Friendship in Autism Spectrum Disorder Is Related to Diverse Developmental Changes Between Toddlerhood and Adolescence.

PURPOSE: Follow-up studies of children diagnosed with autism spectrum disorder (ASD) in early childhood that focus on friendship formation during adolescence are scarce. The present study focused on exploring characteristics possibly related to the ability to establish friendships during adolescence among children diagnosed with ASD in toddlerhood. METHODS: The cohort included 43 participants who underwent comprehensive assessments during toddlerhood and adolescence. Participants were divided into two groups [Friendship(+)/Friendship(-)] based on (1) adolescent social insight as assessed by professionals and (2) parental and adolescent self-reports regarding having or not having friends. No differences in IQ, ASD symptoms, or adaptive behavior during early childhood were found between the two groups. RESULTS: Different and better changes in social communication, adaptive socialization, and daily living skills were observed for the Friendship(+) group. Adolescents with ASD in the Friendship(+) group exhibited greater social independence. Attention-deficit/hyperactivity disorder incidence, anxiety symptom severity, and placement in mainstream or special education classes did not differ between the two groups. CONCLUSION: This long-term study highlights that for children with ASD, longitudinal growth in social communication and adaptive functioning is possible, highly important for and related to the development of the complex ability to establish friendship.

Sibling Relationships in Families of Autistic and Typical Children: Similarities and Differences in the Perspectives of Siblings and Mothers.

This study investigates mothers' and siblings' perspectives regarding similarities and differences in siblingships with and without autism. Twenty-nine typical children (Mage = 8.78 years, SD = 2.05) whose younger siblings have a diagnosis of autism and their mothers constituted the 'autism group.' Forty-six typical children (Mage = 9.12 years, SD = 2.06) with younger typical siblings and their mothers constituted the 'typical group'. Children and mothers completed the Sibling Relationship Questionnaires and were interviewed. Children's reports illustrated similarities in sibling relationships across groups, with no between-group differences in overall warmth, conflict, rivalry, or relative power in the sibling relationship. Mothers of autistic children reported their children to have less warmth and closeness (F(1,72) = 5.63, p = .02, η2 = .073) and less conflict (F(1,72) = 6.66, p = .012, η2 = .085) with their siblings than mothers of typical children. More disagreement was found between mothers and children in the autism group than in the typical group. Mothers and children reported less intimacy and less quarreling between the siblings in the autism group than in the typical group. The qualitative analysis suggests that siblings focused on the present experience, while mothers also referred to processes in the sibling relationship. Interviewees in the autism group referred to various specificities in the siblingships without explicitly using the term "autism". The findings highlight a typical-like experience for siblings of autistic children. At the same time, mothers' perspectives emphasize differences and challenges in siblingships, reporting a pattern of decreased involvement. It is important to consider both perspectives in research and clinical work with families of autistic children.

Parents' and Teachers' Perspectives of Autism and Co-Morbidity Symptom Severity in Young Children with ASD Over One School Year.

PURPOSE: Only a few studies examined the longitudinal pattern of parent-teacher reports on autism severity and comorbidities in autism spectrum disorder (ASD) and yielded conflicting results. The study's aims were to compare parents and teachers' perception of autism, attention deficit hyperactivity disorder (ADHD) and anxiety symptoms severity in children with ASD, at the start (T1) and end (T2) of the school year, to assess changes in their perception over time and to examine correlations between their reports. METHODS: The study included 73 participants, (M = 61), aged 2:10 - 7:6 years (M = 4:10, SD = 1:0), who attended ASD special education classes and were receiving intensive interventions. Parents and teachers completed measures of autism severity and ADHD and anxiety symptoms at T1 and T2. RESULTS: Teachers, in comparison to parents, rated more severe social-communication impairments and inattention symptoms at T1, but not at T2. A significant improvement in teachers' ratings of autism and inattention symptoms severity was documented at T2. At both time points, parents reported more severe anxiety symptoms. Significant correlations between parents' and teachers' reports were noted for autism severity at T1 and T2, but not for inattention and anxiety symptoms severity. CONCLUSION: The study emphasizes the contribution of multiple perspectives for better collaboration between home and school environments. Obtaining accurate information from parents and teachers at the start of the school year may help to identify factors needed for better adjustment at school and to better address difficulties at home.

Relationship between Parental Concerns about Social-Emotional Reciprocity Deficits and Their Children's Final ASD Diagnosis.

Concerns raised by parents regarding their child's development are compatible with the child's final diagnosis of autism spectrum disorder. A better understanding of the relationship between parental concerns and a final diagnosis of autism spectrum disorder is therefore critical. In the current study, we compared the frequencies of parental concerns related to DSM-5 criteria for autism spectrum disorder between pair-matched groups with and without a final diagnosis of autism spectrum disorder and determined which parental concerns predicted a final diagnosis of autism spectrum disorder. The cohort included 80 participants (48-154 months of age, IQ > 70) assessed for a possible autism spectrum disorder diagnosis. Parental concerns were retrieved from the free-description portion of the introductory questions of the Autism Diagnostic Interview-Revised and analyzed to assess whether they corresponded to any of the seven DSM-5 criteria for ASD. The two groups only differed in the frequency of parental concerns relating to deficits in social-emotional reciprocity. Parents of children diagnosed with autism spectrum disorder were four times as likely to report deficits in social-emotional reciprocity. This finding highlights the significance of parental concerns regarding deficits in social-emotional reciprocity in predicting a final diagnosis of autism spectrum disorder.

Relationship between cognitive ability and predictors for age at the time of autism spectrum disorder diagnosis.

The rising prevalence of autism spectrum disorder (ASD) has increased awareness of the need for early diagnosis and intervention; however, not all children are diagnosed at preschool age. In the literature, findings regarding factors that may play a role in later diagnosis are inconsistent. Presence or absence of intellectual disability is a possible factor. This study aimed to identify factors associated with later diagnosis of ASD among children grouped according to low and high cognitive levels. Data of children who were previously diagnosed with ASD between 2002 and 2016 at a national autism center were analyzed. Better cognitive ability, having more siblings, and previous diagnosis of attention-deficit/hyperactivity disorder were predictors of later diagnosis among the entire cohort. Children exhibiting lower cognitive levels (LC-ASD; DQ/IQ < 70; n = 209) were diagnosed much earlier. Among this group, later ASD diagnosis was predicted by poorer adaptive behavior, more severe restricted and repetitive behaviors, and previous diagnosis of epilepsy. In the higher cognitive level group (HC-ASD; DQ/IQ ≥ 70; n = 321), familial variables and more severe social impairments were predictors of later ASD diagnosis. Clinicians should be aware of variables that may affect ASD diagnostic age among children with varying cognitive abilities.

Home-quarantine during the initial Covid-19 outbreak in Israel: parent perceived impact on children with ASD.

Background: Studies have reported that Covid-19 home-quarantine periods have had mostly negative psychological impact on children with ASD and their families. Here we examined parent perceived impact of a 6-week quarantine period imposed in Israel at the beginning of the Covid-19 outbreak, in mid-March 2020. Methods: An anonymous online questionnaire was completed by parents of 268 children with ASD. Parents rated deterioration/improvement in their child's behaviors, abilities, mood, sleep, and anxiety along with changes in their own mood, sleep, parenting skills, and family relationships. We performed t-tests and ANOVA analyses to assess the significance of perceived impact on each domain and potential differences in the impact across families with children of different ages, genders, and levels of required support as well as families that experienced different magnitudes of economic hardships. Results: Parents reported significant deterioration in their mood and sleep along with significant improvements in relationships with their spouse and child with ASD, and in their parenting skills. Parents also reported significant increases in the severity of tantrums, anxiety, and restricted and repetitive behavior symptoms along with significant improvements in social and communication abilities of their child with ASD. Ratings were significantly lower in families of ASD children who regularly require more support and in families that experienced economic hardships. Conclusions: While periods of home-quarantine create numerous hardships for families of children with ASD, they may also offer an opportunity for improving parenting skills, family relationships, and children's social communication abilities with potential relevance for improving remote services.

Early diagnosis of autism in the community is associated with marked improvement in social symptoms within 1-2 years.

LAY ABSTRACT: It is widely believed that early diagnosis and treatment of autism spectrum disorder is essential for better outcome. This is demonstrated by the American Academy of Pediatrics recommendation to screen all 1.5-2.5-year-old toddlers for autism spectrum disorder. However, multiple longitudinal studies of children diagnosed with autism spectrum disorder at 1.5-6 years of age and treated in community settings have not reported any associations between earlier diagnosis and improved outcome in core autism spectrum disorder symptoms. In this study, we measured changes in core autism spectrum disorder symptoms over a 1-2-year period in 131 children diagnosed with autism spectrum disorder at 1.2-5 years of age, and treated in the community. The results revealed that children who were diagnosed before 2.5 years of age were three times more likely to exhibit considerable improvements in social autism spectrum disorder symptoms in comparison to children diagnosed at later ages. These results highlight the importance of early diagnosis and treatment of autism spectrum disorder even in community settings with heterogeneous services. In addition, these results motivate further prioritization of universal screening for autism spectrum disorder before 2.5 years of age.

Increased influence of prior choices on perceptual decisions in autism.

Autism spectrum disorder (ASD) manifests sensory and perceptual atypicalities. Recent theories suggest that these may reflect a reduced influence of prior information in ASD. Some studies have found reduced adaptation to recent sensory stimuli in ASD. However, the effects of prior stimuli and prior perceptual choices can counteract one-another. Here, we investigated this using two different tasks (in two different cohorts): (i) visual location discrimination and (ii) multisensory (visual-vestibular) heading discrimination. We fit the data using a logistic regression model to dissociate the specific effects of prior stimuli and prior choices. In both tasks, perceptual decisions were biased toward recent choices. Notably, the 'attractive' effect of prior choices was significantly larger in ASD (in both tasks and cohorts), while there was no difference in the influence of prior stimuli. These results challenge theories of reduced priors in ASD, and rather suggest an increased consistency bias for perceptual decisions in ASD.

Dog training intervention improves adaptive social communication skills in young children with autism spectrum disorder: A controlled crossover study.

LAY ABSTRACT: There is some evidence that using therapy dogs for children with autism spectrum disorder generally results in improved social communication skills and reduced behavioral problems. However, well-controlled studies that examine its effectiveness are scarce. This study examined the effectiveness of a "Dog Training Intervention." The study included 73 participants diagnosed with autism spectrum disorder (61 males, 12 females) with age range of 2:10-7:6 years (M = 4:10 ± 1:0) who attend autism spectrum disorder-specific special education schools. The study population was divided into two groups. Each group received the dog training intervention during one part of the school year (first half or second half) in addition to the standard interventions provided by the special education school settings. The dog training intervention was given twice weekly for 4 months within the school setting. The group that received the dog training intervention first showed a significant increase in adaptive social and communication skills in comparison to the second group that did not receive the intervention in this period. This improvement was maintained after the dog training intervention. The second group, which received intervention at the second half of the year, showed improvement in communication and socialization adaptive skills only during the period in which they received the dog training intervention. The positive impact on social communication adaptive skills of the dog training intervention among young children with autism spectrum disorder suggests that dogs may serve as an effective model for establishing social interaction. Dog training intervention appears to be an effective adjunct treatment to the interventions provided in special education schools for young children with autism spectrum disorder.

Characterization and Prediction of Anxiety in Adolescents with Autism Spectrum Disorder: A Longitudinal Study.

Anxiety is one of the most common comorbidities in youth with autism spectrum disorder (ASD). The current study's aims were: To examine the frequency of elevated anxiety symptoms in adolescents diagnosed with ASD in toddlerhood; To explore the impact of comorbid anxiety in adolescents on clinical presentation; To evaluate variables in toddlerhood that associate with anxiety symptom severity in adolescence. The study included 61 adolescents (mean age = 13:8y) diagnosed with ASD in toddlerhood (T1). Participants underwent a comprehensive assessment of cognitive ability, adaptive skills and autism severity at T1 and again as adolescents (T2), and an evaluation of anxiety symptoms at T2. For the first aim, the most prevalent anxiety subtypes noted in adolescence were separation (39.3%), social (27.9%) and generalized anxiety (18.0%). For the second aim, cognitive ability, autism severity and adaptive skills in adolescents with and without elevated anxiety symptoms scores of any type did not differ significantly. For the third aim, younger age at adolescence was associated with more severe separation and generalized anxiety symptoms. Higher cognitive ability and adaptive skills in toddlerhood were associated with elevated generalized anxiety symptoms in adolescence. Lower adaptive behaviors and repetitive behaviors (RRBs) correlated with elevated social anxiety symptoms. Lower cognitive abilities and more severe RRBs in toddlerhood predicted separation anxiety in adolescence. The study sheds light on early characteristics in ASD that associate with anxiety symptom severity in adolescence. The type of elevated anxiety symptoms presented in adolescence associated with the level of cognitive ability, adaptive skills and RRBs in toddlerhood.

From Toddlerhood to Adolescence, Trajectories and Predictors of Outcome: Long-Term Follow-Up Study in Autism Spectrum Disorder.

This study is one of a very few prospective long-term studies in autism spectrum disorder (ASD). The study compared outcome trajectories in three adolescent groups (T2): "best outcome" (BO, n = 11) did not meet cut-off points for ASD and IQ scores ≥85; high functioning (HF-ASD, n = 14); and lower functioning (LF-ASD, n = 43). Additionally, the study searched for characteristics at toddlerhood (T1) that may predict belonging to the above groups. The study included 68 adolescents (63 males) diagnosed with ASD at toddlerhood (mean age: 13:10 years), mean follow-up time was 11:7 years. Participants underwent comprehensive assessments at T1 and T2. Different trajectories were found for the three defined groups. The BO group improved significantly in cognitive ability, autism severity, and adaptive skills in comparison to no improvement for the LF-ASD group or partial progress for the HF-ASD group. At toddlerhood, better cognition and less severe autism social affect symptoms were generally associated with a better outcome. Early social behaviors including better "pointing," "facial expression directed to others," "showing," and "response to joint attention" were associated with membership in the BO group. In addition, the BO group had the lowest prevalence of significant T2 inattention and anxiety symptoms. No significant differences between the three outcome groups were noted in the birth and prevalence of medical problems. Higher cognitive ability and better T1 showing and pointing behaviors predicted better outcome. The study points to the change in autism severity over time and to the prognostic value of early developmental abilities, social engagement behaviors, and the existence of comorbidities. Autism Res 2020, 13: 1130-1143. © 2020 International Society for Autism Research and Wiley Periodicals LLC. LAY SUMMARY: This long-term study compared characteristics of toddlers diagnosed with autism spectrum disorder (ASD) in three outcome groups in adolescence: best outcome (BO-average IQ/not meeting criteria for ASD), high-functioning ASD, and low-functioning ASD (LF-ASD). At toddlerhood, the BO group displayed less severe autism symptoms, mostly in sharing interests, compared to the LF-ASD group. The BO group had fewer inattention and anxiety symptoms than the two ASD groups. Additionally, early cognitive level and social engagement behaviors predicted outcome in ASD.

Toddlers to teenagers: Long-term follow-up study of outcomes in autism spectrum disorder.

This prospective study examined the developmental changes over time of adolescents diagnosed in toddlerhood with autism spectrum disorder and searched for child characteristics at toddlerhood that predict outcome at adolescence. The study included 65 participants who were divided into low cognitive (developmental quotient < 85; N = 41) and high cognitive (developmental quotient ⩾ 85; N = 21) groups in adolescence. Participants underwent a comprehensive assessment of cognitive ability, adaptive skills, and autism severity. Significant differences in the current clinical phenotypes and in developmental changes over time were found between the two cognitive groups. At baseline, the high cognitive group had significantly less severe social communication deficits. Only the high cognitive group showed a decrease in social communication deficits over time. Although the two groups did not differ in their adaptive skills at the time of diagnosis, the high cognitive group had better adaptive skills at adolescence. Better adaptive communication skills in toddlerhood were associated with better outcome at adolescence in cognitive ability, adaptive skills, and fewer autism symptoms. Less impaired baseline social affect and better cognitive ability predicted higher cognitive level and adaptive skills at adolescence. Cognitive potential of individuals with autism spectrum disorder plays an important role in long-term outcome and comprehensive evaluations at toddlerhood have strong prognostic value in adolescence.

Family Accommodation in Autism Spectrum Disorder.

Family accommodation occurs frequently among families of children with OCD and anxiety disorders, with higher levels of accommodation repeatedly associated with greater symptom severity, lower functioning, and poorer treatment outcomes for children. This is the first examination of family accommodation of restricted and repetitive behaviors (RRBs) in children with autism spectrum disorder (ASD). Parents of children with ASD (N = 86) completed questionnaires assessing their children's RRBs and parental accommodation of these symptoms. Most participants (80%) reported engaging in accommodation at least once a month and family accommodation was significantly positively correlated with RRB severity. These results suggest accommodation of RRBs follows a pattern similar to that reported in obsessive compulsive and anxiety disorders, and highlight avenues for potential parent-based interventions.

From Toddlerhood to Adolescence: Which Characteristics Among Toddlers with Autism Spectrum Disorder Predict Adolescent Attention Deficit/Hyperactivity Symptom Severity? A Long-Term Follow-Up Study.

High rates of attention deficit/hyperactivity disorder (ADHD) comorbidity have been described in autism spectrum disorder (ASD). This study searched for predictors at toddlerhood of the severity of ADHD symptoms at adolescence. The study included 65 participants, (mean age = 13:8 year), diagnosed with ASD at toddlerhood. Participants underwent a comprehensive assessment of cognitive ability, adaptive skills and autism severity at toddlerhood and adolescence. More severe restricted and repetitive behaviors (RRB) in toddlerhood predicted the severity of Inattention symptoms. In addition, more severe RRB and lower adaptive skills in the toddler years significantly predicted the severity of Hyperactivity/Impulsivity symptoms. Adolescents with elevated ADHD symptoms diagnosed at toddlerhood with ASD showed lower cognitive and adaptive skills and more severe autism symptoms.

Risk and Protective Environmental Factors Associated with Autism Spectrum Disorder: Evidence-Based Principles and Recommendations.

Autism Spectrum Disorder (ASD) is a complex condition with early childhood onset, characterized by a set of common behavioral features. The etiology of ASD is not yet fully understood; however, it reflects the interaction between genetics and environment. While genetics is now a well-established risk factor, several data support a contribution of the environment as well. This paper summarizes the conclusions of a consensus conference focused on the potential pathogenetic role of environmental factors and on their interactions with genetics. Several environmental factors have been discussed in terms of ASD risk, namely advanced parental age, assisted reproductive technologies, nutritional factors, maternal infections and diseases, environmental chemicals and toxicants, and medications, as well as some other conditions. The analysis focused on their specific impact on three biologically relevant time windows for brain development: the periconception, prenatal, and early postnatal periods. Possible protective factors that might prevent or modify an ASD trajectory have been explored as well. Recommendations for clinicians to reduce ASD risk or its severity have been proposed. Developments in molecular biology and big data approaches, which are able to assess a large number of coexisting factors, are offering new opportunities to disentangle the gene⁻environment interplay that can lead to the development of ASD.

Having Siblings is Associated with Better Social Functioning in Autism Spectrum Disorder.

Sibling relationships play a unique developmental role, especially in emotional and social domains. In autism spectrum disorder (ASD), social-communication skills are often impaired in comparison to typical development. Therefore, studying siblings' effects on social skills of the child with ASD is important. This retrospective study examined how autism severity and functioning were affected by having older and younger sibling/s, the sex of the index child and of the sibling, and the number of siblings. The study population included 150 participants with ASD (mean age = 4:0 ± 1:6), divided into three equal groups (no sibling, older and younger siblings), matched for cognitive level. The evaluation included neurological and standardized behavioral, cognitive, and functional assessments. Children with ASD with older siblings showed less severe social interaction deficits and better social adaptive skills than only children. No significant differences in autism severity and adaptive functioning were noted between the group with younger siblings and the other groups. The more older siblings the affected child had, the better their social functioning. The sex of the participants with ASD and that of the sibling were not associated with social functioning. Social interaction deficits, the presence of older or younger siblings for children with ASD, and higher cognitive ability contributed significantly to the explained variance (48.9%) in social adaptive skills. These findings emphasize that older siblings positively influence the social skills of their younger sibling with ASD. The effect of typically developing younger siblings was modest and seen only in children with ASD and better cognition.

Semantic-Pragmatic Impairment in the Narratives of Children With Autism Spectrum Disorders.

Narrative impairments are common in autism spectrum disorders (ASDs). The Autism Diagnostic Observation Schedule (ADOS) battery includes a story-telling activity using a picture book called Tuesday. The current study aimed to identify differences between children with ASD and children with typical development (TD) on the production of Tuesday narratives, with a special focus on semantic-pragmatic aspects. Participants were 48 cognitively-able boys, in the age range of 4;10-7;0 years. Twenty-four participants were boys with ASD and 24 participants were TD boys. The semantic-pragmatic analysis included measures of: story details (characters setting, objects, and actions), central ideas, evaluative comments, and unrelated text. Results showed that the narratives produced by children with ASD included fewer central ideas, and fewer settings, characters, and actions, but not objects, as compared with the narratives produced by their TD peers. The number of evaluative comments and utterances that were unrelated to the story did not differ between the groups. A negative correlation was found between the autism severity level and the number of central ideas and number of characters mentioned in the narratives of the ASD participants. Taken together, as a group, these findings point to a semantic-pragmatic impairment in ASD. However, individual analysis revealed heterogeneity within the ASD group in this area. Some of the results may be explained by cognitive deficits in maintaining central coherence (the Weak Central Coherence account). This study has important clinical implications. Defining the specific differentiating measures can maximize the use of the ADOS story-telling activity by clinicians. The association found between the autism severity level and some of the semantic measures can be used in evaluating the severity of the ASD symptoms.

Coherence and content of relating emotions to life events in autism spectrum disorder and typical development: a cross-sectional age study.

Understanding one's own emotions is an important part of social-emotional development in early childhood. Few studies have looked at the ability of children with autism spectrum disorder (ASD) to relate their own emotions to previous life events. Our previous study showed that the description of events that elicited specific emotions is qualitatively and quantitatively different in ASD in comparison to typically developing (TD) pre-adolescents. The current study evaluated differences in coherence and content of responses to questions on emotions in ASD and TD in two age groups. The evaluation was based on the section on Emotions of the Autism Diagnostic Observation Schedule Module 3 test. The study included 96 boys, 48 diagnosed with ASD (IQ≥85) and 48 TD children, divided into younger (6:0-8:0y) and older (8:2-11:0y) groups. Young TD children were able to give coherent responses to questions on experiences that evoked basic emotions. Children with ASD gave fewer coherent responses and more 'no response' and 'odd' responses across the examined age range. Only in the TD group was the level of vocabulary associated with the number of coherent statements. TD children gave more responses with content related to interpersonal relationships, self-awareness and social events than children with ASD. Deficits in coherence and content of responses to questions on emotions related to previous life events derive from the core deficits of ASD. The significant quantitative and qualitative gap that exists between ASD and TD may be useful during the diagnostic process of ASD in childhood.

The Presence of Comorbid ADHD and Anxiety Symptoms in Autism Spectrum Disorder: Clinical Presentation and Predictors.

High rates of attention deficit/hyperactivity disorder (ADHD) and anxiety symptoms have been documented in autism spectrum disorder (ASD), and have been associated with social and adaptive impairments. The study examined the frequency of clinically elevated ADHD and anxiety symptoms in an ASD group in comparison to a non-clinical group, compared the clinical presentation in the ASD group with and without ADHD and anxiety, assessed which child and familial variables add to the severity of Inattention, Hyperactivity/Impulsivity (HI), and anxiety symptoms, and evaluated whether having clinically elevated ADHD and/or anxiety symptoms adds to the prediction of adaptive functioning in ASD. The study included 260 participants diagnosed with ASD (mean age: 7.5 ± 1.1), using standardized tests. The rate of clinically elevated ADHD and anxiety symptoms in ASD was 62.7 and 44.6%, respectively, and symptom severity was significantly greater than the non-clinical sample. The entire population was divided into four subgroups: ASD alone, ASD+ADHD, ASD+anxiety, ASD+ADHD+anxiety, based on the parental behavioral questionnaire. The ASD alone group showed less severe autism symptoms in comparison to the other groups. Having ASD+ADHD symptoms was associated with greater impairments in socialization adaptive skills. Only the group with ASD+ADHD+anxiety was associated with poorer daily living adaptive skills. Regression analyses for prediction of ADHD and anxiety symptoms revealed that being a female and having lower adaptive skills scores predicted higher Inattention severity; being older, having better cognition, and more severe Restrictive Repetitive Behavior symptoms predicted more severe HI symptoms; being older and having more severe social impairments predicted higher anxiety scores. A regression analysis for the prediction of adaptive skills revealed that in addition to cognition and autism severity, the severity of Inattention symptoms added to the prediction of overall adaptive skills. In light of these findings, clinicians should diagnose these comorbidities in ASD early on, and provide effective interventions to reduce their negative impact on functioning, thereby improving outcome.