to be considered, along with the perspectives of autistic individuals, in both research and practice.

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

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

Characteristics of Young Adults with Autism Spectrum Disorder Performing Different Daytime Activities

Daytime activity, in terms of engagement in an occupation or education, is highly important for individuals with autism spectrum disorder (ASD), regardless of their level of functioning. In this nationwide survey, the parents of young adults diagnosed with ASD in childhood (n = 1266) provided information about the current daytime activity of their child, as well as behavioral characteristics, comorbidity, history of schooling during primary and secondary school, and availability of support. The young adults without a regular daytime activity constituted approximately one-fifth of the sample and had more behavioral difficulties and comorbidities than young adults with a daytime activity. Intellectual disability, part-time job, history of schooling, including type of school, and availability of support were found to be associated with daytime activity.

The long-term outcomes of a cohort of adolescents and adults from Greece with autism spectrum disorder

BACKGROUND

Autism spectrum disorder (ASD) is a neurodevelopmental disorder. Although it is a lifelong condition, treatments and services can improve a person's symptoms and ability to function. Research on the outcomes in adolescence and adult life and on the associated factors is limited. The objective of the present study is to examine the outcomes as well as the contributing factors in adolescents and adults diagnosed with ASD in Greece.

METHOD

Participants included 69 parents of individuals diagnosed with ASD in their childhood. Interviews were conducted with the parents, and archived medical and psychological records were collected. Participants had been diagnosed in the Child and Adolescent Unit of the 3d Psychiatric Clinic of the AHEPA Hospital in Thessaloniki, Greece between 1990 and 2007.

RESULTS

The overall outcome was poor in most of cases (22.6% "very poor" and 24.5% "poor"); however, a substantial number had "good" (18.9%) or "very good" (22.6%) outcomes. Severity of initial diagnosis (χ ² = 65.956, DF = 8, p < 0.001), presence of comorbid disorders in childhood (χ ² = 14,085, DF = 4, p < 0.007), current comorbidity (χ ² = 15.834, DF = 4, p = 0.003), and certain developmental milestones [early acquisition of language skills (χ ² = 16.991, DF = 8, p = 0.030)] were positively correlated with adult outcomes.

CONCLUSIONS

Overall outcomes in the Greek sample were consistent with international studies. It seems that important contributing factors are comorbidity and especially overall lower cognitive function (intellectual disability), but further research is needed as well as enhanced adult-oriented research and intervention programs.

Outcome for Children Receiving the Early Start Denver Model Before and After 48 Months

The Early Start Denver Model (ESDM) is an intervention program recommended for pre-schoolers with autism ages 12-48 months. The rationale for this recommendation is the potential for intervention to affect developmental trajectories during early sensitive periods. We investigated outcomes of 32 children aged 18-48 months and 28 children aged 48-62 months receiving the ESDM for one year (approximately 20 h per week). Younger children achieved superior verbal DQ gains compared to their older counterparts. There were no group differences with respect to non-verbal DQ and adaptive behavior (with both age-groups undergoing significant change), or ASD severity (with neither age-group showing improvements on the ADOS). The association between verbal DQ gains and age at intake was moderated by baseline verbal level.

Are we good and are we safe? Measuring quality and assessing risk in an adult autism diagnostic service

Purpose

Leeds autism diagnostic service is an adult autism diagnostic service for people of any intellectual ability which also offers consultancy to service users/carers or professionals, as well as a wide range of autism training. The service was set up as a pilot in 2011 and a paper describing the service development was published in this journal in November 2015. The purpose of this paper is to describe the approach taken to measure the quality of the service the authors provide and accurately assess risk in adults with autism.

Design/methodology/approach

The process of evaluating appropriate outcome measures is described, along with considering appropriate risk assessment tools for use in the community. Over 200 people each year complete the autism diagnostic pathway, and 164 patients were invited to respond to service evaluation questionnaires in 2014.

Findings

To date, the most useful outcome measures for this group include a prospective service user questionnaire which enables service user opinion to influence service development. In the absence of any appropriate autism-specific risk assessment tools, the service has developed one which it is currently piloting. This has proved particularly useful in the consultancy setting

Originality/value

This paper is a follow-up paper looking at the day-to-day issues that the team have had to grapple with – how do you assess whether what you are doing is providing the best possible service for the people that you serve and how do you accurately assess risk in this population?

Making Sense in a Fragmentary World

The communicative capabilities of people with autism are impaired and limited in significant ways. The problems are characterized by a lack of intentionality and symbol formation, which indicates that the deviant development of communication in autism is associated with a specific cognitive style. The central coherence theory can offer insight into the specific communication problems of people with autism, since a weaker drive for central coherence leads to problems in sense-making and, consequently, in communication. In the case of the comorbidity of autism and learning disability, the communication problems are aggravated. The crucial point is the determination of the level of sense-making, taking this comorbidity into account. Assessment and intervention have to be tuned to individual needs, in order to increase the communicative competence of people with autism and learning disability.

Formal and Informal Measures on the Effectiveness of the TEACCH Programme

Demonstrating the effectiveness of a large and complex programme such as Division TEACCH is difficult. The problem is compounded by the organic basis of autism and the focus of Division TEACCH on lifelong adaptations, which do not lend themselves to superficial cures or clearly defined milestones. Several different measures have been used to address the evaluation questions: research studies on the effectiveness of specific techniques, outcome data, and anecdotal and statistical information about the impact of Division TEACCH. These measures have been collected and described in response to the many people who contact Division TEACCH inquiring how we know we are having a positive impact on people with autism and their families. The combination of empirical data and informal measures is included to provide a comprehensive perspective.

Outcome in Adult Life for more Able Individuals with Autism or Asperger Syndrome

The paper reviews what is known about outcome in adult life for more able individuals within the autistic spectrum. Because of the problems associated with differential diagnosis, the results of studies involving high-functioning people with autism and Asperger syndrome are combined. The review focuses predominantly on long-term follow-up research and covers outcome in terms of cognitive, linguistic, academic and adaptive functioning; educational and employment history; independence and social relationships; and behavioural and psychiatric problems. The stability of IQ and other measures over time, and variables related to outcome, are also investigated.

A systematic review and meta-analysis of the long-term overall outcome of autism spectrum disorders in adolescence and adulthood

OBJECTIVE

A systematic review and meta-analysis of studies reporting on the overall outcome in terms of a global measure of adjustment in children with autistic disorders followed up in adolescence and adulthood.

METHOD

PubMed, PsycINFO, and EMBASE were systematically searched on 3rd of August 2015. Included studies were analyzed using random-effects models estimating event rates (%) and 95% confidence intervals (95%CI).

RESULTS

From 4350 records identified in the search, 15 studies covering 12 unique samples and a total of N = 828 individuals with autistic disorders were included in the analyses. An estimated 19.7% (95%CI: 14.2-26.6) had a good outcome, 31.1% (95%CI: 23.2-40.4%) a fair outcome, and 47.7% (95%CI: 36.6-59.0) a poor outcome. The meta-analysis showed strong evidence for heterogeneity. The subtype of childhood autism is a significant moderating factor on the risk of having a poor outcome at follow-up, whereas age at follow-up showed statistically significant but inconsistent associations with outcome status.

CONCLUSION

The long-term outcome of almost half of all individuals with autistic disorders is poor. The subtype of autism in childhood may be a predictor for specific long-term outcomes, but in general, little is known about the pathways and predictors.

Do reciprocal associations exist between social and language pathways in preschoolers with autism spectrum disorders?

BACKGROUND

Differences in how developmental pathways interact dynamically in children with autism spectrum disorder (ASD) likely contribute in important ways to phenotypic heterogeneity. This study aimed to model longitudinal reciprocal associations between social competence (SOC) and language (LANG) pathways in young children with ASD.

METHODS

Data were obtained from 365 participants aged 2-4 years who had recently been diagnosed with an ASD and who were followed over three time points: baseline (time of diagnosis), 6- and 12 months later. Using structural equation modeling, a cross-lagged reciprocal effects model was developed that incorporated auto-regressive (stability) paths for SOC (using the Socialization subscale of the Vineland Adaptive Behavior Scales-2) and LANG (using the Preschool Language Scale-4 Auditory Comprehension subscale). Cross-domain associations included within-time correlations and lagged associations.

RESULTS

SOC and LANG were highly stable over 12 months. Small reciprocal cross-lagged associations were found across most time points and within-time correlations decreased over time. There were no differences in strength of cross-lagged associations between SOC-LANG and LANG-SOC across time points. Few differences were found between subgroups of children with ASD with and without cognitive impairment.

CONCLUSIONS

Longitudinal reciprocal cross-domain associations between social competence and language were small in this sample of young children with ASD. Instead, a pattern emerged to suggest that the two domains were strongly associated around time of diagnosis in preschoolers with ASD, and then appeared to become more independent over the ensuing 12 months.

Restricted and repetitive behaviors in individuals with a history of ASDs who have achieved optimal outcomes

Studies of autism spectrum disorders (ASDs) suggest that restricted and repetitive behaviors (RRBs) are particularly difficult to remediate. We examined present and past RRBs in 34 individuals who achieved optimal outcomes (OOs; lost their ASD diagnosis), 45 high-functioning individuals with ASD (HFA) and 34 typically developing (TD) peers. The OO group exhibited minimal residual RRBs at the time of the study. All OO participants were reported to have at least one RRB in early childhood and almost 90 % met the RRB cutoff for ASD in early childhood, but RRBs were not more present in the OO than the TD group at the time of the study. History of RRBs in the HFA and OO groups differed only in oversensitivity to noise and insistence on sameness. Reports of current behavior indicated that RRB's had almost totally disappeared in the OO group. Thus, although RRB's were present in the OO group in childhood, they resolved along with social and communication deficits.

The effects of aging on the BTBR mouse model of autism spectrum disorder

Autism spectrum disorder (ASD) is a complex heterogeneous neurodevelopmental disorder characterized by alterations in social functioning, communicative abilities, and engagement in repetitive or restrictive behaviors. The process of aging in individuals with autism and related neurodevelopmental disorders is not well understood, despite the fact that the number of individuals with ASD aged 65 and older is projected to increase by over half a million individuals in the next 20 years. To elucidate the effects of aging in the context of a modified central nervous system, we investigated the effects of age on the BTBR T + tf/j mouse, a well characterized and widely used mouse model that displays an ASD-like phenotype. We found that a reduction in social behavior persists into old age in male BTBR T + tf/j mice. We employed quantitative proteomics to discover potential alterations in signaling systems that could regulate aging in the BTBR mice. Unbiased proteomic analysis of hippocampal and cortical tissue of BTBR mice compared to age-matched wild-type controls revealed a significant decrease in brain derived neurotrophic factor and significant increases in multiple synaptic markers (spinophilin, Synapsin I, PSD 95, NeuN), as well as distinct changes in functional pathways related to these proteins, including “Neural synaptic plasticity regulation” and “Neurotransmitter secretion regulation.” Taken together, these results contribute to our understanding of the effects of aging on an ASD-like mouse model in regards to both behavior and protein alterations, though additional studies are needed to fully understand the complex interplay underlying aging in mouse models displaying an ASD-like phenotype.

Communication interventions for minimally verbal children with autism: a sequential multiple assignment randomized trial

OBJECTIVE

This study tested the effect of beginning treatment with a speech-generating device (SGD) in the context of a blended, adaptive treatment design for improving spontaneous, communicative utterances in school-aged, minimally verbal children with autism.

METHOD

A total of 61 minimally verbal children with autism, aged 5 to 8 years, were randomized to a blended developmental/behavioral intervention (JASP+EMT) with or without the augmentation of a SGD for 6 months with a 3-month follow-up. The intervention consisted of 2 stages. In stage 1, all children received 2 sessions per week for 3 months. Stage 2 intervention was adapted (by increased sessions or adding the SGD) based on the child's early response. The primary outcome was the total number of spontaneous communicative utterances; secondary measures were the total number of novel words and total comments from a natural language sample.

RESULTS

Primary aim results found improvements in spontaneous communicative utterances, novel words, and comments that all favored the blended behavioral intervention that began by including an SGD (JASP+EMT+SGD) as opposed to spoken words alone (JASP+EMT). Secondary aim results suggest that the adaptive intervention beginning with JASP+EMT+SGD and intensifying JASP+EMT+SGD for children who were slow responders led to better posttreatment outcomes.

CONCLUSION

Minimally verbal school-aged children can make significant and rapid gains in spoken spontaneous language with a novel, blended intervention that focuses on joint engagement and play skills and incorporates an SGD. Future studies should further explore the tailoring design used in this study to better understand children's response to treatment. Clinical trial registration information-Developmental and Augmented Intervention for Facilitating Expressive Language (CCNIA); http://clinicaltrials.gov/; NCT01013545.

How autism became autism: The radical transformation of a central concept of child development in Britain

This article argues that the meaning of the word 'autism' experienced a radical shift in the early 1960s in Britain which was contemporaneous with a growth in epidemiological and statistical studies in child psychiatry. The first part of the article explores how 'autism' was used as a category to describe hallucinations and unconscious fantasy life in infants through the work of significant child psychologists and psychoanalysts such as Jean Piaget, Lauretta Bender, Leo Kanner and Elwyn James Anthony. Theories of autism were then associated both with schizophrenia in adults and with psychoanalytic styles of reasoning. The closure of institutions for 'mental defectives' and the growth in speech therapy services in the 1960s and 1970s encouraged new models for understanding autism in infants and children. The second half of the article explores how researchers such as Victor Lotter and Michael Rutter used the category of autism to reconceptualize psychological development in infants and children via epidemiological studies. These historical changes have influenced the form and function of later research into autism and related conditions.

Social outcomes in mid- to later adulthood among individuals diagnosed with autism and average nonverbal IQ as children

OBJECTIVE

To describe current social functioning in a clinical sample of 60 adults with autism (mean age = 44 years) who were all of average nonverbal IQ (70+) when first diagnosed (mean age = 6.75 years).

METHOD

Outcome measures included standardized diagnostic and cognitive assessments and questionnaires on social functioning. Child and adult variables related to current outcomes were explored.

RESULTS

All individuals continued to meet criteria for autism spectrum disorder (ASD) on the Autism Diagnostic Interview-Revised (ADI-R), but severity of autism symptoms declined over time. Nevertheless, only 10 individuals (17%) were rated as having a "good" or "very good" outcome; the majority (60%) were assessed as having "poor" or "very poor" outcomes. The strongest predictor of adult outcome was the Reciprocal Social Interaction domain score on the ADI at diagnostic confirmation. Change over time was further examined in a subgroup (n = 44) previously assessed 20 years ago earlier (mean age = 26 years). Although severity of autism had continued to decrease during the adult period, social outcomes were poorer than in younger adulthood.

CONCLUSIONS

In this cohort of adults first diagnosed with autism, on average, 37 years previously, social inclusion remains very limited, despite general improvements in autism symptomatology with age. Whether these findings will be replicated in future generations of children with autism, who now have the benefits of earlier diagnosis and wider access to specialist provision, needs to be the focus of further longitudinal research.

Quantifying repetitive speech in autism spectrum disorders and language impairment

We report on an automatic technique for quantifying two types of repetitive speech: repetitions of what the child says him/herself (self-repeats) and of what is uttered by an interlocutor (echolalia). We apply this technique to a sample of 111 children between the ages of four and eight: 42 typically developing children (TD), 19 children with specific language impairment (SLI), 25 children with autism spectrum disorders (ASD) plus language impairment (ALI), and 25 children with ASD with normal, non-impaired language (ALN). The results indicate robust differences in echolalia between the TD and ASD groups as a whole (ALN + ALI), and between TD and ALN children. There were no significant differences between ALI and SLI children for echolalia or self-repetitions. The results confirm previous findings that children with ASD repeat the language of others more than other populations of children. On the other hand, self-repetition does not appear to be significantly more frequent in ASD, nor does it matter whether the child's echolalia occurred within one (immediate) or two turns (near-immediate) of the adult's original utterance. Furthermore, non-significant differences between ALN and SLI, between TD and SLI, and between ALI and TD are suggestive that echolalia may not be specific to ALN or to ASD in general. One important innovation of this work is an objective fully automatic technique for assessing the amount of repetition in a transcript of a child's utterances.

Outcomes in adults with autism spectrum disorders: a historical perspective

In this review, we examine the ways in which researchers have defined successful adult outcomes for individuals with autism spectrum disorders (ASDs) from the first systematic follow-up reports to the present day. The earliest outcome studies used vague and unreliable outcome criteria, and institutionalization was a common marker of poor outcomes. In the past decade, researchers have begun to standardize the measurement of adult outcomes with specific criteria based on friendships, employment, and living arrangements. Although nearly all of these studies have agreed that the majority of adults with ASD have poor outcomes, evolving concepts of what it means to be an adult could have an impact on outcomes measured. For example, some researchers have suggested that taking into account the person-environment fit could reveal a more optimistic picture of outcomes for these adults. Suggestions for future research are discussed.

Predictors for work participation in individuals with an Autism spectrum disorder: a systematic review

INTRODUCTION

Research shows that only about 25% of people with autism are employed.

METHOD

We conducted a systematic review on factors facilitating or hindering work participation of people with autism in longitudinal studies. An extensive search in biomedical and psychological databases yielded 204 articles and 18 satisfied all inclusion criteria. We assessed the methodological quality of included studies using an established criteria list.

RESULTS

Seventeen factors were identified and categorized as disease-related factors, personal factors or external factors. Limited cognitive ability was the only significant predictor consistently found for work outcome. Functional independence and institutionalization were both reported by one study to be significantly related to work outcome. Inconsistent findings or non significant findings were reported for the other fourteen factors.

CONCLUSION

These findings emphasize the need for more high quality cohort studies focussing on work participation as the main outcome among people with Autism.

Early childhood predictors of the social competence of adults with autism

Longitudinal research into adult outcomes in autism remains limited. Unlike previous longitudinal examinations of adult outcome in autism, the twenty participants in this study were evaluated across multiple assessments between early childhood (M = 3.9 years) and adulthood (M = 26.6 years). In early childhood, responsiveness to joint attention (RJA), language, and intelligence were assessed. In adulthood, the parents of participants responded to interviews assessing the adaptive functioning, autistic symptomology and global functioning of their children. RJA and early childhood language predicted a composite measure of adult social functioning and independence. Early childhood language skills and intelligence predicted adult adaptive behaviors. RJA predicted adult non-verbal communication, social skills and symptoms. Adaptive behaviors changed with development, but symptoms of autism did not. Additional factors associated with adult outcomes are discussed.

Adults with autism spectrum disorders

In the decades since autism was first formally described in the 1940s, there have been major advances in research relating to diagnosis, causation, and treatment approaches for children with this condition. However, research into prognosis, outcomes, or effective interventions for adults with autism spectrum disorders (ASDs) is much more limited. In this paper, we review studies of outcome in adulthood. The findings indicate that, as adults, many people with ASD, including those of normal IQ, are significantly disadvantaged regarding employment, social relationships, physical and mental health, and quality of life. Support to facilitate integration within the wider society is frequently lacking, and there has been almost no research into ways of developing more effective intervention programs for adults. Moreover, most of the research on outcome has involved relatively young people in their 20s and 30s-much less is known about outcomes for people with ASD as they reach mid-late adulthood. Systematic follow-up studies from childhood through adulthood are needed if we are to gain a better understanding of trajectories of development over the lifespan, to identify the factors that influence prognosis, and to determine how these factors exert their effects and how they may be modified to ensure a better future.

Trajectory of behavior and emotional problems in autism

High rates of behavior and emotional problems have been consistently reported in children and adolescents with autism. Elevated rates of mental health problems have also been reported in adults with autism. Little is known, however, about the longitudinal development of behavior and emotional problems in autism. This study followed a cohort of children and adolescents over 18 years. Outcomes were evaluated in terms of behavior and emotional problems and autism symptomatology. The role of childhood factors (age, gender, IQ, behavior, and emotional problems) and the environment (socioeconomic disadvantage) were considered in terms of adult outcomes. Overall, improvements in comorbid behavior and emotional problems and autism symptomatology were observed. However, rates of comorbid behavior and emotional problems in adulthood remained high.

Do autistic symptoms persist across time? Evidence of substantial change in symptomatology over a 3-year period in cognitively able children with autism

This study investigated the extent and nature of changes in symptomatology in cognitively able children with autism over a 3-year period. Thirty-seven children diagnosed with an autism spectrum condition involved in an earlier study (M age  =  5 years, 7 months) were followed and reassessed 3 years later (M age  =  8 years, 4 months). Scores on the Social Communication Questionnaire (SCQ; M. Rutter, A. Bailey, & C. Lord, 2003 ) decreased significantly over time in all symptom domains but especially in the social domain, and correlational findings suggested the presence of 2 distinct developmental trajectories-social communication and repetitive behaviors-that interact across time. Furthermore, 7 children (19% of sample) made substantial changes to the extent that they failed to meet criteria on diagnostic instruments (the Autism Diagnostic Observation Schedule-Generic [ADOS-G; C. Lord, M. Rutter, P. C. DiLavore, & S. Risi, 1999 ] and the SCQ) 3 years later. Children showing diagnostic discontinuity were distinguishable from those who fulfilled ADOS-G criteria only in terms of the age at which they began receiving intervention. The presence of a significant proportion of children showing considerable progress over the 3-year period challenges assumptions of diagnostic continuity and highlights the potential long-term benefits of early intervention.

"Language construction in an autistic child: thoughts regarding language acquisition and language therapy": translation, update, and commentary on a 1977 case report

A 1977 Swiss case study is presented in English translation: a mute child with infantile autism is taught to speak starting at the relatively late age of 6. The author, who is the primary therapist and the child's father, details the conditioning procedure, discusses theoretical considerations in speech acquisition, and outlines the limits of the training. The author and translator update the child's status and add commentary.

The activities and participation of adolescents with autism spectrum disorders in Singapore: findings from an ICF-based instrument

BACKGROUND

This study sought to describe the activities and participation of adolescents with autism spectrum disorders (ASD) in Singapore and to examine the suitability of the Activity and Participation component of the International Classification of Functioning, Disability and Health for achieving this purpose. This information may guide the development of intervention programmes for adolescents and adults as well as the provision of a means to document meaningful outcomes.

METHODS

Parents of 20 adolescents with ASD attending special schools in Singapore were interviewed using the Vineland Adaptive Behavioural Scales - Second Edition and the Activities and Participation Rating Scale (APRS), which was developed for this study.

RESULTS

The adolescents with ASD were rated to have more difficulties with participation than with the engagement of activities. Individual domain analyses indicate no difficulties with mobility and mild difficulties with self-care. The performance of general tasks and demands were rated as less problematic than domestic, major life areas, communication and interpersonal interactions. The adolescents with ASD were rated to have more difficulties in communication and community environments than in at home. In addition, analysis of associations between the APRS and Vineland Adaptive Behavioural Scales - Second Edition reveal a pattern of strong relationships between sub-tests.

CONCLUSION

This study highlights the imperative for researchers and practitioners alike to develop a focus on strengths, generalisation and the quality of life of adolescents with ASD. The APRS also shows promise in helping document outcomes for adolescents with ASD in Asia and further development of this instrument is needed.

Brain plasticity and disease: a matter of inhibition

One major goal in Neuroscience is the development of strategies promoting neural plasticity in the adult central nervous system, when functional recovery from brain disease and injury is limited. New evidence has underscored a pivotal role for cortical inhibitory circuitries in regulating plasticity both during development and in adulthood. This paper summarizes recent findings showing that the inhibition-excitation balance controls adult brain plasticity and is at the core of the pathogenesis of neurodevelopmental disorders like autism, Down syndrome, and Rett syndrome.

Autism spectrum disorders

The term autism spectrum disorder refers to a constellation of symptoms involving impairments in social interaction and communication, and restricted, repetitive behaviours and interests. This article highlights the disorder among professionals who may come into contact with people with autism spectrum disorder.