Autism Spectrum and Other Neurodevelopmental Disorders in Children of Immigrants: A Brief Review of Current Evidence and Implications for Clinical Practice

Autistic identity: A systematic review of quantitative research

Autism can be considered both a personal and social identity. Identifying the factors contributing to positive Autistic identity development is crucial given the potential implications for mental health and wellbeing. In this systematic review, we aimed to synthesize quantitative literature on Autistic identity to identify the (individual and environmental) factors associated with Autistic identity, and to ascertain the relationship between Autistic identity and mental health and wellbeing. A total of 3,617 studies were screened and 20 met our inclusion criteria. Results indicated that people developed a more positive Autistic identity when receiving external autism acceptance and external support. The association between individual factors and Autistic identity were largely nonsignificant or inconclusive, highlighting the need for broad support that meets the needs of a range of Autistic people, rather than specific subgroups. Importantly, positive Autistic identity was associated with improved mental health and wellbeing. Peer support and/or self-directed support resources may be valuable mechanisms for supporting Autistic people to cultivate a positive Autistic identity. The evaluation of such support, including the long-term impacts on identity development, will be a critical avenue for future research.

Promoting emotional and behavioral interventions in ASD treatment: Evidence from EPIGRAM, A naturalistic, prospective and longitudinal study

BACKGROUND

Prognostic factors from naturalistic treatment studies of children with Autism Spectrum Disorder (ASD) remain largely unknown. We aimed to identify baseline and treatment-related prognostic predictors at 1-year follow-up after Integrative Care Practices (ICPs).

METHODS

Eighty-nine preschool children with severe ASD were given ICP combining nine therapeutic workshops based on children's needs. Participants were assessed at baseline and during 12 months follow-up with the Psycho-educational Profile-3-R, Children Autism Rating Scale, Parental Global Impression, and the Autistic Behaviors Scale. We assessed prognostic predictors using multivariable regression models and explored treatment ingredients influencing outcome using Classification and Regression Trees (CART).

RESULTS

Multivariable models showed that being a child from first generation immigrant parents predicted increased maladaptive behaviors, whereas play activities had an opposite effect; severity of ASD symptoms and impaired cognitive functions predicted worse autism severity at follow-up; and lower play activities predicted worse parent impression. Regarding treatment effects, more emotion/behavioral interventions predicted better outcomes, and more communication interventions predicted lower autism severity, whereas more education and cognitive interventions had an opposite effect. CART confirmed that more hours of intervention in the emotion/behavioral domain helped classifying cases with better outcomes. More parental support was associated with decreased maladaptive behaviors. Sensorimotor and education interventions also significantly contributed to classifying cases according to outcomes but defined subgroups with opposite prognosis.

CONCLUSION

Children who exhibited the best prognosis following ICPs had less autism severity, better cognition, and non-immigrant parents at baseline. Emotion/behavior interventions appeared key across all outcomes and should be promoted.

Vitamin D levels of pregnant immigrant women and developmental disorders of language, learning and coordination in offspring

BACKGROUND

Prenatal vitamin D deficiency is a common health concern among immigrants. No previous studies have examined the associations between prenatal vitamin D levels and developmental disorders of language, scholastic skills, and coordination in an immigrant sample.

METHODS

The sample included 542 immigrant mothers of cases with language, scholastic, coordination or mixed developmental disorders, 443 immigrant mothers of controls without these disorders and 542 Finnish mothers of controls. Maternal vitamin D was measured in serum samples collected during early pregnancy and stored in a national biobank.

RESULTS

The mean vitamin D levels during pregnancy were 25.0 (SD 14.4) nmol/L for immigrant mothers of cases, 25.4 (SD 15.5) for immigrant mothers of controls and 42.3 (SD 19.1) for Finnish mothers of controls. Low maternal vitamin D levels during pregnancy were not associated with the selected developmental disorders in offspring when immigrant mothers of cases were compared to immigrant mothers of controls (adjusted OR for continuous log-transformed vitamin D: 1.01, 95% CI 0.75-1.36, p = 0.96). When immigrant mothers of cases were compared to Finnish mothers of controls, the adjusted OR for continuous vitamin D was 18.94 (95% CI 11.47-31.25), p <0.001). The results were similar when vitamin D was examined as a categorical variable or divided into quintiles.

CONCLUSIONS

Prenatal vitamin D levels were low, and similar, among immigrant mothers of cases with selected developmental disorders and unaffected controls. This indicates that vitamin D unlikely mediates previously observed associations between maternal immigrant status and the selected developmental disorders in offspring. The proportion of immigrant mothers with severe vitamin D deficiency was very high, which underlines the importance of prenatal counselling and overall public health efforts to improve immigrant health.

Exploring knowledge of autism, its causes and treatment among immigrant and nonimmigrant parents in Somalia\Somaliland

BACKGROUND

The prevalence of autism spectrum disorders (ASDs) has increased over the recent years; however, little is known about the experience of parents of children with autism in Africa such as Somalia. The aim of this study is to understand the knowledge on autism of Somali parents of children with autism and their perceptions of causes and treatment of ASD.

METHODS

We conducted a qualitative study involving 22 parents of children with autism who lived in Mogadishu and Hargeisa; the two largest cities in Somalia. In-depth interviews were used to collect the data. Of the 22 participants, 9 were returned immigrants and 13 were local people (non-immigrants). Data were analysed using thematic analysis.

RESULTS

The data revealed that most of the parents hold the belief that their children's autism were caused by the measles vaccine. The findings demonstrated that parents sought diagnosis and treatment care from outside Somalia due to the lack of experience of health providers in the diagnosis and treatment of autism. The data also revealed a lack of knowledge about autism among the public with resultant stigma and discrimination against children with autism and their families.

CONCLUSIONS

Efforts to increase public knowledge on autism, its causes and treatments are of paramount importance, while a public health campaign designed to eliminate the stigma subjected to children with autism is necessary to improve the quality of life of children with autism and their caregivers. Finally, to counteract vaccine hesitancy, particularly in response to the measles vaccine, health policy makers should take steps to separate the cooccurrence of the onset of autism symptoms and the provision of the measles vaccine.

[What tools can be used to create a parent-child group in a transcultural situation?]

Welcoming migrant families into an early childhood unit forces professionals to reflect on their clinical practices. When faced with parents with whom the therapeutic alliance is hard to establish and with children with developmental delays, a psychologist and a childcare assistant turn to transcultural psychology to find adapted tools. This text presents the reflections, the set up and the beginning of a parent-child therapeutic group.

Perspectives on children's autistic traits in UK-based British and Egyptian/Sudanese communities

BACKGROUND

While most autism research is conducted in White Western samples, culture may affect perceptions and reporting of autistic traits. We explored how UK-based British and Egyptian/Sudanese communities perceive autism features.

METHODS AND PROCEDURES

Nineteen participants self-identifying as British and 20 as Egyptian/Sudanese participated in focus group discussions on child development norms, and individual interviews on items of the Autism-spectrum Quotient: Children's version (AQ-Child; Auyeung et al., 2007), measuring autistic traits. Data were analysed using template analysis.

OUTCOMES AND RESULTS

Three themes were developed: 1) Value judgements of behaviours; 2) Considerations on differences between children; 3) Problematic interpretations of AQ-Child items. These processes may affect how parents and community members report on children's autistic traits. Cross-cultural comparisons suggested subtle differences in interpretations and judgements, and British participants referred to age expectations and comparisons with other children more than Egyptian/Sudanese participants. However, within-group variability, sometimes attributed to socioeconomic status and generation, appeared larger than cross-cultural differences.

CONCLUSIONS AND IMPLICATIONS

Our findings further the insights on influence of culture and within-community factors on reporting children's behaviour relevant to autism. These can inform the adaptation of screening tools in multi-cultural settings, to promote better autism recognition in communities where it may be underdiagnosed.

Health Care for Children in Immigrant Families: Key Considerations and Addressing Barriers

One in four US children is a child in an immigrant family. Children in immigrant families (CIF) have distinct health and health care needs that vary by documentation status, countries of origin, and health care and community experience caring for immigrant populations. Health insurance access and language services are fundamental to providing health care to CIF. Promoting health equity for CIF requires a comprehensive approach to both the health and social determinants of health needs of CIF. Child health providers can promote health equity for this population through tailored primary care services and partnerships with immigrant-serving community organizations.

Developmental disorders among Norwegian-born children with immigrant parents

BACKGROUND

Risk of being diagnosed with different developmental disorders is found to vary with immigrant background. Knowledge about such differences in Norway are a starting point for equity in health services quality, and for early identification and prevention. Our objective was to assess the risk of receiving diagnoses of developmental disorders among children born in Norway (2006-2017) to two or one immigrant parent compared to children with two Norwegian-born parents.

METHODS

Information on developmental disorders was from the Norwegian Patient Register (NPR) and information on immigrant background, parental country of origin, parental education, and household income from Statistics Norway. We estimated hazard ratios (HR) with Cox proportional hazard regressions. With children with Norwegian background as reference category, we estimated HRs for immigration background and region of origin. All analyses were adjusted for sex, year of birth, parental education, and household income.

RESULTS

Children with two immigrant parents had a lower risk of receiving any developmental disorder diagnosis [HR 0.80 (95% CI 0.77, 0.82)] than children with Norwegian background, and lower risk of being diagnosed with attention deficit hyperactivity disorder (ADHD) diagnosis [HR 0.24 (95% CI 0.22, 0.27)], learning difficulties diagnosis [HR 0.39 (95% CI 0.33, 0.47)], and behavioral and emotional disorders [HR 0.52 (95% CI 0.49, 0.55)]. Children with immigrant parents had higher hazard than Norwegian background children of autism spectrum disorder (ASD) [HR 2.21 (95% CI 2.04, 2.39)], mental retardation [HR 1.84 (95% CI 1.64, 2.07)], language disorders [HR 1.30 (95% CI 1.20, 1.40)], and unspecified developmental disorders [HR 1.22 (95% CI 1.17, 1.28)]. Children with only one immigrant parent had lower risk of diagnoses than children of two immigrants.

CONCLUSION

Risk of receiving a diagnosis of various developmental disorders varied substantially by immigrant background. Understanding the underlying mechanisms of these differences is warranted to ensure equity in health services and timely intervention.

Maternal vitamin D during pregnancy and offspring autism and autism-associated traits: a prospective cohort study

BACKGROUND

There has been a growing interest in the association between maternal levels of vitamin D during pregnancy and offspring autism. However, whether any associations reflect causal effects is still inconclusive.

METHODS

We used data from a UK-based pregnancy cohort study (Avon Longitudinal Study of Parents and Children) comprising 7689 births between 1991 and 1992 with maternal blood vitamin D levels recorded during pregnancy and at least one recorded outcome measure, including autism diagnosis and autism-associated traits. The association between each outcome with seasonal and gestational age-adjusted maternal serum 25-hydroxyvitamin D during pregnancy was estimated using confounder-adjusted regression models. Multiple imputation was used to account for missing data, and restricted cubic splines were used to investigate nonlinear associations. Mendelian randomization was used to strengthen causal inference.

RESULTS

No strong evidence of an association between maternal serum 25-hydroxyvitamin D during pregnancy and any offspring autism-associated outcome was found using multivariable regression analysis (autism diagnosis: adjusted OR = 0.98, 95% CI = 0.90-1.06), including with multiple imputation (autism diagnosis: adjusted OR = 0.99, 95% CI = 0.93-1.06), and no evidence of a causal effect was suggested by Mendelian randomization (autism diagnosis: causal OR = 1.08, 95% CI = 0.46-2.55). Some evidence of increased odds of autism-associated traits at lower levels of maternal serum 25-hydroxyvitamin D was found using spline analysis.

LIMITATIONS

Our study was potentially limited by low power, particularly for diagnosed autism cases as an outcome. The cohort may not have captured the extreme lows of the distribution of serum 25-hydroxyvitamin D, and our analyses may have been biased by residual confounding and missing data.

CONCLUSIONS

The present study found no strong evidence of a causal link between maternal vitamin D levels in pregnancy and offspring diagnosis or traits of autism.

Responding to Autism in Low and Middle Income Countries (LMIC): What to Do and What Not to Do

Autism is a spectrum disorder that occurs globally with increasing numbers of children and adults being identified with this condition. Although rates are higher in more affluent nations, the bulk of people with autism reside in Low and Middle Income Countries (LMICs). However, most do not have access to timely and appropriate support. The types of services delivered in high income countries are often ill-suited to the needs and resources of LMICs. Rather alternative forms of provision need to be devised. In common with other public health initiatives, these should be family-focused and community based, with suitably qualified and experienced leaders who in turn train and supervise a cadre of knowledgeable support workers drawn from local communities and cultures. As well as providing personalized, home-based guidance to people with autism and to their primary carers, regular group-based advocacy and training activities are undertaken in partnership with available mainstream services such as schools and social services. The principles and operations of these new forms of services are described in this paper albeit with an acknowledgment of their limitations. In recent decades, the cost-effectiveness of these approaches have been demonstrated with other chronic illnesses and disabling conditions in LMICs but their extension to autism has barely begun. More affluent countries are being forced to adopt similar strategies in response to the increased numbers of people identified with autism. A transformation in research strategies is essential to building better international support for persons with autism.

Migration is associated with baseline severity and progress over time in autism spectrum disorder: Evidence from a French prospective longitudinal study

Background

The prevalence of autism-spectrum disorder (ASD) has been shown to be higher in migrant families, but it is also a challenge for health care professionals to offer adequate services to families that face multiple challenges. In the context of the EPIGRAM study (a French prospective, multisite, longitudinal observational study implementing integrative care practices (ICPs) for children with ASD), we aimed to assess the impact of migration on children with ASD.

Method and findings

89 children with ASD aged 3 to 6 years old (92% males) were recruited and followed up for 12 months. The children were clinically assessed using several instruments. At baseline, children had severe autism on average on the Children Autism Rating Scale (CARS, mean = 44; SD = 6.51) and moderate autism on the PsychoEducational profile-3-R (PEP-3-R) maladaptive behavior category (mean = 30; SD = 29.89). Thirty percent of the families had a low socio-economic status, and 56% were first-generation immigrants. For all clinical variables, children of immigrant parents had more severe autism and developmental delays at baseline. A linear mixed model established an improvement in all clinical characteristics over the 12 months of the study. This trend may be attributed to ICPs or any naturally occurring event during that period. Families shared this positive view over time. However, the improvements were slower for two clinical dimensions of the PEP-3-R in children from migrant families. For the inappropriate behavior category, the time effect diminished by an average of 0.83 percentile/month for children whose parents were migrants vs. children whose parents were non-migrants. Similarly, for verbal behavior characteristics, the time effect diminished by an average of 1.32 percentile/month for children whose parents were migrants vs. children whose parents were non-migrants.

Conclusion

Despite an overall positive improvement, we found that migration is associated baseline severity and progress over time in children with ASD. There is an urgent need to target the migrant population with specific research and understand the avenues that carry such higher severity.

Clinical trial registration

Study registration on clinicaltrials.gov under the number NCT02154828.

TV, computer, tablet and smartphone use and autism spectrum disorder risk in early childhood: a nationally-representative study

Background

Screen media use in early childhood has largely increased in recent years, even more so during the COVID-19 epidemic, and there is much discussion regarding its influence on neurodevelopment, including Autism Spectrum Disorder (ASD).

Methods

We examined the relationship between use of TV, computer, tablet and smartphone at age 2 years and risk of ASD assessed in telephone-based questionnaires among 12,950 children participating in the nationally representative ELFE (‘Etude Longitudinale Française sur les Enfants’) birth cohort study in France.

Results

In inverse-probability weighted (IPW) multinomial regression analyses, children’s weekly or daily screen media use was associated with an increased likelihood of an intermediate risk of ASD (IPW-controlled OR for weekly use:1.07, 95% CI 1.02—1.12; IPW-controlled OR for daily use:1.05, 95% CI 1.02—1.08) but inversely associated with a high risk (IPW-controlled OR for weekly use: 0.60, 95% CI 0.50—0.73; IPW-controlled OR for daily use: 0.75, 95% CI 0.62—0.91), as ascertained by the M-CHAT. This was confirmed when studying TV as well as computer/tablet exposure separately.

Conclusions

Overall, our nationally-representative study conducted among a large sample of 2-year-old children, indicates a complex relationship between screen exposure and ASD risk.

A case study on the effect of light and colors in the built environment on autistic children's behavior

BACKGROUND

The importance of strategies and services by caregivers and family members substantially impact the psychological and emotional wellbeing of autistic children. The rapid research developments in clinical and non-clinical methods benefit the features of autistic children. Among various internal and external factors, the influence of the built environment also impacts the characteristics of autistic children. This study investigates primarily the psychological effect of light and colors on the mood and behavior of autistic children to identify the most favorable and preferred indoor lights and color shades.

METHODS

A questionnaire survey was conducted at an autism center among autistic children and their parents. This study included autistic children aged between 6 and 16 (45 males, 42 females, mean age 8.7 years, standard deviation 2.3). Eighty-seven participants were involved in the survey to determine the sensory perceptions, intolerance, preferences, and sensitivities of children with an autism spectrum disorder toward colors and lighting. The margin of error at the statistical analysis's 95% confidence level is ± 0.481.

RESULTS

As per this case report, the children have various color preferences and respond differently to different shades. Different hues have varying effects on autistic children, with many neutral tones and mellow shades proven to be autistic-friendly with their calming and soothing effect, while bright, bold, and intense colors are refreshing and stimulating. The stimulus of bright-lighting causes behavioral changes in autistic children prone to light sensitivity.

CONCLUSION

The insights gained from this interaction with parents and caretakers of autistic children could be helpful for designers to incorporate specific autistic-friendly design elements that make productive interior spaces. A complete understanding of the effect of factors like color and lighting on the learning ability and engagement of autistic children in an indoor environment is essential for designers and clinicians. The main findings of this study could be helpful for a designer and clinicians to address designing an autism-friendly built environment with a color palette and lighting scheme conducive to their wellbeing and to maximize their cognitive functioning.

Identifying Factors Influencing Attention in Adolescents with a Co-Created Questionnaire: A Citizen Science Approach with Secondary Students in Barcelona, Spain

Studies on factors that can influence attention in healthy adolescents are recent and focus on recurrent topics. Students' contribution to public health research often revolves around collecting data but rarely around creating data collection instruments. The ATENC!Ó project reunited secondary students and scientists to create a questionnaire including factors that students thought could affect their attention. We conducted a cross-sectional study to assess whether the factors included in this questionnaire had an effect on attention in adolescents. A total of 1667 students (13-16 years old) from 28 schools in Barcelona performed a validated attention test and answered the questionnaire. The response speed consistency (attentiveness), expressed as hit reaction time standard error (HRT-SE, in ms), was used as the primary outcome. Analyses were conducted using conditional linear regression with school as strata, adjusted for sociodemographic characteristics and further stratified by gender and maternal social class. Some factors showed a negative influence on attention, including taking medication and not reading regularly. We found a significant 14.3% (95% confidence interval: 3.4%, 25.3%) higher median of HRT-SE (increase inattentiveness) among students who reported not having a good relationship with classmates. Students' input into research is relevant for advancing the knowledge production in public health.