Repetitive Behaviors in Autism and Obsessive-Compulsive Disorder: A Systematic Review

PURPOSE

Obsessive-compulsive disorder (OCD) and autism are characterized by the presence of repetitive behaviors. Differentiating between repetitive behaviors attributable to a diagnosis of autism, and those attributable to OCD, poses challenges for differential and co-occurring diagnosis. Differentiation is important to inform appropriate supports and interventions for phenotypically similar but functionally distinct behaviors. In this systematic review, the quantitative literature was examined to explore the similarities and differences in repetitive behaviors (including restricted and repetitive behaviors and interests, and obsessive-compulsive behaviors) in autistic individuals and those with OCD, and those with co-occurring diagnoses, in terms of: (1) expression, (2) content, and (3) associated factors.

METHODS

Thirty-one studies were identified that compared repetitive behaviors in autistic individuals, individuals with OCD, or individuals with both diagnoses.

RESULTS

The results suggest considerable overlap in the intensity and content of repetitive behaviors between groups. The findings of this review highlight that research aimed specifically at understanding similarities and differences in repetitive behaviors between autistic individuals and individuals with OCD is limited and frequently only compare at total score or composite measure levels.

CONCLUSION

Further research into differences in the presentation of repetitive behaviors at a subscale and item level is required to inform clearer differentiation of specific behaviors in autism versus OCD. Understanding and more accurately differentiating is essential for efficient diagnosis, effective treatment, and better outcomes.

COVID-19 vaccines and adverse events of special interest: A multinational Global Vaccine Data Network (GVDN) cohort study of 99 million vaccinated individuals

BACKGROUND

The Global COVID Vaccine Safety (GCoVS) Project, established in 2021 under the multinational Global Vaccine Data Network™ (GVDN®), facilitates comprehensive assessment of vaccine safety. This study aimed to evaluate the risk of adverse events of special interest (AESI) following COVID-19 vaccination from 10 sites across eight countries.

METHODS

Using a common protocol, this observational cohort study compared observed with expected rates of 13 selected AESI across neurological, haematological, and cardiac outcomes. Expected rates were obtained by participating sites using pre-COVID-19 vaccination healthcare data stratified by age and sex. Observed rates were reported from the same healthcare datasets since COVID-19 vaccination program rollout. AESI occurring up to 42 days following vaccination with mRNA (BNT162b2 and mRNA-1273) and adenovirus-vector (ChAdOx1) vaccines were included in the primary analysis. Risks were assessed using observed versus expected (OE) ratios with 95 % confidence intervals. Prioritised potential safety signals were those with lower bound of the 95 % confidence interval (LBCI) greater than 1.5.

RESULTS

Participants included 99,068,901 vaccinated individuals. In total, 183,559,462 doses of BNT162b2, 36,178,442 doses of mRNA-1273, and 23,093,399 doses of ChAdOx1 were administered across participating sites in the study period. Risk periods following homologous vaccination schedules contributed 23,168,335 person-years of follow-up. OE ratios with LBCI > 1.5 were observed for Guillain-Barré syndrome (2.49, 95 % CI: 2.15, 2.87) and cerebral venous sinus thrombosis (3.23, 95 % CI: 2.51, 4.09) following the first dose of ChAdOx1 vaccine. Acute disseminated encephalomyelitis showed an OE ratio of 3.78 (95 % CI: 1.52, 7.78) following the first dose of mRNA-1273 vaccine. The OE ratios for myocarditis and pericarditis following BNT162b2, mRNA-1273, and ChAdOx1 were significantly increased with LBCIs > 1.5.

CONCLUSION

This multi-country analysis confirmed pre-established safety signals for myocarditis, pericarditis, Guillain-Barré syndrome, and cerebral venous sinus thrombosis. Other potential safety signals that require further investigation were identified.

The provision of general surgery in rural Australia: a narrative review

Rural surgery is most commonly provided by general surgeons to the 29% of people (7 million) living in rural Australia. The provision of rural general surgery to enable equitable and safe surgical care for rural Australians is a multifaceted issue concerning recruitment, training, retention, surgical procedures and surgical outcomes. Sustaining the rural general surgical workforce will be dependent upon growing an increased number of resident rural general surgeons, as well as changed models of care, with a need for ongoing review to track the outcomes of these changes. To increase recruitment, rural general surgical training must improve to be less stressful for trainees and to be incorporated alongside a rural-facing generalist curriculum. Rural general surgical outcomes (excluding some oncology conditions) achieve comparable results to metropolitan centres. Access to, and outcomes of, surgical oncology services continues to be inequitable for rural Australians and should be a major focus for improved service delivery.

Parenting Practices and Externalizing Behaviors in Autistic Children: A Systematic Literature Review

There is limited recent research on the association between parenting practices and externalizing behaviors in autistic children. To address this gap, the current systematic review examined the associations between parenting practices and externalizing behaviors in autistic children, along with the mediating and moderating effects of parent and child variables (PROSPERO registration number CRD42022268667). Study inclusion criteria were (1) Peer-reviewed journals, (2) Participants included parents of autistic children and their children, (3) Quantitative measures of both parenting practices or behaviors/style and child externalizing behaviors, (4) Cross-sectional or longitudinal studies only, and (5) Studies published in English. Study exclusion criteria were: (1) Qualitative studies, (2) Published in a language other than English, (3) Participants included non-human participants, (4) Participants that did not include parents and their autistic children as participants or did not report this group separately, (5) Systematic review and meta-analyses, and (6) No quantitative measures of parenting practices and/or child externalizing behaviors. Quality appraisal and risk of bias were conducted using the McMaster Tool and results were synthesized in Covidence and Excel. Thirty studies were included in the review. Results demonstrated that mindful parenting was associated with fewer or lower levels of externalizing behaviors; positive parenting practices had non-significant associations with externalizing behaviors; specific parenting practices had differing associations with externalizing behaviors; and negative parenting practices were associated with higher levels of externalizing behaviors. We are unable to draw causal relationships due to focus on cross-sectional and longitudinal articles only. The potential for future research to target specific parent practices to support children's externalizing behaviors is discussed.

Longitudinal studies of challenging behaviours in autistic children and adults: A systematic review and meta-analysis

Autistic children and adults are at increased risk of showing behaviours that may be described as challenging, however, little is known about whether or how these behaviours may change over time. Given the profound impact that challenging behaviour can have on both the autistic individual and their support network, it is critical that the trajectory of challenging behaviours be better understood. This systematic review and meta-analysis identified and synthesised observational longitudinal studies of challenging behaviour in autistic individuals. Fifty-six studies were included in the systematic review, and the effect sizes of 37 independent samples arising from 34 of these reports were examined through meta-analysis. Crucially, across the 37 samples, scores on the measures of challenging behaviour reduced by a small, yet significant, extent over time. Although age of the sample at baseline assessment did not moderate the effect, the time between the baseline assessment and final follow-up and age at final follow-up both moderated the magnitude of the effect, with challenging behaviour scores reducing to a larger extent in (a) studies with longer intervals between baseline and final follow-up and (b) studies with older samples at follow-up. The results from the current systematic review and meta-analysis have both theoretical and practical implications for understanding challenging behaviour over time in autistic individuals. Avenues for future research are also highlighted that may allow better understanding, and therefore support of, challenging behaviour in autistic individuals.

A brief online mindful parenting program: Feasibility and initial effects pilot in a community sample

Mindful parenting programs are effective in reducing parenting stress. More efficient offerings may increase accessibility. The current single case study aimed to determine the feasibility, acceptability and initial effects of a brief, online mindful parenting program. Six parents, recruited from the community, completed a 4-week online mindful parenting program (Two Hearts). Feasibility and acceptability were assessed by participant program evaluation, retention, engagement with program materials (i.e., videos), and home practice. Parents completed primary outcome measurements of parenting stress, and general distress, at pre- and post-intervention, and 4-week follow-up. Individual level reliable change index and clinically significant change were calculated for outcome measures. All parents were retained through the study; all participants reported obtaining something of lasting value from the training. Program adherence varied over time. At post-intervention, four parents reported 40-50 minutes practice per week; two parents reported 10-15 minutes practice per week. At follow-up, 50% of parents reported 30-50 minutes practice per week. Three parents showed a reliable reduction in parenting stress; two of these parents demonstrated clinically significant change. Improvements in parent general distress were indicated in half the sample. Two parents experienced a clinically significant increase in parenting stress and/or general distress. In conclusion, the Two Hearts program demonstrated good acceptability, and may be a feasible and effective program for some parents. Program adherence and dosage require further investigation. The role of acute stressors (e.g., COVID-19) must be also considered.

Pre-school Skills and School-Age Reading Comprehension in Children on the Autism Spectrum: A Preliminary Investigation

We explored reading comprehension development in children on the spectrum from pre-school to the first (YOS1) and third year of schooling (YOS3). Children were first assessed on meaning-related skills in pre-school. Forty-one children completed follow-up assessments of reading comprehension, reading accuracy, and listening comprehension in YOS1. Nineteen returned for assessments of reading accuracy, reading comprehension, and listening comprehension in YOS3. Children showed poorer reading comprehension than reading accuracy at both timepoints. Reading comprehension, reading accuracy, and listening comprehension were significantly concurrently correlated. Pre-school receptive vocabulary was a significant predictor of YOS3 reading comprehension. Results from this preliminary investigation highlight the potential for early identification of children on the spectrum at risk for reading comprehension difficulties.

A systematic review of the academic achievement of primary and secondary school-aged students with developmental language disorder

BACKGROUND AND AIMS

The ability to communicate is a fundamental skill required to participate in school. Students with Developmental Language Disorder (DLD) have persistent and significant language difficulties that impact daily functioning. However, the impact of DLD on the academic achievement of primary and secondary school-aged students has received limited attention.

METHODS

A systematic review of the empirical research published between 2008 and 2020 was undertaken to identify studies that have examined the academic achievement of school-aged students with DLD within curriculum areas. A total of 44 studies were identified that met inclusion criteria for review.

RESULTS

Students with DLD demonstrated difficulties with academic achievement across all measured curriculum areas compared to their typically developing peers. Most studies focused on literacy skills, including reading, spelling, writing and narratives.

CONCLUSIONS AND IMPLICATIONS

The performance of students with DLD was heterogeneous with individual students demonstrating relative strengths in some areas of academic achievement. The implications of these results for educational practices and future research are discussed.

Autistic Mothers of Autistic Children: A Preliminary Study in an Under-Researched Area

Background

Much research exists on the mental health and well-being of parents of autistic children; however, parents who are themselves autistic have received little attention in the literature. We aimed to compare parenting stress and family outcomes in mothers who do, and do not, identify as being autistic.

Methods

We matched 20 mothers who identified as being autistic to 20 mothers who do not identify as being autistic on variables associated with parental well-being: child externalizing behaviors, score on the Social Communication Questionnaire, child adaptive functioning, family income, and child and maternal age. All mothers had at least one autistic child. Outcome variables were family outcomes (Family Outcome Survey-Revised) and parenting stress (Parent Stress Index 4-Short Form). Paired t-tests were used to compare scores between the two samples.

Results

There were no statistical differences in achievement of family outcomes between the autistic and nonautistic mothers. The small effect size on Family Outcome 4 may suggest that autistic mothers develop stronger support networks, but as a statistical comparison for this item nonsignificant, this should be interpreted with caution. Autistic and nonautistic mothers reported equally high levels of parenting stress.

Conclusions

Further research with larger samples is required to explore this under-researched area. Such research would be of value to understand any interaction between parental and child autism characteristics, well-being, and parenting. This could then inform development of supports, which can be tailored for each child's family.

Lay summary

Why was this research done?: Despite decades of research exploring the well-being and mental health of parents of autistic children, the experience of autistic adults with autistic children has not been researched in detail. In fact, we could find less than five research studies on the topic.What was the purpose of the study?: We wanted to do some preliminary work in the area and look at whether parent well-being or family outcomes are similar or different between autistic and nonautistic mothers of autistic children.What did the researchers do?: We are part of a team of researchers working on a larger study on a different topic. As part of this study, we asked parents about their own experiences and well-being, which included questions on whether or not the parents identify as autistic. This meant that within this larger study, there were the data to look at parent and family outcomes and see if they differ depending on whether or not the mothers themselves identified as being autistic.To do this, we went to the large data set and first identified the mothers who identified as being autistic; this was 20 mothers. Then, one of the researchers (M.S.) carefully matched the 20 autistic mothers to 20 mothers who did not identify as autistic (nonautistic mothers) on a number of areas that previous research has linked with parent and family well-being and outcomes. Trying to make the two groups as similar as possible in the areas shown to impact parent and family outcomes means that we can be more confident that any differences between the two groups are due to the one thing that is purposeful: whether or not the mothers were autistic.What were the results of the study?: We found that in general, parent well-being and family outcomes did not differ between the two groups.What were the potential weaknesses of the study?: The small sample size and the lack of detailed knowledge around parental relationship status and ethnicity mean that it is not possible to assume that these results represent the wider population. We also cannot be sure that mothers who identified as nonautistic were definitely not autistic (i.e., they may have been autistic but as yet undiagnosed).How will these findings help autistic adults now or in the future?: We hope that this study will be a platform to inspire future research in this area, using different research methods (interviews, questionnaires) to learn from the lived experience of autistic mothers. This can provide a way for nonautistic parents, researchers, and professionals to learn from the experience and skills of autistic mothers and potentially inform future practice.

Prompting visual attention to print versus pictures during shared book reading with digital storybooks for preschoolers with ASD compared to TD peers

Prompting children to look at print and picture content during shared book reading (SBR) facilitates joint attention and early language and literacy learning opportunities for typically developing (TD) children. Whether preschoolers with autism spectrum disorder (ASD) respond similarly to bids for joint attention during SBR and how autism characteristics impact upon their responsiveness is currently unclear. This is important given these children are at risk of persistent language and literacy challenges. To address this, we examined the effects of prompts that were solely verbal versus verbal with pointing on visual attention to print and picture targets during SBR with digital storybooks for 34 children with ASD and 27 TD peers. Children with ASD looked as frequently at print targets, but less frequently at picture targets, when prompted compared to TD peers. Both prompt types showed similar effects in shifting children's visual attention to print and picture targets at group level. When groups were combined, autism characteristics influenced children's responsiveness to verbal versus verbal with pointing prompts to print targets, but not to picture targets; children looked more frequently at print targets as autism characteristics increased when verbal prompts were used, with a large effect shown (d = 0.91). Overall, findings suggest that prompting children with ASD to look at print and pictures during SBR with digital storybooks may be helpful in facilitating joint attention to storybook content. Implications for the development of effective early interventions aimed at providing emergent literacy support for children with ASD are discussed. LAY SUMMARY: We looked at how prompting impacted upon where children with autism look during shared book reading with digital storybooks compared to children without autism using eye-tracking. We found the target (pictures or print) was what mattered and number of autism characteristics impacted how responsive children were to different types of prompts. This helps us to understand how prompting may help children with autism to look at print or pictures during shared book reading which could support language or reading interventions.

Field testing an Australian model of practice for teaching young school-age students on the autism spectrum

BACKGROUND

Internationally, many mainstream teachers have identified that they lack the specialised knowledge and skills to adequately include and educate the increasing number of students on the autism spectrum in their classrooms.

AIMS

We investigated the experiences and perceptions of Australian mainstream teachers who field-tested a validated Model of Practice designed to support their daily work with young school-aged students on the spectrum. This new online resource comprised 29 foundational research-informed practices, each accompanied by a 2-page practice brief.

METHODS AND PROCEDURES

A convergent parallel mixed-methods design used semi-structured interviews and surveys to gather data from a sample of teachers (n = 38) prior to and following an 8-week field-testing period. Differentiated levels of professional support to facilitate engagement with the model were provided, with teachers receiving either in-person support, online support, or no additional support.

OUTCOMES AND RESULTS

A majority of teachers endorsed the practice model. Those who engaged with the model reported statistically significant increases in knowledge, confidence, and efficacy. Professional support facilitated teacher use of the model. No significant changes in practice use were found.

CONCLUSIONS AND IMPLICATIONS

This field-testing provides preliminary evidence of the applicability of the practice model in Australian early years classrooms. These findings have wider implications for the ways in which professional development can be targeted to promote research-informed teaching practice. What this paper adds This novel practice-based resource shows promise for building the capacity of mainstream teachers in educating young school-age students on the autism spectrum in the Australian context. Outcomes from this field testing confirm the usefulness of focusing on foundational teaching practices rather than single, stand-alone interventions. In addition, this research has highlighted the benefit of professional support in bridging the research-to-practice gap in autism education.

Clinician Proposed Predictors of Spoken Language Outcomes for Minimally Verbal Children with Autism Spectrum Disorder

Our aim was to explore insights from clinical practice that may inform efforts to understand and account for factors that predict spoken language outcomes for children with Autism Spectrum Disorder who use minimal verbal language. We used a qualitative design involving three focus groups with 14 speech pathologists to explore their views and experiences. Using the Framework Method of analysis, we identified 9 themes accounting for 183 different participant references to potential factors. Participants highlighted the relevance of clusters of fine-grained social, communication, and learning behaviours, including novel insights into prelinguistic vocal behaviours. The participants suggested the potential value of dynamic assessment in predicting spoken language outcomes. The findings can inform efforts to developing clinically relevant methods for predicting children's communication outcomes.

Emergent Literacy Assessment in Children With Autism Spectrum Disorder Who Have Limited Verbal Communication Skills: A Tutorial

Purpose Children with autism spectrum disorder (ASD) are at increased risk of experiencing difficulties with the development of literacy, including the emergent literacy skills recognized to underpin conventional literacy success. Comprehensive assessment is essential. Characteristics of ASD can make assessment challenging, and this can be compounded when children are unable to demonstrate their skills using spoken language. The purpose of this clinical tutorial is to outline the process of emergent literacy assessment for children with ASD who have limited verbal communication skills. A case example of a 5-year-old boy is presented. Method Pertinent literature is reviewed around the literacy profiles of children with ASD, the subgroup of children with ASD who have limited verbal communication skills, key components of emergent literacy, and previous research examining the emergent literacy abilities of children with ASD. The case report is described in depth and emphasizes the key factors to consider when designing an assessment battery and protocol. Results The case example information is interpreted, and its application is discussed. Key outcomes are highlighted including a greater understanding of the child's literacy strengths and needs and the implications for individualized instruction. Conclusion The clinical tutorial highlights the need for a comprehensive, well-planned assessment approach that involves all members of the educational team, and that is considerate to the needs of the individual child and responsive to their communication needs.

Introduction to the Forum: Literacy in Autism-Across the Spectrum

Purpose The purpose of this article is to introduce the LSHSS Forum: Literacy in Autism-Across the Spectrum. The articles in this forum provide an overview of the current evidence related to literacy in autism spectrum disorder (ASD) from preschool to adolescence and highlight the high literacy needs of this population. Method This introduction provides an overview of some of the reasons why children with ASD are at risk of persistent literacy difficulties and a summary of the six articles included in this forum. Conclusion More research is clearly needed to better understand which factors contribute to the high literacy needs in this population. For now, based on the best available evidence, the authors in this forum provide clear clinical implications that should be highly useful for speech-language pathologists and other professionals involved in literacy assessment and intervention for children and adolescents on the autism spectrum.

Looking or talking: Visual attention and verbal engagement during shared book reading of preschool children on the autism spectrum

LAY ABSTRACT

Children who have an autism diagnosis often have trouble learning to talk and read. These difficulties become noticeable before children start school and may be linked to lower attention and engagement in literacy-related activities such as sharing storybooks with their parents. To date, few researchers have looked at possible ways to measure how children on the autism spectrum engage during shared storybook reading, for example, where children look or how much they talk, and how this may be related to their letter-name knowledge and their vocabulary knowledge. In this study, we analyzed videos of 40 preschoolers on the spectrum and their parents sharing an unfamiliar storybook. We wanted to see whether where children looked (i.e. toward the storybook, their parent, or elsewhere) and how much they talked were related to what their parents did (e.g. ask questions or provide prompts) and/or children's letter-name knowledge and vocabulary. The videos were coded for different child and parent behaviors. We found that where children looked and how much they talked were strongly related to each other and what parents did during the shared book reading interaction, particularly asking questions and using prompts. In contrast to what we expected, where children looked was not related to children's letter or vocabulary knowledge. Overall, results of the study draw attention to the connection between what parents do and what preschoolers on the spectrum do when sharing storybooks and provide directions for future research.

Empirically Supported Treatments for Students with Autism: General Education Teacher Knowledge, Use, and Social Validity Ratings

Objective: To examine teachers' knowledge and use of empirically supported treatments (ESTs) for children with autism spectrum disorder (ASD), and the extent to which they deem them socially valid in general education settings. Method: Totally, 155 general education teachers completed an online survey examining knowledge, use, and perceived social validity of ESTs targeting school readiness skills. Sources of information accessed and the relationship of knowledge, use, and social validity with demographic variables were investigated. Results: Teachers reported knowledge of, and were using, all ESTs. ESTs were used more frequently than non-ESTs. Knowledge, use, and social validity of ESTs were strongly associated. Teachers reported accessing a range of sources of information, with varying degrees of trust placed in these sources. Conclusion: Teachers' knowledge of available ESTs for children with ASD is linked to their use. Increasing awareness of social validity of ESTs, and how they can be successfully translated into classroom settings will influence uptake.

Allied Health Professionals' Knowledge and Use of ASD Intervention Practices

Allied health professionals (AHPs) are trusted sources of information and intervention for clients with autism spectrum disorder. However, the level of implementation of empirically-supported therapies and the accuracy of the knowledge they use to inform intervention selection is largely unknown. The present study explored the accuracy of AHPs' knowledge and use of practices, and explored links to individual attitudes and organisational culture. Overall results from the 156 AHPs surveyed suggested general accuracy of knowledge, and use of empirically supported treatments, with accuracy linked to use. Use of practices unsupported by research was linked to organisational culture and openness to new interventions. The presence of misinformation and the impact on selection and use of effective practices are discussed.

School Age Outcomes of Children with Autism Spectrum Disorder Who Received Community-Based Early Interventions

This study followed children with Autism Spectrum Disorder (ASD) from early intervention into their early schooling years, when they were aged between 6 and 9 years, on autism symptom severity and cognitive functioning. The children, matched at pre-intervention, were compared on type of community provided service: 31 were in receipt of community-based group Early Start Denver Model and 28 had received other community provisions for ASD. Irrespective of groups, cognitive functioning was found to have significantly improved by school age compared to pre-intervention. Autism symptom severity increased during the same developmental period, seemingly driven by an increase in restricted and repetitive behaviours over time. In contrast, both groups displayed improved social affect by school age.

Evaluation of a template for countering misinformation-Real-world Autism treatment myth debunking

Misinformation poses significant challenges to evidence-based practice. In the public health domain specifically, treatment misinformation can lead to opportunity costs or direct harm. Alas, attempts to debunk misinformation have proven sub-optimal, and have even been shown to “backfire”, including increasing misperceptions. Thus, optimized debunking strategies have been developed to more effectively combat misinformation. The aim of this study was to test these strategies in a real-world setting, targeting misinformation about autism interventions. In the context of professional development training, we randomly assigned participants to an “optimized-debunking” or a “treatment-as-usual” training condition and compared support for non-empirically-supported treatments before, after, and six weeks following completion of online training. Results demonstrated greater benefits of optimized debunking immediately after training; thus, the implemented strategies can serve as a general and flexible debunking template. However, the effect was not sustained at follow-up, highlighting the need for further research into strategies for sustained change.

Profiles of vocalization change in children with autism receiving early intervention

Children with autism spectrum disorder (ASD) commonly present with comorbid language impairment, negatively impacting their learning and participation across settings. Addressing these needs requires a detailed understanding of their communication trajectories. In this study, we used the language environment and analysis (LENA) system to examine possible changes in children's (a) vocalizations and (b) ratio of speech to nonspeech vocalizations over a 10-month period. Data for 23 children with ASD (17M, 6F; ages 32-67 months) were analyzed, including monthly 3-hr in-class recordings and standardized measures of language, cognition, and ASD characteristics. Using hierarchical generalized linear models, we found significant time-trends for child vocalizations (P ≤ 0.001) and the vocalization ratio (P = 0.02), reflecting a waxing and waning pattern. Children with higher expressive language scores (Mullen scales of early learning, Vineland adaptive behavior scales - 2nd Ed.) and nonverbal cognition (Mullen scales of early learning), and fewer ASD characteristics (social communication questionnaire) demonstrated greater increases in the vocalization ratio over time (P values 0.04-0.01). Children with greater language and cognition difficulties were the most vocal, but produced a higher proportion of nonspeech vocalizations. The results demonstrate that significant fluctuations, as opposed to linear increases, may be observed in children with ASD receiving intervention, highlighting the value of assessment at multiple time-points. In addition, the findings highlight the need to consider both the quantity (vocalization counts) and quality (ratio of speech to nonspeech vocalizations) when interpreting LENA data, with the latter appearing to provide a more robust measure of communication. Autism Research 2019, 12: 830-842. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY ABSTRACT: In this study, we examined possible changes in speech and nonspeech vocalizations in 23 children with autism attending a comprehensive early intervention program over a 10-month period. Contrary to our expectation, we observed a waxing and waning pattern of change in children's vocalizations over time, rather than a steady increase. We also found evidence to suggest that looking at the quality of children's vocalizations (i.e., the ratio of speech to nonspeech vocalizations) provides a more accurate picture of children's development than simply looking at the quantity (i.e., how frequently they vocalize).

Differential outcome subgroups in children with autism spectrum disorder attending early intervention

BACKGROUND

The finding of positive outcomes at the group level for children with autism spectrum disorder (ASD) who complete comprehensive early intervention programmes often masks considerable individual variability. We therefore aimed to identify subgroups of children based on their response to intervention and to compare outcome variables between groups at two points in time.

METHOD

We used model-based cluster analysis to explore response to intervention using a longitudinal design for 210 children with ASD who had completed an early intervention programme. Children were assessed on entry at time 1 and again at time 2, which was after 12 months or when they exited the programme (whichever came first) using measures of ASD symptoms (Social Communication Questionnaire), cognition (Mullen Scales of Early Learning) and adaptive behaviour (Vineland Adaptive Behaviour Scales-II).

RESULTS

A two-cluster solution was identified, including a high change group who improved consistently more than the low change group across measures, and showed significantly fewer autism symptoms, higher non-verbal and verbal cognition and adaptive behaviour composite scores at time 1.

CONCLUSIONS

The findings indicated that children's response to early intervention is not uniform but instead included subgroups characterised by patterns of high and low change. Further research is needed to identify clinically relevant mediators of differential response group membership.

Therapeutic drug monitoring of isoniazid and rifampicin during anti-tuberculosis treatment in Auckland, New Zealand

SETTING

There is uncertainty as to the optimal therapeutic concentrations of anti-tuberculosis drugs to achieve cure.

OBJECTIVE

To characterise the use of therapeutic drug monitoring (TDM), and identify risk factors and outcomes for those with concentrations below the drug interval.

DESIGN

Patients treated for tuberculosis (TB) who had rifampicin (RMP) or isoniazid (INH) concentrations measured between 1 January 2005 and 31 December 2012 were studied retrospectively. Matched concentrations and drug dosing time were assessed according to contemporary regional drug intervals (RMP > 6 μmol/l, INH > 7.5 μmol/l) and current international recommendations (RMP > 10 μmol/l, INH > 22 μmol/l). Outcomes were assessed using World Health Organization criteria.

RESULTS

Of 865 patients, 121 had concentrations of either or both medications. RMP concentrations were within the regional drug intervals in 106/114 (93%) and INH in 91/100 (91%). Concentrations were within international drug intervals for RMP in 76/114 (67%) and INH in 53/100 (53%). Low weight-based dose was the only statistically significant risk factor for concentrations below the drug interval. Of the 35 patients with low concentrations, 21 were cured, 9 completed treatment and 5 transferred out. There were no relapses during follow-up (mean 66.5 months).

CONCLUSION

There were no clinically useful characteristics to guide use of TDM. Many patients had concentrations below international therapeutic intervals, but were successfully treated.

Protocol for a prospective longitudinal study investigating the participation and educational trajectories of Australian students with autism

INTRODUCTION

Autism is associated with high cost to individuals, families, communities and government. Understanding educational and participation trajectories during the school years, and factors influencing these, is fundamental to reducing financial and personal costs. The primary aim of this study is to document the trajectories of Australian students with autism during their education. The secondary aim is to examine personal (eg, student skills) and environmental (eg, school setting) factors associated with differing trajectories and outcomes.

METHODS AND ANALYSIS

The cross-sequential longitudinal study will recruit two cohorts of 120 parents/caregivers of children with autism. Cohort 1 aged between 4 and 5 years and cohort 2 between 9 and 10 years to start the study. Information will be gathered from parents, teachers and school principals at six annual time points (T1 to T6). Parents will be emailed a link to an online initial questionnaire (T1) and then contacted annually and asked to complete either an extended questionnaire (T3, T5 and T6) or an abbreviated questionnaire (T2, T4). Where consent is given, the child's current school will be contacted annually (T1 to T6) and teacher and school principal asked to complete questionnaires about the child and school. Parent and school questionnaires are comprised of questions about demographic and school factors that could influence trajectories and a battery of developmental and behavioural assessment tools designed to assess educational and participation trajectories and outcomes. Surveys will provide longitudinal data on educational and participation trajectories for children and adolescents with autism. In addition cross-sectional comparisons (within or between age groups) at each time point and cohort effects will be explored.

ETHICS AND DISSEMINATION

Ethics approvals have been granted for this study by all recruiting sites and universities in the project. Study findings will inform policy and practice to promote successful inclusion and participation of children with autism in education. Results will be disseminated through journal publication, conference and seminar presentation.

Inconsistent staffing and its impact on service delivery in ASD early-intervention

BACKGROUND

Inconsistent staffing (high turnover, casual workforce) is problematic in organisations, with the potential to impact both staff and services provided. Research has primarily focused on the impacts of inconsistent staffing in child welfare and community services with little evidence surrounding their ability to impact the outcomes for children with Autism Spectrum Disorders attending early-intervention services.

AIM

The aim of this study was to explore staff views regarding the impact of staff turnover on the delivery of group based early intervention for children with ASD.

METHODS AND PROCEDURES

We conducted five focus groups involving 29 professional (e.g. teachers, behaviour therapists), para-professional (e.g. child care workers), and managerial staff to explore their views. Audio recordings were transcribed verbatim for use in thematic analysis.

OUTCOMES AND RESULTS

Two central themes, comprising five categories emerged to encompass participants' views. "Impacts on Staff" accounted for the challenges existing staff felt when working with new and untrained staff in the centre. Participants also expressed concerns for the "Impacts on Service Delivery" that resulted from dynamic staffing, affecting fidelity of interventions and the program itself.

CONCLUSIONS AND IMPLICATIONS

The findings suggest that lacking a consistent staffing structure is problematic when attempting to provide high quality early intervention services to children with ASD and suggest that future research should investigate the extent of inconsistent staffing, impacts of inconsistent staffing on providing intervention, and develop a range of tools to help measure these effects.

Diagnostic evaluation for autism spectrum disorder: a survey of health professionals in Australia

OBJECTIVES

There is currently no agreed Australian standard for the diagnosis of autism spectrum disorder (ASD) even though there are specific diagnostic services available. We suspected inconsistency in the diagnostic practices of health professionals in Australia and aimed to assess these practices across the nation by surveying all relevant professional groups.

DESIGN

In this study, we completed a survey of 173 health professionals whose clinical practice includes participating in the diagnostic process for ASD in Australia. Participants completed an online questionnaire which included questions about their diagnostic setting, diagnostic practice and diagnostic outcomes in 2014-2015.

PARTICIPANTS

Participants covered a range of disciplines including paediatrics, psychiatry, psychology, speech pathology and occupational therapy. All states and territories of Australia were represented.

SETTING

Participants came from a range of service settings which included hospitals, non-governmental organisations, publicly funded diagnostic services and private practice.

RESULTS

There was variability in diagnostic practices for ASD in Australia. While some clinicians work within a multidisciplinary assessment team, others practice independently and rarely collaborate with other clinicians to make a diagnostic decision. Only half of the respondents reported that they include a standardised objective assessment tool such as the Autism Diagnostic Observation Schedule in ASD assessments, and one-third indicated that they do not include measures of development, cognition and language in assessments where ASD is suspected.

CONCLUSIONS

Reported practice of some professionals in Australia may not be consistent with international best practice guidelines for ASD diagnosis. These findings highlight the need for a minimum national standard for ASD diagnosis throughout Australia that ensures best practice regardless of the type of setting in which the service is provided.

Volunteering as a Productive Aging Activity: Incentives and Barriers to Volunteering by Australian Seniors

Recent research demonstrates that involvement in productive activities, particularly volunteering, has important societal and individual benefits in the contemporary aging environment. However, less attention has been paid to the structural dimension of volunteering or what encourages or discourages older people regarding volunteering. The authors present the findings from a two-phase Australian case study that explores the incentives and barriers to volunteering by those aged 50 and older, all members of a national seniors organization. Results suggest that governments and organizations need to consider many issues if more seniors are to be attracted to volunteering. Ensuring appropriate incentives to encourage volunteering was viewed as particularly important, with incentives including the need for more training, more flexible and diverse options, and more opportunities for intergenerational volunteering. Potential barriers included negative perceptions of volunteer activities, fear of encountering ageism, and concerns about the increasingly regulatory organizational environment.

The proportion of minimally verbal children with autism spectrum disorder in a community-based early intervention programme

BACKGROUND

Estimates of the proportion of children with autism spectrum disorder (ASD) who are minimally verbal vary from 25%to 35%. However, there is a lack of consensus in defining minimally verbal and few detailed reports of communication outcomes for these children following intervention. The aim of this study was to explore how minimally verbal children have been defined and to document the proportion of minimally verbal children in a group of children with ASD receiving a community based early intervention programme.

METHOD

A longitudinal cohort design was used to examine the proportion of children who met criteria for minimally verbal in 246 children with ASD when they entered and exited an early intervention programme.

RESULTS

Overall, 26.3% of the children in this study exited the programme using 'fewer than five spontaneous and functional words' and 36.4% exited not using 'two word phrases' as indicated by direct assessment. However, our findings were mixed depending on measures and definitions used, with parent report indicating that as many as 29.4% of children were not 'naming at least three objects' consistently, and 43.3% not using 'phrases with a noun and verb' consistently at exit. More than half of the children who entered the programme with minimal speech exited the programme with a similar language profile. A small percentage of children (1.2%-4.7%) regressed in their language level over time.

CONCLUSIONS

Despite advances in early intervention, and access to services at a younger age, around a quarter of individuals with ASD in this study exited early intervention with significant communication needs. Our findings are considered in relation to the literature and clinical implications, and future research directions are discussed.

Autism in Toddlers Born Very Preterm

OBJECTIVE

This study aimed to determine the prevalence of autism spectrum disorder (ASD) by using the Autism Diagnostic Observation Schedule-Generic (ADOS-G) classifications in children born very preterm during their toddler years.

METHODS

Two birth cohorts of toddlers (2 and 4 years old) each recruited over 12 months and born at <29 weeks' gestation were administered the Modified Checklist of Autism in Toddlers-Follow-up Interview (M-CHAT-FI) screen, the ADOS-G, and developmental assessments. The ADOS-G was conducted on toddlers with M-CHAT-FI-positive screens.

RESULTS

Data were available on 88% (169/192) of children. In total, 22 (13%) toddlers screened positive and 3 (1.8%) were confirmed diagnostically with ASD. These 3 cases reached the highest ADOS-G threshold classification of autism. All but 1 child who scored below the ADOS-G thresholds (11/12) demonstrated some difficulty with social communication. Risk was significantly increased for co-occurring neurodevelopmental problems in 21 of the 22 positive-screen ASD cases. Adaptive behavior (P < .001) was the only co-occurring factor independently predictive of ASD in toddlers.

CONCLUSIONS

Children born very preterm are at increased risk of ASD. By using the ADOS-G, we found a lower incidence of ASD in children born at <29 weeks' gestation compared with previous studies. Children who screened positive for ASD on the M-CHAT-FI had developmental delays consistent with subthreshold communication impairment.

Effectiveness and feasibility of the early start denver model implemented in a group-based community childcare setting

A recent study documented the efficacy of the Early Start Denver Model (ESDM) delivered in a 1:1 fashion. In the current study we investigated the effectiveness and feasibility of the ESDM in the context of a long-day care community service, with a child-staff ratio of 1:3. Outcomes of 27 preschoolers with ASD undergoing 15-25 h per week of ESDM over 12 months were compared to those of 30 peers with ASD undergoing a different intervention program delivered in a similar community long-day care service. Children in both groups made gains in cognitive, adaptive and social skills. Participants in the ESDM group showed significantly higher gains in developmental rate and receptive language.

Social maturity and theory of mind in typically developing children and those on the autism spectrum

BACKGROUND

Results of several studies using the Vineland scale to explore links between social behavior and theory of mind (ToM) have produced mixed results, especially for children on the autism spectrum. The present pair of studies developed a psychometrically sound, age-referenced measure of social maturity to explore these issues further.

METHOD

In Study 1, 37 typically developing preschoolers took a battery of standard false belief tests of ToM and were rated by their teachers on a newly developed age-referenced social maturity scale with 7 items. In Study 2, a further group of 43 children aged 4 to 12 years (13 with autism, 14 with Asperger's disorder and 16 with typical development) took part in the same procedure.

RESULTS

In Study 1, ToM was found to predict typical preschoolers' social maturity independently of age and verbal maturity. In Study 2, children with autism scored below age-matched and younger typical developers in both ToM and social maturity. Those with Asperger's disorder did well on ToM but poorly on social maturity. Study 2 replicated Study 1's finding (for typical children and for the full sample) that ToM was linked with social maturity independently of age and verbal ability, although the link was not independent of autism diagnosis.

CONCLUSIONS

Teachers are capable of rating children's social behavior with peers as advanced, on-time or delayed for their age. Suggestive links between these ratings and ToM require further investigation, especially among children on the autism spectrum.

Social maturity and theory of mind in typically developing children and those on the autism spectrum

BACKGROUND

Results of several studies using the Vineland scale to explore links between social behavior and theory of mind (ToM) have produced mixed results, especially for children on the autism spectrum. The present pair of studies developed a psychometrically sound, age-referenced measure of social maturity to explore these issues further.

METHOD

In Study 1, 37 typically developing preschoolers took a battery of standard false belief tests of ToM and were rated by their teachers on a newly developed age-referenced social maturity scale with 7 items. In Study 2, a further group of 43 children aged 4 to 12 years (13 with autism, 14 with Asperger's disorder and 16 with typical development) took part in the same procedure.

RESULTS

In Study 1, ToM was found to predict typical preschoolers' social maturity independently of age and verbal maturity. In Study 2, children with autism scored below age-matched and younger typical developers in both ToM and social maturity. Those with Asperger's disorder did well on ToM but poorly on social maturity. Study 2 replicated Study 1's finding (for typical children and for the full sample) that ToM was linked with social maturity independently of age and verbal ability, although the link was not independent of autism diagnosis.

CONCLUSIONS

Teachers are capable of rating children's social behavior with peers as advanced, on-time or delayed for their age. Suggestive links between these ratings and ToM require further investigation, especially among children on the autism spectrum.

Toddler subtraction with large sets: further evidence for an analog-magnitude representation of number

Two experiments were conducted to test the hypothesis that toddlers have access to an analog-magnitude number representation that supports numerical reasoning about relatively large numbers. Three-year-olds were presented with subtraction problems in which initial set size and proportions subtracted were systematically varied. Two sets of cookies were presented and then covered. The experimenter visibly subtracted cookies from the hidden sets, and the children were asked to choose which of the resulting sets had more. In Experiment 1, performance was above chance when high proportions of objects (3 versus 6) were subtracted from large sets (of 9) and for the subset of older participants (older than 3 years, 5 months; n = 15), performance was also above chance when high proportions (10 versus 20) were subtracted from the very large sets (of 30). In Experiment 2, which was conducted exclusively with older 3-year-olds and incorporated an important methodological control, the pattern of results for the subtraction tasks was replicated. In both experiments, success on the tasks was not related to counting ability. The results of these experiments support the hypothesis that young children have access to an analog-magnitude system for representing large approximate quantities, as performance on these subtraction tasks showed a Weber's Law signature, and was independent of conventional number knowledge.

Usefulness of color Doppler proximal isovelocity surface area method in quantitating valvular regurgitation

To define the clinical utility of the color Doppler proximal isovelocity surface area (PISA) method for estimating regurgitant stroke volume (SV), 160 regurgitant lesions were evaluated in 104 patients with mitral (MR), aortic (AR), and tricuspid (TR) regurgitation. Regurgitant SV by PISA was calculated as 2 pi R2 x V x (time-velocity integral/peak flow velocity), where R is the radius corresponding to the first blue-red interface velocity of the maximal PISA during the cardiac cycle. The time-velocity integral and peak flow velocity from the continuous-wave Doppler recording of the regurgitant jet were used to correct PISA for phasic variations in regurgitant flow. Fifteen lesions were excluded because of difficulty in tracing the continuous-wave Doppler regurgitant curve. Among 145 remaining regurgitant lesions, PISA was measurable in 50 (78%) of 64 cases of MR and 24 (69%) of 35 cases of TR but in only 12 (26%) of 46 cases of AR (p < 0.001). Regurgitant SV by PISA correlated modestly well with jet area/atrial area in all atrioventricular valve lesions (MR: r = 0.55; TR: r = 0.65; p < 0.001). However, the correlation improved if only central jets were considered (MR: r = 0.70; TR; r = 0.75; p < 0.001). These findings are not unexpected because jet area/atrial area underestimates the true severity of regurgitation in cases of eccentric (wall-impinging) jets. PISA was detected in all severe cases of regurgitation but in only 64% of cases of mild MR, 45% of cases of mild TR, and 6% of cases of mild AR (p < 0.01). The color Doppler PISA method is clinically useful in estimating regurgitant SV in MR and TR, including mild cases, but is less useful in AR.

Decreased carbonic anhydrase III levels in the liver of the mouse mutant 'toxic milk' (tx) due to copper accumulation

The mouse mutant 'toxic milk' (tx) is characterized by marked hepatic accumulation of copper, similar to that found in patients with the genetic disorder of copper transport, Wilson disease. In addition, lactating tx females produce copper-deficient milk. To characterize further the biochemical basis of this defect, Western blots of tissue extracts from normal and tx mice were probed with various heavy-metal radioisotopes (63Ni. 65Zn and 64Cu). A 30 kDa Ni/Zn-binding polypeptide was found to be markedly decreased in the livers of the tx mice. This protein was isolated from normal adult mice using a procedure based on Ni-chelation chromatography. The amino acid sequences of two CNBr peptides were identical with portions of the mouse skeletal muscle carbonic anhydrase III (CAIII) sequence. Two other peptides sequenced had closely related sequences to that of CAIII, but with two differences in 45 amino acids. These two peptides may be derived from a novel CAIII isoform, which we term CAIIIB to distinguish it from the published form, CAIIIA. We isolated a cDNA clone corresponding to CAIIIA and used this to show that CAIIIA mRNA was also decreased in the mutant liver, but not in muscle. Copper loading of normal mice also decreased hepatic CAIIIA mRNA, suggesting that the decrease in CAIII mRNA in the tx mouse liver is a secondary consequence of the high copper levels in the liver.

Acute cocaine administration induces ventricular regional wall motion and ultrastructural abnormalities in an anesthetized rabbit model

Whether acute doses of cocaine can induce left ventricular (LV) regional wall motion abnormalities in animals with otherwise normal coronary arteries is unknown. We studied rabbits receiving constant cocaine infusions (group I: 0.025 to 1.5 mg/kg/min, n = 10), multiple cocaine boluses (group II: 3-5 mg/kg each bolus, n = 10), or saline (group III; n = 8). In group I rabbits, short-axis LV area and diameter increased by 15% to 40% at 60 minutes compared to baseline and to controls (p < 0.01), but percentage of global area fractional shortening was unchanged. Eight rabbits in each of groups I and II, but no controls, developed LV regional wall motion abnormalities as detected by echocardiography: 15 (7 hypokinesis and 8 akinesis or dyskinesis) in the anteroseptal and 2 (hypokinesis) in the posterior LV wall. Among rabbits showing LV wall motion abnormalities, anteroseptal fractional shortening and % area reduction averaged > 20% less (p = 0.03 for area reduction) at 30 minutes versus controls. Only 50% of group I or II rabbits with LV anteroseptal wall motion abnormalities had intraventricular conduction disturbances. Radioactive microsphere flow studies (n = 6) 1 minute after a 4 mg/kg cocaine bolus revealed an equivalent decrease (10% to 20%, average) in septal and LV free wall perfusion (p value not significant). Electron microscopy revealed myocardial cell contraction band necrosis in 3 and sarcoplasmic reticular edema in 7 of 10 cocaine rabbits (unrelated to dose). We conclude that acute cocaine administration in rabbits frequently produces LV anteroseptal wall motion abnormalities even in the absence of differentially decreased perfusion or intraventricular conduction disturbances and produces ultrastructural abnormalities of the myocytes. These findings suggest a direct, nonuniform effect of cocaine on the LV myocardium.

Correlation of minimum coronary lumen diameter with left ventricular functional impairment induced by atrial pacing

To understand whether quantitative measurement of minimal coronary luminal diameter is a better method than percent diameter narrowing for assessing the functional impairment of myocardial contractility produced by coronary artery stenoses, measurements were made from 37 stenotic segments in 27 patients with coronary artery disease and from corresponding segments in 10 subjects without coronary artery narrowing. An assessment of the reliability of the 2 types of measurements was made by correlating them with the physiologic parameters of both segmental wall motion and global ejection fraction response induced by atrial pacing. Digitally acquired coronary angiograms were used to facilitate quantitative analysis. Measurements by edge detection and videodensitometry correlated closely (r = 0.94). Percent diameter narrowing correlated moderately with the change in ejection fraction (r = -0.41) or with the change in segmental wall motion (r = -0.44). The measurement of minimal lumen diameter correlated with the change in global ejection fraction (r = 0.61) and did so even better with the change in segmental wall motion (r = 0.78, p less than 0.05). A minimal lumen diameter of less than or equal to 1.5 mm identified patients likely to have a functional impairment during atrial pacing as assessed by either global ejection fraction or segmental wall motion defects. We conclude that minimal coronary luminal diameter provides a better method than percent diameter narrowing calculations to measure the anatomic severity of coronary artery narrowing.

Determination of the optimal timing for performing digital ventriculography during atrial pacing stress tests in coronary heart disease

To determine the optimal time for recording left ventricular angiograms during atrial pacing stress tests, digital subtraction left ventriculograms were obtained using 12 ml of contrast material in 40 patients at rest and at peak pacing. Nineteen of the 40 patients had a third digital left ventriculogram performed between 5 and 10 seconds and 21 patients had a third digital left ventriculogram performed 30 seconds after pacing was stopped. Coronary angiography showed significant coronary artery disease (CAD) in 29 patients and no evidence of significant CAD in 11 patients. Ejection fraction (EF) increased or did not change at peak pacing in 10 of 11 patients without CAD. In the 29 patients with CAD, mean EF decreased an average of 10 percentage points (p less than 0.001) and fell 2 or more percentage points in 25 patients (86%) at peak pacing. These changes in EF were accompanied by the development of wall motion abnormalities, which occurred in segments of myocardium that were supplied by coronary arteries with angiographic CAD (more than 50% diameter narrowing). In contrast, the mean EF during the postpacing studies decreased only 2.2 percentage points (difference not significant) over rest values. Moreover, 15 of 29 patients (52%) with CAD had a decrease in EF of 2 or more percentage points. Therefore, the sensitivity of the atrial pacing stress test was diminished when the analysis was performed at 10 or 30 seconds after pacing. It is concluded that EF changes and wall motion abnormalities induced by atrial pacing are of short duration.(ABSTRACT TRUNCATED AT 250 WORDS)