Association of cognitive and adaptive skills with internalizing and externalizing problems in autistic children and adolescents.

The presence of an intellectual disability (ID) alongside autism is considered to increase the risk for mental health and behavior problems in children and adolescents. Existing evidence is restricted by looking at ID as a categorical classification. The study aimed to examine the association of cognitive and adaptive behavior skills with internalizing and externalizing problems in a large sample of autistic children and adolescents, across a wide range of cognitive skills. Participants were 2759 children and adolescents aged between 4 and 18 years recruited as part of the Simons Simplex Collection (SSC), of whom 709 (approximately 25%) had ID. Multiple regression models examined associations of internalizing and externalizing problems with cognitive and adaptive skills (communication, daily living, and socialization skills). Cognitive skills were not associated with externalizing problems but were associated with more internalizing problems in autistic children without ID (Cog ß: 0.126). All adaptive skill domains were inversely associated with externalizing (Communication ß: -0.145; Daily-Living ß: -0.132; Socialization ß: -0.289) and internalizing problems (Communication ß: -0.074; Daily-Living ß: -0.064; Socialization ß: -0.213) in those without ID. Daily living (ß: -0.158) and socialization skills (ß: -0.104) were inversely correlated with externalizing problems in autistic children with ID, while only socialization problems (ß: -0.099) were associated with internalizing problems in this group. Socialization skills were systematically associated with internalizing and externalizing problems across all levels of cognitive functioning. Supporting social skills development may benefit all aspects of child mental health, while recognizing that children with higher cognitive skills are more vulnerable to internalizing problems might assist with earlier identification of these problems.

Effects of positive behaviour support delivered by direct staff on challenging behaviours and quality of life of adults with intellectual disabilities: A multicentre cluster-controlled trial.

BACKGROUND: Effects of staff provided positive behaviour support (PBS) for individuals with intellectual disabilities are unclear. METHOD: Using a multicentre non-randomised cluster controlled design, 26 teams of residential group homes, including 245 staff members of 167 individuals with intellectual disabilities, were allocated to a PBS or control group. Conducting multilevel analyses (n = 123) we examined individuals' changes in irritability, other challenging behaviours and quality of life. RESULTS: Compared to controls, irritability did not significantly decrease more in the intervention group, but lethargic behaviours did. Personal development and self-determination significantly increased. Irritability of individuals in the PBS group with higher levels of irritability or lower levels of intellectual disability significantly reduced more compared to controls. CONCLUSIONS: PBS was effective in reducing irritability of individuals with severe levels of irritability or intellectual disabilities. Moreover, PBS decreased lethargic behaviours and improved several domains of quality of life.

Difficulties in Addressing Diagnostic, Treatment and Support Needs in Individuals with Intellectual Disability and Persistent Challenging Behaviours: A Descriptive File Study of Referrals to an Expertise Centre.

Service providers may experience difficulties in providing appropriate care to optimize the functioning of individuals with intellectual disability and challenging behaviour. External consultation to identify and address the unmet support needs underlying the behaviour may be beneficial. Applying the multidimensional American Association Intellectual and Developmental Disabilities (AAIDD) model may facilitate this approach. We aimed to describe the content and outcomes of consultation for individuals with intellectual disability and challenging behaviour referred to the Dutch Centre for Consultation and Expertise in relation to the AAIDD model. Interventions were based on the clients' diagnostic, treatment, and support needs and were categorized according to the five dimensions of the AAIDD model. Outcomes of the consultations were assessed based on reports in the file and rated as 'clear improvement', 'improvement' or 'no improvement or deterioration'. In two-thirds of the 104 studied files, consultees were satisfied with the improvement in functioning. Interventions targeted the difficulties of the service providers in supporting their clients and were most often applied within the Health and Context dimensions of the AAIDD model. We may conclude that consultation of an expert team may be valuable to support the care providers, and the use of the AAIDD model may be helpful to address the unmet needs to improve the functioning of individuals with challenging behaviour.

Assessing Autism Knowledge Across the Global Landscape Using the ASK-Q.

Substantial variability exists with regard to autism service provision around the world. Service disparities observed in many low- and middle-income countries may be driven, in part, by limited autism knowledge; however, measurement limitations have made it difficult to quantify autism knowledge across countries. The current study uses the autism stigma and knowledge questionnaire (ASK-Q) to quantify autism knowledge and stigma between different countries and demographics. The current study compiled data from 6830 participants collected using adapted versions of the ASK-Q administered in 13 different countries, representing four different continents. Structural equation modeling was used to examine how autism knowledge varied across country and individual factors. Results reveal cross country variability with a large, 17-point difference between the countries with the highest knowledge (Canada) and the lowest knowledge (Lebanon). As expected, countries with higher economies had higher levels of knowledge. We also documented differences based on country worldview, participant occupation, gender, age, and education level. These results help to identify specific regions and populations that might most need greater information about autism.

Sex differences in the course of autistic and co-occurring psychopathological symptoms in adolescents with and without autism spectrum disorder.

LAY ABSTRACT: There is an ongoing debate as to whether autism spectrum disorder (ASD) is expressed differently in women than men. Studies on sex differences in autistic symptoms and symptoms of other psychiatric problems present in individuals with autism generally do not include a general population comparison group, making it unclear whether differences are specific to autism or merely reflecting development in the general population. In this study, we compared sex differences in the course of autistic and at the same time present symptoms of other psychiatric problems in adolescents with milder forms of ASD to those in a group of the general population with an equal intelligence quotient (IQ) and socioeconomic status. Data of five assessment moments from ages 11 to 22 years were analyzed using a statistic procedure that allowed us to determine which factors affect the course of symptoms over time. We found that in adolescence, sex differences in the course of psychopathological symptoms specific for autism are confined to the repetitive stereotyped domains. Males had higher scores on the sensory/stereotypic and resistance to change domains, the latter difference disappeared during the course of adolescence due to an increase of these problems in autistic females. Other sex differences, among which an increase over time in mood and anxiety problems in females was the most outstanding, were also observed in females without autism. These sex-specific differences have relevance in the clinical care of autistic men and women, although they are subtle compared to differences between individuals with and without autism.

Preferred outcome measures in treatments for challenging behaviour in individuals with intellectual disabilities: Results of an inclusive Delphi method.

BACKGROUND: Interventions for challenging behaviours in individuals with intellectual disabilities benefit from outcome monitoring that takes clients' preferences into account. We determined clients' and representatives' preferred outcome domains and measures to secure their involvement in treatment decisions for challenging behaviours. METHOD: We used an inclusive Delphi method. A focus group of individuals with mild intellectual disabilities and representatives of those with moderate and severe intellectual disabilities prepared the first round by assisting us in collecting possible outcomes. Panels of individuals with intellectual disabilities and representatives were composed to achieve consensus on instruments for preferred outcome domains. RESULTS: Preferred outcome domains were behaviour, side-effects of psychotropic drugs, quality of life, daily functioning, caregiver burden and family quality of life. Corresponding outcome measures included self-report, interview and proxy-scales, including spoken versions. CONCLUSION: Including the preferred domains on outcomes of interventions for challenging behaviours is recommended. Research on corresponding outcome measures is necessary.

Parental rejection in early adolescence predicts a persistent ADHD symptom trajectory across adolescence.

Despite a general decrease of attention-deficit/hyperactivity disorder (ADHD) symptoms during adolescence, these may persist in some individuals but not in others. Prior cross-sectional studies have shown that parenting style and their interaction with candidate genes are associated with ADHD symptoms. However, there is a lack of longitudinal research examining the independent and interactive effects of parenting and plasticity genes in predicting the course of attention-deficit/hyperactivity disorder (ADHD) symptoms across adolescence. Here, we investigated how children perceived their parents' parenting style (i.e., rejection, overprotection, and emotional warmth) at the age of 11, and their interaction with DRD4, MAOA, and 5-HTTLPR genotypes on parent-reported ADHD symptoms at three time points (mean ages 11.1, 13.4, and 16.2 years) in 1730 adolescents from the TRacking Adolescents' Individual Lives Survey (TRAILS). Growth Mixture Modeling in Mplus identified four ADHD symptom trajectories: low, moderate stable, high decreasing, and high persistent. Perceived parental rejection predicted class membership in the high persistent trajectory compared to the other classes (p < 0.001, odds ratios between 2.14 and 3.74). Gene-environment interactions were not significantly related to class membership. Our results indicate a role of perceived parental rejection in the persistence of ADHD symptoms. Perceived parental rejection should, therefore, be taken into consideration during prevention and treatment of ADHD in young adolescents.

Network Structure of Autism Spectrum Disorder Behaviors and Its Evolution in Preschool Children: Insights from a New Longitudinal Network Analysis Method.

Network modeling of the social, communication and restrictive/repetitive behaviors (RRBs) included in the definition of Autism Spectrum Disorder was performed. The Autism Diagnostic Interview-Revised (ADI-R) assessed behaviors in 139 pre-school cases at two cross-sections that averaged 34.8 months apart. Cross-sectional networks were based on the correlation matrix of the ADI-R behavioral items and the "bootCross" method was developed and enabled the estimation of a longitudinal network. At both stages, RRB items/nodes formed a consistent peripheral cluster, while social and communication nodes formed a core cluster that diverged with time. These differences in the nature and evolution of the RRB and socio-communicative dimensions indicate that their inter-behavior dynamics are very different. The most central behaviors across stages are proposed as prime targets for efficient therapeutic intervention.

Exploring the association of staff characteristics with staff perceptions of quality of life of individuals with intellectual disabilities and challenging behaviours.

BACKGROUND: This study aimed to examine the associations between individual staff and staff team characteristics and quality of life of individuals with intellectual disabilities and challenging behaviours. METHOD: With multilevel analyses, we examined educational level, experience, attitudes and behaviours of 240 staff members, in relation to their perception of quality of life of 152 individuals with intellectual disabilities and challenging behaviours they cared for. RESULTS: Two individual staff characteristics were related to better quality of life: higher educational and self-reflection levels. Of the team characteristics, higher educational level, higher self-efficacy and more friendly behaviour were associated with better quality of life. Unexpectedly, higher staff-individual ratio was related to lower quality of life. CONCLUSIONS: Both individual staff and staff team characteristics are associated with quality of life, indicating the need to take staff team characteristics into account when examining quality of life.

Normative data for the self-reported and parent-reported Strengths and Difficulties Questionnaire (SDQ) for ages 12-17.

BACKGROUND: The Strengths and Difficulties Questionnaire (SDQ) is widely used to screen for psychosocial problems among adolescents. As the severity of such problems is known to be related to age and gender, screening could be improved by interpreting SDQ scale scores with age-specific and perhaps gender-specific norms. Up to now, such norms are lacking. The aim of the current study is to present gender-specific and joint normative data per year of age for the Dutch self-reported and parent-reported SDQ versions for use among 12- to 17-year-old adolescents. METHODS: The norm groups for the self-reported and parent-reported SDQ versions consisted of 993 adolescents and 736 parents, respectively, from the general Dutch population. Per SDQ version, both gender-specific norms and joint norms (percentiles and cutoffs) per year of age were calculated through regression-based norming (Rigby in J Roy Stat Soc Ser C 54:507, 2005). Additionally, these norms were compared to the widely used British norms that are neither age-specific nor gender-specific. RESULTS: By design, gender-specific 'abnormal' cutoffs (i.e., cutoffs aimed at identifying max. 10% of the most extremely scoring males and max. 10% of the most extremely scoring females) resulted in about equal percentages of 'abnormal' scoring male and female adolescents per SDQ scale. In contrast, joint 'abnormal' cutoffs (i.e., cutoffs aimed at identifying max. 10% of the most extremely scoring adolescents) resulted in relatively more male (7.6 to 13.6%, depending on age) than female (3.3 to 8.9%, depending on age) adolescents as scoring 'abnormal' on scales measuring externalizing behavior (self-reported and parent-reported SDQ versions), and relatively more female (3.9 to 14.3%, depending on age) than male (1.8 to 6.9%, depending on age) adolescents as scoring 'abnormal' on scales measuring internalizing behavior (self-reported SDQ version). In both types of norms, minor age effects were present. Among Dutch adolescents, the British norms yielded detection rates much lower than the expected 10%. CONCLUSIONS: Our findings indicate that detection rates depend on the reference group that is used (British or Dutch general adolescent population; specific gender group or not). The normative data in this paper facilitate the comparison of an adolescent's scores to different reference groups, and allow for cross-country/cultural comparisons of adolescents' psychosocial behavior.

Early-Life Environmental and Child Factors Associated with the Presence of Disruptive Behaviors in Seven-Year-Old Children with Autistic Traits in the Avon Longitudinal Study of Parents and Children.

We studied the association of early-life environmental and child factors with disruptive behaviors in children with autistic traits around age 7, in the Avon Longitudinal Study of Parents and Children (n = 6,401). Logistic regression with the least absolute shrinkage and selection operator indicated that disruptive behaviors were associated with prenatal smoking, no seafood-consumption during pregnancy, breech presentation at delivery, neonatal feeding problems, low social-economic situation, suboptimal preschool family environment, maternal depression, maternal antisocial behavior, male sex, and difficult child temperament. Compared to controls, male sex, maternal depression, and suboptimal preschool family environment were related to autistic traits without disruptive behaviors. Thus, there may be a difference in early-life factors related to autism spectrum disorder with and without disruptive behaviors.

Validity Aspects of the Strengths and Difficulties Questionnaire (SDQ) Adolescent Self-Report and Parent-Report Versions Among Dutch Adolescents.

In this study, validity aspects of the Strengths and Difficulties Questionnaire (SDQ) self-report and parent-report versions were assessed among Dutch adolescents aged 12 to 17 years (community sample: n = 962, clinical sample: n = 4,053). The findings mostly support the continued use of both SDQ versions in screening for psychosocial problems as (a) exploratory structural equation analyses partially supported the grouping of items into five scales; (b) investigation of associations between scales of the SDQ and the Child Behavior Checklist, Youth Self-Report, and Intelligence Development Scales-2 provided evidence for the SDQ versions' convergent and divergent validity; and (c) receiver operating characteristics curves yielded evidence for both SDQ versions' criterion validity by showing that these questionnaires can be used to screen for psychosocial problems, except for the adolescent-reported version for males. Regardless of the adolescent's gender, the receiver operating characteristics curves showed both SDQ versions to be useful for screening for three specific types of problems: anxiety/mood disorder, conduct/oppositional deviant disorder, and attention-deficit/hyperactivity disorder. Additionally, parent-rated SDQ scores were found to be useful for screening for autism spectrum disorder.

Application of Latent Class Analysis to Identify Subgroups of Children with Autism Spectrum Disorders who Benefit from Social Skills Training.

With Latent Class Analysis applied on data of 98 children with autism spectrum disorder (ASD) (9-12 years; 17 girls) participating in social skills training (SST) in a randomized controlled trial (Dekker et al. 2019), four subgroups were detected, based on social-communicative skills before, and response patterns to training. Two subgroups improved after SST. Characterizing the subgroups based on participant and intervention characteristics showed that improvement was related to lower parent-reported perceived difficulty of social-communicative skills at start, higher verbal ability, younger age and milder symptoms of ASD and anxiety. The lowest performing non-improving subgroup participated more often in SST without parent/teacher involvement, compared to all other subgroups. Response to SST in ASD seems to vary depending on participant characteristics.

The combined self- and parent-rated SDQ score profile predicts care use and psychiatric diagnoses.

The Strengths and Difficulties Questionnaire (SDQ) is widely used, based on evidence of its value for screening. This evidence primarily regards the single informant total difficulties scale and separate difficulties subscales. We assessed to what degree adolescents' SDQ profiles that combined all self- and parent-rated subscales were associated with use of care and psychiatric diagnoses, and examined the added value thereof over using only a single informant and the total scale. Cluster analysis was used to identify common SDQ profiles based on self- and parent-reports among adolescents aged 12-17 in mental healthcare (n = 4282), social care (n = 124), and the general population (n = 1293). We investigated associations of the profiles with 'care use' and 'DSM-IV diagnoses', depending on gender. We identified six common SDQ profiles: five profiles with varying types and severities of reported difficulties, pertaining to 95% of adolescents in care, and one without difficulties, pertaining to 55% of adolescents not in care. The types of reported difficulties in the profiles matched DSM-IV diagnoses for 88% of the diagnosed adolescents. The SDQ profiles were found to be more useful for predicting care use and diagnoses than SDQ scores reported by the adolescent as single informant and the total difficulties scale. The latter indicated the presence of problems among 42-63% of the adolescents in care, missing a substantial number of adolescents with reported emotional difficulties and borderline problem severity. These findings advocate the use of combined self- and parent-rated SDQ score profiles for screening.

Psychometric Properties of the Dutch Strengths and Difficulties Questionnaire (SDQ) in Adolescent Community and Clinical Populations.

This study assessed the factor structures of the Strengths and Difficulties Questionnaire (SDQ) adolescent and parent versions and their measurement invariance across settings in clinical (n = 4,053) and community (n = 962) samples of Dutch adolescents aged 12 to 17 years. Per SDQ version, confirmatory factor analyses were performed to assess its factor structure in clinical and community settings and to test for measurement invariance across these settings. The results suggest measurement invariance of the presumed five-factor structure for the parent version and a six-factor structure for the adolescent version. Furthermore, evaluation of the SDQ scale sum scores as used in practice, indicated that working with sum scores yields a fairly reasonable approximation of working with the favorable but less easily computed factor scores. These findings suggest that adolescent- and parent-reported SDQ scores can be interpreted using community-based norm scores, regardless of whether the adolescent has been referred for mental health problems.

Network Analysis of Behaviors in the Depression and Autism Realms: Inter-Relationships and Clinical Implications.

Depression-, anxiety-, OCD- and autism-related behaviors were assessed in 118 high-functioning individuals with autism spectrum disorders (ASD) and in 2016 controls. The ASD group had a higher rate of clinical depression and markedly higher "insomnia" and "restlessness" scores. Network analysis and hierarchical cluster analysis in the ASD group revealed that depression and anxiety items clustered together, but separately from autism-related items. Compared to controls, "insomnia" and "restlessness" items in the ASD network of depression items were much more central (higher closeness, and betweenness centrality). Combined networks of depression-, anxiety-, and OCD-related items revealed that the control group depression item module was not preserved in ASD. The results indicate that depression is atypical in autism and suggest specific intervention targets.

Factors related to parental pre-treatment motivation in outpatient child and adolescent mental health care.

The aim of this study was to investigate the relation between a variety of child, parent, family and environmental factors and pre-treatment motivation of parents of children and adolescents newly referred to a mental health care clinic in The Netherlands. Data were collected of 521 parents most involved in the upbringing of the child (443 mothers and 78 fathers; Dutch origin 97.1%) of 207 girls and 314 boys (age M = 10.2, range 1-18 years). Treatment motivation was measured by the Parent Motivation Inventory. Least absolute shrinkage and selection operator (LASSO) regression was used to investigate the prediction strength of 33 factors in 5 domains: (1) source of referral and prior use of healthcare services, (2) child characteristics, (3) characteristics of the primary parent, (4) parenting characteristics of the primary parent, and (5) family characteristics. Twenty-one factors were statistically relevant, explaining 21.3% of the deviance in pre-treatment motivation. Child characteristics, mainly type and severity of problems, contributed most to the model. Notably, internalising problems contributed more than externalising problems. Furthermore, we found relations between parental pre-treatment motivation and parents' perceived self-efficacy, parents' perceived parenting competence, financial problems and source of referral. Our findings provide insight into the multifacetedness of parental motivation prior to starting treatment and inform health professionals of specific contextual factors of interest in parents' readiness to change their behaviour and participate in treatment.

ADHD symptoms across adolescence: the role of the family and school climate and the DRD4 and 5-HTTLPR genotype.

We examined bidirectional relations between attention-deficit/hyperactivity disorder (ADHD) symptoms and family and school climate, and the possible role of DRD4 and/or 5-HTTLPR genotypes herein. Three-wave longitudinal data of 1860 adolescents (mean ages 11, 13.5, and 16 years) from the general population and clinic-referred cohort of TRacking Adolescents' Individual Lives Survey were used. Using a multigroup Random Intercept Cross-Lagged Panel Model, we tested between-person (i.e., stable trait levels) and within-person (i.e., causal processes) associations across ADHD symptoms, family and school climate, and the extent to which these depended on genotype. Findings indicated no influence of genotype. Results did show significant between-person differences (ADHD symptoms with family climate r = .38; and school climate r = .23, p values < .001), indicating that higher stable levels of ADHD symptoms were associated with a less favorable family and school climate. Regarding within-person causal processes, ADHD symptoms predicted a less favorable family climate in early adolescence (ß = .16, p < .01), while ADHD symptoms predicted a more favorable family climate in the later phase of adolescence (ß = - .11, p < .01), a finding which we explain by normative developmental changes during adolescence. Overall, this study showed that negative associations between ADHD symptoms and both family and school climate are largely explained by stable between-person differences. We recommend applying the Random Intercept Cross-Lagged Path Model to developmental data to tease stable associations and change processes apart.

Network Analysis of Anxiety in the Autism Realm.

The anxiety and autism realms are each complicated and heterogeneous, and relationships between the two areas are especially complex. Network analysis offers a promising approach to the phenotypic complexities of typical and atypical human behavior. The Revised Children's Anxiety and Depression Scale (RCADS) was used to assess anxiety in 126 high-functioning 9-13 year-olds with ASDs. Network graphs of Autism Diagnostic Observation Schedule items and RCADS anxiety total score, social, generalized, panic and separation anxiety subscores consistently found the anxiety node (score) to be highly peripheral. Also, the networks of RCADS anxiety items themselves were similar for the ASDs group and a general population comparison group (n = 2017). The results suggest anxiety is not a central part of autism and that anxiety is dynamically similar (aspects of anxiety relate to one another in a similar manner) in high-functioning autism and the general population.

Social skills group training in children with autism spectrum disorder: a randomized controlled trial.

In 122 high-functioning children with autism spectrum disorder (ASD; 9-13 years; 19 girls), we investigated the effectiveness of a 15-session social skills group training (SST) with and without parent and teacher involvement (PTI) in a randomized controlled trial with three conditions: SST (n = 47), SST-PTI (n = 51), and care-as-usual (CAU, n = 24). Hierarchical linear modeling was used for immediate and 6-month follow-up analyses. Measures were administered before randomization (blind), post-treatment and at follow-up (not blind). Trial registration: Dutch Trial Register; http://www.trialregister.nl ; NTR2405. At post-treatment, children in both SSTs had improved significantly more than CAU on the primary outcome, Vineland Socialization (SST: Cohen's d = 0.39; 95% CI - 2.23 to 3.11 and SST-PTI: d = 0.43; 95% CI - 2.19 to 3.15) and on the secondary outcome parent-SSRS "Cooperation" (SST: d = 0.43; 95% CI - 0.23 to 1.15 and SST-PTI: d = 0.45; 95% CI - 0.21 to 1.17), with no difference between post-treatment and follow-up. Additionally, children in SST-PTI improved significantly more on the teacher-SSRS than in CAU ["Cooperation" d =0.42 (95% CI - 0.33 to 1.13); "Assertion" d =0.34 (95% CI - 0.39 to 1.11); "Self-Control" d =0.61 (95% CI - 0.08 to 1.34)] and in SST ["Cooperation" d =0.34 (95% CI - 0.37 to 1.05); "Self-Control" d =0.59 (95% CI - 0.13 to 1.32)]. The current study corroborates earlier findings in smaller samples and wider age ranges, with small but statistically significant effects of SST for high-functioning pre-adolescent children with ASD. Parental and teacher involvement intensified treatment, yet did not yield an additional effect relative to SST for children only, as reported by parents. 6 months after training, no further improvement or decline was found.