Practitioner Review: Attention-deficit hyperactivity disorder and autism spectrum disorder - the importance of depression.

Young people with neurodevelopmental disorders, such as attention-deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD), show high rates of mental health problems, of which depression is one of the most common. Given that depression in ASD and ADHD is linked with a range of poor outcomes, knowledge of how clinicians should assess, identify and treat depression in the context of these neurodevelopmental disorders is much needed. Here, we give an overview of the latest research on depression in young people with ADHD and ASD, including possible mechanisms underlying the link between ADHD/ASD and depression, as well as the presentation, assessment and treatment of depression in these neurodevelopmental disorders. We discuss the implications for clinicians and make recommendations for critical future research in this area.

The double empathy problem: A derivation chain analysis and cautionary note.

Work on the "double empathy problem" (DEP) is rapidly growing in academic and applied settings (e.g., clinical practice). It is most popular in research on conditions, like autism, which are characterized by social cognitive difficulties. Drawing from this literature, we propose that, while research on the DEP has the potential to improve understanding of both typical and atypical social processes, it represents a striking example of a weak derivation chain in psychological science. The DEP is poorly conceptualized, and we find that it is being conflated with many other constructs (i.e., reflecting the "jingle-jangle" fallacy). We provide examples to show how this underlies serious problems with translating theoretical claims into empirical predictions and evidence. To start tackling these problems, we propose that DEP research needs reconsideration, particularly through a better synthesis with the cognitive neuroscience literature on social interaction. Overall, we argue for a strengthening of the derivation chain pertaining to the DEP, toward more robust research on (a)typical social cognition. Until then, we caution against the translation of DEP research into applied settings. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Re-examining the association between the age of learning one is autistic and adult outcomes.

LAY ABSTRACT: An interesting recent study found that people who learned they were autistic at a younger age felt more positive about their lives (i.e., had better quality of life) than those who learned at an older age. However, this study has some limitations: (a) the study only involved a fairly small group of university students, (b) whether 'learning one is autistic' referred to learning about one's diagnosis or receiving one's diagnosis was unclear, (c) the influence of other factors on the link between age of learning one is autistic and quality of life was not considered, and (d) the assessment of different areas of quality of life was limited. Addressing these limitations, we re-examined whether the age at which one learns they are autistic relates to quality of life in adulthood. Contrary to the previous study, we found the age at which one learns about their autism does not have a significantly independent impact on their quality of life as an adult. Rather, other factors (e.g., autistic traits, sex, and additional mental health conditions) may have a greater impact. Given our participant sample was larger and more diverse in age and education level compared to previous research, this finding is likely to be more applicable to autistic adults from different backgrounds. Importantly, however, we are not suggesting that individuals should be made aware of their diagnosis later than sooner. Getting a timely diagnosis remains crucial for autistic people and their families to access appropriate support.

Perceived misdiagnosis of psychiatric conditions in autistic adults.

Background: Many autistic people, particularly women, do not receive an autism diagnosis until adulthood, delaying their access to timely support and clinical care. One possible explanation is that autistic traits may initially be misinterpreted as symptoms of other psychiatric conditions, leading some individuals to experience misdiagnosis of other psychiatric conditions prior to their autism diagnosis. However, little is currently known about the frequency and nature of psychiatric misdiagnoses in autistic adults. Methods: Using data collected in the first half of 2019 from an ongoing longitudinal register of autistic adults in the Netherlands, this study explored the frequency of perceived psychiatric misdiagnoses before receiving an autism diagnosis. Gender differences were also explored. A sample of 1211 autistic adults (52.6% women, mean age 42.3 years), the majority of whom were Dutch and relatively highly educated, was evaluated. Findings: Results showed that 24.6% (n = 298) of participants reported at least one previous psychiatric diagnosis that was perceived as a misdiagnosis. Personality disorders were the most frequent perceived misdiagnoses, followed by anxiety disorders, mood disorders, chronic fatigue syndrome/burnout-related disorders, and attention-deficit/hyperactivity disorder. Autistic women (31.7%) reported perceived misdiagnoses more frequently than men (16.7%). Women were specifically more likely than men to report perceived misdiagnoses of personality disorders, anxiety disorders, and mood disorders. Women also reported prior psychiatric diagnoses more often in general (65.8% versus 34.2% in men). Within the group of individuals with a prior diagnosis, perceived misdiagnoses were equally likely for men and women. Interpretation: One in four autistic adults, and one in three autistic women, reported at least one psychiatric diagnosis, obtained prior to being diagnosed with autism, that was perceived as a misdiagnosis. Inaccurate diagnoses are linked to long diagnostic pathways and delayed recognition of autism. These findings highlight the need for improved training of mental health practitioners, in order to improve their awareness of the presentation of autism in adulthood and of the complex relationship between autism and co-occurring conditions. The current study constitutes a first step towards showing that autistic adults, and particularly women, may be at greater risk of experiencing misdiagnoses. Future studies based on larger, more representative samples are required, to replicate current findings and provide more reliable estimates of the overall frequency of misdiagnoses as well as the frequency of misdiagnoses for specific psychiatric conditions. Funding: This study was made possible by funding from the Netherlands Organisation for Health Research and Development (ZonMW), project number 60-63600-98-834.

Unpacking the overlap between Autism and ADHD in adults: A multi-method approach.

The overlap between Autism and Attention-Deficit Hyperactivity Disorder (ADHD) is widely observed in clinical settings, with growing interest in their co-occurrence in neurodiversity research. Until relatively recently, however, concurrent diagnoses of Autism and ADHD were not possible. This has limited the scope for large-scale research on their cross-condition associations, further stymied by a dearth of open science practices in the neurodiversity field. Additionally, almost all previous research linking Autism and ADHD has focused on children and adolescents, despite them being lifelong conditions. Tackling these limitations in previous research, 5504 adults - including a nationally representative sample of the UK (Study 1; n = 504) and a large pre-registered study (Study 2; n = 5000) - completed well-established self-report measures of Autism and ADHD traits. A series of network analyses unpacked the associations between Autism and ADHD at the individual trait level. Low inter-item connectivity was consistently found between conditions, supporting the distinction between Autism and ADHD as separable constructs. Subjective social enjoyment and hyperactivity-impulsivity traits were most condition-specific to Autism and ADHD, respectively. Traits related to attention control showed the greatest Bridge Expected Influence across conditions, revealing a potential transdiagnostic process underlying the overlap between Autism and ADHD. To investigate this further at the cognitive level, participants completed a large, well-powered, and pre-registered study measuring the relative contributions of Autism and ADHD traits to attention control (Study 3; n = 500). We detected age- and sex-related effects, however, attention control did not account for the covariance between Autism and ADHD traits. We situate our findings and discuss future directions in the cognitive science of Autism, ADHD, and neurodiversity, noting how our open datasets may be used in future research.

Measuring self and informant perspectives of Restricted and Repetitive Behaviours (RRBs): psychometric evaluation of the Repetitive Behaviours Questionnaire-3 (RBQ-3) in adult clinical practice and research settgs.

BACKGROUND: Brief questionnaires that comprehensively capture key restricted and repetitive behaviours (RRBs) across different informants have potential to support autism diagnostic services. We tested the psychometric properties of the 20-item Repetitive Behaviours Questionnaire-3 (RBQ-3), a questionnaire that includes self-report and informant-report versions enabling use across the lifespan. METHOD: In Study 1, adults referred to a specialised adult autism diagnostic service (N = 110) completed the RBQ-3 self-report version, and a relative or long-term friend completed the RBQ-3 informant-report version. Clinicians completed the abbreviated version of the Diagnostic Interview for Social and Communication Disorders (DISCO-Abbreviated) with the same adults as part of the diagnostic process. For half of the assessments, clinicians were blind to the RBQ-3 ratings. We tested internal consistency, cross-informant reliability and convergent validity of the RBQ-3. In Study 2, a follow-up online study with autistic (N = 151) and non-autistic (N = 151) adults, we further tested internal consistency of the RBQ-3 self-report version. We also tested group differences and response patterns in this sample. RESULTS: Study 1 showed good to excellent internal consistency for both self- and informant-report versions of the RBQ-3 (total score, α = 0.90, ω = 0.90, subscales, α = 0.76-0.89, ω = 0.77-0.88). Study 1 also showed cross-informant reliability as the RBQ-3 self-report scores significantly correlated with RBQ-3 informant-report scores for the total score (rs = 0.71) and subscales (rs= 0.69-0.72). Convergent validity was found for both self and informant versions of the RBQ-3, which significantly correlated with DISCO-Abbreviated RRB domain scores (rs = 0.45-0.54). Moreover, the RBQ-3 scores showed significantly weaker association with DISCO -Abbreviated scores for the Social Communication domain, demonstrating divergent validity. Importantly, these patterns of validity were found even when clinicians were blind to RBQ-3 items. In Study 2, for both autistic and non-autistic groups, internal consistency was found for the total score (α = 0.82-0.89, ω = 0.81-0.81) and for subscales (α = 0.68-0.85, ω = 0.69-0.85). A group difference was found between groups. LIMITATIONS: Due to the characteristics and scope of the specialist autism diagnostic service, further testing is needed to include representative samples of age (including children) and intellectual ability, and those with a non-autistic diagnostic outcome. CONCLUSIONS: The RBQ-3 is a questionnaire of RRBs that can be used across the lifespan. The current study tested its psychometric properties with autistic adults without intellectual disability and supported its utility for both clinical diagnostic and research settings.

Exploring autistic adults' psychosocial experiences affecting beginnings, continuity and change in camouflaging over time: A qualitative study in Singapore.

LAY ABSTRACT: Over their lifetimes, many autistic people learn to camouflage (hide or mask) their autism-related differences to forge relationships, find work and live independently in largely non-autistic societies. Autistic adults have described camouflaging as a 'lifetime of conditioning . . . to act normal' involving 'years of effort', suggesting that camouflaging develops over an autistic person's lifetime and may start early on, in childhood or adolescence. Yet, we know very little about why and how autistic people start to camouflage, or why and how their camouflaging behaviours continue or change over time. We interviewed 11 Singaporean autistic adults (9 male, 2 female, 22-45 years old) who shared their camouflaging experiences. We found that autistic adults' earliest motivations to camouflage were largely related to the desire to fit in and connect with others. They also camouflaged to avoid difficult social experiences (such as being teased or bullied). Autistic adults shared that their camouflaging behaviours became more complex and that, for some, camouflaging became a part of their self-identity over time. Our findings suggest that society should not pathologise autistic differences, but instead accept and include autistic people, to reduce the pressure on autistic people to hide who they truly are.

Psychological strengths and well-being: Strengths use predicts quality of life, well-being and mental health in autism.

LAY ABSTRACT: It is often suggested that supporting autistic people to identify and use their strengths will lead to positive outcomes. However, little research has explored if this is true. To date, no research has explored whether autistic people already have knowledge of and use their strengths, nor whether increased strengths knowledge and use is linked to good outcomes, such as a better quality of life, well-being and improved mental health. Comparing large samples of autistic and non-autistic people, this study tested these unanswered questions. We found that autistic and non-autistic people reported similar strengths, but autistic people reported less knowledge and use of their strengths compared to non-autistic people. Importantly however, autistic people who reported using their strengths often had better quality of life, well-being and mental health than autistic people who reported using their strengths less frequently. We, therefore, propose that supporting autistic people to use their strengths more often may be a valuable way to boost well-being in this population.

Attention-deficit hyperactivity disorder traits are a more important predictor of internalising problems than autistic traits.

Autism Spectrum Disorder (ASD) and Attention-Deficit Hyperactivity Disorder (ADHD) are both linked to internalising problems like anxiety and depression. ASD and ADHD also often co-occur, making their individual statistical contributions to internalising disorders difficult to investigate. To address this issue, we explored the unique associations of self-reported ASD traits and ADHD traits with internalising problems using a large general population sample of adults from the United Kingdom (N = 504, 49% male). Classical regression analyses indicated that both ASD traits and ADHD traits were uniquely associated with internalising problems. Dominance and Bayesian analyses confirmed that ADHD traits were a stronger, more important predictor of internalising problems. However, brief depression and anxiety measures may not provide a comprehensive index of internalising problems. Additionally, we focused on recruiting a sample that was representative of the UK population according to age and sex, but not ethnicity, a variable that may be linked to internalising disorders. Nevertheless, our findings indicate that while ASD and ADHD uniquely predict internalising problems, ADHD traits are a more important statistical predictor than ASD traits. We discuss potential mechanisms underlying this pattern of results and the implications for research and clinical practice concerning neurodevelopmental conditions.

Understanding the Contributions of Trait Autism and Anxiety to Extreme Demand Avoidance in the Adult General Population.

Autism and anxiety are thought to be related to extreme demand avoidance (EDA), which is characterised by intense avoidance of everyday demands. However, the relative importance of autism and anxiety to EDA has yet to be investigated, and little is known about EDA in adulthood. We conducted two online survey studies (Ns = 267 and 549) with adults in the general population to establish the relative importance of autistic traits and anxiety as predictors of demand avoidance, using dominance analysis. Both autistic traits and anxiety were unique and equally important predictors of demand avoidance. These findings suggest EDA is linked to autism and are consistent with the theory that demand avoidance behaviours are potentially anxiety-driven in adults.

The Four-Item Mentalising Index (FIMI) is a valid, reliable, and practical way to assess mentalising: Reply to Murphy et al. (2022).

Murphy et al. (2022) raised concerns regarding the validity of the Four-Item Mentalising Index (FIMI). We wholeheartedly agree with Murphy et al. that there are problems in the social cognition literature hampering research. However, we maintain the FIMI is conceptually grounded in empirical and theoretical research, and that concerns regarding its construct validity are overstated. Drawing on recent research, we also discuss issues concerning the interpretation of discriminant validity analyses and discuss approaches to improve objectivity in future research. Overall, we argue that the FIMI is a conceptually and psychometrically sound measure, which has utility in future social cognition research and clinical practice. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Emotion processing differences mediate the link between sex and autistic traits in young adulthood.

Background: The male preponderance in autism diagnoses is widely reported, yet the psychological mechanisms (e.g., emotion processing) underlying this sex difference are poorly understood. Contributing to this gap in knowledge, most research has not been designed to investigate the intermediary (i.e., mediating) role of psychological processes in the relationship between sex and autism. Compounding this issue, concerns that autism measures are not reliably measuring the same constructs in males and females, and bias against females in clinical samples, make it difficult to investigate the psychological mechanisms underlying sex differences in autism. Methods: Over two cross-sectional studies, 1656 young adults from the general population reported their sex (as assigned at birth) and completed questionnaires indexing their emotion processing differences, as well as a measure of autistic traits suggested to tap into the same psychometric construct in males and females. Results: Emotion processing differences mediated the relationship between sex and autistic traits, whereby being male was associated with more emotion processing differences, which were subsequently linked with greater levels of autistic traits. There remained a direct effect of sex on autistic traits after accounting for emotion processing differences. Conclusions: Emotion processing differences are a potential psychological mechanism underpinning higher prevalence of autism in males, which may serve a compensatory function in females; for example, females may seek out emotion-inducing experiences to help compensate for social-emotional difficulties. These findings inform our understanding of autism-related sex differences and have potential implications for clinical practice, where the need for sex-specific support and diagnostic processes is increasingly being recognised.

Rethinking fast and slow processing in autism.

Following the popularity of dual process models in social and cognitive psychology, there is major interest in the possibility that autism is associated with impaired "fast" intuitive thinking but enhanced "slow" or "rational" deliberative thinking. If correct, this has great potential to help understand various strengths and difficulties characteristic of autism. Previous empirical investigations of this phenomenon, however, are marred by concerns about the measurement of intuitive and deliberative processing, as well as broader problems in clinical psychological science (e.g., small underpowered studies, lack of replication). Making a step change, we conducted four large-scale studies to examine dual processing in autism, including a preregistered comparison of 200 autistic and nonautistic adults. Participants completed contemporary cognitive and self-report measures of intuitive and deliberative processing, as well as a psychometrically robust measure of general cognitive ability. Except for lower self-reported intuitive thinking, we found no unique contributions of autism to intuitive or deliberative thinking across all four studies, as evidenced by frequentist and Bayesian analyses. Overall, these studies indicate that intuitive and deliberative thinking is neither enhanced nor particularly impaired in relation to autism. We deliberate on the implications of these findings for theories of autism and future investigation of strengths and difficulties in autistic people. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Anthropomorphic tendencies in autism: A conceptual replication and extension of White and Remington (2019) and preliminary development of a novel anthropomorphism measure.

LAY ABSTRACT: Anthropomorphism is the tendency to attribute human-like qualities (e.g. thoughts and feelings) to non-human entities (e.g. objects and weather systems). Research by White and Remington (2019) suggested that anthropomorphism is more common in autistic compared to neurotypical adults, which is interesting given that autistic individuals sometimes misunderstand the thoughts and feelings of other people. In this article, we re-examined the link between autism and anthropomorphism in a large sample of adults with varying degrees of autistic traits, with several important methodological advances on previous research. Across two studies, we found that individuals with more autistic traits reported greater anthropomorphic tendencies. As part of these analyses, we had to develop a new, refined measure of anthropomorphism, which showed better reliability and validity than the original measure. This measure will be useful in future autism-related research. Overall, advancing White and Remington's study, these findings help us to better understand individual differences in socially relevant processes, including those that may be enhanced in autism (e.g. anthropomorphism).

"Late-onset" ADHD symptoms in young adulthood: Is this ADHD?

Objective: We investigated whether "late-onset" ADHD that emerges in adolescence/adulthood is similar in risk factor profile to: (1) child-onset ADHD, but emerges later because of scaffolding/compensation from childhood resources; and (2) depression, because it typically onsets in adolescence/adulthood and shows symptom and genetic overlaps with ADHD. Methods: We examined associations between late-onset ADHD and ADHD risk factors, cognitive tasks, childhood resources and depression risk factors in a population-based cohort followed-up to age 25 years (N=4224-9764). Results: Parent-rated late-onset ADHD was like child-onset persistent ADHD in associations with ADHD polygenic risk scores and cognitive task performance, although self-rated late-onset ADHD was not. Late-onset ADHD was associated with higher levels of childhood resources than child-onset ADHD and did not show strong evidence of association with depression risk factors. Conclusions: Late-onset ADHD shares characteristics with child-onset ADHD when parent-rated, but differences for self-reports require investigation. Childhood resources may delay the onset of ADHD.

Further developing the Frith-Happé animations: A quicker, more objective, and web-based test of theory of mind for autistic and neurotypical adults.

The Frith-Happé Animations Test, depicting interactions between triangles, is widely used to measure theory of mind (ToM) ability in autism spectrum disorder (ASD). This test began with recording, transcribing, and subjectively scoring participants' verbal descriptions, which consistently found ToM-specific difficulties in ASD. More recently in 2011, White et al. created a more objective version of this ToM test using multiple-choice questions. However, there has been surprisingly little uptake of this test, hence it is currently unclear if White et al.'s findings replicate. Further, the lack of an online version of the test may be hampering its use in large-scale studies and outside of research settings. Addressing these issues, we report the development of a web-based version of the Frith-Happé Animations Test for autistic and neurotypical adults. An online version of the test was developed in a large general population sample (study 1; N = 285) and online data were compared with those collected in a lab-based setting (study 2; N = 339). The new online test was then administered to adults with a clinical diagnosis of ASD and matched neurotypical controls (study 3; N = 231). Results demonstrated that the test could successfully be administered online to autistic adults, who showed ToM difficulties compared to neurotypical adults, replicating White et al.'s findings. Overall, we have developed a quicker, more objective, and web-based version of the Frith-Happé Animations Test that will be useful for social cognition research within and beyond the field of autism, with potential utility for clinical settings. LAY SUMMARY: Many autistic people find it hard to understand what other people are thinking. There are many tests for this 'mentalising' ability, but they often take a long time to complete and cannot be used outside of research settings. In 2011, scientists used short silent animations of moving shapes to create a fast way to measure mentalising ability. We developed this into an online test to use in research and clinics to measure mentalising ability in autism.

Autonomic dysfunction in autism: The roles of anxiety, depression, and stress.

LAY ABSTRACT: The autonomic nervous system (ANS) is responsible for the functioning of the heart, bladder, pupils and several other bodily functions. Therefore, when the ANS functions abnormally, individuals can experience a number of physical symptoms, including dizziness, abnormal sweating and digestive difficulties. Currently, it is unclear if autistic adults experience ANS dysfunction. Therefore, in this study, we investigated whether autistic adults report more ANS-related physical symptoms, indicating greater ANS dysfunction, and whether this may be related to autism, or rather anxiety, depression, or stress. The findings suggest that ANS dysfunction, where found in autism, is due to co-occurring stress and anxiety. We therefore propose that treating stress and anxiety may be an effective way to ameliorate ANS-related health problems in autistic adults.

Development and validation of the Four-Item Mentalising Index.

Mentalising, also known as "Theory of Mind", is the ability to understand and infer the cognitions of others, such as their perceptions, intentions, and beliefs. Although several tools have been designed to measure mentalising in adults, there exist methodological and practical limitations. Many of the existing measures conflate mentalising with similar constructs (e.g., empathy), and most are lengthy measures that are unsuitable for large population-based studies and clinical practice. These issues are currently hampering clinical and non-clinical investigations into mentalising and related social-cognitive abilities. Drawing on questionnaire measures of social cognition, we conceived a self-report mentalising scale, the Four-Item Mentalising Index (FIMI; Studies 1a and b). The FIMI was developed through a series of studies examining its factor structure and reliability (Studies 2a and b) and by testing its construct validity against a cognitive mentalising task, autistic traits, and comparing scores in autistic and non-autistic people (Studies 3a and b). Together, we demonstrate that the FIMI is a conceptually and methodologically robust tool for measuring mentalising ability in the general population, including autistic and non-autistic people. Future research directions and practical (clinical) applications of the scale are discussed, with a focus on improving understanding and management of (a)typical mentalising ability. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Variable Emergence of Autism Spectrum Disorder Symptoms From Childhood to Early Adulthood.

OBJECTIVE: Autism spectrum disorder (ASD) is currently considered an early-onset neurodevelopmental condition. Follow-up studies of clinic-ascertained autism suggest that autistic symptoms typically decline with age, although symptom improvement is limited for some. To date there have been no population-based prospective studies investigating the natural history of autistic symptoms from childhood to adulthood. The aim of this study was to characterize the development and heterogeneity of autistic symptoms in a population-based cohort from childhood to age 25. METHODS: Data were analyzed in a prospective U.K. population-based cohort (ALSPAC). Trajectories were derived using five assessments of the parent-rated Social and Communication Disorders Checklist (SCDC) spanning ages 7-25. Additional measures were used to validate symptom trajectories. RESULTS: Three distinct SCDC symptom trajectory classes were identified: low (88.5%), declining (5.0%), and late-emerging (6.5%). Both the declining and late-emerging trajectory classes were associated with child and adult ASD measures, low IQ, communication problems, peer problems, and worse adult functioning compared with the low trajectory class. Male sex was associated with a higher likelihood of being in the declining trajectory class (odds ratio=2.84, 95% CI=2.19, 3.69). This sex difference was not observed in the late-emerging class (odds ratio=1.00, 95% CI=0.80, 1.24) compared with the low trajectory class. CONCLUSIONS: ASD symptom levels that emerged early tended to decline across development, although impairment was still present in adulthood for some. For others, autistic symptoms emerged across adolescence and adulthood. This challenges our current understanding that ASD symptoms inevitably first manifest early in development.