Noninvasive brain stimulation in autism: review and outlook for personalized interventions in adult patients.

Noninvasive brain stimulation (NIBS) has been increasingly investigated during the last decade as a treatment option for persons with autism spectrum disorder (ASD). Yet, previous studies did not reach a consensus on a superior treatment protocol or stimulation target. Persons with ASD often suffer from social isolation and high rates of unemployment, arising from difficulties in social interaction. ASD involves multiple neural systems involved in perception, language, and cognition, and the underlying brain networks of these functional domains have been well documented. Aiming to provide an overview of NIBS effects when targeting these neural systems in late adolescent and adult ASD, we conducted a systematic search of the literature starting at 631 non-duplicate publications, leading to six studies corresponding with inclusion and exclusion criteria. We discuss these studies regarding their treatment rationale and the accordingly chosen methodological setup. The results of these studies vary, while methodological advances may allow to explain some of the variability. Based on these insights, we discuss strategies for future clinical trials to personalize the selection of brain stimulation targets taking into account intersubject variability of brain anatomy as well as function.

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Autism spectrum disorder (ASD) is one of the neurodevelopmental disorders in children, and there are currently no specific treatments, with the main interventions focusing on educational training and behavioral correction. Virtual reality, as an emerging technology, is a computer-based environmental simulation system that achieves interactive dynamics and immersive experiences by integrating information from multiple sources. In recent years, it has been gradually applied in intervention training for children with ASD. This paper reviews the recent studies on the effects of virtual reality intervention on emotional cognition, social skills, daily living skills, motor skills, and specific phobias in children with ASD, offering a new direction for ASD intervention training.

Time Limited Benefits of Physical and Proprioceptive Training on Physical Fitness Components in Children With Autism Spectrum Disorders.

In this study, we explored the immediate and three-month follow-up effects of physical training on physical fitness in children with autism spectrum disorder (ASD). We randomly assigned 20 children with ASD (age 8-11 years) into an experimental group (EG; n = 10) and a control group (CG; n = 10). The EG participated in an 8-week training program involving both strength and proprioceptive exercises (three 60-minute sessions/week), while the CG simply maintained their daily activities. We assessed physical fitness components for each participant at baseline, post-training, and at a 3-month follow-up. The physical training intervention significantly improved physical fitness of these children with ASD in terms of their flexibility (p < .001; 32.46%), lower limbs strength (p = .003; 36.98%), lower body power (p < .001; 41.78%) and functional mobility (p < .001; 25.56%). However, these addition training-induced gains were lost at follow-up for lower limbs strength (p < .001), flexibility (p < .001), and functional mobility (p = .034)). Physical training was effective for improving physical fitness in children with ASD, but the loss of these gains at three months follow-up underscored the need for continuous physical exercise.

Comparison of the efficacy of parent-mediated NDBIs on developmental skills in children with ASD and fidelity in parents: a systematic review and network meta-analysis.

BACKGROUND: Recently, studies on behavioral interventions for autism have gained popularity. Naturalistic Developmental Behavior Interventions (NDBIs) are among the most effective, evidence-based, and widely used behavior interventions for autism. However, no research has been conducted on which of the several NDBI methods is most effective for parents and children with autism spectrum disorders. Therefore, we conducted a network meta-analysis to compare the specific effects of each type of parental-mediated NDBI on children's developmental skills and parent fidelity. METHODS: PubMed, Embase, Cochrane Library, Medline, Web of Science, China National Knowledge Infrastructure (CNKI), CINAHL, and Wanfang databases were searched from inception to August 30, 2023. A total of 32 randomized controlled trial studies that examined the efficacy of different NDBIs were included. RESULTS: Parents of children with ASD who received Pivotal Response Treatment (PRT) reported significant improvements in their children's social skills (SUCRA, 74.1%), language skills (SUCRA, 88.3%), and parenting fidelity (SUCRA, 99.5%). Moreover, parents who received Early Start Denver Model (ESDM) reported significant improvements in their children's language (SMD = 0.41, 95% CI: 0.04, 0.79) and motor skills (SMD = 0.44, 95% CI: 0.09, 0.79). In terms of the efficacy of improving parent fidelity, the results showed that the Improving Parents as Communication Teachers (ImPACT) intervention significantly improved parent fidelity when compared with the treatment-as-usual group (TAU) (SMD = 0.90, 95% CI: 0.39, 1.42) and the parental education intervention (PEI) (SMD = 1.10, 95% CI:0.28, 1.91).There was a difference in parent fidelity among parents who received PRT(SMD = 3.53, 95% CI: 2.26, 4.79) or ESDM(SMD = 1.42, 95% CI: 0.76, 2.09) training compared with PEI. CONCLUSION: In conclusion, this study revealed that parents can achieve high fidelity with the ImPACT intervention, and it can serve as an early first step for children newly diagnosed with ASD. It also showed that parent-mediated ESDM is effective in improving language and motor skills for children with ASD and can be used as part of the second stage of parent training. Parent-mediated PRT can also be used as a third stage of parent training with sufficient training intensity to further improve language, social, and motor skills.

Integrating Structural and Experiential Family Therapy in Neurodivergent Families: A Case Study.

Autism Spectrum Disorder (ASD) is widely regarded as the most severe childhood behavioral disorder. However, society's lack of awareness regarding neurodevelopmental disorders, like autism, has led to a limited understanding of their profound impact on children and their families. Challenges include unique sensory experiences, communication and social interactions, strain on familial relationships, emotional toll on parents, and educational hurdles, which can significantly impact the well-being of individuals and their families. This case study explores the integration of Structural and Experiential Family Therapy in a neurodivergent family coping with ASD and Attention-Deficit/Hyperactivity Disorder (ADHD). Structural interventions focus on clarifying roles and redistributing caregiving responsibilities, addressing issues of communication, and power dynamics. Experiential interventions target emotion-focused techniques, empathy building, and cultural sensitivity training. This integration may promote lasting change in family dynamics and a call to empower parents within neurodivergent families through tailored interventions, contributing to a sustainable therapeutic approach.

Reversing valproic acid-induced autism-like behaviors through a combination of low-frequency repeated transcranial magnetic stimulation and superparamagnetic iron oxide nanoparticles.

Transcranial magnetic stimulation (TMS) is a neurostimulation device used to modulate brain cortex activity. Our objective was to enhance the therapeutic effectiveness of low-frequency repeated TMS (LF-rTMS) in a rat model of autism spectrum disorder (ASD) induced by prenatal valproic acid (VPA) exposure through the injection of superparamagnetic iron oxide nanoparticles (SPIONs). For the induction of ASD, we administered prenatal VPA (600 mg/kg, I.P.) on the 12.5th day of pregnancy. At postnatal day 30, SPIONs were injected directly into the lateral ventricle of the brain. Subsequently, LF-rTMS treatment was applied for 14 consecutive days. Following the treatment period, behavioral analyses were conducted. At postnatal day 60, brain tissue was extracted, and both biochemical and histological analyses were performed. Our data revealed that prenatal VPA exposure led to behavioral alterations, including changes in social interactions, increased anxiety, and repetitive behavior, along with dysfunction in stress coping strategies. Additionally, we observed reduced levels of SYN, MAP2, and BDNF. These changes were accompanied by a decrease in dendritic spine density in the hippocampal CA1 area. However, LF-rTMS treatment combined with SPIONs successfully reversed these dysfunctions at the behavioral, biochemical, and histological levels, introducing a successful approach for the treatment of ASD.

The potential of repetitive transcranial magnetic stimulation for addressing sleep difficulties in children with autism - A brief communication.

Sleep difficulties can co-occur with autistic traits and have been frequently reported in children diagnosed with autism. Thus, sleep difficulties may impact neural development, cognition, and behavioural functioning in children with autism. Interventions, such as repetitive transcranial magnetic stimulation (rTMS), that target aberrant neural structures underpinning autistic traits and sleep difficulties in children could have beneficial effects. The rTMS effects on the pathophysiological pathways hypothesised to underpin autism and sleep difficulties are well-established in the literature; however, clinical evidence of its potential to improve sleep difficulties in children with autism is limited. While the preliminary data is promising, further robust rTMS studies are warranted to encourage its use in clinical practices.

Beyond imagination: Sorting out and treating psychosis in the context of autism spectrum disorder.

In the last decades, growing caseness for Autism Spectrum Disorder (ASD) has been observed, owing to the diagnostic accretion of low-impairment forms, over and above other possible causes. Unrecognized ASD is likely to be mislabeled as a psychotic disorder (PD), as people in the spectrum may show 'pseudopsychotic' symptoms, resembling both negative and positive symptoms. On the other hand, PDs are likely to be overlooked when they arise in people with ASD, due to the 'diagnostic overshadowing' of new-onset conditions by lifelong core autistic symptoms. The three available metanalyses on the occurrence of psychosis in adults with ASD convergently reported a rate of PDs that is at least ten times higher than in the general population. Therefore, the lack of literature addressing risk factors, outcomes, and treatment options for psychosis in the context of ASD is utterly concerning. The present review aims to summarize up-to-date knowledge of PDs with comorbid ASD in terms of clinical features, course, and treatment.

Identification and support of autistic individuals within the UK Criminal Justice System: a practical approach based upon professional consensus with input from lived experience.

BACKGROUND: Autism spectrum disorder (hereafter referred to as autism) is characterised by difficulties with (i) social communication, social interaction, and (ii) restricted and repetitive interests and behaviours. Estimates of autism prevalence within the criminal justice system (CJS) vary considerably, but there is evidence to suggest that the condition can be missed or misidentified within this population. Autism has implications for an individual's journey through the CJS, from police questioning and engagement in court proceedings through to risk assessment, formulation, therapeutic approaches, engagement with support services, and long-term social and legal outcomes. METHODS: This consensus based on professional opinion with input from lived experience aims to provide general principles for consideration by United Kingdom (UK) CJS personnel when working with autistic individuals, focusing on autistic offenders and those suspected of offences. Principles may be transferable to countries beyond the UK. Multidisciplinary professionals and two service users were approached for their input to address the effective identification and support strategies for autistic individuals within the CJS. RESULTS: The authors provide a consensus statement including recommendations on the general principles of effective identification, and support strategies for autistic individuals across different levels of the CJS. CONCLUSION: Greater attention needs to be given to this population as they navigate the CJS.

Attention-deficit Hyperactivity Disorder and Autism Spectrum Disorder: Towards Better Diagnosis and Management.

Background: Attention-deficit hyperactivity disorder (ADHA) is one of the most common comorbid disorders of autism spectrum disorder (ASD) that can accompany autism, triggered by it, or be a consequence of it. Objective: This review explored the prevalence of the comorbidity of both disorders, neurobiological background, symptoms, latest assessment methods, and therapeutic approaches. Results and Discussion: It concluded that effective assessment, diagnosis and management of ADHD in ASD children and adults is essential for this group of patients to thrive and live a good quality of life. Further research is recommended to explore the most effective intervention for such important members of our society. Conclusion: More studies are needed to understand the mechanisms underlying these comorbidities, and to prevent the misdiagnosis and mismanagement of these disorders. Also, to develop up to date personalized therapeutic plans for such children.

Validation of key components in designing a social skills training content using virtual reality for high functioning autism youth-A Fuzzy Delphi method.

The use of virtual reality in social skills training for high functioning autism spectrum disorder (HFASD) youth has been found to be engaging and enjoyable. Despite the promising results, previous literature indicates that there has been no consensus on the social skills target in the training content. There is also limited research on how evidence-based strategies like cognitive and behaviour techniques are instantiated into the VR environment to teach social skills. The aim of this study is to determine the key components to design a social skills training content using virtual reality for youths with HFASD. The Fuzzy Delphi method (FDM) was used to obtain expert consensus on social skills difficulties and cognitive behavioral techniques included in the content in three phases. In phase 1, a questionnaire was developed from in-depth interviews and scientific literature review. The in-depth interviews were conducted with 13 HFASD youth, 7 parents and 6 experts. In phase 2, 3 experts rated the relevance of the items in the questionnaire using an item-level content validity index (I-CVI) assessment. In phase 3, the questionnaire was distributed to 10 experts to rate their level of agreement on each component using a 7-point Likert scale. Components that received a value above 75%, threshold value (d) ≤ 0.2, fuzzy score (A) ≥ α - cut value = 0.5 and higher rank based on defuzzification score were prioritized to be included in the content. Items that received higher expert consensus on social skills difficulties included assessing non-verbal responses, initiating, maintaining, and leaving conversations, emotional difficulties and difficulties in perspective taking. Cognitive and behavioral techniques that received higher expert consensus were psychoeducation, modelling, relaxation techniques, reinforcements, and perspective-taking questions. These key components can be used as a framework for the development of virtual learning content for social skills training in future studies.

ESDM intervention in severe preschool autism: an Italian Case report, psychological and social medicine reflections.

BACKGROUND: The goal of our contribution is to discuss a preschool intervention based on the Early Start Denver Model and the use of the main tools for the detection of adaptive behaviour in cases of autism: Vineland, ABAS. CASE PRESENTATION: the work is the presentation of a clinical case that has benefited from an intervention with the Early Start Denver Model methodology for the benefit of a child with socio-cultural and economic disadvantages. This early intervention, in a child of 36 months, which followed the diagnosis, was possible thanks to the intervention of many third-sector organizations which allowed this child, with a serious autism profile, to receive an evidence-based intervention for free. At the beginning of the intervention, the child presented a diagnosis of severe autism with absence of gaze, vocalizations and other communicative impairments. The level of motor clumsiness was also quite high, as were stereotypies. CONCLUSIONS: Research has shown the usefulness of intervening in this area with an early assessment and/or diagnosis and immediate intervention; however, public health services are not always able to maintain this pace. Our contribution therefore shows on the one hand the evidence of the improvements achieved by the child despite the low intensity of the treatment, and on the other hand, demonstrates the total versatility and adaptability of the Denver Model to the Italian context. In our conclusions, there are also some reflections on the tools used to measure adaptive behavior which seem to have a number of limitations and criticalities.

Neurofeedback training of executive function in autism spectrum disorder: distinct effects on brain activity levels and compensatory connectivity changes.

BACKGROUND: Deficits in executive function (EF) are consistently reported in autism spectrum disorders (ASD). Tailored cognitive training tools, such as neurofeedback, focused on executive function enhancement might have a significant impact on the daily life functioning of individuals with ASD. We report the first real-time fMRI neurofeedback (rt-fMRI NF) study targeting the left dorsolateral prefrontal cortex (DLPFC) in ASD. METHODS: Thirteen individuals with autism without intellectual disability and seventeen neurotypical individuals completed a rt-fMRI working memory NF paradigm, consisting of subvocal backward recitation of self-generated numeric sequences. We performed a region-of-interest analysis of the DLPFC, whole-brain comparisons between groups and, DLPFC-based functional connectivity. RESULTS: The ASD and control groups were able to modulate DLPFC activity in 84% and 98% of the runs. Activity in the target region was persistently lower in the ASD group, particularly in runs without neurofeedback. Moreover, the ASD group showed lower activity in premotor/motor areas during pre-neurofeedback run than controls, but not in transfer runs, where it was seemingly balanced by higher connectivity between the DLPFC and the motor cortex. Group comparison in the transfer run also showed significant differences in DLPFC-based connectivity between groups, including higher connectivity with areas integrated into the multidemand network (MDN) and the visual cortex. CONCLUSIONS: Neurofeedback seems to induce a higher between-group similarity of the whole-brain activity levels (including the target ROI) which might be promoted by changes in connectivity between the DLPFC and both high and low-level areas, including motor, visual and MDN regions.

Errorless Training Benefits Motor Learning and Kinematic Outcomes in Children With Autism Spectrum Disorders.

Most children with Autism Spectrum Disorder (ASD) have some form of motor deficits. Additionally, based on executive dysfunction, working memory is often atypical in these children. Errorless learning reduces demands on working memory. In this study, we investigated the effectiveness of errorless training on these children's ability to learn golf putting. Participants (N = 20), aged 9-13 years (M = 10.15, SD = 1.4), were randomly assigned to either: (a) an errorless (ER) training group (n = 10) or (b) an explicit instruction (EI) group (n = 10). The ER group practiced putting from different distances without any instruction, while the EI group practiced putting at a particular distance with instruction. We measured motor performance (e.g., putting accuracy) and kinematic variables (e.g., putter face angle). One-way analyses of variance showed that motor performance significantly improved in both groups, but that the ER group showed significantly better accuracy retention (p < .028) and transfer learning (p < .047) than the instructional group. Kinematic variables were also significantly different between the two groups on the transfer test. These findings supported the benefits of errorless training compared to explicit instruction to teach motor skills to children with ASD.

A Randomized Controlled Trial Comparing Face-to-Face Versus Remote Delivery of Low-Tech Augmentative and Alternative Communication in Nonspeaking Children With Autism Spectrum Disorder.

PURPOSE: Thirty percent of children diagnosed with autism spectrum disorder (ASD) do not develop spoken language. To provide a means of communication for this subset of the population, augmentative and alternative communication (AAC) systems are often utilized. Low-tech options have traditionally been delivered through the in-person modality. However, due to the COVID-19 pandemic, changes to service delivery models have been required. This randomized controlled trial was conducted in order to assess the efficacy of low-tech AAC delivered face-to-face versus remotely on communication outcomes in nonspeaking children with ASD. CONCLUSIONS: Both participant groups demonstrated similar gains in AAC proficiency, number and type of nonspeaking acts, and number of spoken communication acts. Remote delivery of low-tech AAC treatment is a viable alternative to face-to-face instruction.

Culturally Adapted Dental Visual Aids Effect on Behavior Management during Dental Visits in Children with Autism Spectrum Disorder.

AIM: Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by unique behavioral patterns, treating children with ASD in the dental clinic has been a great challenge due to their behavior. This study aims to determine the effectiveness of culturally adapted dental visual aids in modifying behavior patterns during dental visits in children with ASD. MATERIALS AND METHODS: A controlled, blinded, randomized, clinical trial, with 64 children diagnosed with ASD, were randomly divided into two groups. The study took place between January 2019 and January 2021. The experimental group was provided with culturally adapted dental visual aids created especially for this research and the control group was provided with universal dental visual aids. The children's behavior patterns were evaluated before and after using the dental visual aids. SPSS v.25 was used to process all the data. RESULTS: Behavior patterns have modified significantly in the experimental group (p < 0.001) however, it was statistically insignificant in the control group (p = 0.077). In terms of behavioral patterns, the experimental group outperformed the control group significantly (p < 0.001). CONCLUSION: The culturally adapted dental visual aids have shown effectiveness in modifying behavior patterns in children diagnosed with ASD during dental visits. CLINICAL SIGNIFICANCE: By evaluating the impact of culturally adapted visual aids on behavior management, the study can enhance the accessibility and effectiveness of dental care for this vulnerable population, ultimately promoting better oral health outcomes and reducing potential trauma associated with dental visits for children with ASD. How to cite this article: Aljubour AA, AbdElBaki M, El Meligy O, et al. Culturally Adapted Dental Visual Aids Effect on Behavior Management during Dental Visits in Children with Autism Spectrum Disorder. J Contemp Dent Pract 2024;25(1):20-28.

Occupational therapy interventions in promoting social communication skills among children with autism spectrum disorder: A scoping review.

INTRODUCTION: Children with Autism Spectrum Disorder (ASD) often face significant challenges in verbal communication, social interaction, and exhibit repetitive behavioral patterns. These challenges persist across various developmental stages, particularly impacting their social communication abilities. This scoping review aims to explore the range of occupational therapy interventions that are employed to enhance social communication skills in children with ASD. MATERIALS AND METHODS: A literature search was conducted independently on scientific databases: Scopus, Google Scholar, Science Direct, and Web of Science (WOS). The process was carried out according to the PRISMA guidelines. RESULT: Of the 195 studies identified, 8 articles involving 185 participants, aged 17 months to 12 years old, across six countries met the inclusion criteria. The majority of studies indicate significant improvement in social communication abilities, while one study demonstrates insignificant results and another study presents mixed outcomes, utilising two different assessment tools. CONCLUSION: Occupational therapy has showed promise in improving social communication in children with ASD. Nonetheless, this review emphasises the need for greater indepth study and long-term evaluation to better explain and sustain these benefits. More research is needed to develop OT interventions that are both effective and evidence-based.

Disparity in the dental care of children and adolescents with autism spectrum disorder in Korea: a national population-based cross-sectional study.

Individuals with autism spectrum disorders (ASD) have difficulty accessing dental care. We aim to verify whether individuals with ASD are properly managed by checking the frequency of dental visits, cost and severity of dental treatment compared with those without ASD. This cross-sectional study used the Korean Health Insurance Database to analyze the frequency, cost and severity of dental treatment in 209,780 people under the age of 19 with or without ASD in 2020. The average frequency of dental visits for individuals without ASD was 2.98 times, which was significantly higher (p < 0.001) than the 2.89 times for those with ASD. However, the average dental cost for individuals with ASD was USD 132.63, which was significantly higher (p < 0.001) than USD 116.57 for those without ASD. Additionally, the average number of times that individuals without ASD received severe dental treatment was 1.23 times, significantly higher than the 1.15 times for those with ASD. Further, per 10,000 people, we found that trauma treatment was recorded for an average of 21.90 individuals with ASD, significantly higher than the 7.75 recorded for those without ASD (p < 0.001). Individuals with ASD encounter significant disparities in accessing dental care, as evidenced by their relatively infrequent dental visits. This discrepancy can be attributed to various barriers including the financial burden compared with those without ASD.

The impact of the physical activity intervention on sleep in children and adolescents with autism spectrum disorder: A systematic review and meta-analysis.

Pharmacological treatments (i.e., melatonin) and non-pharmacological therapies (e.g., parent-based sleep education programs and behavioural interventions) have been found to result in improved sleep in children and adolescents with autism spectrum disorder (ASD). However, there are several limitations to these treatment approaches, including concerns about the possible side-effects and safety, high-cost and uncertainties of long-term effects. Physical activity (PA) intervention is a promising behavioural intervention that has received increasing attention. However, the effects of PA intervention on sleep are still unclear in this clinical group. This study aimed to synthesize available empirical studies concerning the effects of PA interventions on sleep in children and adolescents with ASD. Following PRISMA guidelines, seven electronic databases: APA PsychInfo, CINAHL Ultimate, ERIC, MEDLINE, PubMed, SPORTDiscus, and Web of Science, were searched from inception to March 2023. Randomized controlled trials/quasi-experimental designs with comparison groups were included. Initially, 444 articles were identified, 13 articles underwent systematic review, and 8 studies with control groups and sufficient statistical data were selected for meta-analysis. Compared to no-treatment control groups, PA interventions had a large positive effect on parent-reported general sleep problems, night awakenings, sleep resistance, sleep duration and actigraphy-assessed sleep efficiency in children and adolescents with ASD.

Combined repetitive transcranial magnetic stimulation and gut microbiota modulation through the gut-brain axis for prevention and treatment of autism spectrum disorder.

Autism spectrum disorder (ASD) encompasses a range of neurodevelopmental conditions characterized by enduring impairments in social communication and interaction together with restricted repetitive behaviors, interests, and activities. No targeted pharmacological or physical interventions are currently available for ASD. However, emerging evidence has indicated a potential association between the development of ASD and dysregulation of the gut-brain axis. Repetitive transcranial magnetic stimulation (rTMS), a noninvasive diagnostic and therapeutic approach, has demonstrated positive outcomes in diverse psychiatric disorders; however, its efficacy in treating ASD and its accompanying gastrointestinal effects, particularly the effects on the gut-brain axis, remain unclear. Hence, this review aimed to thoroughly examine the existing research on the application of rTMS in the treatment of ASD. Additionally, the review explored the interplay between rTMS and the gut microbiota in children with ASD, focusing on the gut-brain axis. Furthermore, the review delved into the integration of rTMS and gut microbiota modulation as a targeted approach for ASD treatment based on recent literature. This review emphasizes the potential synergistic effects of rTMS and gut microbiota interventions, describes the underlying mechanisms, and proposes a potential therapeutic strategy for specific subsets of individuals with ASD.