A Multisite, Multidisciplinary Delphi Consensus Study Describing "Usual Care" Intervention Strategies for School-Age to Transition-Age Youth With Autism.

Understanding usual care is important to reduce health disparities and improve the dissemination of evidence-based practices for youth (ages 7-22 years) with autism spectrum disorder (ASD). A barrier to describing "usual ASD care" is the lack of a common vocabulary and inventory of the practices used by a diverse provider field. To address this barrier, we gathered input from expert providers to develop an inventory of usual care practices and assess expert familiarity and perceptions of these practices as interventions for anxiety, externalizing, and social difficulties in ASD. Purposeful sampling recruited 66 expert ASD providers representing multiple disciplines from 5 sites. Via a 2-round Delphi poll, experts reviewed, suggested revisions to and rated 49 literature-derived practices on several dimensions (familiarity, usefulness, common use, research support). A revised list of 55 practices and anonymous summary of group characteristics and ratings was then returned for further review. Results yielded 55 intervention practices, 48 of which were identified as "familiar" approaches by consensus (≥ 75% endorsement). Greater variation was observed in practices identified by consensus as most often used, useful, and research supported, depending upon the target problem. Findings provide an inventory of practices, reflective of the multidisciplinary language and approaches of expert ASD providers. This inventory may be used to better assess what constitutes usual care for youth with ASD in the United States. Moreover, findings offer insights from clinical experts regarding the range and acceptability of practices that may inform and ground treatment research, dissemination, and implementation efforts.

Co-occurring psychiatric conditions in autism spectrum disorder.

Individuals with autism spectrum disorder (ASD) are at increased risk for experiencing one or more co-occurring psychiatric conditions. When present, these conditions are associated with additional impairment and distress. It is therefore crucial that clinicians and researchers adequately understand and address these challenges. However, due to symptom overlap, diagnostic overshadowing, and ambiguous symptom presentation in ASD, the assessment of co-occurring conditions in ASD is complex and challenging. Likewise, individual difference factors, such as age, intellectual functioning, and gender, may influence the presentation of co-occurring symptoms. Relatedly, a transdiagnostic framework may offer utility in assessing and treating co-occurring conditions. However, with the exception of anxiety disorders, treatment research for co-occurring psychiatric conditions in ASD is relatively limited. Therefore, the present paper aims to summarize and review available research on the most common co-occurring psychiatric disorders in ASD, with a focus on estimated population-based prevalence rates, diagnostic challenges, the influence of individual differences, and assessment guidelines. The utility of a transdiagnostic framework for conceptualizing co-occurring disorders in ASD is discussed, and the state of treatment research for co-occurring disorders is summarized. This study concludes with a summary of the extant literature, as well as recommendations for future research.

Predictors of expert providers' familiarity with intervention practices for school- and transition-age youth with autism spectrum disorder.

LAY ABSTRACT: School-age children, adolescents, and young adults with autism spectrum disorder encounter many different types of providers in their pursuit of treatment for anxiety, behavior problems, and social difficulties. These providers may all be familiar with different types of intervention practices. However, research has not yet investigated patterns in expert providers' familiarity with different practices nor how these patterns are related to the characteristics of providers (years in practice, academic discipline, setting) and the youth (age and intellectual disability) they typically support. A panel of 53 expert transdisciplinary providers rated their familiarity with 55 intervention practices (derived from research and expert nominations) via an online Delphi poll. Advanced statistical methods were used to identify types of intervention practices with which providers were familiar, which included two approaches (cognitive and behavioral) and two strategies (engagement and accessibility). Providers who practiced outside a school setting or treated clients without intellectual disability were more familiar with cognitive approaches. Clinical psychologists, behavior analysts, and school-based providers were more familiar with behavioral approaches. Providers practicing outside school settings were also more familiar with engagement strategies, and providers with more years in practice were more familiar with accessibility strategies. These results may help families and researchers to better anticipate how services may vary depending on the types of autism spectrum disorder providers seen and work to reduce disparities in care that may result.

From Clinic to Classroom: Two Case Studies of Youth With ASD and Anxiety From the School-Based Facing Your Fears Program.

Cognitive behavioral therapy (CBT) is considered best practice for treating anxiety in youth with autism spectrum disorder (ASD) in clinic settings. However, there is significant need to translate CBT into school settings. This paper presents two case illustrations of students who participated in the Facing Your Fears: School-Based program (FYF-SB), a manualized, group CBT intervention for anxiety in ASD, adapted for delivery in schools by interdisciplinary school providers. Students showed improvement in anxiety across multiple domains following intervention, according to clinical interview and parent- and self-report. These outcomes suggest that anxious youth with ASD can benefit from CBT delivered by interdisciplinary school providers. Importantly, decreases in anxiety symptoms were evident in domains that were not explicitly targeted during intervention. Overall, these case illustrations help frame areas of future research, including examining how treatment gains may generalize across anxiety domains as well as whether corresponding improvement in school functioning occurs.

A transdiagnostic model of psychiatric symptom co-occurrence and autism spectrum disorder.

Understanding whether the co-occurrence of psychiatric symptoms within autism spectrum disorder (ASD) are specific to the ASD diagnosis or reflect similar higher-order patterns observed in both ASD and non-ASD samples, or a confluence of the two, is of critical importance. If similar, it would suggest that comorbid psychiatric conditions among individuals with ASD are not symptoms of specific, non-ASD psychiatric disorders per se, but reflect a general liability to psychopathology associated with ASD. To this end, the current study examined whether the higher-order structure of co-occurring psychiatric symptoms was the same within ASD and non-ASD youth. Parents of clinic-referred youth with (n = 280) and without (n = 943) ASD completed a DSM-IV-referenced psychiatric symptom rating scale. A confirmatory factor analytic framework was used to examine four levels of measurement invariance across groups to determine the extent to which transdiagnostic factors were comparable. Transdiagnostic factors were characterized by symptoms of the same disorders (configural invariance) and the same factor loadings across groups (metric invariance). Furthermore, both groups evidenced equivalent numbers of symptoms of most psychiatric conditions with the notable exceptions of attention deficit hyperactivity disorder (ADHD) and social anxiety (partial strong invariance), which were higher in the ASD sample. It was concluded that disparities in the co-occurrence of psychiatric symptoms between youth with and without ASD may be largely reflective of transdiagnostic factor level differences associated with ASD and not indicative of the ASD diagnosis per se. However, for ADHD and social anxiety, there appears to be some specific associations with the ASD diagnosis. Autism Res 2020, 13: 579-590. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Few transdiagnostic dimensions relate common mental disorder diagnoses with one another. These dimensions explain psychiatric comorbidity (i.e., the finding that many persons possess several disorder diagnoses simultaneously). However, it is unclear if these dimensions differ among children with autism spectrum disorder (ASD), compared with their non-ASD counterparts. The results of this study demonstrate that underlying transdiagnostic dimensions are similar in both ASD and non-ASD children. However, there appear to be ASD-specific differences when it comes to social anxiety and attention deficit hyperactivity disorder.

Correction to: Externalizing and Internalizing Symptoms Moderate Longitudinal Patterns of Facial Emotion Recognition in Autism Spectrum Disorder.

The original version of this article unfortunately contained a mistake. In the heading "Data Analytic Plan", under "Level 2" the following equations were published incorrectly.

Autism severity, co-occurring psychopathology, and intellectual functioning predict supportive school services for youth with autism spectrum disorder.

Supportive school services are a primary service modality for youth with autism spectrum disorder. Autism spectrum disorder, as well as co-occurring psychiatric symptoms and low intellectual abilities, interfere with academic achievement and therefore influence decisions about school services. Therefore, we examined the association of parent, teacher, and clinician ratings of autism spectrum disorder and co-occurring psychiatric symptom severity and intellectual functioning with school services. In total, 283 youth with autism spectrum disorder were assessed with clinical evaluation via the Autism Diagnostic Observation Schedule and parent and teacher versions of the CASI-4R (Child and Adolescent Symptom Inventory). Full Scale Intelligence Quotient scores were obtained from case records. Clinical and teacher evaluations of autism spectrum disorder severity predicted services and were more strongly associated with school services than parent ratings. Teacher ratings were only associated with common school services (e.g. speech/language therapy, occupational therapy, and/or social skills training) frequency at medium and high levels of clinician-rated autism spectrum disorder severity. Higher IQ and parent-rated externalizing symptoms predicted lower likelihood of receiving school services, whereas internalizing symptoms were not predictive of school services. Autism spectrum disorder symptoms may overshadow externalizing and internalizing symptoms when considering school service supports. Results highlight the importance of evaluating autism spectrum disorder severity via multiple sources, especially in cases of unclear symptom presentation, when examining correlates of school services for youth with autism spectrum disorder.

Discrete electrocortical predictors of anxiety and anxiety-related treatment response in youth with autism spectrum disorder.

There are two established electroencephalogram (EEG) indices that putatively relate to anxiety symptoms: a) the error-related negativity (ERN), which reflects endogenous threat sensitivity, and b) resting-state EEG relative right frontal activity (rRFA), which relates to approach/withdrawal motivation. We examined these indices conjointly to better elucidate differential mechanisms underlying the common anxiety phenotype in youth with autism spectrum disorder (ASD), in relation to subjective reports of symptomatology and treatment response. EEG was recorded from 53 youth with ASD who participated in a 10-week social skills intervention (SSI). More negative ERN related to higher self-reported social anxiety symptoms at baseline, and predicted improvements in self-reported social anxiety symptoms following SSI. Although rRFA did not relate to anxiety symptoms at baseline, more rRFA predicted improvement in parent-reported anxiety domains but worsening in self-reported anxiety symptoms. This study provides evidence for unique neural mechanisms of anxiety symptoms and changes in anxiety after SSI in youth with ASD.

Error-related brain activity and anxiety symptoms in youth with autism spectrum disorder.

Individuals with autism spectrum disorder (ASD) often experience symptoms associated with generalized anxiety disorder, obsessive-compulsive disorder, and social anxiety disorder. In other populations, these same symptoms are associated with a larger error-related negativity (ERN), an event-related potential that reflects endogenous threat sensitivity. As such, it is possible that the ERN may relate to the clinical presentation of anxiety in ASD. However, studies examining these associations in youth with ASD have yielded mixed results. The present study aimed to clarify this relationship by examining the ERN in relation to these specific anxiety symptoms in ASD, and by accounting for typical covariates (e.g., age, verbal abilities, depression, ASD symptoms) of the ERN. Fifty-one youth, ages 8-17, with ASD and intact cognitive ability completed a modified Flanker task, from which the ERN component was obtained. Measures of anxiety, verbal abilities, depression, and ASD symptoms were collected from participants and parents. Results revealed that greater self-reported social anxiety symptoms, specifically performance fears but not humiliation/rejection fears, were associated with an increased neural response to errors, as measured by the ERN. This relationship remained after controlling for other anxiety symptoms, as well as age, verbal IQ, depression symptoms, and ASD symptoms. Findings suggest that heightened threat sensitivity may be characteristic of individuals with ASD who exhibit social fearfulness. Autism Res 2018, 11: 342-354. © 2017 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: The error-related negativity (ERN) is a physiological measure of the brain's response to errors which is thought to reflect threat sensitivity and has been implicated in anxiety disorders in individuals without autism spectrum disorder (ASD). The present study revealed that the ERN is related to social anxiety symptoms, specifically performance fears, in a sample of youth with ASD. Findings suggest that heightened threat sensitivity may be characteristic of individuals with ASD who exhibit social fearfulness.

Externalizing and Internalizing Symptoms Moderate Longitudinal Patterns of Facial Emotion Recognition in Autism Spectrum Disorder.

Facial emotion recognition (FER) is thought to be a key deficit domain in autism spectrum disorder (ASD). However, the extant literature is based solely on cross-sectional studies; thus, little is known about even short-term intra-individual dynamics of FER in ASD over time. The present study sought to examine trajectories of FER in ASD youth over 18 weeks of repeated measurement, and evaluate the effects of internalizing and externalizing symptoms on these trajectories. Hierarchical Linear Modeling analyses revealed that FER errors decreased over time, even for particularly difficult stimuli. Moreover, FER improvement was enhanced by internalizing symptoms but attenuated by externalizing symptoms. Implications for models of FER development, reciprocal relations between FER and comorbidity, and intervention design and planning are discussed.