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Autistic young people experience high levels of co-occurring mental health difficulties, including anxiety, depression and behavioural difficulties, across their lifespan. Understanding the neuropsychological mechanisms which underlie these difficulties is vital in developing personalised supports and interventions. Cognitive inflexibility is one candidate mechanism which is associated with co-occurring mental health comorbidities but is also associated with other features of autism such as restricted and repetitive behaviours. This study investigates the distinct longitudinal association between cognitive inflexibility, measured using objective neuropsychological measures and emotional and behavioural problems across adolescence and early adulthood. Eighty-one autistic people from a population-based longitudinal study were assessed at 16 and 23 years on measures of emotional and behavioural problems, with cognitive inflexibility, restricted and repetitive behaviours and verbal intelligence quotient measured at 16 years. We used structural equation modelling to investigate the relationship between cognitive inflexibility and emotional and behavioural symptoms at both timepoints while accounting for the severity of restricted and repetitive behaviours and verbal intelligence quotient. Our results indicate an effect of cognitive inflexibility on increased behavioural problems at 16 years and emotional problems across timepoints, which is distinct from restricted and repetitive behaviours and verbal intelligence quotient. Exploratory mediation analyses suggest that cognitive inflexibility may be one mechanism through which emotional difficulties are maintained longitudinally.

The heterogeneous nature of Autism Spectrum Disorder (ASD) makes accurate diagnosis challenging. Best practice assessments in schools can open pathways to appropriate interventions and educational placements for those with ASD, as well as help identify a student's strengths. There are various tools used in school settings to assess autism. In this review, we briefly discuss those instruments with a specific focus on the use of the Autism Diagnostic Observation Schedule-Second Edition (ADOS-2), one of the most widely used and well-researched assessment tools. We address special considerations that may impact the psychometric properties of the ADOS-2 as well as outline practical implications and recommendations for practitioners in schools.

Purpose: Sentence diversity is a measure of early language development that has yet to be applied to individuals with autism spectrum disorder (ASD). The primary aim of this study was to identify whether children with ASD show change in sentence diversity over 6 months of treatment with Naturalistic Developmental Behavioral Intervention (NDBI). The secondary aim was to examine possible predictors of changes in children's sentence diversity, including caregiver use of NDBI strategies, naturally occurring instances of caregiver "Toy Talk," and child characteristics. Method: Fifty children with ASD (ages 2-4 years) and their caregivers, who were receiving NDBI, engaged in two 10-min video-recorded play interactions, 6 months apart. Child speech was transcribed and coded for sentence diversity. Caregiver input was transcribed and coded for naturally occurring "Toy Talk." Zero-inflated negative binomial mixed models were used to explore predictors of change in child sentence diversity. Results: Children's sentence diversity improved over time. Changes in caregiver NDBI strategy use and caregiver baseline "Toy Talk" were significant predictors of changes in sentence diversity, as were baseline age, nonverbal ratio IQ, and child sex. Additionally, a significant interaction of caregiver baseline "Toy Talk" and change in caregiver NDBI strategies emerged; the effect of caregiver baseline "Toy Talk" on children's sentence diversity change was stronger when NDBI strategy use improved. Conclusions: Sentence diversity is a developmentally sensitive measure of language development in ASD. NDBI strategies that facilitate reciprocal social communication, combined with input composed of declarative sentences with noun or third-person pronoun subjects, may provide optimal support for children's sentence development.

Describing the relative severity and change in autism symptoms is crucial for the appropriate characterization of clinical and research populations. The calibrated severity score (CSS) of the Autism Diagnostic Observation Schedule-2 (ADOS-2; Lord et al., 2012) was created to better describe autism symptom severity consistently across different ages and language levels. The CSS has been widely used to quantify and compare symptom severity on a 10-point scale across Modules; however, its test re-test reliability has not been studied. With 608 ADOS observations, we showed strong test re-test reliability of the CSS across all ADOS Modules. The results support the use of the ADOS CSS as a reliable tool to quantify autism symptom severity across development.

Symptoms of autism spectrum disorder and attention-deficit/hyperactivity disorder often co-occur, challenging timely, and accurate diagnosis. We assessed the performance of three parent-report measures in discriminating autism spectrum disorder from attention-deficit/hyperactivity disorder without autism spectrum disorder (ADHD[subscritpt w/oASD]) in school-age verbally fluent children. We examined the Autism Symptom Interview -- School-Age and two widely used parent questionnaires: Social Responsiveness Scale -- 2nd Edition and Social Communication Questionnaire -- Lifetime. Receiver operating characteristic curves assessed each instrument's performance against the best-estimate clinician "Diagnostic and Statistical Manual of Mental Disorders, 5th Edition" diagnosis of autism spectrum disorder or of ADHD[subscript w/oASD] (n = 74, n = 102, respectively; 6-11 years). These yielded moderate accuracies: area under the curve = 0.85, 0.79, and 0.78 for Social Communication Questionnaire -- Lifetime, Autism Symptom Interview, and Social Responsiveness Scale -- 2nd Edition, respectively. Area under the curve pairwise comparisons reached our statistical significance (p < 0.01) for the Social Communication Questionnaire -- Lifetime versus the Social Responsiveness Scale -- 2nd Edition. Within instruments, sensitivity and specificity varied across autism spectrum disorder cutoffs. Along with the between-instrument variability, this indicates that clinicians and researchers have valid options, depending on the settings and their goals. Comparing children correctly and incorrectly classified as autism spectrum disorder showed no differences in demographics, intellectual abilities, or in any specific clinical profile(s), except for the degree of parent concerns across autism spectrum disorder and comorbid psychopathology-related symptoms. Together, results suggest that complementing parent screeners with multiple sources may be needed to best differentiate school-age verbally fluent children with autism spectrum disorder versus ADHD[subscript w/oASD].

Siblings play an important role in shaping the developmental trajectories of individuals with autism spectrum disorder. Having siblings has been associated with better social communication, non-verbal communication, and theory of mind abilities in autism spectrum disorder. However, little is known about the impact of siblings on adaptive skill growth over time, even though adaptive behavior competencies are among the strongest predictors of positive outcomes in autism spectrum disorder. This study examined the influence of sibling constellation factors, including the presence of siblings, position in birth order, gender of closest-age sibling, and gender match of sibling dyad on the adaptive behavior trajectories of individuals with autism spectrum disorder and non-spectrum disorders from ages 9 to 26 years. Participants with one or more siblings experienced faster growth rates in adaptive behavior from childhood to adulthood than participants without siblings across both Black and White participants, although effects were magnified in Black participants. Furthermore, among participants with siblings, those with male closest-age siblings and those with gender-matched siblings, irrespective of birth order, demonstrated the steepest adaptive skill growth within their respective groups over the 17-year period. Results suggest that siblings may serve an important role in improving the adaptive functioning trajectories and overall outcomes of individuals with autism spectrum disorder.

In this paper we review the impact of DSM-III and its successors on the field of autism--both in terms of clinical work and research. We summarize the events leading up to the inclusion of autism as a "new" official diagnostic category in DSM-III, the subsequent revisions of the DSM, and the impact of the official recognition of autism on research. We discuss the uses of categorical vs. dimensional approaches and the continuing tensions around broad vs. narrow views of autism. We also note some areas of current controversy and directions for the future.

There is a critical need for validated screening tools for autism spectrum disorder in very young children so families can access tailored intervention services as early as possible. Few screeners exist for children between the recommended screening ages of 18-24 months. This study examined the utility of a new autism-specific parent-report screening tool, the Early Screening for Autism and Communication Disorders for children 12-36 months. Field-testing was conducted from five sites with 471 children screened for communication delays in primary care or referred for familial risk or concern for autism spectrum disorder. The Early Screening for Autism and Communication Disorders was evaluated in three age groups: 12-17, 18-23, and 24-36 months. A best-estimate diagnosis of autism spectrum disorder, developmental delay, or typical development was made. Receiver operating characteristic curves were examined for all 46 items and the 30 items that best discriminated autism spectrum disorder from the non-spectrum groups. Area under the curve estimates for the total were greater than 0.90 across age groups. Cutoffs were established for each age group with sensitivity between 0.86 and 0.92 and specificity between 0.74 and 0.85. Results provide preliminary support for the validity of the Early Screening for Autism and Communication Disorders as an autism-specific screener in children 12-36 months with elevated risk of communication delay or autism spectrum disorder.

Purpose: Several studies have reported that "useful speech" at 5 years of age predicts outcomes in individuals with autism spectrum disorder (ASD), but this skill has been vaguely defined. This study investigates which specific aspects of expressive language in children with ASD best predict adult language and communication outcomes. Method: Language samples from 29 children (ages 47-72 months) enrolled in a longitudinal project (e.g., Lord et al., 2006) were transcribed and coded for spoken language features. Hierarchical linear regression was used to compare the following childhood variables as predictors of adult language and communication outcomes: noun diversity, verb diversity, mean length of utterance, and proportion of utterances that were socially motivated. Results: Childhood verb diversity was a value-added predictor of all four adult outcome measures (i.e., verbal IQ, Autism Diagnostic Observation Schedule Communication + Social Interaction Algorithm totals, Peabody Picture Vocabulary Test scores, and Vineland Adaptive Behavior Scales Communication Domain scores), while noun diversity and proportion of utterances that were socially motivated were not value-added predictors of any adult outcome measures. In a second set of regression analyses, mean length of utterance was substituted for verb diversity and was a value-added predictor of two out of four adult outcome measures (i.e., verbal IQ and Vineland Adaptive Behavior Scales Communication Domain scores). The pattern of findings for the other predictors remained the same as in the previous analyses. Conclusion: These results have implications for our understanding of early language in ASD and for clinical decision making in early childhood.

Longitudinal data on the functioning of adults referred for possible autism as children are sparse and possibly different from datasets consisting of adult clinical referrals. A total of 123 young adults, mean age of 26, referred for neurodevelopmental disorders in early childhood were categorized into three outcome groups: autism spectrum disorder (ASD) diagnosis at some point and current intelligence quotient (IQ) [greater than or equal to] 70 (Ever ASD-Higher IQ), ever ASD and current IQ < 70 (Ever ASD-Lower IQ), and individuals who never received an ASD diagnosis (Never ASD). Independence and well-being were assessed through direct testing, questionnaires, and interviews. Verbal IQ, beyond intellectual disability status, accounted for group differences in employment; autistic features (Autism Diagnostic Observation Schedule Calibrated Severity Score) were uniquely related to adaptive skills and friendships. In many ways, the Never ASD group had similar outcomes compared to the ASD groups. However, lower well-being and fewer positive emotions were related to ASD diagnosis across IQ. The Ever ASD-Lower IQ group had the highest levels of irritability, hyperactivity, and medications. Families played a major role in supporting adults with and without ASD at all intellectual levels. Realistic ways of increasing independence should be developed through working with adults and their families, while acknowledging the contribution of individual differences in mental health, intelligence, and autism symptoms across neurodevelopmental disorders.

We compared the presence of autistic and comorbid psychopathology and functional impairments in young adults who received a clinical diagnosis of Pervasive Developmental Disorders Not Otherwise Specified or Asperger's Disorder during childhood to that of a referred comparison group. While the Autism Spectrum Disorder group on average scored higher on a dimensional ASD self- and other-report measure than clinical controls, the majority did not exceed the ASD cutoff according to the Autism Diagnostic Observation Schedule. Part of the individuals with an ASD diagnosis in their youth no longer show behaviors that underscribe a clinical ASD diagnosis in adulthood, but have subtle difficulties in social functioning and a vulnerability for a range of other psychiatric disorders.

Little is known about their stability and the factors that influence their persistence or change over the life-course. To address this, we use data from 158 participants from the Special Needs and Autism Project cohort studied at three time-points from 12 to 23 years. We used latent growth models to study the role of child, family, and contextual characteristics on the conduct, emotional, and attention deficit hyperactivity disorder domains of the parent-reported Strengths and Difficulties Questionnaire. Symptoms decreased significantly over time for all three domains, but many participants still remained above the published cutoffs for likely disorder on at least one of the three domains. Individual trajectories showed high levels of persistence. Higher initial adaptive function and language levels predicted a greater decline in conduct and attention deficit hyperactivity disorder symptoms. In contrast, increased emotional symptoms were predicted by higher language functioning, lower levels of autism symptom severity and higher parental education. Greater neighborhood deprivation was associated with more conduct problems but also a greater decline over time. Our findings highlight that it may be possible to accurately predict mental health trajectories over this time period, which could help parents and carers in planning and help professionals target resources more efficiently.

Although electrophysiological (electroencephalography) measures of executive functions (e.g. error monitoring) have been used to predict academic achievement in typically developing children, work investigating a link between error monitoring and academic skills in children with autism spectrum disorder is limited. In this study, we employed traditional electrophysiological and advanced time-frequency methods, combined with principal component analyses, to extract neural activity related to error monitoring and tested their relations to academic achievement in cognitively able kindergarteners with autism spectrum disorder. In total, 35 cognitively able kindergarteners with autism spectrum disorder completed academic assessments and the child-friendly "Zoo Game" Go/No-go task at school entry. The Go/No-go task successfully elicited an error-related negativity and error positivity in children with autism spectrum disorder as young as 5 years at fronto-central and posterior electrode sites, respectively. We also observed increased response-related theta power during errors relative to correct trials at fronto-central sites. Both larger error positivity and theta power significantly predicted concurrent academic achievement after controlling for behavioral performance on the Zoo Game and intelligence quotient. These results suggest that the use of time-frequency electroencephalography analyses, combined with traditional event-related potential measures, may provide new opportunities to investigate neurobiological mechanisms of executive function and academic achievement in young children with autism spectrum disorder.

This study aimed to provide initial validity and reliability of the "Measure of NDBI Strategy Implementation-Caregiver Change" ("MONSI-CC"), a novel measure that captures changes in caregivers' implementation of NDBI strategies during early intervention. The MONSI-CC was applied to 119 observations of 43 caregiver-child dyads of preschoolers with autism spectrum disorders (ASD). The MONSI-CC showed high inter-rater and test-retest reliability and captured significant improvements in caregivers' implementation of NDBI strategies. Significant associations between improvements in caregiver NDBI implementation and improvements in the child's ASD symptoms also emerged. Our work shows promising evidence for the utility of the MONSI-CC to evaluate implementation of NDBI strategies by caregivers as a mediating and moderating factor for treatment effects on children with ASD.

Few measures are appropriate to assess autism symptoms in minimally verbal adolescents and adults. The Autism Diagnostic Observation Schedule, 2nd Edition (ADOS-2, Lord et al., in Autism diagnostic observation schedule--2nd edition (ADOS-2). Western Psychological Services, Los Angeles, 2012) Modules 1 and 2 were designed and validated with children whose spoken language ranges from few- to- no words to phrase speech. This study describes the development and initial validation of the Adapted-ADOS (A-ADOS), which includes tasks, materials and behavioral codes modified to be suitable for assessing older minimally verbal individuals. A-ADOS algorithms exhibit comparable sensitivity and improved specificity relative to ADOS-2 Modules 1 and 2. Although further validation is needed, the A-ADOS will facilitate research to further understanding of minimally verbal adults and symptom trajectories across the lifespan.

This study investigated health-related QoL (HRQoL) and care-related quality of life (CarerQol) in clinically referred children with an autism spectrum disorder (ASD), and their primary and secondary caregivers. The EuroQol five-dimensional (EQ-5D) and the CarerQol questionnaires were used to respectively measure health-related QoL and care-related QoL. Primary caregivers reported pain/discomfort (42%) and anxiety/depression (40%). In caring, they mostly experienced problems in the relationship with the child (84%), and in combining care with daily activities (51%). Children with ASD had a relevantly lower QoL. Despite negative effects, almost all caregivers (96%) derived fulfillment from caring for their affected children. HRQoL and CarerQol reports of primary caregivers and children were correlated, both providing useful information to ASD measurement and treatment.

Functional speech by 5 years of age is widely established as increasing the probability of long-term positive outcomes across a range of domains for autistic individuals. While terms such as functional or useful speech are often used, what defines these terms is not well established. Furthermore, most research focusing on language development has emphasized the transition from little or no language to use of single words, but much less is known about the transition from single words to phrase speech, which could be equally important. The verb lexicon is foundational to the development of simple, generative phrases and has been linked to prosocial behaviors and general developmental outcomes including better social communication skills, socioemotional reciprocity, and nonverbal communication in autistic children. The current systematic review synthesized information from 20 independent samples to characterize autistic children who transitioned from single words to phrase speech. On average, 48% of the pooled sample transitioned to phrase speech during the study periods. Results were highly variable across studies. Participants under the age of 5 years were more likely to transition to phrases than participants over the age of 5. Though average standard scores were above 50, children who transitioned to phrases generally demonstrated below average adaptive and cognitive skills and moderate-high ASD symptomatology. Variable measures of cognition made it difficult to ascertain patterns in cognitive skills; nonetheless, nonverbal IQ emerged as a salient predictor of the transition to phrases across studies. More research is needed to better understand who transitions beyond single words, clinical benchmarks on the way to generative phrase speech and the factors that predict this transition. Such information can be used to inform clinical decision making and develop or improve targeted interventions based on individual communication profiles. This could make the use of phrases more likely for a greater number of autistic individuals, increasing the likelihood that these individuals communicate independently and effectively with others.

This study aims to determine the validity and reliability of applying the coding strategy from the Brief Observation of Social Communication Change, a newly validated treatment outcome measure, to videotaped segments of the Autism Diagnostic Observation Schedule. Results indicate strong reliability and validity of the Brief Observation of Social Communication Change ratings using the Autism Diagnostic Observation Schedule segments in detecting changes in social communication over the course of treatment in young, minimally verbal children with autism spectrum disorder. Results also suggest that the Brief Observation of Social Communication Change, when applied to Autism Diagnostic Observation Schedule segments, may be more sensitive in detecting subtle changes in social communication compared to the Autism Diagnostic Observation Schedule Calibrated Severity Scores. These results may support the application of the Brief Observation of Social Communication Change to pre-existing datasets of Autism Diagnostic Observation Schedule videos to examine treatment responses.

Although caregiving responsibilities and need for support persist and evolve across the life course in families with autistic youth or youth with other developmental disabilities (DDs), little is known about support during their childs adulthood years. Therefore, the present study used a mixed-methods approach to examine change and stability in formal and informal family support across the transition to adulthood. Caregivers of 126 individuals with autism or DDs completed a modified version of the Family Support Scale, including open-ended questions, at five time points from adolescence (age 16) into young adulthood (age 22). Caregivers reported that informal support from family members was the most frequently used, helpful, and valued source of support with relative stability across time. In contrast, the reported helpfulness, use, and value of formal support (e.g., professionals, schools) for caregivers declined over time. Qualitative content analyses revealed characteristics of highly valued support included support type (e.g., instrumental or emotional) and features of the support source (e.g., their understanding). There was a shift to valuing emotional support more than instrumental support over time, especially for caregivers of less able adults. Partnership and dependability emerged as highly valued features of the support source. These findings fit within a social convoy perspective and likely reflect the service cliff experienced by autistic individuals or people with DDs and their families. As social networks shrink over time and formal services are less readily available in adulthood, remaining sources of support, particularly from family members, become increasingly important.

Purpose: The need for community-viable, evidence-based intervention strategies for toddlers with autism spectrum disorder (ASD) is a national priority. The purpose of this research forum article is to identify gaps in intervention research and needs in community practice for toddlers with ASD, incorporate published findings from a randomized controlled trial (RCT) of the Early Social Interaction (ESI) model (Wetherby et al., 2014) to illustrate community-based intervention, report new findings on child active engagement from the ESI RCT, and offer solutions to bridge the research-to-community practice gap. Method: Research findings were reviewed to identify gaps in the evidence base for toddlers with ASD. Published and new findings from the multisite ESI RCT compared the effects of two different ESI conditions for 82 toddlers with ASD to teach parents how to support active engagement in natural environments. Results: The RCT of the ESI model was the only parent-implemented intervention that reported differential treatment effects on standardized measures of child outcomes, including social communication, developmental level, and adaptive behavior. A new measure of active engagement in the natural environment was found to be sensitive to change in 3 months for young toddlers with ASD and to predict outcomes on the standardized measures of child outcomes. Strategies for utilizing the Autism Navigator collection of web-based courses and tools using extensive video footage for families and professional development are offered for scaling up in community settings to change developmental trajectories of toddlers with ASD. Conclusions: Current health care and education systems are challenged to provide intervention of adequate intensity for toddlers with ASD. The use of innovative technology can increase acceleration of access to evidence-based early intervention for toddlers with ASD that addresses health disparities, enables immediate response as soon as ASD is suspected, and rapidly bridges the research-to-practice gap.

Statistical learning-extracting regularities in the environment-may underlie complex social behavior. 124 children, 56 with autism and 68 typically developing, ages 2-8 years, completed a novel visual statistical learning task on an iPad. Averaged together, children with autism demonstrated less learning on the task compared to typically developing children. However, multivariate classification analyses characterized individual behavior patterns, and demonstrated a subset of children with autism had similar learning patterns to typically developing children and that subset of children had less severe autism symptoms. Therefore, statistically averaging data resulted in missing critical heterogeneity. Variability in statistical learning may help to understand differences in autism symptoms across individuals and could be used to tailor and inform treatment decisions.

In order to shed more light on why referred girls are less likely to be diagnosed with autism spectrum disorder than boys, this study examined whether behavioral characteristics influence the probability of an autism spectrum disorder diagnosis differently in girls versus boys derived from a multicenter sample of consecutively referred children aged 2.5-10 years. Based on information from the short version of the Developmental, Dimensional and Diagnostic Interview and the Autism Diagnostic Observation Schedule, 130 children (106 boys and 24 girls) received a diagnosis of autism spectrum disorder according to "Diagnostic and Statistical Manual of Mental Disorders" (4th ed., text rev.) criteria and 101 children (61 boys and 40 girls) did not. Higher overall levels of parent-reported repetitive and restricted behavior symptoms were less predictive of an autism spectrum disorder diagnosis in girls than in boys (odds ratio interaction = 0.41, 95% confidence interval = 0.18-0.92, p = 0.03). In contrast, higher overall levels of parent-reported emotional and behavioral problems increased the probability of an autism spectrum disorder diagnosis more in girls than in boys (odds ratio interaction = 2.44, 95% confidence interval = 1.13-5.29, p = 0.02). No differences were found between girls and boys in the prediction of an autism spectrum disorder diagnosis by overall autistic impairment, sensory symptoms, and cognitive functioning. These findings provide insight into possible explanations for the assumed underidentification of autism spectrum disorder in girls in the clinic.

Background: Previous research underscores the importance of psychosexual guidance for adolescents with autism spectrum disorder (ASD). Such guidance is provided in the Tackling Teenage Training (TTT) program, in which adolescents with ASD receive psycho-education and practice communicative skills regarding topics related to puberty, sexuality, and intimate relationships. This randomized controlled trial investigated the effects of the TTT program on (a) cognitive outcomes (i.e. psychosexual knowledge, and insight in interpersonal boundaries) and (b) behavioral outcomes (i.e. skills needed for romantic relationships and problematic sexual behavior). Methods: A total of 189 cognitively able adolescents with ASD, aged 12-18 years old, were randomized to an intervention condition (n = 95) or a waiting-list control condition (n = 94). We assessed outcomes using self-reported as well as parent-reported questionnaires at baseline (T1), posttreatment (T2; after 6 months), and follow-up (T3; after 12 months). Results: Linear mixed model analyses showed significant treatment effects for psychosexual knowledge and adequate insight in boundaries, both posttreatment and at follow-up. All adolescents increased significantly over time in their social responsiveness and decreased their problematic sexual behavior, irrespectively of condition. The TTT program was most effective for younger adolescents with ASD; following the TTT program resulted in higher psychosexual knowledge, and higher social functioning for these adolescents. Conclusions: The results of this study indicate that the TTT program is effective as a psycho-educational program to provide adolescents with ASD with the knowledge and insight they need to prepare themselves for a healthy psychosexual development. Further research is needed to investigate how this increased knowledge and insight can subsequently ameliorate improvements in romantic skills and prevent the development of problematic sexual behavior and victimization.

To gain further insight into psychosexual functioning, including behaviors, intrapersonal and interpersonal aspects, in adolescents with Autism Spectrum Disorder (ASD), comprehensive, multi-informant measures are needed. This study describes (1) the development of a new measure of psychosexual functioning in both parent- and self-reports (Teen Transition Inventory; TTI) covering all three domains of psychosexual functioning (i.e. psychosexual socialization, psychosexual selfhood, and sexual/intimate behavior). And (2) the initial testing of this instrument, comparing adolescents with ASD (n = 79 parent-report; n = 58 self-report) to Typically Developing (TD) adolescents (n = 131 parent-report; n = 91 self-report) while taking into account gender as a covariate. Results from both informants indicate more difficulties regarding psychosexual socialization and psychosexual selfhood in the ASD group. With regard to sexual/intimate behavior, only parents reported significantly more problems in adolescents with ASD.

Children with autism have atypical gaze behavior but it is unknown whether gaze differs during distinct types of reciprocal interactions. Typically developing children (N = 20) and children with autism (N = 20) (4-13 years) made similar amounts of eye contact with an examiner during a conversation. Surprisingly, there was minimal eye contact during interactive play in both groups. Gaze behavior was stable across 8 weeks in children with autism (N = 15). Lastly, gaze behavior during conversation but not play was associated with autism social affect severity scores (ADOS CSS SA) and the Social Responsiveness Scale (SRS-2). Together findings suggests that eye contact in typical and atypical development is influenced by subtle changes in context, which has implications for optimizing assessments of social communication skills.

This paper provides an overview of the design and cohort characteristics of the Social Spectrum Study: a clinical cohort study that used a two-phase sampling design to identify children at risk for ASD. After screening 1281 children aged 2.5-10 years who had been consecutively referred to one of six mental health services in the Netherlands, children who screened positive for ASD (n = 428) and a random selection of screen negatives (n = 240) were invited to participate in diagnostic assessments and questionnaires regarding the child, family and society. A 1-year follow-up was also conducted. Results from this study may contribute to knowledge of the identification and characterization of children with ASD, family processes, and the impact of ASD on the family and society.

Individuals with autism spectrum disorder (ASD) tend to have significant delays in adaptive functioning. In this study, the relationship between adaptive behavior and ASD symptomatology was investigated in minimally verbal, school-aged children with ASD (n = 333). Both the social affect (SA) and restricted and repetitive behavior (RRB) domains from the Autism Diagnostic Observation Schedule (ADOS) were analyzed in relation to adaptive skills. ADOS SA scores contributed unique variance to scores in each Vineland domain, though cognitive ability and age accounted for considerably more variance across domains. Results indicate that there is a significant, but small, association between social affect deficits and adaptive skills, challenging clinicians, educators, and caregivers to target adaptive skills in addition to more specific features of ASD.

We know that many autistic people feel lonely, but we dont know whether their loneliness changes over time. Our research study followed autistic people and people with other non-spectrum neurodevelopmental disabilities from childhood through young adulthood and asked them about their loneliness. While many people told us they felt lonely or very lonely, a sizable group also told us that they do not feel lonely. We found that people who reported feeling lonely earlier in life were likely to also report feeling lonely later in life. Overall, autistic people and people with other neurodevelopmental disabilities in our study became lonelier from adolescence to adulthood. People described multiple ways they cope with feeling lonely, such as distracting themselves or reaching out to connect with another person. People who used distraction tended to be lonelier than those who did not. Our findings tell us that there is a need for greater support of social connections for many autistic people as they become adults.

Rates of participation in intervention research have not been extensively studied within autism spectrum disorder. Such research is important given the benefit of early intervention on long-term prognosis for children with autism spectrum disorder. The goals of this study were to examine how family demographic factors predicted treatment attendance and adherence in a caregiver-mediated randomized controlled trial targeting core deficits of autism spectrum disorder, and whether treatment attendance and adherence predicted outcome. In all, 147 caregiver-child dyads from a low-resourced population were randomized to in-home caregiver-mediated module or group-based caregiver education module treatment. Treatment attendance, adherence, and outcome (time spent in joint engagement) were the primary outcome variables. The majority of families who entered treatment (N = 87) maintained good attendance. Attendance was significantly predicted by socioeconomic status, site, and treatment condition. Families in caregiver-mediated module reported lower levels of treatment adherence, which was significantly predicted by site, condition, caregiver stress, and child nonverbal intelligence quotient. Dyads in caregiver-mediated module had significantly longer interactions of joint engagement, which was significantly predicted by an interaction between treatment attendance and condition. Overall, the results from this study stress the importance of considering demographic variables in research design when considering barriers to treatment attendance and adherence.

The current study investigated the utility of the Brief Observation of Social Communication Change-Phrase Speech Young Fluent (BOSCC-PSYF) as an outcome measure of treatment response by analyzing the measures psychometric properties and initial validity. The BOSCC coding scheme was applied to 345 administrations from 160 participants diagnosed with autism. Participants included individuals of any age with phrase speech, or individuals under the age of 8 years with complex sentences. All were receiving behavioral intervention throughout the study. Test-retest and inter-rater reliability were good for the Early Communication and Social Reciprocity/Language domains, and fair for the Restricted and Repetitive Behavior domain. Significant changes occurred over time in the Early Communication and Social Reciprocity/Language domains, and Core Total scores. The BOSCC-PSYF may provide a low-cost, flexible, and user-friendly outcome measure that reliably measures changes in broad social communicative behaviors in a short period of time.

IntroductionSocietal perceptions and lack of understanding of autism spectrum disorder can be stigmatizing for autistic individuals and their families. This may be particularly the case for individuals who meet criteria for profound autism. Despite the considerable service needs of this marginalized group, there is little data on the prevalence of profound autism, nor on the experiences of those with profound autism and their families.MethodsThe current study leveraged a mixed-methods approach to address these gaps. First, the prevalence of profound autism was examined in six samples-three from the United States and three from Western Europe. Second, inductive thematic analysis was used to code interviews from 20 caregivers of profoundly autistic adults.ResultsThe prevalence of profound autism varied widely across the six samples-from 11% to 48%. There were also notable differences between samples in prevalence by gender, race, and ethnicity. Two overarching themes were identified via inductive thematic analysis: Community Perceptions of Autism and Family Support Needs and Advocacy Challenges. Though caregivers were not directly asked about stigmatization during interviews, 85% of caregivers reported at least one instance of perceived stigma.DiscussionFuture research should continue to examine the unique needs and stigmatization experiences of profoundly autistic individuals and their families across the life course.

The current 7-year follow-up study investigated: (1) the stability of ASD severity, and (2) associations of ASD severity in adolescence with (a) childhood and concurrent psychiatric comorbidity, and (b) concurrent societal functioning. The Autism Diagnostic Observation Schedule (ADOS) and the Diagnostic Interview Schedule for Children were administered in childhood (ages 6--12) and in adolescence (ages 12-20) to 72 individuals with a pervasive developmental disorder-not otherwise specified (PDD-NOS). ADOS calibrated severity scores showed a large stability (r = 0.51). Psychiatric comorbidity in childhood and adolescence were not associated with ASD severity in adolescence. Mental health care use (87%) and special education needs were high (71%). Reevaluation of ASD severity and psychiatric comorbidity later in life seem useful when PDD-NOS is diagnosed in childhood.

The current study was a 7-year follow-up of 74 6-12 year old children with Pervasive Developmental Disorder-Not Otherwise Specified. We examined the rates and 7 year stability of comorbid psychiatric diagnoses as ascertained with the Diagnostic Interview Schedule for Children: Parent version at ages 6-12 and again at ages 12-20. Also, we examined childhood factors that predicted the stability of comorbid psychiatric disorders. The rate of comorbid psychiatric disorders dropped significantly from childhood (81%) to adolescence (61%). Higher levels of parent reported stereotyped behaviors and reduced social interest in childhood significantly predicted the stability of psychiatric comorbidity. Re-evaluation of psychiatric comorbidity should be considered in clinical practice, since several individuals shifted in comorbid diagnoses.

Daily living skills (DLS), such as personal hygiene, meal preparation, and money management, are important to independent living. Research suggests that many individuals with autism spectrum disorder exhibit impairments in daily living skills relative to their cognitive skills. This study examined predictors of daily living skills attainment and trajectories of daily living skills in a longitudinal sample referred for possible autism spectrum disorder and followed from 2 to 21?years of age. Consistent with previous studies, participants with autism spectrum disorder and nonspectrum diagnoses showed continual development of daily living skills throughout childhood and adolescence. Early childhood nonverbal mental age was the strongest predictor of daily living skills attainment for both diagnostic groups. Group-based modeling suggested two distinct trajectories of daily living skills development for participants with autism spectrum disorder. Skill levels for both groups of young adults with autism spectrum disorder remained considerably below age level expectations. Whereas the "High-DLS" group gained approximately 12?years in daily living skills from T2 to T21, the "Low-DLS" group's daily living skills improved 3-4?years over the 16- to 19-year study period. Nonverbal mental age, receptive language, and social-communication impairment at 2?years predicted High- versus Low-DLS group membership. Receiving greater than 20?h of parent-implemented intervention before age 3 was also associated with daily living skills trajectory. Results suggest that daily living skills should be a focus of treatment plans for individuals with autism spectrum disorder, particularly adolescents transitioning to young adulthood.

Standardized calibrated severity scores (CSS) have been created for Autism Diagnostic Observation Schedule, 2nd edition (ADOS-2) Modules 1-4 as a metric of the relative severity of autism-specific behaviors. Total and domain CSS were created for the Toddler Module to facilitate comparison to other modules. Analyses included 388 children with ASD age 12-30 months and were replicated on 435 repeated assessments from 127 children with ASD. Compared to raw scores, associations between total and domain CSS and participant characteristics were reduced in the original sample. Verbal IQ effects on Social Affect-CSS were not reduced in the replication sample. Toddler Module CSS increases comparability of ADOS-2 scores across modules and allows studies of symptom trajectories to extend to earlier ages.

Individuals with autistic traits are considered to be prone to develop psychosexual problems due to their limited social skills and insight. This study investigated the longitudinal relation between autistic traits in childhood (T1; age 10-12 years) and parent-reported psychosexual problems in early adolescence (T2; age 12-15 years). In a general population cohort study (n = 1873; the Tracking Adolescents' Individual Lives Survey (TRAILS)), autistic traits and psychosexual problems were determined. Logistic regression analyses were used to investigate whether childhood autistic traits, in individuals displaying no psychosexual problems in childhood, predicted the presence of psychosexual problems in adolescence, while controlling for pubertal development and conduct problems. Higher levels of autistic traits at T1 significantly predicted mild psychosexual problems at T2, above and beyond pubertal development and conduct problems. Particularly two dimensions of autistic traits at T1 were significant predictors; i.e. "reduced contact/social interest" and "not optimally tuned to the social situation". Children with autistic traits--especially those with limited social interest and social regulation problems--showed to have a higher risk to develop psychosexual problems, albeit mild, in early adolescence as reported by parents. Although we showed that autistic traits predict psychosexual problems, it is only one of multiple predictors.

Social communication impairments are a core deficit in autism spectrum disorder. Social communication deficit is also an early indicator of autism spectrum disorder and a factor in long-term outcomes. Thus, this symptom domain represents a critical treatment target. Identifying reliable and valid outcome measures for social communication across a range of treatment approaches is essential. Autism Speaks engaged a panel of experts to evaluate the readiness of available measures of social communication for use as outcome measures in clinical trials. The panel held monthly conference calls and two face-to-face meetings over 14?months. Key criteria used to evaluate measures included the relevance to the clinical target, coverage of the symptom domain, and psychometric properties (validity and reliability, as well as evidence of sensitivity to change). In all, 38 measures were evaluated and 6 measures were considered appropriate for use, with some limitations. This report discusses the relative strengths and weaknesses of existing social communication measures for use in clinical trials and identifies specific areas in need of further development.

The screening accuracy of the parent and teacher-reported Social Responsiveness Scale (SRS) was compared with an autism spectrum disorder (ASD) classification according to (1) the Developmental, Dimensional, and Diagnostic Interview (3Di), (2) the Autism Diagnostic Observation Schedule (ADOS), (3) both the 3Di and ADOS, in 186 children referred to six mental health centers. The parent report showed excellent correspondence to an ASD classification according to the 3Di and both the 3Di and ADOS. The teacher report added significantly to the screening accuracy over and above the parent report when compared with the ADOS classification. Findings support the screening utility of the parent-reported SRS among clinically referred children and indicate that different informants may provide unique information relevant for ASD assessment.

In a sample of 50 verbally fluent adolescents and adults with autism spectrum disorders (age: 16-31 years; verbal IQ: 72-140), we examined the pattern of response and associations between scores on common measures of depressive symptoms, participant characteristics, and clinical diagnosis of depressive disorders. Beck Depression Inventory--Second Edition item descriptives in this autism spectrum disorder sample were compared to previously published data from a large typically developing sample, with results suggesting that cognitive-attributional symptoms of depression may be particularly prevalent in autism spectrum disorder. Scores on a variety of self- and parent-report depression measures were not associated with chronological age or verbal IQ, and were relatively highly correlated with each other and with clinical diagnosis of a mood disorder. The Beck Depression Inventory-Second Edition and the Adult Self-Report "Depressive" scale best identified both depressed and non-depressed participants in this sample, though neither was particularly strong. Validation studies of depression measures in the autism spectrum disorder population are necessary to advance research into this prevalent and impairing comorbidity.

Despite consistent and substantive research documenting a large male to female ratio in Autism Spectrum Disorder (ASD), only a modest body of research exists examining sex differences in characteristics. This study examined sex differences in developmental functioning and early social communication in children with ASD as compared to children with typical development. Sex differences in adaptive behavior and autism symptoms were also examined in children with ASD. Participants (n = 511) were recruited from the Florida State University FIRST WORDS® Project and University of Michigan Autism and Communication Disorders Center. Analyses did not reveal significant effects of sex or a diagnostic group by sex interaction, suggesting a similar phenotype in males and females early in development. Further research is needed to examine sex differences across development.

A new language measure, the Observation of Spontaneous Expressive Language (OSEL), is intended to document spontaneous use of syntax, pragmatics, and semantics in 2-12-year-old children with Autism Spectrum Disorder (ASD) and other communication disorders with expressive language levels comparable to typical 2-5 year olds. Because the purpose of the OSEL is to provide developmental norms for use of language, the first step involves assessment of the scale's feasibility, validity, and reliability using a sample of 180 2-5 year-old typically developing children. Pilot data from the OSEL shows strong internal consistency, high reliabilities and validity. Once replicated with a large population-based sample and in special populations, the scale should be helpful in designing appropriate interventions for children with ASD and other communication disorders.

In an earlier investigation, the authors assessed the reliability of the ADI-R when multiple clinicians evaluated a single case, here a female 3 year old toddler suspected of having an autism spectrum disorder (Cicchetti et al. in "J Autism Dev Disord" 38:764-770, 2008). Applying the clinical criteria of Cicchetti and Sparrow ("Am J Men Def" 86:127-137, 1981); and those of Cicchetti et al. ("Child Neuropsychol" 126-137, 1995): 74% of the ADI-R items showed 100% agreement; 6% showed excellent agreement; 7% showed good agreement; 3% manifested average agreement; and the remaining 10% evidenced poor agreement. In this follow-up investigation, the authors described and applied a novel method for determining levels of statistical significance of the reliability coefficients obtained in the earlier investigation. It is based upon a modification of the Z test for comparing a given level of inter-examiner reliability with a lower limit value of 70% (Dixon and Massey in "Introduction to statistical analysis." McGraw-Hill, New York, 1957). Results indicated that every item producing a clinically acceptable level of inter-examiner reliability was also statistically significant. However, the reverse was not true, since a number of the items with statistically significant reliability levels did not reach levels of agreement that were clinically meaningful. This indicated that clinical significance was an accurate marker of statistical significance. The generalization of these findings to other areas of diagnostic interest and importance is also examined.

Background: Delayed, abnormal language is a common feature of autism and language therapy often a significant component of recommended treatment. However, as with other disorders with a language component, we know surprisingly little about the language trajectories and how varied these might be across different children. Thus, we know little about how and when language problems might resolve, whether there are periods of relative stability or lack of change and what periods might offer more favourable circumstances for intervention. Methods: Expressive and receptive language was measured on six occasions between age 2 and 19 on a cohort of 192 children initially referred for autism. Latent class growth models were fitted to characterize the patterns of heterogeneous development. Results: Latent class growth analysis identified seven classes. Between age 6 and 19, all classes tracked in parallel. Between ages 2 and 6, development was more heterogeneous with considerable variation in relative progress. In all groups, receptive and expressive language developed very largely in tandem. Conclusions: The results confirmed previous analysis of children with specific language impairment where progress beyond age 6 was remarkably uniform. Greater variation was evident before this age with some groups making clearly better or worse progress compared to others. While this developmental heterogeneity may simply be a reflection of variation in preexisting and unchanging biological disposition, it may also reflect, at least in part, greater sensitivity in the early years to environments that are more or less supportive of language development. These findings contribute to the case for the importance of early intervention.

Background: This study examines the social relationships of elementary school children with high-functioning autism, focusing on how gender relates to social preferences and acceptance, social connections, reciprocal friendships, and rejection. Method: Peer nomination data were analyzed for girls with and without ASD (n = 50) and boys with and without ASD (n = 50). Girls and boys with ASD were matched by age, gender, and IQ. Each child with ASD was matched by age and gender to a typically developing classmate. Results: Consistent with typically developing populations, children with ASD preferred, were accepted by, and primarily socialized with same-gender friends. With fewer nominations and social relationships, girls and boys with ASD appear more socially similar to each other than to the same-gender control group. Additionally, girls and boys with ASD showed higher rates of social exclusion than their typically developing peers. However, boys with ASD were more overtly socially excluded compared to girls with ASD, who seemed to be overlooked, rather than rejected. Conclusions: Our data suggest a number of interesting findings in the social relationships of children with ASD in schools. Like typically developing populations, children with ASD identify with their own gender when socializing and choosing friends. But given the social differences between genders, it is likely that girls with ASD are experiencing social challenges that are different from boys with ASD. Therefore, gender is an important environmental factor to consider when planning social skills interventions at school.

Standardized Autism Diagnostic Observation Schedule (ADOS) scores provide a measure of autism severity that is less influenced by child characteristics than raw totals (Gotham et al. in "Journal of Autism and Developmental Disorders," 39(5), 693-705 2009). However, these scores combine symptoms from the Social Affect (SA) and Restricted and Repetitive Behaviors (RRB) domains. Separate calibrations of each domain would provide a clearer picture of ASD dimensions. The current study separately calibrated raw totals from the ADOS SA and RRB domains. Standardized domain scores were less influenced by child characteristics than raw domain totals, thereby increasing their utility as indicators of Social-Communication and Repetitive Behavior severity. Calibrated domain scores should facilitate efforts to examine trajectories of ASD symptoms and links between neurobiological and behavioral dimensions.

The recently published Autism Diagnostic Observation Schedule, 2nd edition (ADOS-2) includes revised diagnostic algorithms and standardized severity scores for modules used to assess younger children. A revised algorithm and severity scores are not yet available for Module 4, used with verbally fluent adults. The current study revises the Module 4 algorithm and calibrates raw overall and domain totals to provide metrics of autism spectrum disorder (ASD) symptom severity. Sensitivity and specificity of the revised Module 4 algorithm exceeded 80 % in the overall sample. Module 4 calibrated severity scores provide quantitative estimates of ASD symptom severity that are relatively independent of participant characteristics. These efforts increase comparability of ADOS scores across modules and should facilitate efforts to examine symptom trajectories from toddler to adulthood.