Oculomotor randomness is higher in autistic children and increases with the severity of symptoms

A variety of studies have suggested that at least some children with autism spectrum disorder (ASD) view the world differently. Differences in gaze patterns as measured by eye tracking have been demonstrated during visual exploration of images and natural viewing of movies with social content. Here we analyzed the temporal randomness of saccades and blinks during natural viewing of movies, inspired by a recent measure of "randomness" applied to micro-movements of the hand and head in ASD (Torres et al., 2013; Torres & Denisova, 2016). We analyzed a large eye-tracking dataset of 189 ASD and 41 typically developing (TD) children (1-11 years old) who watched three movie clips with social content, each repeated twice. We found that oculomotor measures of randomness, obtained from gamma parameters of inter-saccade intervals (ISI) and blink duration distributions, were significantly higher in the ASD group compared with the TD group and were correlated with the ADOS comparison score, reflecting increased "randomness" in more severe cases. Moreover, these measures of randomness decreased with age, as well as with higher cognitive scores in both groups and were consistent across repeated viewing of each movie clip. Highly "random" eye movements in ASD children could be associated with high "neural variability" or noise, poor sensory-motor control, or weak engagement with the movies. These findings could contribute to the future development of oculomotor biomarkers as part of an integrative diagnostic tool for ASD.

Large increase in ASD prevalence in Israel between 2017 and 2021

Accurate estimation of annual changes in autism spectrum disorders (ASD) prevalence is critical for planning the expansion of diagnostic, education, and intervention services at an adequate rate. Previous studies from Israel have reported that ASD prevalence among 8-year-old children has increased from estimates of 0.3% in 2008 to 0.65% in 2015 and 1.3% in 2018. Here, we analyzed data acquired from the National Insurance Institute of Israeli (NII), a governmental organization that approves and monitors all ASD children who receive welfare services in Israel, and Clalit Health Services (CHS), the largest Health Maintenance Organization in Israel that provides health services to ~52% of the population. Data from both sources included annual data files from 2017 to 2021 containing the number of ASD cases per year of birth for 1-17-year-old children. This allowed us to estimate annual ASD prevalence among 3.5 million children born between 2000 and 2020 in Israel. Both data sources revealed a nearly two-fold increase in ASD prevalence among 1-17-year-old children from 2017 to 2021. Estimated prevalence rates differed across age groups with 2-3-year-old (day-care) children increasing from 0.27% to 1.19% (>4 fold change), 4-6-year-old (pre-school) children increasing from 0.8% to 1.83%, and 8-year-old children increasing from 0.82% to 1.56% in NII data. These results demonstrate that autism prevalence continues to increase in Israel with a shift towards diagnosis at earlier ages. These findings highlight the challenge facing health and education service providers in meeting the needs of a rapidly growing autism population.

Idiosyncratic pupil regulation in autistic children

Recent neuroimaging and eye tracking studies have suggested that children with autism spectrum disorder (ASD) may exhibit more variable and idiosyncratic brain responses and eye movements than typically developing (TD) children. Here we extended this research for the first time to pupillometry recordings. We successfully completed pupillometry recordings with 103 children (66 with ASD), 4.5-years-old on average, who viewed three 90 second movies, twice. We extracted their pupillary time-course for each movie, capturing their stimulus evoked pupillary responses. We then computed the correlation between the time-course of each child and those of all others in their group. This yielded an average inter-subject correlation value per child, representing how similar their pupillary responses were to all others in their group. ASD participants exhibited significantly weaker inter-subject correlations than TD participants, reliably across all three movies. Differences across groups were largest in responses to a naturalistic movie containing footage of a social interaction between two TD children. This measure enabled classification of ASD and TD children with a sensitivity of 0.82 and specificity of 0.73 when trained and tested on independent datasets. Using the largest ASD pupillometry dataset to date, we demonstrate the utility of a new technique for measuring the idiosyncrasy of pupil regulation, which can be completed even by young children with co-occurring intellectual disability. These findings reveal that a considerable subgroup of ASD children have significantly more unstable, idiosyncratic pupil regulation than TD children, indicative of more variable, weakly regulated, underlying neural activity.

The Importance of Language Delays as an Early Indicator of Subsequent ASD Diagnosis in Public Healthcare Settings

Previous studies have reported that ASD children with more severe symptoms are diagnosed earlier. However, previous studies in community settings have mostly relied on retrospective parental reports without the use of quantitative standardized test scores. Here, we evaluated the association of language, cognitive, and ASD severity standardized scores with the age of diagnosis in 1-6-year-old children diagnosed in a public healthcare setting. The results revealed that language scores were the strongest variable associated with the age of diagnosis, explaining ~ 30% of the variability across children. Indeed, all children diagnosed before 30-months of age exhibited moderate-to-severe language delays. These results further substantiate the prominence of language delay as a highly visible symptom associated with earlier ASD diagnosis in community clinical settings.

Comparison of three bioinformatics tools in the detection of ASD candidate variants from whole exome sequencing data

Autism spectrum disorder (ASD) is a heterogenous multifactorial neurodevelopmental condition with a significant genetic susceptibility component. Thus, identifying genetic variations associated with ASD is a complex task. Whole-exome sequencing (WES) is an effective approach for detecting extremely rare protein-coding single-nucleotide variants (SNVs) and short insertions/deletions (INDELs). However, interpreting these variants' functional and clinical consequences requires integrating multifaceted genomic information. We compared the concordance and effectiveness of three bioinformatics tools in detecting ASD candidate variants (SNVs and short INDELs) from WES data of 220 ASD family trios registered in the National Autism Database of Israel. We studied only rare (< 1% population frequency) proband-specific variants. According to the American College of Medical Genetics (ACMG) guidelines, the pathogenicity of variants was evaluated by the InterVar and TAPES tools. In addition, likely gene-disrupting (LGD) variants were detected based on an in-house bioinformatics tool, Psi-Variant, that integrates results from seven in-silico prediction tools. Overall, 372 variants in 311 genes distributed in 168 probands were detected by these tools. The overlap between the tools was 64.1, 22.9, and 23.1% for InterVar-TAPES, InterVar-Psi-Variant, and TAPES-Psi-Variant, respectively. The intersection between InterVar and Psi-Variant (I ∩ P) was the most effective approach in detecting variants in known ASD genes (PPV = 0.274; OR = 7.09, 95% CI = 3.92-12.22), while the union of InterVar and Psi Variant (I U P) achieved the highest diagnostic yield (20.5%).Our results suggest that integrating different variant interpretation approaches in detecting ASD candidate variants from WES data is superior to each approach alone. The inclusion of additional criteria could further improve the detection of ASD candidate variants.

Adherence to treatment and parents' perspective about effectiveness of melatonin in children with autism spectrum disorder and sleep disturbances

OBJECTIVE

Melatonin is considered an effective pharmacological treatment for the sleep disturbances that are reported in > 50% of children with autism spectrum disorder (ASD). However, real-life data about the long-term course and effectiveness of melatonin treatment in children with ASD is lacking.

METHODS

In this retrospective cohort study, we assessed the adherence to melatonin treatment and parents' perspective of its effect on sleep quality and daytime behavior in children with ASD via a parental phone survey of children in the Azrieli National Center for Autism and Neurodevelopment Research (ANCAN) database. Cox regression analysis was used to assess the effect of key demographic and clinical characteristics on treatment adherence.

RESULTS

Melatonin was recommended for ~ 8% of children in the ANCAN database. These children were characterized by more severe symptoms of autism. The median adherence time for melatonin treatment exceeded 88 months, with the most common reason for discontinuation being a lack of effectiveness (14%). Mild side-effects were reported in 14% of children, and 86%, 54%, and 45% experienced improvements in sleep onset, sleep duration and night awakenings, respectively. Notably, melatonin also improved the daytime behaviors of > 28% of the children. Adherence to treatment was independently associated with improvements in night awakenings and educational functioning (aHR = 0.142, 95%CI = 0.036-0.565; and aHR = 0.195, 95%CI = 0.047-0.806, respectively).

CONCLUSIONS

Based on parents' report, melatonin is a safe and effective treatment that improves both sleep difficulties and daily behavior of children with ASD.

Association Between Early Developmental Milestones and Autism Spectrum Disorder

Early diagnosis and treatment of autism spectrum disorder (ASD) has been shown to lead to better prognosis. Here, we examined the association of commonly measured early developmental milestones (DMs) with later diagnosis of ASD. We conducted a case-control study of 280 children with ASD (cases) and 560 typically developed children (controls) matched to cases by date of birth, sex, and ethnicity in a control/case ratio of 2:1. Both cases and controls were ascertained from all children whose development was monitored at mother-child health clinics (MCHCs) in southern Israel. DM failure rates during the first 18 months of life in three developmental categories (motor, social, and verbal) were compared between cases and controls. Conditional logistic regression models were used to assess the independent association of specific DMs with the risk of ASD, while adjusting for demographic and birth characteristics.Significant case-control differences in DM failure rates were observed as early as 3 months of age (p < 0.001), and these differences increased with age. Specifically, cases were 2.4 times more likely to fail ≥ 1 DM at 3 months (aOR = 2.39; 95%CI = 1.41-4.06), and 15.3 times more likely to fail ≥ 3 DMs at 18 months (aOR = 15.32; 95%CI = 7.75-30.28). The most notable DM-ASD association was observed for social DM failure at 9-12 months (aOR = 4.59; 95%CI = 2.59-8.13). Importantly, the sex or ethnicity of the participants did not affect these DM-ASD associations. Our findings highlight the potential role of DMs as early signs of ASD that could facilitate earlier referral and diagnosis of ASD.

Sleep of mothers, fathers, and infants: a longitudinal study from pregnancy through 12 months

STUDY OBJECTIVES

This study assessed and compared mothers' and fathers' sleep trajectories from pregnancy and throughout the first year of the infant's life. We also examined associations between maternal, paternal, and infant sleep.

METHODS

Two hundred and thirty-two couples were recruited for the study during pregnancy. Data were collected during pregnancy and at 4, 8, and 12 months postpartum. Maternal, paternal, and infant sleep were monitored at home for seven nights, using actigraphy, sleep diaries, and the Insomnia Severity Index (ISI).

RESULTS

Mothers showed more impaired sleep quality than fathers, at all assessments, whereas fathers had shorter sleep duration. Based on the ISI, about 70% of mothers and 50% of fathers showed at least subclinical insomnia at the different assessments. Trajectory analyses (controlling for feeding method and sleeping arrangements) demonstrated a significant deterioration in diary-based and actigraphy sleep quality for both parents, from pregnancy to 4 months. Both parents and infants had an increase in sleep quality from 4 to 12 months, though some parental sleep variables showed a quadratic pattern with a decrease in sleep quality at 8 months. Statistically significant triadic associations at the different assessments were found between mothers', fathers', and infants' sleep. Maternal and infant sleep measures were more strongly correlated than paternal and infant sleep.

CONCLUSIONS

The findings highlight the importance of considering the family context of sleep, by demonstrating similarities and differences in the changes that sleep undergoes in new mothers and fathers and by showing how sleep is interrelated between all family members.

Exogenous oxytocin administration during labor and autism spectrum disorder

BACKGROUND

Oxytocin is a neuropeptide hormone that plays a key role in social behavior, stress regulation, and mental health. Synthetic oxytocin administration is a common obstetrical practice, and importantly, previous research has suggested that intrapartum exposure may increase the risk of neurodevelopmental disorders, such as autism spectrum disorder.

OBJECTIVE

This study aimed to examine the association between synthetic oxytocin exposure during labor and autism spectrum disorder diagnosis in the child.

STUDY DESIGN

This population-based retrospective cohort study compared 2 cohorts of children: (1) all children born in British Columbia, Canada between April 1, 2000 and December 31, 2014 (n=414,336 births), and (2) all children delivered at Soroka University Medical Center in Be'er-Sheva, Israel between January 1, 2011 and December 31, 2019 (n=82,892 births). Nine different exposure groups were examined. Cox proportional hazards models were used to estimate crude and adjusted hazard ratios of autism spectrum disorder in both cohorts on the basis of induction and/or augmentation exposure status. To further control for confounding by indication, we conducted sensitivity analyses among a cohort of healthy, uncomplicated deliveries and among a group that was induced only for postdates. In addition, we stratified our analyses by infant sex to assess for potential sex differences.

RESULTS

In the British Columbia cohort, 170,013 of 414,336 deliveries (41.0%) were not induced or augmented, 107,543 (26.0%) were exposed to oxytocin, and 136,780 (33.0%) were induced or augmented but not exposed to oxytocin. In the Israel cohort, 51,790 of 82,892 deliveries (62.5%) were not induced or augmented, 28,852 (34.8%) were exposed to oxytocin, and 2250 (2.7%) were induced or augmented but not exposed to oxytocin. On adjusting for covariates in the main analysis, significant associations were observed in the Israel cohort, including adjusted hazard ratios of 1.51 (95% confidence interval, 1.20-1.90) for oxytocin-augmented births and 2.18 (95% confidence interval, 1.32-3.57) for those induced by means other than oxytocin and not augmented. However, oxytocin induction was not significantly associated with autism spectrum disorder in the Israel cohort. In the Canadian cohort, there were no statistically significant adjusted hazard ratios. Further, no significant sex differences were observed in the fully adjusted models.

CONCLUSION

This study supports that induction of labor through oxytocin administration does not increase the risk of autism spectrum disorder in the child. Our international comparison of 2 countries with differences in clinical practice regarding oxytocin administration for induction and/or augmentation suggests that previous studies reporting a significant association were likely confounded by the underlying indication for the induction.

Sleep disturbances are associated with irritability in ASD children with sensory sensitivities

BACKGROUND

Parent reports suggest that 44-84% of children with ASD exhibit sleep disturbances that are of clinical concern. Previous studies have reported that, in children with ASD, the severity of sleep disturbances is associated with the severity of either sensory problems or aberrant behaviors, but none have performed combined analyses with measures of both sensory and aberrant behaviors symptom domains from the same children.

METHODS

We examined parent reports of 237 children with ASD, 1.4-8.7 years old, using the child sleep habits questionnaire (CSHQ), sensory profile (SP), and aberrant behaviors checklist (ABC).

RESULTS

The analyses revealed that sleep disturbances were most strongly associated with SP sensory sensitivity and ABC irritability scores. Together these scores explained 35% of the variance in total CSHQ scores. Moreover, sensory sensitivity scores moderated the association between irritability and sleep disturbances, indicating that sleep disturbances were significantly associated with irritability only in children with moderate to severe sensory sensitivities.

CONCLUSION

We suggest that the three symptom domains may interact and exacerbate each other such that successful intervention in one symptom domain may have positive impact on the others. Further intervention studies testing this hypothesis are highly warranted.

Children with autism exhibit similar longitudinal changes in core symptoms when placed in special or mainstream education settings

LAY ABSTRACT

Today, children with autism spectrum disorder (ASD) are placed in mainstream or special education settings somewhat arbitrarily with no clear clinical recommendations. Here, we compared changes in core ASD symptoms, as measured by the Autism Diagnostic Observation Schedule, 2nd edition (ADOS-2) clinical assessment, across ASD preschool children placed in special or mainstream education. Longitudinal changes in ADOS-2 scores did not differ significantly across settings over a 1- to 2-year period. While some children improved in core ASD symptoms, others deteriorated in both settings. This highlights the need to identify specific criteria for establishing meaningful placement recommendations.

Pediatric psychiatric emergency rooms during COVID-19: a multi-center study

BACKGROUND

The COVID-19 (SARS-CoV-2) pandemic has been a major stressor for the mental health and well-being of children and adolescents. Surveys and reports from hotlines indicate a significant rise in mental health problems. As the psychiatric emergency room (ER) is a first-line free-of-charge facility for psychiatric emergencies, we expected to see a significant increase in visits, specifically of new patients suffering from anxiety, depression, or stress-related disorders.

METHODS

Data from two psychiatric hospital ERs and one general hospital were included. All visits of children and adolescents from the computerized files between March and December of 2019 were analyzed anonymously and compared to the same months in 2020, using multilevel linear modeling.

RESULTS

There was a significant decline in the total number of visits (p = .017), specifically among those diagnosed as suffering from stress-related, anxiety, and mood disorder groups (p = .017), and an incline in the proportion of visits of severe mental disorders (p = .029).

DISCUSSION

The limited use of child and adolescent psychiatric emergency facilities during the pandemic highlights the importance of tele-psychiatry as part of emergency services. It also suggests the importance of the timeline of the emergence of clinically relevant new psychiatric diagnoses related to the pandemic. Future studies are needed to establish the long-term effects of the pandemic and the expeditious use of tele-psychiatry.

Objective and subjective sleep and caregiving feelings in mothers of infants: a longitudinal daily diary study

Study Objectives

This study explored the links between mothers’ objective and subjective sleep and their caregiving feelings toward their infant (i.e. patience for the infant, desire to be with the infant, and anger toward the infant), using a diary study design. We were particularly interested in examining whether nights of lower sleep quality within individual mothers predict more negative maternal caregiving feelings the following day.

Methods

The sample included 151 women, who were recruited during pregnancy. Data were collected at 4 and 8 months after delivery. Maternal sleep was monitored at home for seven nights using actigraphy and sleep diaries. Mothers rated their caregiving feelings each evening.

Results

Multilevel modeling (controlling for depressive symptoms, feeding method, and background variables) revealed that actigraphic and subjective sleep variables were associated with maternal caregiving feeling, both at the between- and within-person levels. For example, lower sleep percent predicted reduced levels of maternal patience for the infant at 4 and 8 months (between-person effect). Moreover, when a mother had a lower sleep percent on a given night (compared to her average), she reported lower levels of patience for her infant the following day (within-person prospective effect).

Conclusions

The findings demonstrate, for the first time, that maternal nightly variations in objective and subjective sleep quality predict daily changes in maternal feelings toward her infant at two different assessment points. Improving maternal sleep quality might be an important target for future interventions which may help mothers to feel more positively toward their infants.

A proposed service model for early identification of autism spectrum disorder in ethnic communities in Southern Israel

Early autism spectrum disorder (ASD) detection is a precondition for effective intervention and facilitates significant improvements in functioning. In Israel, toddlers undergo general developmental screening by public health nurses (PHNs) at maternal and child health centres (MCHCs). Nevertheless, there are disparities among ethnic groups in the reported incidence of ASD. By means of an ecological model (EM), we identified strategies that improve ASD detection in the Bedouin community by investigating the social and policy factors that affect diagnosis. We conducted in-depth interviews with 18 policy makers and service providers and three focus groups of PHNs and paediatricians. We mapped the strategies for identifying toddlers with ASD based on the three EM levels. Correlations were established by comparing the codes within and between the EM levels. At the macro-level, the policy makers' strategy for improving ASD detection in the Bedouin community reflected the ideology, values and goals of the PHNs and included the MCHCs as the sole institution involved in detecting ASD. At the meso-level of the service providers, the key elements of the strategy consisted of actualising the professional potential of PHNs and patients' case management. At the micro-level was the population that utilises the services and complies with recommendations. A correlation was established between the PHNs' values and goals and patients' case management. Actualising their professional potential influenced the population's compliance. To reduce gaps in ASD diagnosis between Bedouin communities and the general population, it is necessary to identify and change the policy factors that influence access to services for children with ASD at every EM level while incorporating PHNs from the Bedouin community in future services. Culturally appropriate policies, screening policies and interventions must be developed to serve the needs of Bedouin children.

Home-quarantine during the initial Covid-19 outbreak in Israel: parent perceived impact on children with ASD

Background

Studies have reported that Covid-19 home-quarantine periods have had mostly negative psychological impact on children with ASD and their families. Here we examined parent perceived impact of a 6-week quarantine period imposed in Israel at the beginning of the Covid-19 outbreak, in mid-March 2020.

Methods

An anonymous online questionnaire was completed by parents of 268 children with ASD. Parents rated deterioration/improvement in their child's behaviors, abilities, mood, sleep, and anxiety along with changes in their own mood, sleep, parenting skills, and family relationships. We performed t-tests and ANOVA analyses to assess the significance of perceived impact on each domain and potential differences in the impact across families with children of different ages, genders, and levels of required support as well as families that experienced different magnitudes of economic hardships.

Results

Parents reported significant deterioration in their mood and sleep along with significant improvements in relationships with their spouse and child with ASD, and in their parenting skills. Parents also reported significant increases in the severity of tantrums, anxiety, and restricted and repetitive behavior symptoms along with significant improvements in social and communication abilities of their child with ASD. Ratings were significantly lower in families of ASD children who regularly require more support and in families that experienced economic hardships.

Conclusions

While periods of home-quarantine create numerous hardships for families of children with ASD, they may also offer an opportunity for improving parenting skills, family relationships, and children's social communication abilities with potential relevance for improving remote services.

OUP accepted manuscript

Multiple pieces of evidence support the prenatal predisposition of autism spectrum disorder (ASD). Nevertheless, robust data about abnormalities in foetuses later developing into children diagnosed with ASD are lacking. Prenatal ultrasound is an excellent tool to study abnormal foetal development as it is frequently used to monitor foetal growth and identify foetal anomalies throughout pregnancy. We conducted a retrospective case-sibling-control study of children diagnosed with ASD (cases); their own typically developing, closest-in-age siblings (TDS); and typically developing children from the general population (TDP), matched by year of birth, sex and ethnicity to investigate the association between ultrasonography foetal anomalies and ASD. The case group was drawn from all children diagnosed with ASD enrolled at the National Autism Research Center of Israel. Foetal ultrasound data from the foetal anatomy survey were obtained from prenatal ultrasound clinics of Clalit Health Services in southern Israel. The study comprised 659 children: 229 ASD, 201 TDS and 229 TDP. Ultrasonography foetal anomalies were found in 29.3% of ASD cases versus only 15.9% and 9.6% in the TDS and TDP groups [adjusted odds ratio (aOR) = 2.23, 95% confidence interval (CI) = 1.32-3.78, and aOR = 3.50, 95%CI = 2.07-5.91, respectively]. Multiple co-occurring ultrasonography foetal anomalies were significantly more prevalent among ASD cases. Ultrasonography foetal anomalies in the urinary system, heart, and head and brain were the most significantly associated with ASD diagnosis (aORUrinary = 2.08, 95%CI = 0.96-4.50 and aORUrinary = 2.90, 95%CI = 1.41-5.95; aORHeart = 3.72, 95%CI = 1.50-9.24 and aORHeart = 8.67, 95%CI = 2.62-28.63; and aORHead&Brain = 1.96, 95%CI = 0.72-5.30 and aORHead&Brain = 4.67, 95%CI = 1.34-16.24; versus TDS and TDP, respectively). ASD females had significantly more ultrasonography foetal anomalies than ASD males (43.1% versus 25.3%, P = 0.013) and a higher prevalence of multiple co-occurring ultrasonography foetal anomalies (15.7% versus 4.5%, P = 0.011). No sex differences were seen among TDS and TDP controls. ASD foetuses were characterized by a narrower head and a relatively wider ocular-distance versus TDP foetuses (ORBPD = 0.81, 95%CI = 0.70-0.94, and aOROcular distance = 1.29, 95%CI = 1.06-1.57). Ultrasonography foetal anomalies were associated with more severe ASD symptoms. Our findings shed important light on the multiorgan foetal anomalies associated with ASD.

Diagnostic Yield and Economic Implications of Whole-Exome Sequencing for ASD Diagnosis in Israel

Whole-exome sequencing (WES) is an effective approach to identify the susceptibility of genetic variants of autism spectrum disorder (ASD). The Israel Ministry of Health supports WES as an adjunct tool for ASD diagnosis, despite its unclear diagnostic yield and cost effectiveness. To address this knowledge gap, we applied WES to a population-based sample of 182 Bedouin and Jewish children with ASD from southern Israel, and assessed its yield in a gene panel of 205 genes robustly associated with ASD. We then compared the incremental cost-effectiveness ratios (ICERs) for an ASD diagnosis by WES, chromosomal microarray analysis (CMA), and CMA + WES. Overall, 32 ASD candidate variants were detected in 28 children, corresponding to an overall WES diagnostic yield of 15.4%. Interestingly, the diagnostic yield was significantly higher for the Bedouin children than for the Jewish children, i.e., 27.6% vs. 11.1% (p = 0.036). The most cost-effective means for genetic testing was the CMA alone, followed closely by the CMA + WES strategy (ICER = USD 117 and USD 124.8 per child). Yet, WES alone could become more cost effective than the other two approaches if there was to be a 25% increase in its yield or a 50% decrease in its cost. These findings suggest that WES should be recommended to facilitate ASD diagnosis in Israel, especially for highly consanguineous populations, such as the Bedouin.

Association Between Antenatal Antimicrobial Therapy and Autism Spectrum Disorder-A Nested Case-Control Study

Background: Multiple prenatal factors have been associated with autism spectrum disorder (ASD) risk. However, current data about the association between antimicrobial use during pregnancy and ASD is limited. Methods: A nested matched case-control study of children with ASD (cases), and children without ASD or other psychiatric or genetic disorders (controls). We compared the use of antimicrobial therapy during the 3 months before conception or during pregnancy between mothers of cases and controls and used multivariate conditional logistic regression models to assess the independent association between maternal use of antimicrobials during pregnancy and the risk of ASD in their offspring. Results: More than half of the mothers in the study (54.1%) used antimicrobial drugs during the 3 months before conception or during pregnancy. Rates of antimicrobial use were lower for mothers of children with ASD compared to mothers of controls (49.0 vs. 55.1%, respectively; p = 0.02), especially during the third trimester of pregnancy (18.8 vs. 22.9%, respectively; p = 0.03), and for the use of penicillins (15.7 vs. 19.7%, respectively; p = 0.06). These case-control differences suggest that antimicrobial administration during pregnancy was associated with a reduced risk of ASD in the offspring (aOR = 0.75, 95% CI = 0.61-0.92). Interestingly, this association was seen only among Jewish but not for the Bedouin mothers (aOR = 0.62, 95% CI = 0.48-0.79 and aOR = 1.21, 95% CI = 0.82-1.79). Conclusions: The reduced risk of ASD associated with prenatal antimicrobials use only in the Jewish population suggest the involvement of other ethnic differences in healthcare services utilization in this association.

A longitudinal study of the links between maternal and infant nocturnal wakefulness

STUDY OBJECTIVES

To examine the longitudinal links between maternal and infant nocturnal wakefulness by employing a trajectory-based approach, and to assess whether the strength of these links differs as a function of sleep assessment method (actigraphy vs. self-report) and sleeping arrangements.

METHODS

Maternal and infant nocturnal wakefulness were assessed with actigraphy and sleep diaries at home for 5 nights, at 3 (N = 191), 6 (N = 178), 12 (N = 155), and 18 (N = 135) months postpartum. Outcome measures included the number of night-wakings (NW) and the length of nocturnal wakefulness (WASO).

RESULTS

Strong associations between maternal and infant nocturnal wakefulness (controlling for nighttime breastfeeding) were found for NW and WASO. Trajectory analyses demonstrated that the strength of these relations decreased linearly from 3 to 18 months. Furthermore, the findings showed that the links between maternal and infant NW and WASO were stronger for maternal reports than for actigraphy. No consistent differences were found in the strength of the relations between maternal and infant NW and WASO as a function of sleeping arrangements (ie, room-sharing vs. solitary-sleeping families).

CONCLUSIONS

The results suggest that infant and maternal sleep are strongly intertwined, especially during the first 6 months. The decline in the synchronization between maternal and infant nocturnal wakefulness through infant development may be attributed to the growing ability of infants to self-soothe during the night. The findings emphasize the need to study sleep within a family context.

Early diagnosis of autism in the community is associated with marked improvement in social symptoms within 1-2 years

LAY ABSTRACT

It is widely believed that early diagnosis and treatment of autism spectrum disorder is essential for better outcome. This is demonstrated by the American Academy of Pediatrics recommendation to screen all 1.5-2.5-year-old toddlers for autism spectrum disorder. However, multiple longitudinal studies of children diagnosed with autism spectrum disorder at 1.5-6 years of age and treated in community settings have not reported any associations between earlier diagnosis and improved outcome in core autism spectrum disorder symptoms. In this study, we measured changes in core autism spectrum disorder symptoms over a 1-2-year period in 131 children diagnosed with autism spectrum disorder at 1.2-5 years of age, and treated in the community. The results revealed that children who were diagnosed before 2.5 years of age were three times more likely to exhibit considerable improvements in social autism spectrum disorder symptoms in comparison to children diagnosed at later ages. These results highlight the importance of early diagnosis and treatment of autism spectrum disorder even in community settings with heterogeneous services. In addition, these results motivate further prioritization of universal screening for autism spectrum disorder before 2.5 years of age.

Maternal emotional distress and infant sleep: A longitudinal study from pregnancy through 18 months

This longitudinal study examined whether changes in maternal emotional distress (depressive, anxiety, and parenting-stress symptoms) predict changes over time in subjective and objective infant sleep. We recruited 226 Israeli expectant mothers (M age 28.8 ± 3.3), most representing the middle-upper socioeconomic class. Maternal depressive and anxiety symptoms were assessed in the third trimester of pregnancy. After delivery (3, 6, 12, and 18 months), infant sleep quality and duration were assessed for 5 nights using actigraphy and the Brief Infant Sleep Questionnaire. Maternal depressive and anxiety symptoms were reassessed, and maternal parenting-stress was measured at all postpartum assessments. The findings demonstrated significant correlations between maternal emotional distress and mothers' subjective ratings of infant sleep problems (rs >.16 and < .46). Latent trajectory analyses indicated no significant effects of changes in maternal emotional distress variables on changes in infant subjective or objective sleep. Post hoc power analyses demonstrated that we had enough statistical power to reject the null hypothesis. The results suggest that mothers with higher emotional distress symptoms-and especially those with parenting-stress symptoms-are more likely to experience their infant's sleep as problematic. However, our results challenge the assumption that maternal emotional distress symptoms contribute to infant sleep disturbances over time. The findings are relevant to mothers with mild to moderate emotional distress symptoms and must not be generalized to mothers who experience major clinical depression. Future studies should evaluate whether maternal emotional distress interacts with other risk factors, such as infant temperament, to predict infant sleep disturbances. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Basic oculomotor function is similar in young children with ASD and typically developing controls

A variety of eye tracking studies have demonstrated that young children with ASD gaze at images and movies of social interactions differently than typically developing children. These findings have supported the hypothesis that gaze behavior differences are generated by a weaker preference for social stimuli in ASD children. The hypothesis assumes that gaze differences are not caused by abnormalities in oculomotor function including saccade frequency and kinematics. Previous studies of oculomotor function have mostly been performed with school-age children, adolescents, and adults using visual search, anti-saccade, and gap saccade tasks that are less suitable for young pre-school children. Here, we examined oculomotor function in 144 children (90 with ASD and 54 controls), 1-10-years-old, as they watched two animated movies interleaved with the presentation of multiple salient stimuli that elicited saccades-to-targets. The results revealed that the number of fixations, fixation duration, number of saccades, saccade duration, saccade accuracy, and saccade latency did not differ significantly across groups. Minor initial differences in saccade peak velocity were not supported by analysis with a linear mixed model. These findings suggest that most children with ASD exhibit similar oculomotor function to that of controls, when performing saccades-to-targets or freely viewing child-friendly movies. This suggests that previously reported gaze abnormalities in children with ASD are not due to underlying oculomotor deficiencies. LAY SUMMARY: This study demonstrates that children with ASD perform similar eye movements to those of controls when freely observing movies or making eye movements to targets. Similar results were apparent across groups in the number of eye movements, their accuracy, duration, and other measures that assess eye movement control. These findings are important for interpreting previously reported differences in gaze behavior of children with ASD, which are likely due to atypical social preferences rather than impaired control of eye movements.

Association between abnormal fetal head growth and autism spectrum disorder

Introduction

Despite evidence for the prenatal onset of abnormal head growth in ASD children, studies on fetal ultrasound data in ASD are limited and controversial.

Objectives

To understand whether people with ASD have abnormal head growth during gestation

Methods

A longitudinal matched case-sibling-control study on prenatal ultrasound biometric measures of ASD children was conducted. Children with ASD were matched to two control groups: (1) typically developed sibling (TDS) and (2) typically developed population (TDP). The cohort comprised 528 children (72.7% males): 174 ASD, 178 TDS, and 176 TDP.

Results

Second-trimester ASD and TDS fetuses had significantly smaller biparietal diameter (BPD) than TDP fetuses (aOR_zBPD=0.685, 95%CI=0.527-0.890 and aOR_zBPD=0.587, 95%CI=0.459-0.751, respectively). However, these differences became statistically indistinguishable in the third trimester. Head biometric measures were associated with the sex of the fetus, with males having larger heads than females within and across groups. A linear mixed-effect model assessing the effects of sex and group assignment on fetal longitudinal head growth indicated faster BPD growth in TDS vs both ASD and TDP in males (β=0.084 and β=0.100 respectively; p<0.001) but not in females, suggesting an ASD–sex interaction in head growth during gestation. Fetal head shape showed sex-specific characteristics, and head growth was inversely correlated with ASD severity in males and females, thus further supporting the sex effect on the association between fetal head growth and ASD.

Conclusions

Our findings suggest that abnormal fetal head growth is a familial trait of ASD, which is modulated by sex and is associated with the severity of the disorder.

Disclosure

No significant relationships.

Association Between Abnormal Fetal Head Growth and Autism Spectrum Disorder

OBJECTIVE

Despite evidence for the prenatal onset of abnormal head growth in children with autism spectrum disorder (ASD), studies on fetal ultrasound data in ASD are limited and controversial.

METHOD

We conducted a longitudinal matched case-sibling-control study on prenatal ultrasound biometric measures of children with ASD, and 2 control groups: (1) their own typically developed sibling (TDS) and (2) typically developed population (TDP). The cohort comprised 528 children (72.7% male), 174 with ASD, 178 TDS, and 176 TDP.

RESULTS

During the second trimester, ASD and TDS fetuses had significantly smaller biparietal diameter (BPD) than TDP fetuses (adjusted odds ratio for the z score of BPD [aOR_zBPD] = 0.685, 95% CI = 0.527-0.890, and aOR_zBPD = 0.587, 95% CI = 0.459-0.751, respectively). However, these differences became statistically indistinguishable in the third trimester. Interestingly, head biometric measures varied by sex, with male fetuses having larger heads than female fetuses within and across groups. A linear mixed-effect model assessing the effects of sex and group assignment on fetal longitudinal head growth indicated faster BPD growth in TDS versus both ASD and TDP in male fetuses (β = 0.084 and β = 0.100 respectively; p < .001) but not in female fetuses, suggesting an ASD-sex interaction in head growth during gestation. Finally, fetal head growth showed conflicting correlations with ASD severity in male and female children across different gestation periods, thus further supporting the sex effect on the association between fetal head growth and ASD.

CONCLUSION

Our findings suggest that abnormal fetal head growth is a familial trait of ASD, which is modulated by sex and is associated with the severity of the disorder. Thus, it could serve as an early biomarker for ASD.

Improving the parent-child relationship and child adjustment through parental reflective functioning group intervention

Parental reflective functioning (PRF) is a core element in the parent-child relationship. This study set out to investigate changes in PRF following the DUET program, a 12-week group intervention program. We proposed that the DUET intervention would enhance maternal reflective capacities, resulting in better mother-child emotional availability, better child self-regulation, and decreased child behavioral problems. Seventy mothers completed the DUET group intervention. Of these mothers, nine mothers were first allocated to the waiting-list group and thereafter were included in an intervention group. PRF was measured using observation (mind-mindedness) and an interview (PDI). Following the intervention, a significant improvement was evident in PRF, in parental beliefs about feeling, and in parental sense of efficacy. In addition, the mother-child interaction was more positive, child behavioral problems decreased, and child self-regulation increased. This improvement remained stable over a period of 6 months. Clinical and future directions of this study are discussed.

Sleep Disturbances and Sensory Sensitivities Co-Vary in a Longitudinal Manner in Pre-School Children with Autism Spectrum Disorders

Previous research has demonstrated that sleep disturbances are positively correlated with sensory sensitivities in children with ASD. Most of these studies, however, were based on cross-sectional analyses, where the relationship across symptom domains was examined at a single time-point. Here, we examined the development of 103 pre-school children with ASD over a 1–3-year period. The results revealed that spontaneous longitudinal changes in sleep disturbances were specifically correlated with changes in sensory sensitivities and not with changes in other sensory processing domains nor with changes in core ASD symptoms. These finding demonstrate a consistent longitudinal relationship between sleep disturbances and sensory sensitivities, which suggests that these symptoms may be generated by common or interacting underlying physiological mechanisms.

Young Autism Spectrum Disorder Children in Special and Mainstream Education Settings Have Similar Behavioral Characteristics

In many countries, parents can place autism spectrum disorder (ASD) children in either mainstream or special education settings, which differ in their ability to provide structured early intervention programs. There are no clear guidelines for how to make initial placement decisions and ongoing debate about the benefits and drawbacks of each educational setting. Previous studies have mostly examined placement of school-age children and reported that those with poorer cognitive abilities and more severe ASD symptoms tend to be placed in special education. The placement of younger children has rarely been studied. Here, we utilized the database at the National Autism Research Center of Israel to examine whether ASD severity, cognitive abilities, and parent education influenced the placement of 242 children. We performed the analyses separately for 1-3-year-old children who were placed in daycare centers and 3-5-year-old children who were placed in pre-school kindergartens. Our analyses revealed surprisingly small differences across special and mainstream education settings, particularly in daycare centers. Cognitive scores and parent education were significantly higher in ASD children placed in mainstream education, but these differences were of moderate effect size and explained a relatively small percentage of the variability in placement choices (<15%). Indeed, we found considerable overlap in the characteristics of ASD children across educational settings, which suggests that initial placement decisions are performed with little regard to the children's abilities. Given the importance of optimal early intervention, further studies are warranted to determine whether children with specific abilities and needs benefit more from placement in either educational setting. LAY SUMMARY: Currently, there are no clear recommendations for placing young children with ASD in special versus mainstream education settings. We examined the influence of ASD severity, cognitive abilities, and parent education on the initial placement of 242 children. While we found significantly higher cognitive scores and parental education in children placed in mainstream education, there was a remarkable overlap in the characteristics of children across both settings, suggesting that initial placement is performed with limited regard to the children's abilities. Autism Res 2021, 14: 699-708. © 2020 International Society for Autism Research and Wiley Periodicals LLC.

Mother-Infant Sleep and Maternal Emotional Distress in Solo-Mother and Two-Parent Families

OBJECTIVE

This study examined for the first time mother-infant sleep and emotional distress in solo mother families compared with two-parent families and explored whether the links between mother-infant sleep and maternal emotional distress differ as a function of family structure.

METHODS

Thirty-nine solo-mother families and 39 two-parent families, with an infant within the age range of 6-18 months participated in the study. Actigraphy and sleep diaries were used to assess maternal and infant sleep at home. Mothers completed questionnaires to assess maternal depressive and anxiety symptoms, social support, sleeping arrangements, breastfeeding, and demographics.

RESULTS

Solo mothers were older and more likely to breastfeed and share a bed with their infants than married mothers. There were no significant differences between the groups in mother-infant sleep and maternal emotional distress, while controlling for maternal age, breastfeeding, and sleeping arrangements. Family structure had a moderating effect on the associations between maternal emotional distress and mother-infant sleep. Only in solo-mother families, higher maternal emotional distress was associated with lower maternal and infant sleep quality.

CONCLUSIONS

Our findings suggest that, although there are no significant differences in maternal and infant sleep between solo-mother families and two-parent families, the strength of the associations between maternal emotional distress and both infant and maternal sleep quality are stronger in solo-mother families, compared with two-parent families. Hopefully, understanding which aspects of parenting may contribute to the development of sleep problems in solo-mother families could be helpful in tailoring interventions to this growing population.

Reduced sleep pressure in young children with autism

Study Objectives

Sleep disturbances and insomnia are highly prevalent in children with Autism Spectrum Disorder (ASD). Sleep homeostasis, a fundamental mechanism of sleep regulation that generates pressure to sleep as a function of wakefulness, has not been studied in children with ASD so far, and its potential contribution to their sleep disturbances remains unknown. Here, we examined whether slow-wave activity (SWA), a measure that is indicative of sleep pressure, differs in children with ASD.

Methods

In this case-control study, we compared overnight electroencephalogram (EEG) recordings that were performed during Polysomnography (PSG) evaluations of 29 children with ASD and 23 typically developing children.

Results

Children with ASD exhibited significantly weaker SWA power, shallower SWA slopes, and a decreased proportion of slow-wave sleep in comparison to controls. This difference was largest during the first 2 hours following sleep onset and decreased gradually thereafter. Furthermore, SWA power of children with ASD was significantly negatively correlated with the time of their sleep onset in the lab and at home, as reported by parents.

Conclusions

These results suggest that children with ASD may have a dysregulation of sleep homeostasis that is manifested in reduced sleep pressure. The extent of this dysregulation in individual children was apparent in the amplitude of their SWA power, which was indicative of the severity of their individual sleep disturbances. We, therefore, suggest that disrupted homeostatic sleep regulation may contribute to sleep disturbances in children with ASD.

RSRC1 mutation affects intellect and behaviour through aberrant splicing and transcription, downregulating IGFBP3

RSRC1, whose polymorphism is associated with altered brain function in schizophrenia, is a member of the serine and arginine rich-related protein family. Through homozygosity mapping and whole exome sequencing we show that RSRC1 mutation causes an autosomal recessive syndrome of intellectual disability, aberrant behaviour, hypotonia and mild facial dysmorphism with normal brain MRI. Further, we show that RSRC1 is ubiquitously expressed, and that the RSRC1 mutation triggers nonsense-mediated mRNA decay of the RSRC1 transcript in patients' fibroblasts. Short hairpin RNA (shRNA)-mediated lentiviral silencing and overexpression of RSRC1 in SH-SY5Y cells demonstrated that RSRC1 has a role in alternative splicing and transcription regulation. Transcriptome profiling of RSRC1-silenced cells unravelled specific differentially expressed genes previously associated with intellectual disability, hypotonia and schizophrenia, relevant to the disease phenotype. Protein-protein interaction network modelling suggested possible intermediate interactions by which RSRC1 affects gene-specific differential expression. Patient-derived induced pluripotent stem cells, differentiated into neural progenitor cells, showed expression dynamics similar to the RSRC1-silenced SH-SY5Y model. Notably, patient neural progenitor cells had 9.6-fold downregulated expression of IGFBP3, whose brain expression is affected by MECP2, aberrant in Rett syndrome. Interestingly, Igfbp3-null mice have behavioural impairment, abnormal synaptic function and monoaminergic neurotransmission, likely correlating with the disease phenotype.

Real life Experience of Medical Cannabis Treatment in Autism: Analysis of Safety and Efficacy

There has been a dramatic increase in the number of children diagnosed with autism spectrum disorders (ASD) worldwide. Recently anecdotal evidence of possible therapeutic effects of cannabis products has emerged. The aim of this study is to characterize the epidemiology of ASD patients receiving medical cannabis treatment and to describe its safety and efficacy. We analysed the data prospectively collected as part of the treatment program of 188 ASD patients treated with medical cannabis between 2015 and 2017. The treatment in majority of the patients was based on cannabis oil containing 30% CBD and 1.5% THC. Symptoms inventory, patient global assessment and side effects at 6 months were primary outcomes of interest and were assessed by structured questionnaires. After six months of treatment 82.4% of patients (155) were in active treatment and 60.0% (93) have been assessed; 28 patients (30.1%) reported a significant improvement, 50 (53.7%) moderate, 6 (6.4%) slight and 8 (8.6%) had no change in their condition. Twenty-three patients (25.2%) experienced at least one side effect; the most common was restlessness (6.6%). Cannabis in ASD patients appears to be well tolerated, safe and effective option to relieve symptoms associated with ASD.

Autism Prevalence and Severity in Bedouin-Arab and Jewish Communities in Southern Israel

The vast majority of autism spectrum disorder (ASD) research focuses on Caucasian populations in western world countries. While it is assumed that autism rates are similar across ethnic groups regardless of genetic background and environmental exposures, few studies have specifically examined how autism prevalence and severity may differ between majority and minority populations with distinct characteristics. Therefore, we evaluated ethnic differences in ASD prevalence and severity of Bedouin-Arab and Jewish children in the south of Israel. We compared demographic and clinical characteristics of 104 children from a Bedouin-Arab minority with 214 Jewish children who were referred to the main ASD clinic in Southern Israel with suspected communication disorders. Data were obtained from medical records. Jewish children's referral rates were almost 6 times more than that of Bedouin-Arab referral rates (21:1000 and 3.6:1000, respectively). The percentage of high functioning children with ASD was much higher in Jewish than in Bedouin-Arab children (29.6 and 2.6%, respectively). Bedouin-Arab children showed more severe autistic manifestations. Moreover, Bedouin-Arab children were more likely than Jewish children to have additional diagnosis of intellectual disability (14.5 and 6.9%, respectively). Autism prevalence and severity differs markedly between the Bedouin-Arab and Jewish populations in the south of Israel. Most striking is the almost complete absence of children with high-functioning autism in the Bedouin community. A better understanding of the causes for autism prevalence and severity differences across ethnic groups is crucial for revealing the impact of multiple genetic and environmental factors that may affect autism development in each group.

Characteristics Associated with Drug Prescription and Compliance Among Young Children with Autism Spectrum Disorder

OBJECTIVES

Psychotropic drugs are prescribed to people with autism spectrum disorder (ASD) usually as a means to alleviate comorbidities associated with the disorder. However, despite the uncertainty regarding the efficacy of these treatments for ASD, their prevalence is continuously increasing. The goal of this study was to understand the characteristics associated with drug prescription and compliance among young children with ASD.

MATERIALS AND METHODS

We studied patterns of drug utilization in a population-based sample of 211 young children with ASD in Southern Israel. Data regarding drug prescription and compliance (percentage of purchased drugs out of total prescriptions) were acquired from the electronic records of these patients. Compliance rates (CRs) were calculated as percentage of purchased drugs of the total number of prescriptions.

RESULTS

A total of 122 prescriptions were made for 75 children in our sample. Drug prescription was significantly associated with the severity of ASD and the types of comorbidity (p < 0.05). Atypical antipsychotic drugs were the most prevalent drugs (49 children; 23.2%), followed by stimulants (28 children; 13.2%) and first-generation antipsychotic drugs (16 children; 7.6%). The average CR in our sample was 75% ± 3% with about half of the children demonstrating full compliance, and less than fifth of them not complying at all with their drug prescription. CR had a positively linear association with ASD severity at a marginal statistical significance of p = 0.06. No other variables were statistically associated with drug compliance in our study.

CONCLUSIONS

Our results highlight the significant effect of ASD severity on both the prescription and CRs of drugs among young children with ASD. Further examination of drug utilization for longer periods and larger samples will help confirming our findings and test the effects of other variables on these pharmaceutical parameters.

Sleep disturbances are associated with specific sensory sensitivities in children with autism

Background

Sensory abnormalities and sleep disturbances are highly prevalent in children with autism, but the potential relationship between these two domains has rarely been explored. Understanding such relationships is important for identifying children with autism who exhibit more homogeneous symptoms.

Methods

Here, we examined this relationship using the Caregiver Sensory Profile and the Children’s Sleep Habits Questionnaire, which were completed by parents of 69 children with autism and 62 age-matched controls.

Results

In line with previous studies, children with autism exhibited more severe sensory abnormalities and sleep disturbances than age-matched controls. The sleep disturbance scores were moderately associated with touch and oral sensitivities in the autism group and with touch and vestibular sensitivities in the control group. Hypersensitivity towards touch, in particular, exhibited the strongest relationship with sleep disturbances in the autism group and single-handedly explained 24% of the variance in total sleep disturbance scores. In contrast, sensitivity in other sensory domains such as vision and audition was not associated with sleep quality in either group.

Conclusions

While it is often assumed that sensitivities in all sensory domains are similarly associated with sleep problems, our results suggest that hypersensitivity towards touch exhibits the strongest relationship with sleep disturbances when examining children autism. We speculate that hypersensitivity towards touch interferes with sleep onset and maintenance in a considerable number of children with autism who exhibit severe sleep disturbances. This may indicate the existence of a specific sleep disturbance mechanism that is associated with sensitivity to touch, which may be important to consider in future scientific and clinical studies.

A Double Dissociation Between Inattentive and Impulsive Traits, on Tasks of Visual Processing and Emotion Regulation

OBJECTIVE

To dissociate between inattentive and impulsive traits common in attention deficit hyperactivity disorder (ADHD) using a non-dichotomous measurment of these traits.

METHOD

120 university students who completed the Conner's adult ADHD rating scales (CAARS) were also tested on the Microgenesis task which requires visual attention and on the Cyber Cruiser task which requires emotion regulation.

RESULTS

Results show that a measure of inattention was specifically related to a measure of effortful visual processing condition. In addition, a measure of impulsivity was specifically related to the tendency to fail in refueling one's car on time, although this relation was opposite to the predicted direction. Furthermore, by using exploratory and confirmatory factor analyses, the CAARS' factor structure was confirmed to be relevant to an Israeli population.

CONCLUSION

The current experiment supports the idea that visual attention may play a part in inattentive symptoms, and that emotion regulation may play a part in impulsivity symptoms.

[DSM-5 AND AUTISM: DIAGNOSTIC CHANGES AND CLINICAL IMPLICATIONS IN EARLY CHILDHOOD]

Autistic spectrum disorders (ASDs) are characterized by significant disability in interpersonal communication, social interactions and patterns of unusual behavior. In recent decades the worldwide prevalence of ASDs is rising almost exponentially, without a clear known etiological explanation. Until recently, ASDs were defined by the American Manual of Psychiatric Diagnoses: The DSM-IV-TR, under one conceptual umbrella of "Pervasive Developmental Disorders" (PDD). Under this category, there were five separate diagnoses. The DSM-5 eliminated the separate,diagnoses and created one continuum (Autism Spectrum Disorder = ASD). By this definition, the symptomatic manifestation was reduced and the criteria for diagnosis are fixed for the entire spectrum. The differences between individuals are expressed in the levels of severity rated. Studies evaluating the transition from PDD to ASD, found an increase in the specificity of the diagnosis and its potential ability to distinguish between clinical and non-clinical populations. Alongside the increase in consistency and stability, there is a decrease in sensitivity, and about a quarter of the children who were previously diagnosed with PDD are not diagnosed as such, due to a failure to meet all the necessary symptoms. These changes especially affect the clinical diagnosis of young children as their symptomatic manifestation is not yet clear and distinct enough due to their age and maturation processes. This article discusses the clinical implications of these findings and demonstrates it from a case report.