Prevalence and Disparities in the Detection of Autism Without Intellectual Disability

Physical health trajectories of young people with neurodevelopmental conditions: a protocol for a systematic review of longitudinal studies

INTRODUCTION

There is now emerging evidence to suggest a longitudinal association between specific neurodevelopmental conditions (NDCs) in childhood or adolescence (ie, autism, attention deficit hyperactivity disorder (ADHD) and tic disorders) and certain physical long-term conditions (LTCs) in adulthood. However, to date, this literature has never been comprehensively collated and appraised. As a result, our understanding of all the future health risks that young people with NDCs may collectively be at risk of is limited, and the factors which drive these adult health outcomes also remain obscure.

METHODS AND ANALYSIS

A search strategy has been developed in collaboration with two medical librarians and will be used to conduct systematic searches of MEDLINE, EMBASE, APA PsycINFO, CINAHL and Web of Science. Prospective longitudinal studies exploring the association between three common NDCs in childhood or adolescence (ie, ADHD, autism and tic disorders <18 years of age) and any physical LTC in adulthood (ie, >18 years of age) will be selected through title and abstract review, followed by a full-text review. Data extracted will include the definition of exposure and outcome, mediators or moderators investigated, confounders adjusted for, and crude and adjusted effect estimates. Risk of bias assessment will be conducted. Results will be synthesised narratively and, if the data allow, a meta-analysis will also be conducted.

ETHICS AND DISSEMINATION

Ethics approval is not applicable for this study since no original data will be collected. The results of the review will be widely disseminated locally, nationally and internationally through peer-reviewed publications, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42024516684.

Implementation of M-Chat for Screening of Early Signs of Autism in the Brazilian Health Care System: A Feasibility Study

Background: Although screening for early signs of autism spectrum disorder (ASD) using the Modified Checklist for Autism in Toddlers (M-CHAT) has been recommended by the Brazilian Ministry of Health since 2014, the feasibility of this intervention and its effects in primary care have not been sufficiently investigated. Objectives: (1) to verify the feasibility of implementing the M-CHAT in the Brazilian Unified Health System, through routine childcare vaccination; (2) to evaluate the level of knowledge and practices of nursing professionals in Brazilian primary health care in relation to ASD to check the expertise to apply M-CHAT to verify early signs of this condition; (3) to verify, after implementation, the frequency of children with possible early signs of ASD using the M-CHAT. Methods: This is an observational, cross-sectional study conducted in a medium-sized city in southeastern Brazil. A total of 97 nursing professionals from 21 health facilities participated. The professionals answered a questionnaire on knowledge and practices regarding ASD, attended training on early signs of ASD and for the use of M-CHAT. Finally, they administered the M-CHAT to 267 parents of children aged 16 to 57 months in primary care settings. Results: Insufficient knowledge of ASD was identified among the nursing professionals evaluated. Approximately 80% agreed that the training was satisfactory, and 88% agreed that they felt competent to use the M-CHAT; 74% agreed with the benefits of using the M-CHAT to detect early signs of ASD in public health settings. However, 91% of the professionals reported that incorporating the M-CHAT into the day care routine overloaded their work, and less than 50% agreed that the instrument should continue to be used in the day care routine. Sixty-seven (25.09%) children screened positive for possible early signs of ASD by M-CHAT. Conclusions: The insufficient level of knowledge on ASD found among nursing professionals suggests gaps in Brazilian academic and professional training in this area. Although most participants recognized the importance of early detection of signs of ASD in primary care settings, the implementation of the M-CHAT in the routine primary care settings was not well accepted for most participants due to work overload, which indicates the need for public health policies to offer working conditions that minimize the overload of professionals, maintaining early screening interventions for ASD in Brazilian primary care institutions.

Clinician-caregiver informant discrepancy is associated with sex, diagnosis age, and intervention use among autistic children

Clinician and caregiver reports of autism features are both integral to receiving an autism diagnosis and appropriate intervention, yet informant discrepancies are present in clinical practice and may differ by demographic characteristics of the child and family. The present study examined how clinician-caregiver discrepancies in ratings of a child's autism-related behaviors relate to a child's sex at birth, age at first diagnosis, and amount of intervention received. Participants were 280 children (76.8% male, 67.9% White), 6-11 years old (M = 8.5 ± 1.6), with a diagnosis of autism spectrum disorder. Variable-centered and person-centered approaches were used to examine relationships between standardized clinician-caregiver discrepancy and participant characteristics. Both analytic approaches indicated that clinicians rated autism-related behaviors lower than caregivers for females and higher than caregivers for males. In addition, lower clinician ratings of autism features, relative to caregiver ratings, were associated with older age at diagnosis and fewer hours of intervention. Findings underscore the importance of incorporating multiple informants, especially caregivers, in the diagnostic process and developing diagnostic procedures sensitive to the female autism phenotype to facilitate diagnosis, intervention, and subsequent development.Lay abstractIn some cases, a clinician's perceptions of a child's autism-related behaviors are not the same as the child's caregiver's perceptions. Identifying how these discrepancies relate to the characteristics of the child is critical for ensuring that diagnosis procedures are unbiased and suitable for all children. This study examined whether discrepancies between clinician and caregiver reports of autism features related to the child's sex at birth. We also explored how the discrepancies related to the age at which the child received their autism diagnosis and how much intervention they received. We found that clinicians rated autism features higher than caregivers for boys and rated autism features lower than caregivers for girls. In addition, lower clinician relative to parent ratings was related to being diagnosed at an older age and receiving less intervention. These findings suggest that there is more to learn about the presentation of autism-related behaviors in girls. When caregiver and clinician ratings of autism features do not align, it may be important to consider caregivers' ratings to obtain a more accurate picture of the child's autism features and the support they may need.

Utility of the Modified Anxiety Dimensional Observation Scale in Autistic Preschoolers with Varying Intellectual Functioning

OBJECTIVE

Co-occurring anxiety affects 40-80% of autistic individuals; however, little is understood about how anxiety manifests in young autistic children, especially those with intellectual disability (ID), partly due to the paucity of measures designed to assess anxiety symptoms in this population. The present study examined the utility of the Modified Anxiety Dimensional Observation Scale (M-Anx-DOS), an observational measure of anxiety-related behaviors, in preschool-aged autistic children with and without ID.

METHOD

This study included 48 autistic children (Mean age = 43.96 months; 81.3% with ID) and 30 non-autistic (NA) controls (Mean age = 43.66 months). Anxiety-related behaviors were measured during the M-Anx-DOS. Parent-reported anxiety symptoms were assessed via the Preschool Anxiety Scale-Revised (PAS-R).

RESULTS

Groups exhibited comparable scores on both the M-Anx-DOS and PAS-R. Within the autism group, a subset of M-Anx-DOS scores were related to age, autistic features, or IQ. The M-Anx-DOS exhibited excellent inter-rater reliability and acceptable internal consistency. Convergent validity was promising, with specific M-Anx-DOS scores correlated with parent-reported social, separation, and overall anxiety symptoms. M-Anx-DOS scores were not correlated with parent-reported ADHD or externalizing symptoms, suggesting strong discriminant validity.

CONCLUSIONS

This study provides preliminary evidence of the reliability and validity of the M-Anx-DOS. These findings are promising given the importance of observational measurement of anxiety and lack of existing measures for this critical developmental period. Given the sample size and the complexity of identifying prodromal signs of anxiety in young autistic preschoolers with ID, future longitudinal work is essential to replicate and extend this work.

Tooth brushing behavior and oral health care of people with early childhood autism in Germany

OBJECTIVES

Only a little is known about the tooth brushing behaviors and oral health care of people with early childhood autism (P-EA). To remedy this, a survey was carried out with P-EA of all ages.

MATERIALS AND METHODS

In summer 2021, an online survey questionnaire with 124 questions, addressed only at caregivers of P-EA, was sent to all members of the Bundesverband Autismus Deutschland e.V. Our present study evaluated the 20 survey questions related to dental self-care.

RESULTS

In total, 130 questionnaires were evaluated. The mean age of the P-EA was 22.7 years (min: 3y; max: 60y; SD ± 14.1y). Only 17.7% (n =23) of the P-EA were female, while 82.3%(n =107) were male. Overall, 54.6% (n = 71) of P-EA are always actively assisted in tooth brushing. Although 57.7% (n = 75) of P-EA brushed teeth twice daily, 39.2% brushed for one to two minutes (n = 51). P-EA younger than 18 years old selected toothpaste primarily for taste reasons (32.7%;n = 18). Only 9.3% (n = 7) of adult P-EA selected toothpaste because of the fluoride content. Manual toothbrushes were preferred by 40.8% (n = 53) of the P-EA, and electric toothbrushes by 34.6% (n = 45). Almost three quarters (71.5%;n = 93) did not use additional dental care implements. The same number (75.4%;n = 98) of P-EA had not practiced supervised brushing in a dental office.

CONCLUSIONS/CLINICAL RELEVANCE

Active support in dental self-care is crucial for a majority of the P-EA in Germany, regardless of their age. Professional support needs to be fundamentally improved. Clinical concepts for practical instruction in dental hygiene should be developed for P-EA.

Improving Access to Early Developmental Evaluation in Academic Primary Care Centers

Introduction

Developmental disorders (DDs) affect approximately 1 in 6 children in the United States. Early identification and treatment improve developmental outcomes and child and family functioning. Disparities exist in the diagnosis of DD that leads to inequitable access to developmental services during important periods of neuroplasticity. Improve access to the developmental and behavioral pediatrics (DBP) clinic for developmental evaluation when developmental delays occur among children 3-5 years of age by increasing the percentage of children scheduled for and completing an initial visit in 90 days from 20% to 40%.

Methods

We used the Institute of Health Improvement model, executed mapping failure modes, created a key driver diagram and conducted plan-do-study-act cycles. We plotted data over time in a statistical control chart. The key intervention was an expedited, collaborative referral and scheduling process developed, tested, and implemented by the general pediatric clinic and DBP stakeholders. Additional interventions included reminder notifications and calls to patients who missed appointments.

Results

The percentage of patients referred to DBP who scheduled and completed their initial visit in DBP within 90 days increased from 20% to 40%. DBP clinicians suspecting that patients had global developmental delay and/or autism spectrum disorder at the initial DBP visit referred them for more extensive developmental testing with psychology and speech-language providers.

Conclusions

Access to developmental evaluation for preschool-aged children at risk for delayed diagnosis and treatment was improved using quality improvement methodology focused on flexible and creative priority scheduling practices from within the medical home.

Parents' and guardians' experiences of barriers and facilitators in accessing autism spectrum disorder diagnostic services for their children: a qualitative systematic review

OBJECTIVE

The objectives of this review were to comprehensively identify the best available qualitative evidence on parents' and guardians' experiences of barriers and facilitators in accessing autism spectrum disorder (ASD) diagnostic services for their children, and to develop recommendations based on the review for addressing barriers to timely diagnosis and early intervention.

INTRODUCTION

Early identification of ASD is a priority because the best chance for improving symptoms occurs through early and intensive intervention. A definitive ASD diagnosis is often a prerequisite for children to access publicly funded services, yet obtaining a diagnosis in itself can be stressful, frustrating, and time-consuming for many families. It is essential to understand the barriers and facilitators parents and guardians face in accessing ASD diagnostic services for their children.

INCLUSION CRITERIA

This qualitative systematic review considered studies conducted worldwide that included parents and guardians of children up to 18 years of age who had accessed or who were attempting to access ASD diagnostic services for their children.

METHODS

This review was conducted in accordance with the JBI methodology for systematic reviews of qualitative evidence. A literature search included CINAHL (EBSCOhost), CINAHL Plus (EBSCOhost), MEDLINE (EBSCOhost), APA PsycINFO (EBSCOhost), Social Services Abstracts (ProQuest), ERIC (EBSCOhost), and Embase. Gray literature sources included ProQuest Dissertations and Theses, Google Scholar, Google, OpenGrey, other online resources (government and organizational websites), and reference lists of retrieved records. No language, date, or country limits were applied to the searches. Retrieved records from the academic databases, gray literature, and reference lists of retrieved records were screened, with potentially relevant records examined in full against the inclusion criteria. Eligible studies were critically appraised for methodological quality, and those included in this review were subjected to data extraction of descriptive details and study findings relevant to the review question. Study findings were synthesized and assigned confidence scores. All reviewers agreed upon the categories and finalized synthesized findings.

RESULTS

The 36 included studies varied in qualitative research designs and were assessed as having high methodological quality. There were 661 eligible participants, and 55 credible and unequivocal research findings were extracted. The research findings yielded 6 categories and 3 synthesized findings with moderate confidence scores. Parents' and guardians' ability to access ASD diagnostic services for their children is affected by i) encountering health care providers who actively listened to and addressed parents' and guardians' concerns instead of dismissing them, providing a sense of support and validation; ii) facing extended waiting times and associated financial burdens, resulting in frustration and associated financial impact when delays occurred; and iii) encountering health care providers lacking specialized knowledge about ASD, contributing to parents' and guardians' confusion due to inaccurate or conflicting diagnoses related to ASD comorbidities.

CONCLUSION

Many parents described their journey in accessing ASD assessment and diagnostic services for their children as cumbersome. Parents' and guardians' experiences were affected by the level of perceived support by and knowledge of health care providers; confusion surrounding inaccurate/mixed diagnoses related to ASD, lengthy delays, and systemic and contextual barriers in navigating the pathway to ASD assessment and diagnosis that included socioeconomic and cultural disparities.

REVIEW REGISTRATION

PROSPERO CRD42018100127.

Effect of the social environment on olfaction and social skills in wild-type and a mouse model of autism

Autism spectrum disorders (ASD) are complex, polygenic and heterogenous neurodevelopmental conditions. The severity of autism-associated variants is influenced by environmental factors, particularly social experiences during the critical neurodevelopmental period. While early behavioral interventions have shown efficacy in some children with autism, pharmacological support for core features - impairments in social interaction and communication, and stereotyped or restricted behaviors - is currently lacking. In this study, we examined how the social environment influences both wild-type (WT) and Shank3 knockout (KO) mice, a model reflecting core autism-like traits. Our findings revealed that chronic social isolation enhanced social interaction and olfactory neuron responses in WT animals. Furthermore, it restored impairments in social novelty preference and olfactory function, as well as self-grooming in Shank3 KO mice. Conversely, an enriched social environment heightened social interest toward novel conspecifics in WT mice, but elicited the opposite effect in Shank3 KO mice. Notably, Shank3 KO mice displayed distinct social responses when exposed to WT or Shank3 KO mice. These results offer novel insights that could favor the implementation of behavioral interventions and inclusive classroom programs for children with ASD.

Resilience and strengths in the Black autism community in the United States: A scoping review

Gaps in research knowledge pertaining to resiliency factors and strengths among the Black autism community, inclusive of autistic persons and their support system exist. A scoping review was conducted to further explore quantitative, qualitative, and mixed methods studies that investigate resiliency factors and related strengths in the Black autism community in the United States. A total of 436 articles were identified, with 28 studies included in the final review. Results demonstrated that (1) strengths of Black autistic persons across the life course have been disregarded in research; (2) Black caregiver advocacy, while common, is also a developmental process that can be supported by community-based interventions; (3) informal supports including family and friends play an instrumental role in supporting the well-under investigated being of Black parents of autistic children; and (4) spirituality is often endorsed by Black caregivers of autistic children, such as playing a role in acceptance of the autism diagnosis and with coping with difficult life situations. Research and practice implications are discussed.

Challenges in the Differential Classification of Individual Diagnoses from Co-Occurring Autism and ADHD Using Survey Data

Autism and Attention-Deficit Hyperactivity Disorder (ADHD) are two of the most commonly observed neurodevelopmental conditions in childhood. Providing a specific computational assessment to distinguish between the two can prove difficult and time intensive. Given the high prevalence of their co-occurrence, there is a need for scalable and accessible methods for distinguishing the co-occurrence of autism and ADHD from individual diagnoses. The first step is to identify a core set of features that can serve as the basis for behavioral feature extraction. We trained machine learning models on data from the National Survey of Children's Health to identify behaviors to target as features in automated clinical decision support systems. A model trained on the binary task of distinguishing either developmental delay (autism or ADHD) vs. neither achieved sensitivity >92% and specificity >94%, while a model trained on the 4-way classification task of autism vs. ADHD vs. both vs. none demonstrated >65% sensitivity and >66% specificity. While the performance of the binary model was respectable, the relatively low performance in the differential classification of autism and ADHD highlights the challenges that persist in achieving specificity within clinical decision support tools for developmental delays. Nevertheless, this study demonstrates the potential of applying behavioral questionnaires not traditionally used for clinical purposes towards supporting digital screening assessments for pediatric developmental delays.

Survey of the Landscape of Society Practice Guidelines for Genetic Testing of Neurodevelopmental Disorders

Genetic testing of patients with neurodevelopmental disabilities (NDDs) is critical for diagnosis, medical management, and access to precision therapies. Because genetic testing approaches evolve rapidly, professional society practice guidelines serve an essential role in guiding clinical care; however, several challenges exist regarding the creation and equitable implementation of these guidelines. In this scoping review, we assessed the current state of United States professional societies' guidelines pertaining to genetic testing for unexplained global developmental delay, intellectual disability, autism spectrum disorder, and cerebral palsy. We describe several identified shortcomings and argue the need for a unified, frequently updated, and easily-accessible cross-specialty society guideline. ANN NEUROL 2024;96:900-913.

Assessment of Knowledge and Attitude of General Practitioners Regarding Autism and Associated Factors at Gondar University Hospital, Gondar, Ethiopia

Background: The neurodevelopmental conditions known as autism spectrum disorders (ASDs) start in early childhood and last the entirety of a person's life. They are characterized by distorted social interaction, difficulties communicating, and repetitive, stereotypical behavior. Objective: This study sought to evaluate general practitioners (GPs)' attitudes and knowledge of ASDs and related factors at Gondar University Hospital. Methods: An institutional-based cross-sectional study design was used. Using a convenience-sample method, three-hundred sixty individuals were chosen for this study. Data were collected using a self-administered questionnaire. The GPs who took part in this survey were characterized by descriptive statistics. The relationship between the dependent variables (knowledge and attitude) and the sociodemographic characteristics was examined using an independent two-sample t-test and Pearson correlation analysis. The Statistical Package for the Social Sciences Version 25 was used for all data analyses. Results: In this study, the GPs had an average age of 31.82 years, with an average of 18 years since graduation and 16 years of practice. Participants' average overall knowledge and attitude scores on autism were 15.83 (SD = 3.27) and 29.54 (SD = 3.21), respectively, both falling within the moderate range. Using an independent t-test, we found a significant difference (p < 0.001) between the attitudes of male and female GPs regarding autism. The study also identified weakly significant correlations between GPs' age and their attitudes toward autism (r = 0.271⁣∗∗, p < 0.001) and between years of practice and attitudes (r = 0.105⁣∗, p=0.046). However, no significant correlations emerged between GPs' knowledge and their age, years since graduation, or years of practice (r = 0.069, p=0.194; r = 0.069, p=0.193; and r = -0.053, p=0.312, respectively). In addition, we observed a weakly significant association (r = 0.004⁣∗∗, p < 0.001) between GPs' knowledge and their attitudes about autism. Conclusion: Based on their total scores, the participants had a moderate level of knowledge and attitudes toward autism. There was a favorable correlation found between the study subjects' attitudes regarding autism and their age, as well as their practice year. Furthermore, a clear correlation was observed between GPs' attitudes and their understanding of autism.

Intranasal Insulin Eases Autism in Rats via GDF-15 and Anti-Inflammatory Pathways

In rat models, it is well-documented that chronic administration of propionic acid (PPA) leads to autism-like behaviors. Although the intranasal (IN) insulin approach is predominantly recognized for its effects on food restriction, it has also been shown to enhance cognitive memory by influencing various proteins, modulating anti-inflammatory pathways in the brain, and reducing signaling molecules such as interleukins. This study seeks to explore the potential therapeutic benefits of IN insulin in a rat model of autism induced by PPA. Thirty male Wistar albino rats were categorized into three cohorts: the control group, the PPA-induced autism (250 mg/kg/day intraperitoneal PPA dosage for five days) group, treated with saline via IN, and the PPA-induced autism group, treated with 25 U/kg/day (250 µL/kg/day) insulin via IN. All treatments were administered for 15 days. After behavioral testing, all animals were euthanized, and brain tissue and blood samples were collected for histopathological and biochemical assessments. Following insulin administration, a substantial reduction in autism symptoms was observed in all three social behavior tests conducted on the rats. Moreover, insulin exhibited noteworthy capabilities in decreasing brain MDA, IL-2, IL-17, and TNF-α levels within autism models. Additionally, there is a notable elevation in the brain nerve growth factor level (p < 0.05) and GDF-15 (p < 0.05). The assessment of cell counts within the hippocampal region and cerebellum revealed that insulin displayed effects in decreasing glial cells and inducing a significant augmentation in cell types such as the Purkinje and Pyramidal cells. The administration of insulin via IN exhibits alleviating effects on autism-like behavioral, biochemical, and histopathological alterations induced by PPA in rats. Insulin-dependent protective effects show anti-inflammatory, anti-oxidative, and neuroprotective roles of insulin admitted nasally.

Female Infertility and Neurodevelopmental Disorders in Children: associations and evidence for familial confounding in Denmark

IMPORTANCE

Existing research suggests the impact of infertility on the risk of neurodevelopmental disorders in children, however, studies to date have failed to separate the impact of male and female infertility, often blurring the lines with proxies that encompass all forms of infertility. Moreover, while both health conditions co-occurring with infertility and genetic factors operating upstream have been suggested to influence the association between infertility and child outcomes, their roles and potential impact on observed associations remain unclear.

OBJECTIVE

The objectives of this study are to investigate the relationship between female infertility and autism in the child, differentiating it from the effects of male and the couple infertility; consider the role of various maternal and birth factors in the association; and examine the effects of shared familial confounders on the association.

DESIGN SETTING AND PARTICIPANTS

Danish population-based cohort study, including all singleton live births in Denmark 1998-2015, their parents and parents' siblings. The cohort was followed up until December 31, 2016.

EXPOSURES

The exposure was a history of female infertility in the mother and the mother's sister. We examined four definitions of female infertility based on the ICD-10 codes derived from the Danish National Patient Register - any female infertility; specified female infertility; female exclusive infertility; and female or male infertility.

MAIN OUTCOME AND MEASURES

The outcome was diagnosis of autism spectrum disorder (ASD) in the Danish Psychiatric Central Research Register or the national patient register. A multivariable Cox regression model was used to estimate the associations between female infertility and autism, accounting for child's sex, year of birth, maternal age, education level, chronic comorbidities, and pregnancy and birth complications. The effects of shared familial factors on the association were analyzed using exposure information from the child's maternal aunt.

RESULTS

The cohort included 1,131,899 mother-child pairs, among which 18,374 children with ASD diagnosis. History of female infertility in the mother (all definitions) was significantly associated with autism in the child, with the association remaining robust after adjustment for covariates (HRadj=1.14 (95% CI, 1.03-1.26) for specified infertility). The diagnosis of infertility in a child's maternal aunt was also significantly linked to the child's autism risk, even after adjustment for maternal infertility (HRadj=1.10 (95% CI, 1.00-1.20).

CONCLUSIONS AND RELEVANCE

in This population-based birth cohort study, we found a slightly higher risk of autism in children born to mothers with a history of infertility, with the association remaining consistent across various definitions of female infertility and robust to adjustments for demographic, child, and maternal factors. The study suggests for the first time that shared familial factors, possibly both genetic and non-genetic, could be influencing both female infertility and the risk of autism in children, indicating a need for further investigation into these familial effects.

Aerobic exercise improves cognitive flexibility and modulates regional volume changes in a rat model of autism

Gestational exposure to valproic acid (VPA) is a risk factor for autism spectrum disorder (ASD). Rodents exposed to VPA in utero display common features of ASD, including volumetric dysregulation in higher-order cognitive regions like the medial prefrontal cortex (mPFC), the anterior cingulate cortex (ACC), and the hippocampus. Exercise has been shown in elderly populations to boost cognition and to buffer against brain volume losses with age. This study employed an adolescent treadmill exercise intervention to facilitate cognitive flexibility and regional brain volume regulation in rats exposed to VPA during gestation. It was found that exercise improved performance on extra-dimensional shifts of attention on a set-shifting task, which is indicative of improved cognitive flexibility. Exercise decreased frontal cortex volume in females, whereas in males exercise increased the ventral hippocampus. These findings suggest that aerobic exercise may be an effective intervention to counteract the altered development of prefrontal and hippocampal regions often observed in ASD.

Diagnostic findings and yield of investigations for children with developmental regression

Childhood conditions that feature developmental regression are poorly understood. Phenotype-genotype characterization and diagnostic yield data are needed to inform clinical decision-making. The aim of this study was to report the conditions featuring developmental regression and assess diagnostic yields of investigations. A retrospective chart review of children presenting with developmental regression to a tertiary pediatric genetic clinic between 2018 and 2021 was performed. Of 99 children, 30% (n = 30) had intellectual disability (ID), 21% (n = 21) were autistic, 39% (n = 39) were autistic with ID, and 9% (n = 9) did not have ID or autism. Thirty-two percent (n = 32) of children received a new diagnosis, including eight molecular findings not previously reported to feature developmental regression. Of the children investigated, exome sequencing (ES) provided the highest diagnostic yield (51.1%, n = 24/47), highest (63.6%, n = 14/22) for children with ID, 50% for autistic children with ID (n = 6/12) and children without autism or ID (n = 3/6), and 14.3% (n = 1/7) for autistic children without ID. We highlight the conditions that feature developmental regression and report on novel phenotypic expansions. The high diagnostic yield of ES, regardless of autism or ID diagnosis, indicates the presence of developmental regression as an opportunity to identify the cause, including for genetic differences not previously reported to include regression.

Females evaluated for autism: characteristics and co-occurring and differential DSM-5 diagnoses

Objective: While sex differences in autism spectrum disorder (ASD) have been identified in areas such as neurocognitive functioning, behavior patterns, and diagnostic criteria, less work has focused on differences within females referred for ASD evaluation, including those who did not go on to receive a diagnosis. This study examined psychological and behavioral characteristics and co-occurring and differential DSM-5 diagnoses between pediatric female participants who received an ASD diagnosis (ASD+) and those who did not (ASD-). Method: Data on cognitive functioning, adaptive functioning, internalizing symptoms, externalizing symptoms, and ADOS-2 scores were analyzed among 137 3- to 20-year-old patients. The sample was divided into two age groups (ages 3-8 and ages 9-20) for analyses of between-group differences (ASD+ vs. ASD-) and predictors of group membership. Results: Females in the ASD+ group were significantly younger, had lower cognitive scores, lower internalizing and externalizing symptoms, and had higher Autism Diagnostic Observation Schedule-2 (ADOS-2) scores than those in the ASD- group. ADOS-2 scores were also the only significant predictor of ASD group membership across age groups. The ASD+ group had a higher percentage of intellectual disability while the ASD- group had higher percentages of anxiety disorder, attention-deficit/hyperactivity disorder, and disruptive behavior disorders. Conclusions: Psychological and behavioral presentations among females referred for ASD evaluation varied with age and ASD diagnostic groups. These results highlight potential female differences in ASD referrals and identification of ASD and the need to improve care for females in consideration of demographic factors.

Familial Recurrence of Autism: Updates From the Baby Siblings Research Consortium

OBJECTIVES

Autism spectrum disorder (ASD) is estimated to be ∼10 times higher in children with versus without an autistic sibling in population-based studies. Prospective studies of infant siblings have revealed even higher familial recurrence rates. In the current prospective longitudinal study, we provide updated estimates of familial ASD recurrence using a multinational database of infants with older autistic siblings.

METHODS

Data were collated across 18 sites of the Baby Siblings Research Consortium, an international network studying the earliest manifestations of ASD. A total of 1605 infants with an older autistic sibling were followed from early in life to 3 years, when they were classified as ASD or non-ASD. Hierarchical generalized linear modeling, with site as a random effect, was used to examine predictors of recurrence in families and calculate likelihood ratios.

RESULTS

A total of 20.2% of siblings developed ASD, which is not significantly higher than the previously reported rate of 18.7%. Male infant sex and >1 older affected sibling were significant predictors of familial recurrence. Proband sex also influenced recurrence rates, with siblings of female probands significantly more likely to develop ASD than siblings of male probands. Race and maternal education were also associated with recurrence in families.

CONCLUSIONS

The familial recurrence rate of ASD, as measured in infant sibling studies, has not changed appreciably since previous estimates were made in 2011. Younger siblings of autistic children, particularly those who are male, have an affected female sibling, multiple affected siblings, or are impacted by social inequities, should be closely monitored and promptly referred for diagnostic evaluation.

The Reliability of Field-Based Static and Dynamic Balance Tests in Primary School-Aged Autistic Children

Previous research has proven that the balance of autistic children is poor. However, the reliability of assessing balance in this cohort has been inadequately researched. This study therefore aimed to examine if field-based static and dynamic balance tests can be reliably assessed in autistic children, to determine the number of familiarisation sessions required and whether autistic severity impacts on the reliability of these balance tests. The balance of eighteen primary school-aged autistic children was assessed three times a week over five weeks, using the flamingo balance test, a modified version of the balance error scoring system (BESS), the low beam walking test, and the heel to toe walking test. Reliability criteria included an intraclass correlation coefficient (ICC) level of ≥0.75 and a coefficient of variance (CV%) of ≤46% for the low beam walking test, the heel to toe walking test, and the BESS, and a CV% of ≤82% or the flamingo balance test. Inter-session reliability was achieved and required the least number of familiarisation sessions for the flamingo balance test, compared to the low beam walking test, which required a greater number of familiarisation sessions to achieve inter-session reliability. The heel to toe walking test and the BESS achieved inter-session reliability and familiarisation in an acceptable time frame. Due to the large CV% values reported in the current study, practitioners need to be aware that balance interventions need to achieve improvements greater than the CV% in this cohort.

Game Changer: Exploring the Role of Board Games in the Lives of Autistic People

This mixed methods paper reports findings from three studies examining the overlap between autism and hobbyist board gaming. The first was a quantitative survey of over 1600 board gamers, showing that autistic individuals are overrepresented in this hobby compared to the general population and that autistic traits measured by the AQ are significantly elevated amongst board gamers. Study 1 also assessed gamers' motivations and preferences and reported key differences as well as similarities between autistic and non-autistic gamers. The second was a qualitative study that reported the results of 13 interviews with autistic individuals who are hobbyist board gamers. Using Interpretive Phenomenological Analysis (IPA), four key themes were uncovered, including a preference for systemising, escapism and passions, the social lubrication effect of games and difficulties with deception. In the third, 28 autistic individuals were introduced to board games in groups of 5-10 over an afternoon. Subsequent focus groups were then analysed using IPA. This analysis uncovered themes around how board games are challenging but encouraged growth and how they were an alternative vehicle for forging social relationships. Through this paper, we discuss how and why board games may be a popular hobby amongst the autistic population, and its potential utility for improving autistic wellbeing.

"There is No Help:" Caregiver Perspectives on Service Needs for Adolescents and Adults with Profound Autism

The underrepresentation of individuals with profound autism (who require 24/7 access to care) in autism research has resulted in limited knowledge about their service needs and a lack of evidence-based practices tailored to those needs. This study explored caregiver perspectives on service needs, barriers to accessing care, and treatment priorities to guide treatment development and improvement of service delivery. A sequential mixed-methods design integrated quantitative survey data (n = 423; Mage = 18.89 years; 26.7% female) with qualitative interviews (n = 20) with caregivers of adolescents and adults with profound autism. Quantitative findings indicated regular socialization opportunities were the most frequently endorsed unmet service need (60.3% of caregivers), followed by primary health care with autism-trained staff (59.3%), social skills instruction (55.8%), life skills instruction (51.3%), and behavioral support (47.3%). Higher likelihood of needing social activity groups was associated with elevated emotional reactivity, higher language level, minoritized ethnicity, and lower household income. Greater need for specialized primary health care was associated with lower income, while the need for social and life skills instruction was associated with increased age and elevated dysphoria. Qualitative analysis identified 10 themes that converged and expanded quantitative findings by highlighting a pervasive shortage of individualized, goal-oriented services, common barriers to care, and the priority of developing centralized treatment settings that coordinate care throughout adulthood. This study identified pressing service needs for adolescents and adults with profound autism in the United States. These insights are crucial for improving the accessibility and quality of clinical care.

Psychometric evaluation of a revised version of the body appreciation scale-2 for autistic adults (BAS-2A)

Emerging evidence points to unique conceptualisations of positive body image in autistic individuals. However, there are no existing measures of positive body image that have been developed or validated for use with autistic adults. To rectify this, we developed a revised version of the BAS-2 - the BAS-2A - and examined its factorial validity and psychometric properties in a sample of autistic adults from the United Kingdom. Based on the results of exploratory factor analysis and scale purification, we extracted a 12-item, unidimensional model of BAS-2A scores in a first split-subsample (n = 273). Confirmatory factor analysis supported the unidimensional model of BAS-2A scores in a second split-subsample (n = 277). BAS-2A scores presented adequate composite reliability, measurement invariance across gender identity, and patterns of construct validity. For both women and men, BAS-2A scores correlated positively with self-esteem, well-being, quality of life, and adaptive coping, and inversely with dietary restraint, weight/shape overvaluation, body dissatisfaction, and depression. Finally, BAS-2A scores demonstrated incremental validity, predicting self-esteem over-and-above body dissatisfaction. However, temporal stability of the BAS-2A over three weeks was not supported. These results support the BAS-2A as a psychometrically robust measure of body appreciation for use in autistic adults from the United Kingdom.

Screening for Autism: A Review of the Current State, Ongoing Challenges, and Novel Approaches on the Horizon

Screening for autism is recommended in pediatric primary care. However, the median age of autism spectrum disorder (ASD) diagnosis is substantially higher than the age at which autism can reliably be identified, suggesting room for improvements in autism recognition at young ages, especially for children from minoritized racial and ethnic groups, low-income families, and families who prefer a language other than English. Novel approaches are being developed to utilize new technologies in aiding in autism recognition. However, attention to equity is needed to minimize bias. Additional research on the benefits and potential harms of universal autism screening is needed. The authors provide suggestions for pediatricians who are considering implementing autism-screening programs.

Theoretical-Methodological Foundations for the Global Integration Method (Método de Integração Global-MIG) in the Treatment of Autism Spectrum Disorder

Currently, there is no intervention model for autism spectrum disorder (ASD) that addresses all levels and factors of the International Classification of Functioning, Disability and Health (ICF, WHO). The most researched programs focus on naturalistic, developmental and behavioral approaches to socio-communication. Less attention has been paid to motor and environmental reactivity aspects (behavior/interest restriction and sensory reactivity). The evidence rationale for the Global Integration Method (MIG, "Método de Integração Global"), a model addressing sensorimotor reactivity in addition to socio-communication, is presented. MIG is an integrative, interdisciplinary, family-oriented intervention and naturalistic program that addresses all levels and moderating factors of ASD's impact. MIG's theoretical rationale is based on the predictive coding impairment and embodied cognition hypotheses. MIG incorporates both bottom-up (flexible therapeutic suit, social-motor synchronization) and top-down (schematic social information processing, narratives, imagery) strategies to promote the building and use of accurate, flexible and context-sensitive internal predictive models. MIG is based on the premises that predictive coding improves both socio-communication and environmental reactivity, and that the postural stabilization provided by the flexible therapeutic suit frees information processing resources for socio-cognitive learning. MIG builds on interdisciplinary, professionally and parentally mediated work based on behavioral principles of intensive training in a situated environment.

Schema therapy in adults with autism spectrum disorder: A scoping review

BACKGROUND

Schema therapy (ST) in adults with autism spectrum disorder (ASD) have gained increasing interest in clinical practice and research. However, to date, there has been no synthesis of the literature on ST as treatment for adults with ASD. Through a scoping review, we aim to summarize the emerging research and literature on ST for adults with ASD.

METHODS

A comprehensive literature search of three electronic databases was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. Publications were included that examined ST in adults with ASD and non-clinical adults with autistic traits.

RESULTS

Systematic searches identified a total of 11 publications, all published since 2014, with the majority being conducted by Dutch and Japanese researchers. Of the 11 publications, 1 described an ST-informed social interaction training, 1 was an ST protocol, 2 described conceptual ST models, 2 were case examples, 2 examined early maladaptive schemas (EMSs) and 3 investigated the effectiveness of ST interventions. In summary, the theoretical exploration, practical examples of the application of ST and research findings with preliminary evidence of ST, EMSs and schema modes (SMs) in adults with ASD point towards the potential of ST for the treatment of adults with ASD.

DISCUSSION

The current scoping review highlights preliminary research findings and offers valuable suggestions for clinicians treating adults with ASD. This review underscores the need for development of and research in specialized ST protocols and programmes tailored to adults with ASD with chronic mental conditions, such as personality disorders (PDs).

An individual-supported program to enhance placement in a sheltered work environment of autistic individuals mostly with intellectual disability: a prospective observational case series in an Italian community service

Introduction

Autism spectrum disorder is a lifelong neurodevelopmental disorder. The profile of functioning in autistic people is very heterogeneous, and it is necessary to take into account individual characteristics to better support integration in the workplace. However, unemployment rates are higher for autistic people than for other types of disabilities. We present a prospective case series to explore the feasibility and efficacy of an individual-supported program to enhance placement in a sheltered work environment delivered by an Italian community day care center.

Methods

Autistic subjects, aged from 12 to 31 years, participated in an individual-supported program regarding employment in sheltered art workshops, integrated into the regular activity of a semi-residential center three times a week for 1 year. Their feasibility retention rate and time worked per session were registered; moreover, working methods efficacy and self-organization improvement were tracked by the Likert-based rating system. Secondary outcome measures span functional levels, challenge behaviors, and sensory problems.

Results

All the individuals presented a good adaptation to the environment, with a significant increase in time worked per session. After 1 year, the intervention allowed an increase in tasks completed in an assigned complex job and an improvement in self-organization within the work schedule in a group of subjects consisting mainly of severe-to-moderate levels of autism severity (86.6%). Finally, we observed a significant increase in independent functioning areas of the TEACCH transitional assessment profile. Challenge behaviors and sensory problems were also recorded.

Conclusion

This case series supports the idea that individual-supported programs for placement in sheltered job environments delivered by community day care centers could be feasible and effective for ASD with higher levels of severity and co-occurring intellectual disability. Further targeted studies based on community models and accessible methods need to be planned to define the effectiveness of the intervention and promote improved practice at the community level with a better social impact.

Newborn Screening for Neurodevelopmental Disorders May Exacerbate Health Disparities

Newborn screening (NBS) began in the early 1960s with screening for phenylketonuria on blood collected on filter paper. The number of conditions included in NBS programs expanded significantly with the adoption of tandem mass spectrometry. The recommended uniform screening panel provides national guidance and has reduced state variability. Universality and uniformity have been supported to promote equity. Recently, a number of researchers have suggested expanding NBS to include genomic sequencing to identify all genetic disorders in newborns. This has been specifically suggested for genes that increase the risk for neurodevelopmental disorders (NDDs), with the presumption that early identification in the newborn period would reduce disabilities. We offer arguments to show that genomic sequencing of newborns for NDDs risks exacerbating disparities. First, the diagnosis of NDD requires clinical expertise, and both genetic and neurodevelopmental expertise are in short supply, leading to disparities in access to timely follow-up. Second, therapies for children with NDDs are insufficient to meet their needs. Increasing early identification for those at risk who may never manifest developmental delays could shift limited resources to those children whose parents are more poised to advocate, worsening disparities in access to services. Rather, we suggest an alternative: genomic sequencing of all children with diagnosed NDDs. This focused strategy would have the potential to target genomic sequencing at children who manifest NDDs across diverse populations which could better improve our understanding of contributory genes to NDDs.

Detection of autism spectrum disorder (ASD) in children and adults using machine learning

Autism spectrum disorder (ASD) presents a neurological and developmental disorder that has an impact on the social and cognitive skills of children causing repetitive behaviours, restricted interests, communication problems and difficulty in social interaction. Early diagnosis of ASD can prevent from its severity and prolonged effects. Federated learning (FL) is one of the most recent techniques that can be applied for accurate ASD diagnoses in early stages or prevention of its long-term effects. In this article, FL technique has been uniquely applied for autism detection by training two different ML classifiers including logistic regression and support vector machine locally for classification of ASD factors and detection of ASD in children and adults. Due to FL, results obtained from these classifiers have been transmitted to central server where meta classifier is trained to determine which approach is most accurate in the detection of ASD in children and adults. Four different ASD patient datasets, each containing more than 600 records of effected children and adults have been obtained from different repository for features extraction. The proposed model predicted ASD with 98% accuracy (in children) and 81% accuracy (in adults).