Changes in the severity of autism symptom domains are related to mental health challenges during middle childhood

LAY ABSTRACT

For many autistic children, the severity of their autism symptoms changes during middle childhood. We studied whether these changes are associated with the emergence of other mental health challenges such as anxiety and attention-deficit hyperactivity disorder. Children who had increased social-communication challenges had more anxiety and attention-deficit hyperactivity disorder symptoms and disruptive behavior problems than other children. Children who decreased their restricted and repetitive behaviors, on the contrary, had more anxiety. We discuss why these changes in autism symptoms may lead to increases in other mental health concerns.

Gastrointestinal problems are associated with increased repetitive behaviors but not social communication difficulties in young children with autism spectrum disorders

LAY ABSTRACT

Individuals with autism spectrum disorder are more likely than typically developing individuals to experience a range of gastrointestinal abnormalities, including chronic diarrhea, constipation, food sensitivities, and abdominal pain. These gastrointestinal symptoms have been associated with higher levels of irritability and aggressive behavior, but less is known about their relationship with core autism spectrum disorder symptoms. We investigated the relationship between autism spectrum disorder symptom severity and gastrointestinal symptoms while accounting for three associated behavioral symptom domains (Irritability, Aggressiveness, and Specific Fears), in a sample of 176 children (140 males and 36 females) ages 2-7 years old with autism spectrum disorder. A large majority (93.2%) of the sample had at least one reported gastrointestinal symptom, and most (88.1%) participants had more than one gastrointestinal symptom. Various types of gastrointestinal symptoms were reported; the most common symptoms reported were constipation, food limits, gas/bloating, and stomach pain. After accounting for each associated behavioral symptom domain, repetitive behaviors and stereotypies were significantly associated with gastrointestinal symptom severity. Increased severity of autism spectrum disorder symptoms was correlated with increased gastrointestinal symptom severity. Social and communication difficulties were not significantly associated with gastrointestinal symptom severity after accounting for associated behavioral symptoms. Our findings replicate a previously described association between irritability and aggression and gastrointestinal symptoms. Furthermore, we found that repetitive behaviors, but not social or communication symptoms, are associated with gastrointestinal symptom severity, even after accounting for associated behavioral symptoms. This suggests that gastrointestinal symptoms may exacerbate repetitive behaviors, or vice versa, independent from other associated behavioral symptoms.

Parent and professional perspectives on behavioral inflexibility in autism spectrum disorders: A qualitative study

Restricted and repetitive behaviors are a core feature of autism spectrum disorder; however, research on the functional impact of these behaviors on the quality of life for individuals with autism spectrum disorder and their families remains scarce. We conducted focus groups with parents of children with autism spectrum disorder and clinicians in order to better characterize the functional impact of behavioral inflexibility, which represents one potential dimensional construct that could account for the breadth of behaviors comprising the restricted and repetitive behavior domain. Transcripts of the focus groups were analyzed using qualitative analysis coding methods to determine parent and clinician beliefs on a range of issues related to behavioral inflexibility including overall impact, types of child behaviors, and strategies for managing behavioral inflexibility. Thematic analysis revealed that parents and clinicians view behavioral inflexibility as an important behavior that impacts multiple areas of functioning, relates to other restricted and repetitive behaviors as well as social communication behaviors, and warrants targeted treatment. Notably, many parents and clinicians emphasized some positive consequences of behavioral inflexibility as well. These findings add crucial insights into the functional impact of behavioral inflexibility and restricted and repetitive behaviors as a whole and suggest that behavioral inflexibility represents an important avenue for future research.

Variation in restricted and repetitive behaviors and interests relates to inhibitory control and shifting in children with autism spectrum disorder

Symptoms of restricted and repetitive behaviors and interests in autism are theoretically linked to executive functioning, which includes problem-solving abilities such as inhibition and cognitive flexibility. This study examined whether inhibition and flexibility are related to higher order restricted and repetitive behaviors and interests (e.g. circumscribed interests and ritualistic behavior) and sensorimotor behaviors (e.g. stereotyped and repetitive movements and sensory preoccupations) among 102 school-aged children with autism spectrum disorder who had cognitive abilities in the average or above average range. The ability to inhibit interfering information and shifting ability were related to higher order restricted and repetitive behaviors and interests, and each uniquely accounted for variance. This suggests that the ability to suppress interfering information as well as the ability to flexibly shift between patterns of responding is protective against higher order restricted and repetitive behaviors and interest symptoms in autism. In addition, the ability to proactively slow one's reaction time in order to respond more carefully was related to sensorimotor restricted and repetitive behaviors. These results support the importance of distinguishing between higher order and sensorimotor symptoms due to their distinct relationships to executive functioning abilities.

The clinician perspective on sex differences in autism spectrum disorders

Research studies using existing samples of individuals with autism spectrum disorders have identified differences in symptoms between males and females. Differences are typically reported in school age and adolescence, with similarities in symptom presentation at earlier ages. However, existing studies on sex differences are significantly limited, making it challenging to discern if, how, and at what point in development females with autism spectrum disorder actually exhibit a different behavioral presentation than males. The purpose of this study was to gather impressions from a large group of clinicians to isolate specific areas for future study of sex differences. Clinicians were surveyed about their opinions and perceptions of symptom severity in females, as compared to males, at different points during development. They were also asked to provide open-ended responses about female symptom presentation. Consistent with previous literature, clinicians noted more sex-related differences in restricted and repetitive behaviors and fewer differences for social communication features. Differences were most commonly observed in school age and adolescence, suggesting this time period as a critical and particularly vulnerable window for females with autism spectrum disorder. The results are discussed in the context of other male/female differences across development so that more targeted investigations of autism spectrum disorder sex differences across development.

Sensory and repetitive behaviors among children with autism spectrum disorder at home

Atypical sensory and repetitive behaviors are defining features of autism spectrum disorder and are thought to be influenced by environmental factors; however, there is a lack of naturalistic research exploring contexts surrounding these behaviors. This study involved video recording observations of 32 children with autism spectrum disorder (2-12 years of age) engaging in sensory and repetitive behaviors during home activities. Behavioral coding was used to determine what activity contexts, sensory modalities, and stimulus characteristics were associated with specific behavior types: hyperresponsive, hyporesponsive, sensory seeking, and repetitive/stereotypic. Results indicated that hyperresponsive behaviors were most associated with activities of daily living and family-initiated stimuli, whereas sensory seeking behaviors were associated with free play activities and child-initiated stimuli. Behaviors associated with multiple sensory modalities simultaneously were common, emphasizing the multi-sensory nature of children's behaviors in natural contexts. Implications for future research more explicitly considering context are discussed.

Psychometric analysis of the Systematic Observation of Red Flags for autism spectrum disorder in toddlers

The purpose of this study was to examine the utility of the Systematic Observation of Red Flags as an observational level-two screening measure to detect risk for autism spectrum disorder in toddlers when used with a video-recorded administration of the Communication and Symbolic Behavior Scales. Psychometric properties of the Systematic Observation of Red Flags were examined in a sample of 247 toddlers of 16- to 24 months old: 130 with autism spectrum disorder, 61 with developmental delays, and 56 typically developing. Individual items were examined for performance to create an algorithm with improved sensitivity and specificity, yielding a total Composite score and Domain scores for Social Communication and Restricted Repetitive Behaviors. Codes indicating clear symptom presence were collapsed to yield a count of the number of Red Flags for the overall scale and each symptom domain. Results indicated significant group differences with large effects for the Composite, both Domain scores, and Red Flags score, and good discrimination (area under the curve = 0.84-0.87) between autism spectrum disorder and nonspectrum groups for the Composite, Social Communication Domain, and Social Communication Red Flags score. The Systematic Observation of Red Flags provides an observational screening measure for 16- to 24-month-olds with good discrimination, sensitivity, and specificity. A cutoff of 20 on the Composite is recommended to optimally detect autism spectrum disorder risk.

Characterizing caregiver responses to restricted and repetitive behaviors in toddlers with autism spectrum disorder

Restricted and repetitive behaviors are a core feature of autism spectrum disorder. This descriptive study documented the presence of restricted and repetitive behaviors in 85 toddlers with autism spectrum disorder as they interacted with their caregiver in a play interaction. For each child restricted and repetitive behavior, a caregiver response/non-response was coded. Caregiver responses were rated as successful or unsuccessful. In all, 83 toddlers demonstrated at least one restricted and repetitive behavior in 10 min. The most common child restricted and repetitive behavior was repetitive object use with 72 children displaying at least one instance of this category of restricted and repetitive behavior. Overall, caregivers responded to fewer than half of their child's restricted and repetitive behaviors, and caregiver response varied by child restricted and repetitive behavior type. The most common response was redirection. Success varied by child restricted and repetitive behavior type and caregiver response--redirections were most successful for child verbal and motor restricted and repetitive behaviors, whereas physical or verbal responses were rated more successful for repetitive object use and visual restricted and repetitive behaviors. This study represents the first attempt to characterize how caregivers respond to restricted and repetitive behaviors. Toddlers with autism spectrum disorder are already demonstrating a variety of restricted and repetitive behaviors within the context of a free play sessions, and caregivers differentially and naturally respond to them.