Mental Health Crises in Autistic Children: A Framework for Prevention and Intervention in Primary Care.

Children with autism are at high risk for experiencing a mental health crisis, which occurs when psychiatric and behavioral symptoms become a danger and caregivers do not have the resources to safely manage the event. Our current mental health systems of care are not fully prepared to manage crisis in autistic individuals, due to the shortage of available mental health providers and programs that are tailored for autistic children. However, new strategies to address crisis are gradually emerging. This article provides a framework to define crisis and implement prevention and intervention approaches that could potentially mitigate risk for crisis.

A pilot, single-arm feasibility study of an integrated cognitive-behavioral treatment for anxiety in young autistic children.

OBJECTIVE: Anxiety is prevalent in young autistic children under 7 years of age. Yet there is a paucity of empirically based interventions for this age group. DINO Strategies for Anxiety and Uncertainty Reduction (DINOSAUR) is an innovative cognitive behavioral intervention that seeks to optimize treatment response in young autistic children by targeting anxiety and the contributing mechanisms of intolerance of uncertainty and parental accommodation using a telehealth delivery model. This pilot, single-arm study examines the preliminary feasibility of DINOSAUR. METHODS: Fourteen autistic children ages 4-6 years with average language and cognitive skills and their parents received the intervention. Quantitative and qualitative data pertaining to parent satisfaction and treatment outcomes were collected. RESULTS: Attendance, retention, and parent satisfaction ratings offer preliminary support for the feasibility of the treatment model. Change in clinical severity ratings on a semi-structured parent interview of anxiety and parents' qualitative report suggests the potential to benefit young autistic children. CONCLUSIONS: Results support future study of the DINOSAUR model in a larger, randomized controlled trial.

Perceptual alterations in the relationship between sensory reactivity, intolerance of uncertainty, and anxiety in autistic children with and without ADHD.

Sensory differences and anxiety disorders are highly prevalent in autistic individuals with and without ADHD. Studies have shown that sensory differences and anxiety are associated and that intolerance of uncertainty (IU) plays an important role in this relationship. However, it is unclear as to how different levels of the sensory processing pathway (i.e., perceptual, affective, or behavioral) contribute. Here, we used psychophysics to assess how alterations in tactile perception contribute to questionnaire measures of sensory reactivity, IU, and anxiety. Thirty-eight autistic children (aged 8-12 years; 27 with co-occurring ADHD) were included. Consistent with previous findings, mediation analyses showed that child-reported IU fully mediated an association between parent-reported sensory reactivity and parent-reported anxiety and that anxiety partially mediated an association between sensory reactivity and IU. Of the vibrotactile thresholds, only simultaneous frequency discrimination (SFD) thresholds correlated with sensory reactivity. Interestingly, we found that sensory reactivity fully mediated an association between SFD threshold and anxiety, and between SFD threshold and IU. Taken together, those findings suggest a mechanistic pathway whereby tactile perceptual alterations contribute to sensory reactivity at the affective level, leading in turn to increased IU and anxiety. This stepwise association can inform potential interventions for IU and anxiety in autism.

Anxiety in autistic preschool children: Phenomenology and a network analysis of correlates.

Anxiety disorders in autistic children are associated with significant functional impairment. Few studies have examined impairing anxiety presentations in autistic preschool children (i.e., 3-5 years old). This cross-sectional study examined the phenomenology of impairing anxiety and the strongest correlates of anxiety in 75 autistic preschool children. Parents completed a diagnostic interview that assesses two anxiety types, DSM-5 anxiety disorders and impairing distinct anxiety presentations, and measures of anxiety correlates. An exploratory network analysis examined connections between anxiety and its correlates. Forty percent of children had impairing anxiety. Specific phobia followed by 'other social fear,' a type of distinct anxiety, were the most common anxiety types. Child intolerance of uncertainty (IU) was the only correlate that was associated with anxiety in a network analysis framework. Child IU linked anxiety to two other correlates, sensory over-responsivity and somatic symptoms. Findings emphasize the need for early intervention for anxiety and further research on its correlates.

Psychiatry training in autism spectrum disorder and intellectual disability: Ongoing gaps and emerging opportunities.

LAY ABSTRACT: Children, adolescents, and adults with autism spectrum disorder and intellectual disability experience high rates of co-occurring psychiatric conditions throughout their lifetime. However, there is a shortage of psychiatrists to treat these populations. We evaluated how much education psychiatrists-in-training receive on how to care for individuals with autism spectrum disorder/intellectual disability. We found that in many psychiatry programs, residents receive limited training experiences in autism spectrum disorder/intellectual disability involving lectures and patient contact and that psychiatry program directors would benefit from more resources to strengthen education in autism spectrum disorder/intellectual disability.

Targeting Mast Cells in Allergic Disease: Current Therapies and Drug Repurposing.

The incidence of allergic disease has grown tremendously in the past three generations. While current treatments are effective for some, there is considerable unmet need. Mast cells are critical effectors of allergic inflammation. Their secreted mediators and the receptors for these mediators have long been the target of allergy therapy. Recent drugs have moved a step earlier in mast cell activation, blocking IgE, IL-4, and IL-13 interactions with their receptors. In this review, we summarize the latest therapies targeting mast cells as well as new drugs in clinical trials. In addition, we offer support for repurposing FDA-approved drugs to target mast cells in new ways. With a multitude of highly selective drugs available for cancer, autoimmunity, and metabolic disorders, drug repurposing offers optimism for the future of allergy therapy.

Exploring the Symptom Profiles of Intolerance of Uncertainty in Autistic Children.

Intolerance of uncertainty (IU) is a multidimensional construct involving maladaptive responses to uncertainty. IU is strongly associated with autism and anxiety, yet no studies have examined its symptom profile in autistic children. This study compares IU symptom profiles in autistic and NT children and in autistic children with and without anxiety using the Intolerance of Uncertainty Scale for Children. Compared to NT peers, autistic children exhibited heightened IU symptoms in all domains, affective, behavioral, and cognitive; affective symptoms had the highest association with autism. Autistic children with anxiety also exhibited elevated IU symptoms in all domains compared to those without anxiety; behavioral IU symptoms had the highest association with anxiety. IU symptom profiles should be considered in assessment and treatment.

Mental Health Crisis Screening in Youth with Autism Spectrum Disorder.

OBJECTIVE: While a growing body of evidence suggests youth with autism are at increased risk of experiencing a mental health crisis, no study has screened for crises in an outpatient setting. The current study fills this gap by examining a) the feasibility and utility of conducting routine crisis screenings; b) the psychometrics of a brief crisis screener (the Mental Health Crisis Assessment Scale-Revised; MCAS-R); and, c) the prevalence of and types of behaviors associated with crises. METHOD: This study was conducted at two different outpatient mental health clinics. Screenings were conducted using the MCAS-R, a 23-item parent report measure. A total of 406 youth with autism (76% Male; 72% White; M = 11.2y; SD = 3.5y), evenly divided across clinics, were screened. Seven clinicians conducted a clinical visit, which incorporated the results of the MCAS-R, to determine whether the child was in crisis. RESULTS: Eighty percent of youth were successfully screened, suggesting crisis screening is feasible. Most parents (73%) felt the MCAS-R helped communicate concerns with the clinician; few (<6%) felt the survey was too long or upsetting. All clinicians (100%) indicated that the MCAS-R was very helpful in facilitating communication and identifying/mitigating safety concerns; although, 33% reported screenings "sometimes" interrupted clinical flow. The MCAS-R strongly aligned with clinician ratings (88% correctly classified). Twenty percent of youth met the cutoff for crisis; aggression and self-injurious behaviors were the most common reasons for crises. CONCLUSION: This study suggests that outpatient crisis screening via the MCAS-R is feasible, accurate, and well received by parents and clinicians. ABBREVIATIONS: ASD: Autism Spectrum Disorder; MCAS-R: Mental Health Assessment Crisis Scale-Revised; DSM-5: Diagnostic and Statistical Manual, 5th Edition; ADOS-2: Autism Diagnostic Observation Schedule, Second Edition; ROC: Receiver Operating Curve.

Project Extension for Community Health Outcomes (ECHO) Autism: A Successful Model to Increase Capacity in Community-Based Care.

Individuals with autism spectrum disorder (ASD) struggle to access high-quality health care due to the shortage of trained providers. ECHO (Extension for Community Healthcare Outcomes) Autism is a unique educational program that allows ASD experts to provide knowledge and skills to professionals in local communities to deliver evidence-based care to children with ASD and their families. The model teaches clinicians how to screen and diagnose ASD, as well as manage common co-occurring medical and mental health issues. ECHO Autism is particularly useful for addressing the complex needs of children with ASD and reducing disparities often present in rural and underserved communities. The model can be disseminated globally due to its flexibility in accommodating local and regional differences in social norms and constructs. This article provides an overview of the format of the ECHO Autism model, data supporting the model's efficacy, and discusses future research directions.

Suicide Risk Screening in Pediatric Outpatient Neurodevelopmental Disabilities Clinics.

OBJECTIVE: The purpose of this study was to describe the implementation of universal suicide risk screening in pediatric neurodevelopmental disabilities (NDD) medical clinics, analyze demographic and clinical characteristics of eligible patients, describe outcomes of positive screenings, and describe factors that influenced participation in screenings. METHODS: A suicide risk screening protocol was developed and implemented for medical clinic patients aged 8 to 18 years. Registered nurses screened patients using the "Ask Suicide-Screening Questions" tool during triage. Positive screenings were referred for further assessment and mental health management. Demographics and clinical data were extracted from medical records using retrospective chart reviews. RESULTS: During the 6-month study period, 2961 individual patients presented for 5260 screening eligible patient visits. In total, 3854 (73.3%) screenings were completed with 261 (6.8%) positive screenings noted. Screenings were declined in 1406 (26.7%) visits. Parents of children with cognitive impairments were more likely to decline screening. Clinics serving children with autism spectrum disorder had higher rates of positive screenings compared with all other clinic attendees. Seventy-two of 187 children (38.5%) with positive screenings were identified and referred to outpatient mental health referrals. Seven (2.5%) of these children required acute psychiatric treatment. CONCLUSION: Routine screening, identification of increased suicide risk, and referral to mental health care among children with NDD are feasible. It remains unclear whether variation in rates among youth with and without NDD may indicate true differences in suicide risk or cognitive impairments or reflect psychiatric comorbidities. High rates of declined participation may have influenced identification of children with NDD and suicide risk. Preliminary findings identified groups of children with NDD at heightened risk for suicidal ideation and behavior. Further research is needed to assess the validity of suicide risk screening tools in children with neurodevelopmental disorders.

Dysregulation in Children and Adolescents Presenting to a Multidisciplinary Autism Clinic.

Research indicates that children with autism spectrum disorder (ASD) frequently exhibit dysregulation, which refers to poorly coordinated affective, behavioral, and cognitive responses to a given situation. We examined the characteristics of dysregulation in children presenting to a multidisciplinary ASD clinic for an ASD diagnostic evaluation. Sixty percent of children presenting for an ASD evaluation exhibited dysregulation. Dysregulation prevalence was higher in children without ASD versus with ASD (69% versus 56%). Severe dysregulation was higher in children without ASD (29% versus 16%). Both groups with severe dysregulation were equally likely to be taking psychiatric medications, however, children with ASD were less likely to be receiving therapy. These findings highlight the importance of implementing dysregulation screening and treatment protocols in ASD centers.

DINOSAUR: an integrated cognitive-behavioral treatment for anxiety in young children with ASD.

BACKGROUND: Anxiety disorders are highly prevalent in children and adolescents with autism spectrum disorder and often emerge before the age of 6 years. Yet, only a few studies have examined anxiety treatment for this group. Preliminary evidence from these studies suggests that utilizing cognitive behavioral therapy (CBT) as well as strategies to target intolerance of uncertainty (IU) and parental accommodation, known mechanistic and maintaining factors of anxiety may improve anxiety and optimize outcomes in this age group. MAIN BODY: To meet this need, we developed an integrated treatment called DINO Strategies for Anxiety and intolerance of Uncertainty Reduction (DINOSAUR), a 12-week group telehealth treatment for 4- to 6-year-old children with ASD. DINOSAUR works with young children and their parents to deliver CBT along with interventions targeting IU and parental accommodation. In this paper, we first discuss the rationale for developing this treatment and then describe a pilot study of its feasibility and preliminary efficacy. CONCLUSIONS: There is a great need to develop anxiety treatments for young children with ASD. We proposed a novel integrated treatment approach that aims to alter the way young children and parents respond to fear, which could potentially improve short- and long-term mental health outcomes for this age group. TRIAL REGISTRATION: ClinicalTrials.gov NCT04432077 on June 03, 2020.

Psychiatric problems during the COVID-19 pandemic in children with autism spectrum disorder.

Children with autism spectrum disorder (ASD) are at elevated risk for psychiatric problems in response to the COVID-19 pandemic. This risk is due to their high rates of pre-pandemic psychiatric comorbidities and the pandemic's disruption to routines and access to necessary supports. Prior research has indicated that children with ASD may experience a worsening of specific psychiatric symptoms in response to COVID-19, though this body of work is limited in scope. The present study expands this literature by examining specific types of psychiatric problems that emerged about 2 months after the onset of the pandemic, and risk factors predicting changes in these psychiatric symptoms. Parents of children with a confirmed ASD diagnosis (N = 257), who enrolled in a clinic registry at an outpatient specialty autism center, were included in this study. All data were gathered online via customized and standardized questionnaires. Results showed that 59% of children experienced either a worsening of their pre-pandemic psychiatric diagnoses and/or the development of new psychiatric symptoms during the pandemic. Multivariable regression models indicated that risk factors for increased psychiatric problems included child understanding of COVID-19, COVID-19 illness in the family, low family income, and elevated parental depression and anxiety symptoms (all p < 0.05). Findings from this study emphasize the urgent need to provide effective and accessible psychiatric services for children with ASD and their families during and after the pandemic. LAY SUMMARY: Children with ASD are at high risk for psychiatric problems during the COVID-19 pandemic. We found that 59% of children in our clinical sample are experiencing increased psychiatric problems. The child's understanding of COVID-19, COVID-19 illness in the family, low family income, and depression and anxiety symptoms in the parent increase the risk for poor mental health during the pandemic. These findings indicate the importance of helping children with ASD access mental health treatment during COVID-19.

An intelligent clustering method for devising the geochemical fingerprint of underground aquifers.

Geochemical fingerprinting is a rapidly expanding discipline in the earth and environmental sciences, anchored in the recognition that geological processes leave behind physical, chemical and sometimes also isotopic patterns in the samples. Furthermore, the geochemical fingerprinting of natural cycles (water, carbon, soil and biota fingerprinting) are influenced by the anthropogenic impact and by the climate change. So, their monitoring is a tool of resilience and adaptation. In recent years, computational statistics and artificial intelligence methods have started to be used to help the process of geochemical fingerprinting. In this paper we consider data from 57 wells located in the province of Ferrara (Italy), all belonging to the same geological group and separated into 4 different aquifers. The aquifer from which each well extracts its water is known only in 18 of the 57 cases, while in other 39 cases it can be only hypothesized based on geological considerations. We devise a novel technique for geochemical fingerprinting of groundwater by means of which we are able to identify the exact aquifer from which a sample is extracted with a sufficiently high accuracy. Then, we experimentally prove that out method is sensibly more accurate than typical statistical approaches, such as principal component analysis, for this particular problem.

A Scoping Review of Anxiety in Young Children with Autism Spectrum Disorder.

Research on anxiety in children and adolescents with autism spectrum disorder (ASD) has burgeoned in the past 15 years. Most of the research has focused on school-age children, ages 6 to 18 years. Yet, recent studies suggest that anxiety can emerge in young children, under 6 years, with ASD. This scoping review synthesized the literature on anxiety in young children with ASD. Three domains of anxiety research were reviewed: (a) prevalence/severity, phenomenology, and course; (b) correlates; and (c) treatment. Four online databases were searched from the start of the database until March 2020. Keywords pertaining to anxiety, autism, and young children were entered. The search identified 44 articles for inclusion. These studies varied with respect to sample source, informants, and measures to assess anxiety. The overall prevalence of anxiety ranged from 1.6 to 62%. Sixteen of 17 studies found that young children with ASD had higher levels of anxiety compared to various control groups. A variety of DSM anxiety symptoms and disorders were present in young children with the most common symptoms being specific, social, and generalized fears. Correlates of anxiety included sensory over-responsivity, sleep disturbance, aggression/defiance, and attention deficit/hyperactivity disorder. Three cognitive behavioral treatment studies for anxiety and one developmental intervention targeting ASD symptoms showed promise in reducing anxiety. Findings indicate an early emergence of anxiety in some children with ASD. Further research on the measurement, pathophysiology, and treatment of anxiety in early childhood is critical to improving outcomes in children with ASD. LAY SUMMARY: This scoping review synthesizes the literature on anxiety in young children with autism spectrum disorder (ASD). Results indicate that children with ASD have higher levels of anxiety than children without ASD. Potential factors that could be contributing to anxiety include sensory, sleep, and behavioral problems. Preliminary studies show that anxiety can improve with cognitive behavioral treatment. These findings suggest that research on anxiety in young children with ASD should be prioritized to improve mental health outcomes.

Value of Precision Medicine in Advanced Non-Small Cell Lung Cancer: Real-World Outcomes Associated with the Use of Companion Diagnostics.

BACKGROUND: Companion diagnostic (CDx) testing for patients with advanced non-small cell lung cancer (aNSCLC) identifies patients more likely to benefit from biomarker-driven treatments. METHODS: Patients with nonsquamous cell (non-Sq) aNSCLC from the Flatiron Health database (diagnosed January 1, 2011-May 31, 2018) who had CDx testing were compared with those who had no reported evidence of testing. The association between CDx testing and overall survival was evaluated by unadjusted and adjusted Cox proportional hazards regression models. Logistic regression analysis identified characteristics associated with CDx testing. The revised modified Lung Cancer Prognostic Index and other factors identified a priori were included in the adjusted models. RESULTS: A total of 17,555 patients with non-Sq aNSCLC (CDx, n = 14,732; no CDx, n = 2,823) with mean ± SD age of 67.2 ± 10.0 years were included. Most were insured (91.7%) and white (67.1%). Asian patients and those who were never-smokers were more likely to undergo CDx testing. Those with CDx testing lived longer than those without (median [95% confidence interval (CI)] survival, 13.04 [12.62-13.40] vs. 6.01 [5.72-6.24] months) and had a decreased mortality risk (adjusted hazard ratio [95% CI], 0.72 [0.69-0.76]). A survival advantage was also seen for patients with CDx testing who received biomarker-driven first-line therapy. CONCLUSION: Patients with non-Sq aNSCLC who had CDx testing had a greater survival benefit than those without, supporting broader use of CDx testing in routine clinical practice to identify patients more likely to benefit from precision medicine. IMPLICATIONS FOR PRACTICE: Companion diagnostic (CDx) testing coupled with biomarker-driven treatment offers a greater survival benefit for patients with advanced non-small cell lung cancer (aNSCLC). In this study, patients with nonsquamous aNSCLC from Flatiron Health, a large, real-world oncology database, with CDx testing had a reduced mortality risk and lived longer than patients without reported evidence of CDx testing; those who received biomarker-driven therapy as their first line of treatment were likely to survive three times longer than those who did not. These results demonstrate the clinical utility of CDx testing as the first step in treating nonsquamous aNSCLC in real-world clinical practice.

Red and Processed Meat, Poultry, Fish, and Egg Intakes and Cause-Specific and All-Cause Mortality among Men with Nonmetastatic Prostate Cancer in a U.S. Cohort.

BACKGROUND: Research on the relationship of meat, fish, and egg consumption and mortality among prostate cancer survivors is limited. METHODS: In the Cancer Prevention Study-II Nutrition Cohort, men diagnosed with nonmetastatic prostate cancer between baseline in 1992/1993 and 2015 were followed for mortality until 2016. Analyses of pre- and postdiagnosis intakes of red and processed meat, poultry, fish, and eggs included 9,286 and 4,882 survivors, respectively. Multivariable-adjusted RRs and 95% confidence intervals (CI) were estimated using Cox proportional hazards models. RESULTS: A total of 4,682 and 2,768 deaths occurred during follow-up in pre- and postdiagnosis analyses, respectively. Both pre- and postdiagnosis intakes of total red and processed meat were positively associated with all-cause mortality (quartile 4 vs. 1: RR = 1.13; 95% CI, 1.03-1.25; P trend = 0.02; RR = 1.22; 95% CI, 1.07-1.39; P trend = 0.03, respectively), and both pre- and postdiagnosis poultry intakes were inversely associated with all-cause mortality (quartile 4 vs. 1 RR = 0.90; 95% CI, 0.82-0.98; P trend = 0.04; RR = 0.84; 95% CI, 0.75-0.95; P trend = 0.01, respectively). No associations were seen for prostate cancer-specific mortality, except that higher postdiagnosis unprocessed red meat intake was associated with lower risk. CONCLUSIONS: Higher red and processed meat, and lower poultry, intakes either before or after prostate cancer diagnosis were associated with higher risk of all-cause mortality. IMPACT: Our findings provide additional evidence that prostate cancer survivors should follow the nutrition guidelines limiting red and processed meat consumption to improve overall survival. Additional research on the relationship of specific meat types and mortality is needed.

Investigating the factor structure of the child behavior checklist dysregulation profile in children and adolescents with autism spectrum disorder.

Dysregulation has been identified as an important risk factor for the development of psychiatric disorders in individuals with autism spectrum disorder (ASD). Therefore, it is necessary to empirically characterize dysregulation and identify psychometrically sound and readily available assessment methods in the ASD population. We sought to evaluate the factor structure of the Child Behavior Checklist-Dysregulation Profile (CBCL-DP), an established dysregulation measure in neurotypical children that is derived from the CBCL, in a large, clinically referred sample of children, ages 6-18 years, with ASD (n = 727). Confirmatory factor analysis was used to characterize dysregulation and assess the validity of the CBCL-DP in children with ASD. Our findings support a bi-factor model of dysregulation in which dysregulation is a broad and distinct syndrome that is associated with the three subdomains of the CBCL-DP, anxiety/depression (AD), attention problems (AP), and aggressive behavior (AGG). Dysregulation was associated with most items in the AD and AGG domains and few items in the AP domain. This association with AD and AGG indicates that dysregulation in ASD may be conceptualized as the combined experience of internalized, negative mood states and externalized, reactive behaviors. These findings provide support as well as important caveats for the use of the CBCL-DP as a measure of dysregulation in the ASD population. Autism Res 2020, 13: 436-443. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Dysregulation is a risk factor for psychiatric disorders in ASD. This study examined if the CBCL-DP, an established measure of dysregulation in neurotypical children, can be used to assess dysregulation in children with ASD. Findings provide evidence that in ASD, dysregulation is a broad construct that exists alongside anxiety/depression, attention problems, and aggression. These findings indicate that the CBCL-DP can be considered a valid measure of dysregulation in the ASD population and could be used in clinical settings.

Investigating mental health crisis in youth with autism spectrum disorder.

Evidence suggests that youth with autism spectrum disorder (ASD) are at increased risk for experiencing a mental health crisis. Yet, limited systematic research exists on this topic. This study examines the prevalence, phenomenology, and correlates of mental health crisis in children, adolescents, and young adults with ASD. Participants included 462 parents of individuals with ASD (83% male, 86% Caucasian, M = 13.7 years, SD = 4.7) who were enrolled in the Interactive Autism Network, a large online registry of families of individuals with ASD. Parents completed the Mental Health Crisis Assessment Scale, a psychometrically sound measure of mental health crisis for youth with ASD, as well as measures of parental depression, family quality of life, and mental health treatment history. Overall, 32% of parents reported that their child had experienced a mental health crisis during the last 3 months. In the younger group, elopement (88%) and self-injury (81%) were the most frequent behaviors contributing to crisis; physical (60%) and verbal (42%) aggression were the most frequent crisis behaviors in the older group. Correlates of crisis included younger age, increased parental depressive symptoms, and lower family quality of life. Approximately 75% of individuals in crisis had seen a psychiatrist or behavioral therapist/psychologist within the last 3 months and 25% were not engaged in any mental health treatment. In summary, mental health crises were quite prevalent in this online sample of youth with ASD. Identification and treatment of these serious events is critical to reduce morbidity in this population. Autism Res 2020, 13: 112-121. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: This study examines the prevalence and characteristics of mental health crisis in children, adolescents, and young adults with autism spectrum disorder. We found that 32% of individuals in our study had experienced a mental health crisis within the last 3 months. Younger age, increased parental depression, and lower quality of life were associated with crisis. These findings emphasize the importance of developing child and family-based interventions to prevent and treat the mental health crisis in this population.