Prevalence and Correlates of the Concurrence of Autism Spectrum Disorder and Obsessive Compulsive Disorder in Children and Adolescents: A Systematic Review and Meta-Analysis.

BACKGROUND: Autism spectrum disorder (ASD) and obsessive compulsive disorder (OCD) are two common and impairing neurodevelopmental conditions with partial symptomatic overlap. The aim of this study is to systematically and meta-analytically examine the following: (i) the prevalence of an OCD diagnosis among young people with ASD, (ii) the prevalence of an ASD diagnosis among young people with OCD, and (iii) the clinical and therapeutic implications of such comorbidity. METHOD: A multistep literature search was performed from database inception until 17 November 2023. This PRISMA/MOOSE-compliant systematic review, registered in PROSPERO (CRD42023480543), identified studies reporting on the prevalence, sociodemographic, psychopathologic, prognostic, and therapeutic correlates of OCD and ASD concurrence in children and adolescents. A quantitative meta-analysis with random effects was conducted to analyse the pooled prevalence of OCD among samples with a mean age of < 18 years old with ASD and the prevalence of ASD among individuals under 18 with OCD. Sensitivity analyses were performed to investigate the effect of diagnostic criteria and different continents. Meta-regression analyses were conducted to examine the effect of gender, age, IQ, and OCD severity scores. A narrative review of the clinical and therapeutical implications of the comorbidity was provided. RESULTS: 42 studies were selected for the systematic review (SR), and 31 of them were also included in one of the meta-analyses. The pooled prevalence of OCD among ASD youth samples (n = 8916, mean age = 10.6 ± 1.6; 16.4% female) was 11.6% (95% confidence intervals [CI] = 6.9%; 18.8%), and the pooled prevalence of ASD among OCD children and adolescent samples (n = 6209, mean age = 14.1 ± 1.4; 45.7% female) was 9.5% (95% CI = 6.0%; 14.7%). Meta-regressions found a statistically higher prevalence of ASD among samples with a lower prevalence of females (ß = -4.7; 95%CI = -8.6; -0.8). Children with both OCD and ASD present higher rates of functional impairment, psychopathology, and other comorbidities, compared to youth with either of the disorders alone. CONCLUSIONS: OCD and ASD are highly concurrent conditions in youth, with symptomatic, prognostic, severity, and therapeutic implications. Future research should focus on conducting longitudinal cohort studies prospectively to determine development trajectories, along with randomized controlled trials to assess the efficacy of specific therapeutic interventions.

Investigating the Effects of Transdiagnostic Processes on Anxiety and Depression Symptoms in Autistic Young People: the Mediating Role of Emotion Dysregulation.

Internalising symptoms are elevated in autism compared to the general population. Few studies have investigated emotional dysregulation (ED) as a potential mediator between specific transdiagnostic processes and anxiety and depression symptoms in autistic youth. In a sample of 94 autistic young people aged 5-18 years referred to a specialist clinic for an autism evaluation, we tested the effects of ED as a mediator between cognitive inflexibility (CI), intolerance of uncertainty (IU) and alexithymia with anxiety and depression symptoms, using structural equation modelling. Effect sizes were compared to a non-autistic comparison group (n = 84). CI and alexithymia did not significantly predict depression symptoms in autistic young people, directly nor via ED. Relationships between CI/alexithymia and depression were fully mediated by ED in the non-autistic sample. There was a direct effect of CI on anxiety in the non-autistic group but not in those with a diagnosis. IU predicted depression symptoms in the autism group; and ED mediated this relationship only in those who did not receive a diagnosis. IU directly predicted anxiety in both groups and this relationship did not occur via ED. The finding of a direct pathway from IU to anxiety and depression in autistic youth is consistent with the literature. The finding that CI did not predict anxiety or depression in those with autism is novel, as was the finding that ED mediated relationships between alexithymia and anxiety/depression symptoms in both samples. The findings may have important implications for the delivery of psychological interventions for autistic youth.

Exploring the association between social camouflaging and self- versus caregiver-report discrepancies in anxiety and depressive symptoms in autistic and non-autistic socially anxious adolescents.

LAY ABSTRACT: Social camouflaging or masking refers to strategies autistic individuals adopt to hide their autism persona when trying to fit in. It is unclear whether camouflaging is only applicable to social differences unique to autism, or more generally to any types of social difference, such as experiences of mental health difficulties. We asked 43 autistic and 39 non-autistic adolescents (aged 14-19 years, all of whom showed similarly high levels of social anxiety) and their primary caregivers to complete questionnaires about their mental health (anxiety and depression) and autistic traits, and adolescents self-reported camouflaging behaviours. We wondered if camouflaging may be used to hide mental health difficulties reported by young people and affect caregiver report on symptom severity. We found that adolescents who self-reported greater levels of autistic traits, anxiety and depression symptoms compared with their caregivers reported greater camouflaging. Adolescents who agreed on having high levels of autistic traits and anxiety symptoms with their caregivers reported greater camouflaging behaviours. We discuss how having high levels of autistic traits and anxiety may increase adolescents' camouflaging behaviours to hide social differences, which may contribute towards poor mental health outcomes. We think it is important to talk with adolescents about how camouflaging social and mental health difference can have negative impacts for mental health as well as possible positive social gains.

Loneliness in Young People with ADHD: A Systematic Review and Meta-Analysis.

Many studies focus on problematic peer functioning in attention deficit/hyperactivity disorder (ADHD) but loneliness has been studied less. This paper examined (1) The loneliness level differences between young people (below 25 years old) with ADHD and those without ADHD, and (2) The association between loneliness and mental health difficulties in young people with ADHD. Six electronic databases were searched and 20 studies were included. A random effects meta-analysis was carried out in RStudio using the metafor package for the first question, while a narrative synthesis summarized the findings for the second question. The meta-analysis (n = 15) found that young people with ADHD reported significantly higher loneliness than those without ADHD, with a small-to-medium weighted pool effect (Hedges' g = 0.41) and high heterogeneity (I2 = 75.1%). For the second question (n = 8), associations between loneliness and mental health difficulties in ADHD was found (r = 0.05-0.68). Targeted research and interventions on loneliness in young people with ADHD is needed.

Co-designing behavioural activation for depression for autistic adolescents: A case series.

Autistic youth are at high risk of depression, but there are few psychological interventions that have been specifically designed for use with this population. Behavioural activation (BA) is a particularly promising approach for autistic adolescents, having an established evidence-base for the treatment of depression in non-autistic people, and with a strong focus on behavioural, rather than cognitive change, which is a challenge for some autistic people. In this study, we worked with autistic adolescents and clinicians to co-design a BA-informed intervention to be delivered in an online format. We then conducted a pilot case-series with seven autistic adolescents with depression. Our focus was on establishing the acceptability and feasibility of the intervention but clinical outcomes on both self- and parent-reported symptoms of depression and anxiety are also presented. Our results indicate the intervention to be acceptable and feasible for autistic adolescents, with six out of seven participants being retained to the end of the intervention. Qualitative feedback indicated that all participants found the intervention a positive experience and would recommend it to others. Similarly, all participants found the online format acceptable, with 64% preferring this format to face-to-face therapy. Qualitative feedback and suggestions for refinement will also be discussed.

Autistic youth are at high risk of depression, but there are few psychological interventions that have been specifically designed for use with this population. Behavioural activation (BA) is a particularly promising approach for autistic adolescents, which has been used previously with non-autistic people. BA-focusses on improving mood through increasing engagement in positive activities and is well suited to being adapted to meet the needs of autistic youth. In this study, we worked with autistic adolescents and clinicians to co-design a BA-informed intervention to be delivered in an online format. We then conducted a pilot case-series with seven autistic adolescents with depression. Our focus was on establishing the acceptability (can participants complete the intervention) and feasibility (can this be done again on a larger scale) of the intervention. Our results indicated that the intervention was acceptable and feasible for autistic adolescents, with six out of seven participants being retained to the end of the intervention. Feedback from young people and their parents indicated that all participants both found the intervention a positive experience and would recommend it to others. Similarly, all participants found the online format acceptable, with 64% preferring this format to face-to-face therapy. Qualitative feedback and suggestions for refinement will also be discussed.

Understanding the relationship between social camouflaging in autism and safety behaviours in social anxiety in autistic and non-autistic adolescents.

BACKGROUND: Social camouflaging (hereafter camouflaging) in autism includes factors such as masking and compensating for one's neurodevelopmental differences, and to assimilate or 'fit in' with non-autistic peers. Efforts to hide one's authentic self and autism traits (masking) resemble impression management (IM) in safety behaviours identified in Clark and Wells' (1995) cognitive model of social anxiety (SA). This study explores the relationship between camouflaging in autism and safety behaviours in SA among autistic and non-autistic adolescents. METHODS: One hundred fifteen adolescents (14-19 years) with (n = 61; 36 female) and without (n = 54; 37 female) a clinical diagnosis of autism matched on age and SA symptom severity were recruited from clinics, schools and online. Adolescents completed online measures including autism traits, SA symptoms, camouflaging behaviours, SA-related safety behaviours and SA-related negative cognitions. Partial and bivariate Pearson's correlations and structural equation modelling were used to understand the relationship between camouflaging, safety behaviours, autism traits and SA in both groups. Exploratory factor analysis assessed item-level factor cross-loadings between camouflaging and safety behaviours. RESULTS: Across both groups, masking and IM were significantly associated with SA symptom severity, not autism traits, via SA-related social cognitions. Exploratory factor analysis indicated construct overlap across masking, assimilation, IM and avoidance behaviours and identified factors analogous to self-focused attention, social avoidance and mental rehearsal identified in the Clark and Wells' (1995) model of SA. CONCLUSIONS: This is the first study using group-matched design to identify that masking (factor in social camouflaging) and IM both relate to SA in autistic and non-autistic adolescents. Assessment and formulation of construct overlap between masking and IM may inform psychoeducation and adaptation of SA treatment for autistic adolescents.

Screening for Attention Deficit Hyperactivity Disorder in Young Autistic Adults: The Diagnostic Accuracy of Three Commonly Used Questionnaires.

OBJECTIVE: Attention Deficit Hyperactivity Disorder (ADHD) is a common co-occurring condition in autistic individuals. ADHD is sometimes first recognised in young adulthood because ADHD symptoms may be misattributed to autism due to superficial overlap in presentation and diagnostic overshadowing. It should be investigated whether ADHD questionnaires are accurate in screening symptoms in young adults with autism. The current study examined this. METHODS: Participants were autistic young adults (N = 119) who took part in the Special Needs and Autism Project (SNAP), a population-based cohort. ADHD research diagnoses were obtained through the parent-informed Young Adult Psychiatric Assessment. Parents and young adults (self-report sample N = 71) completed ADHD questionnaires (Aberrant Behavior Checklist hyperactivity/non-compliance subscale, Conners Adult ADHD Rating Scales ADHD Index, and Strengths and Difficulties Questionnaire ADHD subscale). Receiver operating characteristic analyses were conducted to explore if the questionnaires discriminated ADHD cases from non-cases. To assess whether results varied by intellectual functioning, subgroup analyses were completed for those with an IQ ≥ 70 vs. <70. RESULTS: Weighted ADHD rates were high. Overall although the measures were performing at or close to adequate levels (area under the curve was 0.66 to 0.79 for parent-report and 0.70 to 0.65 for self-report), no single measure met adequate thresholds for sensitivity and specificity simultaneously. Tool performance was not different for those with an IQ ≥ 70 vs. <70. CONCLUSION: No single measure reported adequate performance for distinguishing ADHD from non-ADHD cases in this sample of young autistic adults. Use of current thresholds may lead to under-diagnosis.

Measuring flexibility in autistic adults: Exploring the factor structure of the flexibility scale self report.

Cognitive flexibility differences are common for autistic individuals and have an impact on a range of clinical outcomes. However, there is currently a lack of well validated measurement tools to assess flexibility in adulthood. The Flexibility Scale was originally designed as a parent-report measure of real-world flexibility challenges in youth. The original Flexibility Scale provides a total score and five subscales: Routines and Rituals, Transitions and Change, Special Interests, Social Flexibility, and Generativity. In this study, we evaluate the factorial validity of the Flexibility Scale as a self-report (Flexibility Scale Self Report) measure of cognitive flexibility, adapted from the original Flexibility Scale, for use by autistic adults. This study includes both a primary sample (n = 813; mean age = 40.3; 59% female) and an independently recruited replication sample (n = 120; mean age = 32.8; 74% female) of individuals who completed the Flexibility Scale Self Report. The analysis consisted of an initial confirmatory factor analysis (CFA) of the original Flexibility Scale structure, followed by exploratory factor analysis (EFA) and factor optimization within a structural equation modeling framework to identify the optimal structure for the questionnaire in adults. The identified structure was then replicated through CFA in the replication sample. Our results indicate an alternative optimal scale structure from the original Flexibility Scale, which includes fewer items, and only three (Routines/Rituals, Transitions and Change, Special Interests) of the five subscales contributing to the flexibility total score. Comparisons revealed no structural differences within the scale based on sex assigned at birth. Here the Generativity and Social Flexibility scales are treated as independent but related scales. The implications for measurement of cognitive flexibility in clinical and research settings, as well as theoretical underpinnings are discussed.

Factors associated with mental health symptoms among UK autistic children and young people and their parents during the COVID-19 pandemic.

LAY ABSTRACT: What is already known about the topic: The COVID-19 pandemic and the associated restrictions impacted all of society. There is emerging evidence showing a range of impacts on autistic children and young people and their families. Further research that looks at how individuals coped during the pandemic while considering how they were doing before the pandemic is needed.What this paper adds: This article explores whether how well autistic youth were doing before the pandemic influenced how they coped during the pandemic. It also looked at how well their parents were doing during the pandemic and whether any pre-pandemic factors influenced how they coped. Samples of both primary-school-aged autistic children and autistic teenagers and their parents were surveyed to answer these questions. More engagement and enjoyment in education provision during the pandemic and getting outside more were linked with better child and parental mental health during the pandemic. More attention deficit hyperactivity disorder before the pandemic was linked with more attention deficit hyperactivity disorder and behavioural problems during the pandemic in primary-school-aged autistic children, and more emotional problems during the pandemic in autistic teenagers. Parents with more mental health problems during the pandemic had more mental health problems before the pandemic.Implications for practice, research or policy: Encouraging engagement and enjoyment in education and promoting physical exercise are key intervention targets. Ensuring access to attention deficit hyperactivity disorder medication and support is important, especially if this is managed jointly across school and home.

Autistic young people's experiences of remote psychological interventions during COVID-19.

LAY ABSTRACT: Recently, therapy has been delivered at a distance (i.e. remotely) to help control the spread of coronavirus. Clinicians have voiced concerns that remote delivery is unsuitable for certain individuals, including those who are autistic, but they have also highlighted potential benefits for autistic individuals. Benefits include some individuals feeling more comfortable receiving therapy at home. This is the first study to interview autistic individuals about their experience of remote therapy. Participants were six young people aged 15-18 years and eight clinicians. Participants described their experience of remote delivery, including challenges, benefits, and suggestions. Most of these supported previous research findings, but some were new or provided further insight into those already identified. A newly identified challenge was knowing online social etiquette. All participants found aspects of the experience challenging, but all identified benefits and most voiced that remote sessions should be offered to young people. Participants further identified individual characteristics that may make someone less suited to remote delivery (e.g. shyness). They also identified ways of making the experience of remote delivery easier (e.g. sitting with a pet). Young people's and clinicians' views were similar overall, with only subtle differences. For example, young people uniquely voiced that remote delivery was similar to in-person, that benefits were hard to identify, and provided distinct reasons for the social interaction feeling less intense remotely. Findings may be used to improve remote delivery, for guiding future research, and as a case for continuing to offer it to those who may most benefit.

Autistic and non-autistic young people's and caregivers' perspectives on COVID-19-related schooling changes and their impact on emotional well-being: An opportunity for change?

LAY ABSTRACT: Autistic young people experience poorer mental health and well-being compared to their non-autistic peers. Navigating the complex social, academic, procedural and sensory aspects of school may be particularly challenging for autistic young people and contribute to poorer mental well-being. The COVID-19 pandemic caused unprecedented school changes and provided a unique opportunity to gather caregiver's and young people's perspectives on the impact of school and pandemic-related school changes on the well-being of both autistic and non-autistic young people. We asked for the views of caregivers and young people aged 11-18 years gathered across three timepoints between May and December 2020. Their responses revealed both benefits and challenges associated with school changes. Insights into possible lessons from the pandemic and recommendations for more flexible, individualised and strengths-based educational practices are discussed.

Reward Sensitivity Predicts the Response to Cognitive Behavioral Therapy for Children with Autism and Anxiety.

OBJECTIVE: Cognitive-behavioral therapy (CBT) is an effective treatment for anxiety in youth with autism spectrum disorder (ASD). However, research has yet to examine what cognitive characteristics may influence treatment response. The current study investigated decision-making ability and social cognition as potential (a) predictors of differential treatment response to two versions of CBT and (b) moderators of the effect of treatment condition. METHOD: The study included 148 children (mean age = 9.8 years) with interfering anxiety and a diagnosis of ASD who were enrolled in a randomized clinical trial comparing two versions of CBT for anxiety (standard and adapted for ASD). Participants completed pretreatment measures of decision-making ability (adapted Iowa Gambling Task) and social cognition (Strange Stories) and analyses tested whether task performance predicted treatment response across and between (moderation) treatment conditions. RESULTS: Our findings indicate that decision-making ability moderated treatment outcomes in youth with ASD and anxiety, with a better decision-making performance being associated with higher post-treatment anxiety scores for those who received standard, not adapted, CBT. CONCLUSIONS: Children with ASD and anxiety who are more sensitive to reward contingencies and reinforcement may benefit more from adapted CBT approaches that work more explicitly with reward.

Psychiatric conditions in autistic adolescents: longitudinal stability from childhood and associated risk factors.

Autistic people experience high rates of co-occurring psychiatric diagnoses. Current prevalence estimates vary considerably due to an over-reliance on clinical cohorts and the longitudinal stability of diagnoses from childhood into adolescence is poorly understood. This study aims to provide prevalence rates of co-occurring DSM-5 psychiatric diagnosis for autistic adolescence and investigate, for the first time, the stability of diagnoses from childhood. Using a longitudinal stratified sample of autistic youth (N = 77; 13-17 years; 60% male), selected from a larger community-derived sample of those with pre-existing autism diagnoses (N = 277) weighted prevalence estimates of emotional (anxiety, depression), behavioural (oppositional and conduct disorders) and ADHD diagnoses were calculated based on semi-structured psychiatric interview. Prediction of adolescent psychiatric diagnosis based on childhood diagnostic status, sex, childhood IQ (both assessed at age 4-10 years) was tested. Emotional and behavioural disorders in adolescence were particularly prevalent, and significantly predicted by childhood disorder status. Attention-deficit/hyperactivity-disorder (ADHD) was prevalent but not predicted by childhood ADHD diagnosis. Neither sex nor childhood IQ predicted diagnostic outcomes. Autistic youth have high levels of co-occurring psychiatric conditions, which are broadly persistent across childhood and adolescence. Emotional disorders are particularly prevalent and remain persistent from childhood to adolescence. Greater diagnostic variability was found for ADHD with more adolescents moving across diagnostic thresholds.

Examining the relationship between cognitive inflexibility and internalizing and externalizing symptoms in autistic children and adolescents: A systematic review and meta-analysis.

Compared to neurotypical peers, autistic adolescents show greater cognitive inflexibility (CI) which manifests at the behavioral and cognitive level and potentially increases vulnerability for the development of internalizing (INT) and externalizing (EXT) symptoms. This systematic review and meta-analysis explored the association between CI and INT/EXT in autistic adolescents. PubMed, EMBASE, MEDLINE, PsycINFO and Web of Science databases were searched to identify relevant studies until April 2022 (PROSPERO protocol: CRD42021277294). Systematic review included 21 studies (n = 1608) of CI and INT, and 15 studies (n = 1115) of CI and EXT. A pooled effect size using Pearson's correlation between CI and INT/EXT was calculated and the moderating effects of age, sex, IQ and study quality were investigated using meta-regressions. Sensitivity analyses were completed to investigate the impact of measure variance for CI and co-occurring ADHD on the overall effects. Greater CI is associated with increased INT (nine studies; n = 833; r = 0.39 (moderate effect), 95% confidence interval [0.32, 0.46]) and EXT (six studies; n = 295; r = 0.48 (large effect), 95% confidence interval [0.38, 0.58]). Results withheld when only using parental reports of CI and excluding autistic adolescents with co-occurring ADHD. Increased CI may be a transdiagnostic vulnerability factor that can increase autistic adolescents' rigid or perseverative patterns of unhelpful cognition and behaviors and reduce their ability to access psychological interventions. Addressing CI may improve autistic children and adolescents' engagement with psychological therapy for co-occurring mental health difficulties.

Pathways to adaptive functioning in autism from early childhood to adolescence.

Adaptive functioning is lower in many autistic individuals to a greater extent than would be expected based on IQ. However, the clinical features associated with these difficulties are less well understood. This study examines longitudinal and contemporaneous associations of adaptive functioning in autistic youth across a wide ability range. Parent-reported autism symptoms, co-occurring emotional, behavioral and attention deficit hyperactivity disorder (ADHD) symptoms, and IQ were assessed in early childhood (M age 7 years; T1) and 6 years later in adolescence (M age 13 years; T2) in 179 autistic youth. Adaptive functioning was assessed at T2. Structural equation modeling estimated pathways to adaptive functioning from autism, and psychiatric symptoms at T1 and T2, testing whether associations were driven by continuity of behaviors from T1 to T2 or their contemporaneous effect at T2, or both, controlling for T1 IQ. Lower adaptive functioning at T2 was associated with higher T1 and T2 ADHD symptoms (ß = -0.14, and ß = -0.21) but not behavioral nor emotional symptoms at either timepoint. Lower adaptive functioning at T2 was also associated with lower T1 IQ (ß = 0.43) and higher social communication symptoms (ß = -0.37) at T2 but not T1, but the relationship with ADHD symptoms remained. Paths were not moderated by sex or IQ. Increased symptoms of ADHD, both in early childhood and contemporaneously, were associated with reduced adaptive functioning in adolescence. Co-occurring ADHD may be a modifiable risk factor for adaptive function impairments and should be routinely assessed and when present evidence-based treatments initiated which may benefit adaptive functioning outcomes. LAY SUMMARY: Adaptive functioning is lower in many autistic individuals to a greater extent than would be expected based on IQ. However, the clinical features associated with these difficulties are less well understood. In a community sample higher attention deficit/hyperactivity disorder (ADHD) symptoms, but not emotional or behavioral symptoms, in both early childhood and contemporaneously were associated with lower adaptive functioning in autistic adolescents. Co-occurring ADHD may be a modifiable risk factor for adaptive function difficulties in autism.

Understanding the heterogeneity of anxiety in autistic youth: A person-centered approach.

The present study aimed to examine anxiety profiles among children and adolescents on the autism spectrum. It further aimed to characterize the association between the identified anxiety profiles and key clinical and developmental variables. The Spence Children's Anxiety Scale-Parent Version (SCAS-P) data from a large international pooled sample of 870 caregivers of autistic children and adolescents (Mage  = 11.6 years, SDage  = 2.77; 107 females) was used. Latent profile analysis identified a three-anxiety profile solution exhibiting high entropy (0.80) and high latent profile probabilities, with good classification accuracy. Identified profiles fell along the severity spectrum and were named as the mild (n = 498), moderate (n = 272) and severe (n = 100) anxiety profiles. There were no statistically significant differences between the three anxiety profiles in terms of sex distribution. Participants in the mild profile were significantly younger than those in the severe profile, had significantly fewer social communication difficulties than youth in the moderate anxiety profile group and had significantly fewer restricted and repetitive behaviors and lower cognitive functioning scores compared to participants in moderate and severe anxiety profiles. This is the first study to move beyond identifying associations and group-level differences to exploring and identifying characteristics of anxiety-based subgroups at an individual level that differ on key clinical and developmental variables. The subgroups identified in this study are a preliminary, yet important, first step towards informing future assessment and individualized interventions aiming to support young people on the autism spectrum to reduce and manage anxiety. LAY SUMMARY: This study tried to understand if there are subgroups of autistic young people who may have similar anxiety profiles. We found that we could meaningfully group young people into three groups based on how severe the anxiety symptoms their caregivers reported were: a group with low levels of anxiety, those with moderate anxiety, and those with more severe anxiety. We also found that the young people in the mild group were younger, had fewer autism traits and lower levels of intellectual functioning than young people in the other two groups.

Homotypic and Heterotypic Continuity in Psychiatric Symptoms From Childhood to Adolescence in Autistic Youth.

OBJECTIVE: Despite the high prevalence of mental health difficulties in autistic youth, little is known about the patterns of developmental continuity and change in psychiatric symptoms between childhood and adolescence. Using a stratified community-derived sample of autistic youth (n = 101; 57 males, 44 females), within (homotypic) and between (heterotypic) domain associations between psychiatric symptoms in childhood to adolescence were tested as well as whether any continuities were moderated by sex, IQ, autism symptom severity, social economic status, or parental mental health. METHOD: Autistic youth were assessed for emotional, behavioral, and attention-deficit/hyperactivity disorder (ADHD) symptoms in childhood (age 4-9 years) and adolescence (age 13-17 years) using parental diagnostic interview. Unadjusted and adjusted (accounting for the co-occurrence of psychiatric symptoms in childhood) weighted models tested homotypic and heterotypic associations between symptoms in childhood and adolescence. Moderation of significant pathways was tested using multigroup analysis. RESULTS: Adolescent psychiatric symptoms all were predicted by symptoms of their childhood counterparts (emotional symptoms incidence rate ratio [IRR] = 1.06, 95% CI = 1.02-1.10, p < .01; behavioral symptoms IRR = 1.38, 95% CI = 1.21-1.59, p < .01; ADHD symptoms IRR = 1.11, 95% CI = 1.05-1.19, p < .01); the only heterotypic pathway that remained significant in adjusted analyses was from childhood emotional symptoms to adolescent ADHD symptoms (IRR = 1.04, 95% CI = 1.01-1.07, p = .02). Sex moderated the homotypic ADHD symptoms pathway; associations were significant in female participants only. Child IQ moderated the homotypic behavioral symptoms pathway; the association was stronger in youth with IQ <70. CONCLUSION: Results from this community-based sample suggest that psychiatric symptoms in autistic youth exhibit substantial developmental continuity and thus highlight the importance of early screening and intervention. Sex and IQ may be important factors to consider when predicting likelihood of stability of ADHD and behavioral symptoms.

Examining clinicians' concerns delivering telemental health interventions directly to autistic individuals during COVID-19.

Background: The COVID-19 pandemic necessitated the adoption of telemental health (TMH). Pre-pandemic, clinicians had voiced many TMH concerns, but these had not been investigated with respect to autism spectrum disorder (ASD) even with it being known that there are distinct ASD-associated challenges for in-person mental health interventions. Method: A convenience sample of (n = 55) clinicians completed an online survey regarding their perspectives of adopting TMH interventions in ASD, with closed- and open-answered questions. Quantitative and qualitative data were analysed descriptively/inferentially and via Content Analysis, respectively. Results: Multiple clinicians endorsed each TMH challenges/barrier previously identified as concerns in the non-ASD literature. However, overall levels of concern over challenges/barriers were low, and challenges were more likely to be predicted than experienced and considered to be case/presentation specific. Challenges that were considered ASD-specific included the exacerbation of those associated with in-person delivery in ASD, alongside difficulties with trust and appropriate remote social behaviour. On average, clinicians indicated a preference for 50% TMH interventions post-pandemic. Clinicians' perceived technological competence and extent of professional experience with ASD were not significantly associated with levels of concern, nor number of experienced challenges, with TMH interventions in ASD. Conclusion: In support of the existing TMH literature, challenges/barriers were more likely to be predicted than experienced and were considered to be case/presentation-specific, though this may be more variable in ASD owing to the well-established marked heterogeneity in this population. Remote provision of interventions exacerbated in-person ASD-associated challenges, as predicted, but clinician-level factors appeared not to impact TMH perceptions.

Exploring the impact of adolescent cognitive inflexibility on emotional and behavioural problems experienced by autistic adults.

LAY ABSTRACT: Autistic people experience high levels of co-occurring mental health difficulties. To develop more effective treatments, a greater understanding of the thinking processes that may lead to these difficulties is needed. Cognitive inflexibility, defined as a rigid pattern of thoughts and subsequently behaviours, is one possible thinking trait which has previously been associated with both co-occurring mental health difficulties but also other features of autism such as restricted and repetitive behaviours. Restricted and repetitive behaviours include repetitive movements, ritualistic behaviours, and/or highly focused interests. This study investigates the relationship between, cognitive inflexibility, measured using neuropsychological tasks, and emotional and behavioural problems across adolescence and early adulthood. Eighty-one autistic people who were recruited to be representative of the wider autism population were assessed at 16 and 23 years on measures of emotional and behavioural problems, with cognitive inflexibility, restricted and repetitive behaviours and verbal intelligence measured at 16 years. We used statistical modelling to investigate the relationship between cognitive inflexibility and emotional and behavioural symptoms at both timepoints while accounting for the possible relationship with restricted and repetitive behaviours and verbal intelligence quotient. Our results suggest that cognitive inflexibility may be an important factor associated with emotional difficulties across adolescence and early adulthood. This suggests that developing intervention approaches targeting cognitive inflexibility may be an important step in improving the mental health of those with autism.

The association of adverse life events and parental mental health with emotional and behavioral outcomes in young adults with autism spectrum disorder.

People with autism spectrum disorder (ASD) are at increased risk of developing co-occurring mental health difficulties across the lifespan. Exposure to adverse life events and parental mental health difficulties are known risk factors for developing a range of mental health difficulties. This study investigates the association of adverse life events, parental stress and mental health with emotional and behavioral problems in young adults with ASD. One hundred and fifteen young adults with ASD derived from a population-based longitudinal study were assessed at three time-points (12-, 16-, and 23-year) on questionnaire measures of emotional and behavioral problems. Parent-reported exposure to adverse life events and parental stress/mental health were measured at age 23. We used structural equation modeling to investigate the stability of emotional and behavioral problems over time, and the association between adverse life events and parental stress and mental health and emotional and behavioral outcomes at 23-year. Our results indicate that exposure to adverse life events was significantly associated with increased emotional and behavioral problems in young adults with ASD, while controlling for symptoms in childhood and adolescence. Higher reported parental stress and mental health difficulties were associated with a higher frequency of behavioral, but not emotional problems, and did not mediate the impact of adverse life events. These results suggest that child and adolescent emotional and behavioral problems, exposure to life events and parent stress and mental health are independently associated, to differing degrees, with emotional or behavioral outcomes in early adulthood. LAY SUMMARY: People with autism experience high rates of mental health difficulties throughout childhood and into adult life. Adverse life events and parental stress and mental health may contribute to poor mental health in adulthood. We used data at three time points (12-, 16-, and 23-year) to understand how these factors relate to symptoms at 23-year. We found that emotional and behavioral problems in childhood, adverse life events and parent mental health were all associated with increased emotional and behavioral problems in adulthood.