Motor problems in autism: Co-occurrence or feature?

Motor features of autism have long been acknowledged by clinicians, researchers, and community stakeholders. Current DSM-5 and ICD-11 guidelines allow clinicians to assign a co-occurring diagnosis of developmental [motor] coordination disorder (DCD) for autistic individuals with significant motor problems. DCD is characterized by poor motor proficiency with an onset of symptoms in early development. Studies have shown considerable overlap in the behavioral motor features observed in autism and DCD. However, others indicate that motor problems in autism and DCD may stem from different underlying sensorimotor mechanisms. Regardless of whether autism has a unique motor phenotype or an overlap with DCD, changes need to be made in the clinical pipeline to address motor problems in autism at the stages of recognition, assessment, diagnosis, and intervention. Consensus is needed to address unmet needs in research on the etiology of motor problems in autism and their overlap with DCD, to optimize clinical practice guidelines. The development of screening and assessment tools for motor problems that are valid and reliable for use with autistic individuals is essential, and an evidence-based clinical pipeline for motor problems in autism is urgently needed. WHAT THIS PAPER ADDS: Motor problems in autism are highly prevalent, yet underdiagnosed and poorly managed. An evidence-based clinical pipeline for motor problems in autism is urgently needed.

Association between oral care challenges and sensory over-responsivity in children with Down syndrome.

BACKGROUND: Sensory over-responsivity has been linked to oral care challenges in children with special healthcare needs. Parents of children with Down syndrome (cDS) have reported sensory over-responsivity in their children, but the link between this and oral care difficulties has not been explored. AIM: To investigate the relationship between sensory over-responsivity and oral care challenges in cDS. DESIGN: An online survey examined parent-reported responses describing the oral care of their cDS (5-14 years; n = 367). Children were categorized as either sensory over-responders (SORs) or sensory not over-responders (SNORs). Chi-square analyses tested associations between groups (SORs vs. SNORs) and dichotomous oral care variables. RESULTS: More parents of SOR children than of SNOR reported that child behavior (SOR:86%, SNOR:77%; p < .05) and sensory sensitivities (SOR:34%, SNOR:18%; p < .001) make dental care challenging, their child complains about ≥3 types of sensory stimuli encountered during care (SOR:39%, SNOR:28%; p = .04), their dentist is specialized in treating children with special healthcare needs (SOR:45%, SNOR:33%; p = .03), and their child requires full assistance to brush teeth (SOR:41%, SNOR:28%; p = .008). No intergroup differences were found in items examining parent-reported child oral health or care access. CONCLUSIONS: Parents of SOR children reported greater challenges than parents of SNOR children at the dentist's office and in the home, including challenging behaviors and sensory sensitivities.

Association Between Sensory Features and High-Order Repetitive and Restricted Behaviors and Interests Among Children With Autism Spectrum Disorder.

IMPORTANCE: Children diagnosed with autism spectrum disorder (ASD) are often referred to occupational therapy practitioners so their sensory features and their repetitive and restricted behaviors and interests (RRBIs) can be addressed. RRBIs include an insistence on sameness, narrow interests, rigid routines, and rituals. However, there is a paucity of knowledge concerning the association between sensory features-across patterns, modalities, and contexts-and high-order RRBIs among children with ASD who are cognitively able. OBJECTIVE: To examine the association between sensory features across sensory patterns, modalities, and contexts and high-order RRBIs in children with ASD. DESIGN: Correlational clinical study based on parent questionnaire responses. SETTING: General education system in Israel. PARTICIPANTS: Parents of 39 cognitively able school-age children with ASD (ages 6-10 yr; 34 boys and 5 girls), recruited by means of convenience sampling. OUTCOMES: High-order RRBIs were assessed with relevant subscales from the Repetitive Behavior Scale-Revised (RBS-R), and sensory features across patterns, modalities, and contexts were examined with the Sensory Experiences Questionnaire, Version 2.1. The study hypotheses were formulated before data were collected. RESULTS: Significant correlations were observed between the high-order RRBIs of children with ASD and their sensory features across patterns, sensory modalities, and contexts. Fifty-one percent of the total RBS-R scores were predicted by sensory hyperresponsiveness, and an additional 11% were predicted by sensory-seeking behaviors. CONCLUSIONS AND RELEVANCE: The hypotheses concerning the association between sensory features and high-order RRBIs were confirmed. The findings enhance occupational therapy practitioners' understanding of this association and may assist in the planning of more efficient interventions. What This Article Adds: The findings enhance clinical knowledge concerning the association between sensory features and high-order RRBIs and may lay a better foundation for occupational therapy interventions for children with ASD and their families.

Examining unconscious bias embedded in provider language regarding children with autism.

In healthcare settings, language used by healthcare providers can influence provider-patient encounters with individuals with autism spectrum disorder, impacting feelings of stigma and marginalization. This study highlights the unconscious biases healthcare providers might have regarding their patients with autism spectrum disorder and how those beliefs are articulated. Seven pediatric dentists participated in two focus groups to describe strategies to improve oral care for children with autism spectrum disorder. While completing the primary analyses, additional codes emerged related to healthcare provider biases; these data are the focus of this study. Three themes were identified: (i) "healthcare microaggressions" describe how healthcare providers portray their patients in subtly negative ways; (ii) "marginalization" denotes the use of exclusionary language identifying children with autism spectrum disorder as different; and (iii) "preconceptions" include comments that highlight biases about patients. The findings provide insight into the implicit biases that might be held by healthcare providers and how they manifest in language. Despite increased emphasis on cultural competency, healthcare providers might unconsciously use language that could negatively impact patient-provider rapport and increase stigma in already marginalized populations. Further research is necessary to explore how these biases could relate to quality of care.

Reliability and Validity of the Chinese Version of the Infant/Toddler Sensory Profile.

IMPORTANCE: In Chinese-speaking societies, a reliable and valid measure is needed to enable early identification of young children's challenges in sensory processing. OBJECTIVE: To examine the psychometric properties of the Chinese version of the Infant/Toddler Sensory Profile (ITSP-C) when used with Taiwanese children. DESIGN: Prospective study. SETTING: Multiple settings. PARTICIPANTS: Participants were 367 typically developing (TD) infants ages 0-6 mo (mean [M] age = 3.44 mo, standard deviation [SD] = 1.82) and 677 toddlers ages 7-36 mo (M age = 22.33 mo, SD = 8.15), along with 42 toddlers with developmental disabilities (DD; M age = 28.4 mo, SD = 6.7). OUTCOMES AND MEASURES: The ITSP, a caregiver questionnaire that measures how children respond to sensory events in daily life, was translated and cross-culturally adapted into a Chinese version (ITSP-C). RESULTS: Internal consistency was high for the 0-6 mo subscale (α = .80) and the 7-36 mo subscale (α = .82). Test-retest reliability was excellent for the 7-36 mo subscale (intraclass correlation coefficient = .94). Logistic regression analysis demonstrated that the ITSP-C discriminated between children with DD and TD children. CONCLUSIONS AND RELEVANCE: The ITSP was successfully adapted to Chinese with similar reliability and validity to the original ITSP. The 7-36 mo subscale had a higher level of reliability than the 0-6 mo subscale, and quadrant scores were more reliable than section scores. Moreover, the ITSP-C discriminated children with DD from TD children on the basis of their sensory processing patterns. WHAT THIS ARTICLE ADDS: The ITSP-C has sound psychometric properties and support for its use in early identification of sensory processing difficulties in young Chinese-speaking children.

Somatosensory Discrimination in People With Autism Spectrum Disorder: A Scoping Review.

IMPORTANCE: Sensory symptoms in people with autism spectrum disorder (ASD) are commonly reported by researchers. However, an often overlooked sensory aspect of ASD is sensory discrimination in general, and somatosensory discrimination in particular. OBJECTIVE: To examine what has and what has not yet been learned concerning the somatosensory discrimination abilities of people with ASD and to reveal gaps warranting further research. DESIGN: Scoping review of clinical studies published 1995-2017 located through searches of PsycNET, PubMed, ERIC, and Google Scholar. Inclusion criteria were English-language peer-reviewed studies with (1) participants diagnosed with ASD, (2) a specific somatosensory discrimination measure, and (3) a comparison group. No age or intellectual exclusion criteria were established; studies were excluded if they were theoretical or descriptive, did not incorporate a control group, focused only on neurology or genetics, or used simple threshold detection measures or somatosensory measures integrated with other measures. The final search yielded 12 comparative articles discussing tactile and proprioceptive discrimination in people with ASD. RESULTS: Overall, most results showed atypical somatosensory discrimination in people with ASD, especially among young children. The relationship between sensory discrimination abilities and other sensory symptoms and ASD symptoms is briefly discussed. CONCLUSIONS AND RELEVANCE: Heterogeneous findings concerning somatosensory discrimination in people with ASD shed light on underlying mechanisms of these disorders and can contribute to improvement of occupational therapy intervention for this population. WHAT THIS ARTICLE ADDS: The occupational therapy evaluation of people with ASD can benefit from addressing somatosensory discrimination and its contribution to other clinical symptoms. This type of assessment can help improve intervention strategies for people with ASD by promoting a focus on the effect of discrimination deficits on daily function.

Evaluation of the Reliability and Validity of the Brazilian Version of the Here's How I Write: A Child's Self-Assessment and Goal Setting Tool.

OBJECTIVE: Our objective was to translate the Here's How I Write: A Child's Self-Assessment and Goal Setting Tool (HHIW) to Portuguese; adapt it to the Brazilian culture; and analyze its reliability, validity, and clinical feasibility. METHOD: The study was developed in two steps: adaptation of the HHIW to Brazilian Portuguese, followed by experimental application to examine its validity and reliability. The participants were 60 children and their teachers, divided into two groups: Group 1, whose members had handwriting difficulties, and Group 2, whose members did not. RESULTS: Children with poor handwriting scored lower on the HHIW for both self- and teacher report. Test-retest reliability of the children's (.96) and teachers' (.93) questionnaires as well as internal consistency (.91 and .95, respectively) were excellent. There was good agreement (.74) between the children's and teachers' total scores. CONCLUSIONS: This study adds further evidence of validity and reliability and supports the international use of the HHIW. The HHIW is a useful resource to engage children and teachers in a collaborative relationship to improve handwriting.

Caregiving Experiences of Latino Families With Children With Autism Spectrum Disorder.

OBJECTIVE: Prior research has documented caregiving difficulties in families of children with autism spectrum disorder (ASD). However, Latino families may encounter unique challenges. The purpose of this study was to understand the caregiving experiences of Latino families with children with ASD, including daily activities, coping strategies, and service utilization. METHOD: Fifteen Latino parents of children with ASD were interviewed. The interviews were transcribed for analysis to identify themes of experiences unique to this population. RESULTS: Latino families of children with ASD encounter many similar issues as non-Latino families but also unique issues that affect service utilization. Four themes were identified: dealing with the diagnosis, dealing with stigma and isolation from family and community, understanding the role of mothers in changing family routines, and utilizing services. CONCLUSION: To meet the unique needs of Latino families, services need to be provided in culturally sensitive context that address children's needs within family units.

Feasibility of a sensory-adapted dental environment for children with autism.

OBJECTIVE: To provide an example of an occupational therapy feasibility study and evaluate the implementation of a randomized controlled pilot and feasibility trial examining the impact of a sensory-adapted dental environment (SADE) to enhance oral care for children with autism spectrum disorder (ASD). METHOD: Twenty-two children with ASD and 22 typically developing children, ages 6-12 yr, attended a dental clinic in an urban hospital. Participants completed two dental cleanings, 3-4 mo apart, one in a regular environment and one in a SADE. Feasibility outcome measures were recruitment, retention, accrual, dropout, and protocol adherence. Intervention outcome measures were physiological stress, behavioral distress, pain, and cost. RESULTS: We successfully recruited and retained participants. Parents expressed satisfaction with research study participation. Dentists stated that the intervention could be incorporated in normal practice. Intervention outcome measures favored the SADE condition. CONCLUSION: Preliminary positive benefit of SADE in children with ASD warrants moving forward with a large-scale clinical trial.

Modification of the postrotary nystagmus test for evaluating young children.

This article explores the use of the postrotary nystagmus (PRN) test for children younger than current norms (children 4.0 yr-8.11 yr). In the first study, 37 children ages 4-9 yr were examined in the standard testing position and in an adult-held adapted position to determine whether holding a child affected the reflex. Because the position did not affect the reflex, in the second study, PRN in 44 children ages 2 mo-47 mo was compared with published normative mean raw scores for 44 children age 5 yr to determine whether norms for older children were applicable to younger children. No statistically significant differences were found between <4-yr-old and 5-yr-old children, suggesting that the PRN test can be used in infants and toddlers with valid comparison to current norms for 4-yr-olds on the Sensory Integration and Praxis Tests (4.0 yr-8.11 yr). Future research exploring the predictive value of this measure is warranted.

Sensory integration functions of children with cochlear implants.

OBJECTIVE. We investigated sensory integration (SI) function in children with cochlear implants (CIs). METHOD. We analyzed deidentified records from 49 children ages 7 mo to 83 mo with CIs. Records included Sensory Integration and Praxis Tests (SIPT), Sensory Processing Measure (SPM), Sensory Profile (SP), Developmental Profile 3 (DP-3), and Peabody Developmental Motor Scales (PDMS), with scores depending on participants' ages. We compared scores with normative population mean scores and with previously identified patterns of SI dysfunction. RESULTS. One-sample t tests revealed significant differences between children with CIs and the normative population on the majority of the SIPT items associated with the vestibular and proprioceptive bilateral integration and sequencing (VPBIS) pattern. Available scores for children with CIs on the SPM, SP, DP-3, and PDMS indicated generally typical ratings. CONCLUSION. SIPT scores in a sample of children with CIs reflected the VPBIS pattern of SI dysfunction, demonstrating the need for further examination of SI functions in children with CIs during occupational therapy assessment and intervention planning.

"A scoping review: Social stories supporting behavior change for individuals with Autism".

Social Stories (also known as social narratives) help individuals participate in and understand social situations. This scoping review identifies and synthesizes social narrative research targeting behavior change in individuals with ASD. Using the following questions as a guide: (a) What is the scope of social narrative interventions used for individuals with ASD, (b) What behavior change outcome measures are evaluated, and (c) What research designs are used; five databases were searched from 2007-to-2018. Fifty-six articles met the criteria. Primary outcomes were sorted into two macro-categories: Reduce Disruptive Behaviors and Increase Desired Behaviors. Most, but not all, studies were found to be effective for various behaviors such as aggressive actions, verbal protests, identifying emotions, executive functioning, following directions, and responding in social situations. Social narratives can be used to promote skills/behaviors in individuals with ASD to enable participation, an important goal in occupational therapy practice. They are an accessible and feasible intervention that can be implemented in various settings for behaviors including activities of daily living, social skills, independence, and self-regulation. Most research reviewed the single subject design, which is a limitation of the research as it makes results difficult to generalize. However, through replication, functional relationships can be determined. Additional research utilizing randomized control trials is recommended.

Correction: Raman et al. Relationships between Affect Recognition, Empathy, Alexithymia, and Co-Occurring Conditions in Autism. Brain Sci. 2023, 13, 1161.

In the original publication [...].

Oral care interventions for autistic individuals: A systematic review.

LAY ABSTRACT: Oral care-related challenges are well documented in the autistic community; dental care remains one of the most prevalent unmet health needs among autistic individuals. This review examined interventions designed to improve oral health in autistic individuals from children and adult populations. Through a systematic process, 36 studies were identified. These studies focused on improving home-based oral care skills and routines and reducing fear, anxiety, and/or negative behaviors in the dental clinic. Studies incorporated different types of techniques for facilitating oral care practice, including preparatory interventions to support home-based hygiene activities or improve an approaching dental encounter (n = 29), most often using visual aids, and/or strategies to manage behavioral difficulties exhibited in the dental office (n = 17). Some studies used both approaches (n = 10), combining visual aids prior to a visit with behavior management. Using an evidence-based rubric, we reviewed the methodological quality of the studies and found that most were only "adequate" (n = 8) or "weak" (n = 23) in reporting their evidence. This review has two key findings: (1) there is support for preparatory home-based visual interventions to improve toothbrushing and/or ready patients for dental visits; and (2) distraction or sensory-reducing interventions may also improve experiences in the dental clinic. Only one study purposefully recruited autistic adults, and no studies included intervention elements tailored to race/ethnicity, culture, and/or socioeconomic status. This review highlights the need for more studies investigating the impact of oral care-related interventions for autistic individuals of all ages and identifies a gap in interventions for autistic adults and those from minoritized populations.

Caregiver and youth inter-rater assessment agreement in autism spectrum disorder, developmental coordination disorder, and typical development.

Youth diagnosed with autism spectrum disorder (ASD) and those with developmental coordination disorder (DCD) are at heightened risk for co-occurring mental health diagnoses, especially anxiety and attention-deficit/hyperactivity disorder (ADHD). However, caregiver-child agreement on presence of related symptoms in populations with neurodevelopmental conditions is not well understood. Here, we examine the extent to which 37 ASD, 26 DCD, and 40 typically developing children and their caregivers agree on the degree of the child's symptoms of anxiety and ADHD. All caregiver-child dyads completed the Screen for Child Anxiety Related Emotional Disorders and Conners 3 ADHD Index. Across groups, intraclass correlations indicated generally poor agreement on anxiety and ADHD symptomatology. Although youth generally reported greater internalizing symptoms (i.e., anxiety), caregivers tended to report more observable externalizing behaviors (i.e., ADHD). Together, the results of this study support the need for a multi-informant approach in assessments of anxiety and ADHD in youth with neurodevelopmental disorders.

Comparing sensory processing in children with Down syndrome to a mental age matched sample of children with autism, other developmental disabilities, and typically developing children.

BACKGROUND: Atypical sensory processing impacts children with intellectual and developmental disabilities (IDD). Research has focused on SP in individuals with autism spectrum disorder (ASD); comparatively, little has been written regarding individuals with Down syndrome (DS) and IDDs. AIMS: We compared patterns of sensory processing in children with DS to children with ASD, other IDDs, and typically developing (TD) peers examining the relationship among different sensory processing measures. METHODS AND PROCEDURES: We analyzed cross-sectional data using two caregiver questionnaires (SP, SEQ) and one observational measure (SPA). Groups were compared on three sensory processing patterns: hyporesponsiveness; hyperresponsiveness; and sensory interests, repetitions, and seeking (SIRS) via ANOVA. We assessed concordance through correlations. OUTCOMES AND RESULTS: Children with DS, IDD, and ASD demonstrated more atypical sensory processing behaviors than TD peers. Children with ASD exhibited the most atypical responses across all measures, significantly more than DS children on all but one subscale. The IDD and DS groups differed on several measures. Measurement concordance was higher between caregiver-report versus observational assessment. CONCLUSIONS AND IMPLICATIONS: Differences between three clinical groups indicate that sensory processing features may differ across clinical populations regardless of cognitive functioning. Lower concordance between caregiver-report and observation measures highlights the need to understand sensory processing expression across different tasks and environments.

Relationships between Affect Recognition, Empathy, Alexithymia, and Co-Occurring Conditions in Autism.

Prior studies show differences in empathy and affect-recognition ability between those with autism spectrum disorder (ASD) and typically developing (TD) individuals. Autistic individuals also exhibit increased behavioral, gastrointestinal, and sleep issues. In the current study, we explored the differences in empathy and affect recognition between the ASD and TD groups; and we investigated their associations with conditions co-occurring in ASD. A total of 54 TD and 56 ASD children (8-17 years) were included. As compared to the TD group, the ASD group showed lower scores for affect recognition and perspective taking (PT) and higher scores for personal distress (PD). Interestingly, results from hierarchical linear regressions suggested that disparities in the PD and PT between the groups were primarily attributable to attenuated levels of alexithymia, rather than being mediated by the presence of an autism diagnosis. Differences in affect-recognition ability, however, were mediated by both an autism diagnosis and alexithymia. We also found significant correlations between empathy and affect recognition and measures of related conditions common in ASD. Alexithymia, hence, contributes to difficulties in empathy while both alexithymia and autism are associated with affect-recognition ability in ASD. Additionally, the association between affect recognition and empathic ability with co-occurring conditions in ASD needs to be considered during assessments and interventions.

Sensory Adaptations to Improve Physiological and Behavioral Distress During Dental Visits in Autistic Children: A Randomized Crossover Trial.

Importance: Autistic children have poorer oral health and greater oral care challenges, which are often associated with sensory overresponsivity, than neurotypical peers. It is important to identify innovative solutions enabling dentists to successfully perform standard clinic-based procedures for this population. Objective: To determine whether a sensory-adapted dental environment (SADE) reduces physiological and behavioral distress in autistic children undergoing dental cleanings, compared with a regular dental environment (RDE). Design, Setting, and Participants: This randomized crossover trial was conducted at a pediatric dentistry clinic in a large urban children's hospital between May 2016 and April 2022. Coders were blinded to study condition for physiological but not behavioral measurements. Autistic children aged 6 to 12 years were identified and invited to participate. Interested families were enrolled consecutively; after confirmation of autism diagnosis, children were randomized. Analysis for this per-protocol study were conducted from April to October 2022. Intervention: Each child underwent 1 RDE and 1 SADE dental cleaning, administered in randomized and counterbalanced order approximately 6 months apart. SADE included modified visual, auditory, and tactile stimuli. Main Outcomes and Measures: The primary outcome was physiological stress, assessed by electrodermal activity. The secondary outcome was behavioral distress measured from video recordings. Results: Among 452 families invited to participate, 220 children were enrolled, and 162 children (mean [SD] age, 9.16 [1.99] years; 136 [84.0%] male) with confirmed autism were randomized, with 83 children receiving RDE first and 80 children receiving SADE first. Most children (94 children [58.0%]) had moderate autism severity. Children had significantly lower physiological stress during dental care in SADE compared with RDE (mean difference in skin conductance level, -1.22 [95% CI, -2.17 to -0.27] µS), suggesting decreased sympathetic activity and increased relaxation during SADE dental care. No significant differences were found in nonspecific skin conductance responses (mean difference, -0.30 [95% CI, -0.86 to 0.25] per min). Video-coded frequency and duration of behavioral distress (but not questionnaire) measures were significantly lower in SADE vs RDE (Cohen d = -0.84 to -1.19). Physiological stress was associated with behavioral distress during the dental cleaning (eg, nonspecific skin conductance responses associated with the Frankl Scale: ß = -0.29; 95% CI, -0.39 to -0.19); age, IQ, and expressive communication moderated the intervention's success. No participants withdrew due to adverse effects. Conclusions and Relevance: In this randomized crossover trial of autistic children, using SADE was safe and efficacious in decreasing physiological and behavioral distress during dental care. This is important because enhancing oral care is critical for autistic children; this intervention may also be beneficial for populations beyond autism. Trial Registration: ClinicalTrials.gov Identifier: NCT02430051.

Oral Health Barriers for African American Caregivers of Autistic Children.

The most persistent oral health disparities in the United States impact children from racial and ethnic minoritized groups and children diagnosed as autistic. This paper aims to describe barriers to oral care as depicted by Black/African American (B/AA) parents of autistic children to further explore how and why oral health disparities persist in this population. A purposeful sample of eleven caregivers of autistic children, ages 4 to 14 years, who identified as B/AA were interviewed twice for approximately 60-90 min each. Thematic analysis utilizing a narrative approach was employed. Three themes emerged from the data concerning the barriers that affect oral health experiences: (a) difficulty in maintaining good oral health practices, (b) challenges with access to care and resources, and (c) poor patient-provider relationships. Due to the limited research that examines the intersection of autism, B/AA culture, and oral health practices, this study provides a rich picture of the barriers families face when obtaining oral care. Many families raised issues that other parents of autistic children also identified. B/AA caregivers have demonstrated that despite their own negative dental experiences, they understand the value of good oral care practices and are willing to pursue oral care for their children.

Brief Report: Caregiver Confidence in Reporting Anxiety Symptoms in Children with Autism Spectrum Disorder.

Assessment of anxiety in children with autism spectrum disorder (ASD) most commonly includes parent questionnaires. However, due to the nature of the questions and verbal limitations often present in children with ASD, caregivers may have difficulty completing such measures. Caregivers of 144 children with ASD ages 6 to 12 completed the Child and Adolescent Symptom Inventory-4 ASD Anxiety Scale and rated their level of confidence in responding to each item. Results indicated that parents had a moderate to high level of confidence in rating their children's anxiety symptoms. Parent confidence was not influenced by their child's age, expressive language ability, or intellectual functioning, but was related to their child's anxiety symptom count and ASD severity.