"This study provides important information about psychiatric comorbidity in adult ASD" (again)

The quote titling this post - "This study provides important information about psychiatric comorbidity in adult ASD [autism spectrum disorder]" - comes from the findings published by Jack Underwood and colleagues [1] (open-access available here).

The Underwood study is a bit of a mash-up paper because, alongside examining things like psychiatric comorbidity and other features accompanying or allied to 'adult autism', it also ventures into the possible genetics of autism. Unfortunately, the relatively small sample size - "105 eligible individuals were matched to 76 healthy controls" (authors words not mine) - means that the genetic results in particular need to be treated with some caution. With this in mind, I'm not going to go further into this side of the Underwood report.

So: "105 individuals were all confirmed to have an ASD diagnosis consistent with ICD-10 criteria by case-note review" were the cohort included for study, all derived from the National Centre for Mental Health institution based in Wales. Interviews and questionnaires were disseminated, covering topics like marriage and employment status alongside questions on 'biological offspring' (children, to you and me). Participants were questioned about psychiatric comorbidity (as in, did they have any diagnoses) as well as medication use and substance use/abuse. We are told that: "By definition, control participants did not have psychiatric morbidity and were not using any psychotropic medication."

"Comorbid psychiatric diagnosis was reported by 89.5% (n = 94) of individuals with ASD." If you would have told me that statistic about 10 or 15 years ago I might have been shocked. These days such figures, high figures, on psychiatric comorbidity accompanying autism seem to be reported on almost a weekly basis. I don't say that to downplay the effects of such high comorbidity; just that there is little novelty in their discovery (see here and see here) particularly the high rates of depression and anxiety that were picked up (see here). Oh, and once again I'll question whether the word 'comorbidity' is entirely accurate in the context of various issues appearing alongside autism (see here).

Medication use? Yes, as probably expected, there was quite a bit of that, particularly antidepressants, anxiolitics (for anxiety) and antipsychotics in the autistic group. Again, there's little novelty in those findings (see here) but they do reiterate the need for regular monitoring and good medicines management (see here).

Onward: "Adults with ASD were significantly less likely to be currently working..., to be married or cohabiting..., to be currently off work because of sickness or disablement... and to have alcohol-related problem." Yes, there was more overlap with other independent findings in some of those areas (see here and see here for examples) but also some quite important details. Take for example the category termed 'problems due to alcohol use' which was reported by 36% of the autistic group compared with 8% of controls. Although not exactly great PR for the label of autism, there is an emerging understanding that alcohol use and abuse does seem to be over-represented alongside a diagnosis of autism (see here). The authors opine that this "could be usage to self-medicate for the aforementioned anxiety as suggested by other authors, or to facilitate social interactions" but really we need lots more data about this and the long-term effects of such 'self-medication' if that's what it truly is.

Another details also stuck out for me: "Forty-one (42.7%) individuals with ASD reported lifetime history of migraine headaches compared with 15 (20.5%) control participants." Migraine headaches (or even just headaches) have been talked about before on this blog in the context of autism (see here). With such a large percentage of participants with autism talking about this issue, I'm minded to suggest that a lot more investigation is needed in this area.

There is little in the way of new, novel findings in the Underwood paper but I don't want readers to think that this is a not a valuable addition to the peer-reviewed science literature. It is, simply because it continues important conversations about (a) the presentation of autism into adulthood (see here), (b) the idea that autism rarely appears in some sort of diagnostic vacuum (see here), and (c) the various inequalities - health and social - faced by those on the autism spectrum. What however I would like to see more of is research on 'what helps' to iron out some of these important issues and how services can be effectively delivered. Alongside we need some debates about funding too.

And just before I go, the focus on autism "and no self-report comorbid intellectual disability" in the Underwood paper did not go unnoticed. Autism science also needs to make sure that all voices on the autism spectrum are equally heard (see here). Indeed, another recent paper [2] makes the point very eloquently: "We found selection bias against ID [intellectual disability] throughout all fields of autism research. We recommend transparent reporting about ID and strategies for inclusion for this much marginalised group." I wouldn't disagree...

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[1] Underwood JFG. et al. Autism spectrum disorder diagnosis in adults: phenotype and genotype findings from a clinically derived cohort. Br J Psychiatry. 2019 Feb 26:1-7.

[2] Russell G. et al. Selection bias on intellectual ability in autism research: a cross-sectional review and meta-analysis. Molecular Autism. 2019; 10: 9.

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"Further studies are required to understand links between ASD, ADHD, and gender identity..."

The findings reported by Ada Cheung and colleagues [1] provide the blogging fodder today, and specifically the observation that: "depression was prevalent in 55.7%, anxiety in 40.4%, ASD [autism spectrum disorder] in 4.8% and ADHD [attention-deficit hyperactivity disorder] in 4.3%" in an Australian adult transgender cohort.

The aim of the Cheung study was to "assess referral numbers and describe the sociodemographic and clinical characteristics"of their cohort, with specific reference to the prevalence of ADHD and/or ASD (autism). The autism 'connection' (and why I'm blogging about this research) follows quite a bit of other research suggesting that gender identity issues and/or reassignment behaviours *might* be over-represented when it comes to a diagnosis of autism (see here and see here and see here for examples). I stressed the word *might* because, so far, there is still some doubt about whether autism / autistic features is / are the more important variable above other comorbid features or comorbidity (see here). I'll also come to the idea of whether 4.8% is actually 'over-represented' or not when it comes to the autism [prevalence] numbers game shortly...

Based on data for quite a large number of individuals (N=540), researchers arrived at those pretty standout figures for various psychiatric and behavioural comorbidity being present. They use the words 'not surprisingly' when it came to the depression and/or anxiety prevalence stats garnered, and how "discrimination and difficulties accessing gender-affirming treatments" may be a contributory factor. I'd also draw your attention to the finding that: "Despite relatively high levels of education, unemployment rates of 21.3% were high in this relatively young cohort, four-fold higher than the Australian general population unemployment rate of 5–6%" as another possibility to (partly) account for some of those psychiatric features / diagnoses being reported on (see here).

So, 4.8% of the cohort with ASD. Is this a particularly high figure? Well, it depends. The authors rely on data from the Australian Bureau of Statistics (2015) which listed 0.7% as the "Australian population prevalence" of autism or ASD. I've not been able to find much more in the way of published estimates of adult autism specifically in Australia but would perhaps hazard a guess that 0.7% is likely to be an underestimate of the true autism rate on the basis of other population data for example (see here). Bear also in mind that Cheung et al also relied on "consecutive consultations between 1st January 2011 and 31st December 2016" so covered quite a long period of time period over which referral data was collected.

The Cheung study also ventures into some of the possible hows-and-whys of autism (and ADHD) being potentially over-represented among their transgender cohort. I'm not going to head too much into what these might be here because the long-and-short of it is that we don't know about possible overlapping genetics for example (although autism genes aren't necessarily just genes for autism) or even whether non-genetic factors might be at work: "it has been suggested that endocrine disruptors such as prenatal exposure to phthalates or antidepressants may be an explanation for the increase of ADHD and ASD and relationship with gender variance" (authors words not mine). Likewise whether the presence of autism or autistic traits means that someone is more or less likely to be 'socially conforming' is something that cannot be confirmed or denied in relation to gender variance at the present time.

All I will say is that more research is indicated in this area. Preferential screening for a range of developmental / behavioural / psychiatric issues is probably also implied as and when someone clinically presents for gender-related issues, in order to ensure that the care they receive is tailored specifically to them.

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[1] Cheung AS. et al. Sociodemographic and Clinical Characteristics of Transgender Adults in Australia. Transgend Health. 2018 Dec 26;3(1):229-238.

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Big data does... the extreme male brain theory of autism and the Empathizing–Systemizing theory

"Two long-standing psychological theories – the empathising-systemising theory of sex differences and the extreme male brain theory of autism – have been confirmed by our new study, the largest of its kind to date."

That was the opening sentence to a write-up (see here) of a recent research paper published by David Greenberg and colleagues [1] which sought to "test 10 predictions from the Empathizing–Systemizing (E-S) theory of sex differences and the Extreme Male Brain (EMB) theory of autism." The 'big data' words included in the title of this post refer to the collection of data from hundreds of thousands of people as part of a TV documentary that aired here in Blighty called 'Are you autistic?' whose data were included for study. This follows a similar format from some of the co-authors on the Greenberg paper on previous research occasions (see here).

Minus any charges of plagiarism, a few descriptors might be useful. First: "The first theory, known as the empathising-systemising theory of typical sex differences, posits that, on average, females will score higher on tests of empathy than males, and that, on average, males will score higher on tests of systemising than females." Second: "The second theory, known as the extreme male brain theory of autism, extends the empathising-systemising theory. It posits that autistic people will, on average, show a shift towards “masculinised” scores on measures of empathy and systemising." Researchers also talked about something called a 'd score': "the difference between each person’s score on the systemising and empathy tests" in their research, alongside mention of the words 'brain type'.

As part of the interactivity of that TV documentary, some 670,000 people "who indicated they were males or females" completed various measures: "the Autism Spectrum Quotient-10 (AQ-10)... the Empathy Quotient (EQ)..., Systemizing Quotient-Revised (SQ-R)..., and the Sensory Perception Quotient (SPQ)" via an on-line questionnaire portal. About 36,000 people who took part "indicated that they had been diagnosed with an “Autism Spectrum Condition”." Data from responses to the questionnaires were crunched pertinent to those 10 predictions from both theories (said predictions concerned sex differences based on responses to the questionnaires, those various 'brain types' and how responses might look with reference to the presentation of autistic traits). For good measure, researchers also describe carrying out an 'independent replication' of their findings on a separate cohort of adults ("14,354 participants (226 autistic individuals, and 14,119 controls)"). Although there were some minor differences from the larger main trial, to all intents and purposes the same procedures were employed "for calculating brain types and performing statistical analysis."

Results: well "all 10 predictions from the E-S and EMB theories" were confirmed. So for example, men taking part in the study "had a shift towards a high d score" suggestive of being more likely to be systemisers than empathisers, whilst "typical females had a shift towards a low d score" (i.e. more likely to empathetic than systemiser). The previous STEM (science, technology, engineering, and mathematics) findings [2] were also supported, in that: "STEM professionals on average scored significantly higher on the AQ" suggesting a link between the choice of STEM career and autistic traits. And for those reporting a diagnosis of autism or autism spectrum disorder (ASD): "autistic people, regardless of their sex, had a shift towards an even higher d score than typical males" (systemisers) but "were not more likely to work in STEM occupations, compared with controls."

There is a lot to take in from the Greenberg research and related commentary. The study has a number of things going for it insofar as the huge participant size and the use of an independent replication set to confirm findings. These factors should not be underestimated. The limitations? Well, self-report is still one of them, and the fact that at least one of the questionnaires used is probably picking up a lot more than just 'autistic traits' (see here). I'm also inclined to point out once again that the *correlation* between autistic traits and STEM career choice did not seemingly extend to those with autism being "more likely to work in STEM occupations, compared with controls." Going back to that 'what is being tested' issue, the AQ for example, might also be picking up something linked to "loneliness, social anxiety, depression, and anxiety" [3] or even something approaching the schizophrenia spectrum (see here) or personality disorder (see here). Indeed, one might have to entertain the idea that the definition 'autistic traits' may not tell the whole story in this study.

I have to admit to being still a little sceptical of big psychological theories such as the EMB or the E-S theory of sex differences. The reason? Whilst attractive in their compartmentalising nature, real life is often far from being so clear-cut and linear. The fact also that an important part of the evidence behind such theories remains a little 'fluffy' (see here for example) cannot be readily brushed under the scientific carpet. As for the use of the term 'brain types', well, I can see what the authors were getting at, but I'm not convinced such terminology is particularly useful. 'Brain types' kinda sits in the same category as 'neurotypical' (see here). I was also drawn to the fact that the authors have to explicitly say that their results don't mean that "autistic people lack empathy" and that "autistic people are not hyper-male in general." It kinda tells you how some of the history behind these theories shows that they have not exactly been received with open arms by many.

But even with all that, the Greenberg results cannot be just discounted, and more research on this topic is indicated.

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[1] Greenberg DM. et al. Testing the Empathizing-Systemizing theory of sex differences and the Extreme Male Brain theory of autism in half a million people. Proc Natl Acad Sci U S A. 2018 Nov 12. pii: 201811032.

[2] Ruzich E. et al. Sex and STEM Occupation Predict Autism-Spectrum Quotient (AQ) Scores in Half a Million People. PLoS One. 2015 Oct 21;10(10):e0141229.

[3] Reed P. et al. Loneliness and Social Anxiety Mediate the Relationship between Autism Quotient and Quality of Life in University Students. Journal of Developmental and Physical Disabilities. 2016; 28: 723-733.

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Quality of life and autism continued

"In this study it was found that psychiatric comorbidity, sleeping difficulty, intellectual disability, maladaptive behavior, adaptive functioning, autism symptomatology, main daytime activity and residence were associated with QoL [quality of life], independent of respondent type."

So concluded the findings reported by Ane Knüppel and colleagues [1] continuing an important research theme looking at quality of life with autism in mind (see here and see here and see here). There's nothing specifically novel about the factors reported on as affecting quality of life (QoL) where a diagnosis of autism is mentioned (mental health issues, autism severity, comorbidity, activities, social inclusion) but the fact that authors drew on data from both self-reports and proxy-reports is important and perhaps provides an important dual perspective. Indeed as the authors noted: "Proxy-reported QoL is different from self-reported QoL and should be considered as an alternative source of information." Similar sentiments have been expressed recently (see here).

Having previously talked [2] about the properties of the specific instrument used to gauge QoL with autism in mind, the authors relied on responses on the INICO-FEAPS scale in their investigation. More than 1700 participants with autism completed the scale where: "For 165 individuals with ASD [autism spectrum disorder], self-reports only were available, and for 863 individuals with ASD, only parental proxy-reports were available." The scale itself is pretty comprehensive, consisting of "72 items divided into the following eight subdomains: self-determination, rights, emotional wellbeing, social inclusion, personal development, interpersonal relationships, material wellbeing, and physical wellbeing." A higher score on the INICO-FEAPS scale denotes a higher QoL 'level'. Various other measures were also included for study; some of them based on the setting of the study in Denmark and the fact that Scandinavian countries are particularly 'geared up' for collecting all-manner of details on the basis of various national registries held on the population.

Alongside the results suggesting that various factors seemed to be important to QoL, there were some details to consider. So: "Across all respondent groups, the lowest rated QoL domains were emotional wellbeing (range of means = 71.10–74.05) and interpersonal relationships (range of means = 65.07–71.88), and the highest rated QoL domains were rights (range of means = 83.79–86.21) and material wellbeing." Further, researchers also observed that being employed or in education also correlated with a higher QoL score "compared to individuals without any regular daytime activity" and "significant associations were found for all respondent groups, with lower levels of QoL among individuals living with their parents... and among individuals with ASD living outside the family home with support... compared to individuals living independently without support."

I was also interested in the idea discussed by the authors that: "treating psychiatric comorbidity, reducing maladaptive behavior, raising the level of independence, and offering individuals with ASD an opportunity to be involved in any job-related occupation or to receive education may raise the level of QoL." 'Treating psychiatric comorbidity' is already a research and clinical priority when it comes to autism (see here and see here). Yes, science needs to do a lot better in terms of establishing the 'hows-and-whys' of such comorbidity being over-represented alongside autism but there are some important themes starting to emerge (see here) including that looking at core autism symptoms as being potential risk factors for the appearance of such issues. And once again we can look to an important group of people for further clues as to how such psychiatric issues are indeed perhaps more 'core' than comorbidity (see here).

Although 'reducing maladaptive behaviour' potentially covers a lot of 'challenging' ground - "Behavior classified as self-destructive, breaking belongings, defiant, disruptive, hurtful to others and/or socially offensive" - I don't think anyone would seriously argue against the idea that such behaviours are neither good for the individual nor good for those around them. I'm minded to suggest that the reason(s) for such behaviour are likely to be complex (see here and see here), but one thing that could be useful would be to look at some of the research on particular 'profiles' being present and connected to autism and beyond (see here) as a starting point.

And then there is also the suggestion of a possible effect for society more generally, as in ensuring that education and employment opportunities are available to all and making 'an inclusive society' a priority...

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[1] Knüppel A. et al. Quality of life in adolescents and adults with autism spectrum disorder: Results from a nationwide Danish survey using self-reports and parental proxy-reports. Research in Developmental Disabilities. 2018; 83: 247-259.

[2] Knüppel A. et al. Psychometric properties of the INICO-FEAPS scale in a Danish sample with autism spectrum disorders. Research in Developmental Disabilities. 2018; 75: 11-21.

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The headline: "One in nine young people in Scotland have attempted suicide"

I have to say that I drew a sharp intake of breath when I read the media headline titling this post - "One in nine young people in Scotland have attempted suicide" - based on the findings reported by Rory O'Connor and colleagues [1]. The idea that, from a sample of some 3500 young people in Scotland, some 10% and 15% of respondents to the questions: "Have you ever made an attempt to take your life, by taking an overdose of tablets or in some other way?’ and ‘Have you ever deliberately harmed yourself in any way but not with the intention of killing yourself? (i.e. self-harm)" answered in the affirmative, seemed pretty important. Not least with the question 'why?' in mind.

OK, media headlines aside, the O'Connor findings require some dissection. The reasoning behind studying this issue was not only to look at the very complicated topic of suicide in a part of the UK (Scotland) that authors write "has a higher suicide rate than England", but also to try and understand how non-suicidal self-injury (NSSI) or non-suicidal self-harm (NSSH) presents in young adults and whether there is something important linking NSSH and suicidal thoughts and/or attempts.

The participant group was drawn from "a representative sample of young people aged 18–34 years from across Scotland" who were recruited to the Scottish Wellbeing Study. Lots of measures were completed by participants as part of the wider study initiative but we are told that "only the prevalence of NSSH and suicide attempts information is reported" in the O'Connor article on this occasion. I might also add that participants were compensated to the tune of £25 (pounds sterling) for their time and participation.

Alongside those headline findings on self-reported attempted suicide and self-harm, a few other important trends were observed. So: "More than 20% reported lifetime suicidal thoughts, 2.4% reported that they last thought about suicide in the past week and 10.4% reported they last thought about suicide in the past 12 months." Around 6% of respondents reported that they had both attempted suicide and also engaged in self-injury suggesting that professionals should "routinely enquire about history of self-injurious behaviour, especially as past behaviour is such a strong predictor of suicide." Also: "Earlier age at NSSH or suicide attempt onset was associated with more frequent lifetime NSSH and suicide attempts." And finally: "The prevalence of NSSH and suicide attempts was significantly higher among those classified as unemployed... and economically inactive... compared with those who were employed." Age, societal and environmental factors seem to play some roles too.

Then to another important set of questions: (a) why? and (b) what can be done to reduce these headline-grabbing statistics? Well, there are no easy answers to such questions I'm afraid. The authors do note that: "From a public health perspective, the unemployment and economic inactivity findings are noteworthy" and perhaps suggest that there are some modifiable variables that could influence suicidal thoughts and/or actions focused on getting people into employment and the benefits that this brings (wide-ranging benefits by all accounts). But this probably only covers one side of the issue, as discussions inevitably turn to what role psychiatric and/or behavioural comorbidity might play in such reporting (see here and see here and see here) and whether there may be a need for (a) something like enhanced screening for suicidal thoughts or other 'risks' among selected populations and/or (b) the [careful] use of 'preventative' strategies in such cases (see here and see here). I say all that accepting that diagnoses around mental health probably play an important role in suicide-related behaviours but are not necessarily a pre-requisite...

As always, there is always someone to talk to if needed...

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[1] O'Connor RC. et al. Suicide attempts and non-suicidal self-harm: national prevalence study of young adults. BJPsych Open. 2018; 4: 142-148.

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On recognising "the disabling effects of ME/CFS"

The findings reported by Caroline Kingdon and colleagues [1] observing that "Using SF-36v2™ scores as a proxy, people with ME/CFS [myalgic encephalomyelitis/chronic fatigue syndrome] were measurably more disabled than PWMS [people with multiple sclerosis] or HCs [healthy controls] in this study population" didn't really surprise me.

Although I'm always a little cautious about making sweeping 'who's the more disabled' comparisons when it comes to various diseases / conditions / labels, I've previously talked about how truly quality-of-life-sapping a diagnosis of ME/CFS can be (see here). Indeed, from previous results published by Falk Hvidberg and colleagues [2] for example, the message was pretty clear: "The ME/CFS study population is more disabled and socially marginalized than the average population with regards to the subjects of long-term illness, number of illnesses, proportion of disability pensioners and relationships." Indeed on that research occasion, ME/CFS beat the likes of lung cancer, depression and schizophrenia in terms of measured severity of health-related quality of life.

The Kingdon results add to such sentiments; on this occasion comparing the "impact of disability" associated with ME/CFS with reports from PWMS and asymptomatic (so-called 'healthy') controls. Multiple sclerosis (MS) by the way, refers to an autoimmune condition that affects many different parts of the body "including problems with vision, arm or leg movement, sensation or balance."

The results, based on data "collected as part of the UK ME/CFS Biobank" included reports from over 50 people diagnosed with ME/CFS and similar numbers diagnosed with MS or asymptomatic. We are told that the SF-36v2™ is an instrument that "uses 36 questions to collect information about functional status and well-being from respondents" and covers various domains.

One figure in particular (see here) provides a good visual representation of how disabling ME/CFS was on this [group] study occasion. Median scores from participants with ME/CFS were 'consistently below' scores from the other groups on every domain, indicative of greater disability. I should also note that despite median [group] scores on the mental health domain also being lower for the ME/CFS group than the comparators, they were at least 'nearer' to the other groups than scores on the other domains examined. I say this in the context that mental health is almost certain to be affected by a diagnosis of ME/CFS, but does not need any psychobabble (i.e. psychosomatic / biopsychosocial) explanations thank you very much (see here).

There are a couple of other important trends noted in the Kingdon data worth noting. So: "Disease onset had a greater impact on employment among people with ME/CFS than among PWMS" and "Post disease onset, 83% of people with ME/CFS earned below £20,000, compared with 59% of PWMS and 54% of HCs." ME/CFS it seems, is not only a condition that hits people hard in a physical sense, it also represents an important route to financial hardship too. Further: "Unemployment costs are borne by both the individual and society." So not only does it make good sense to cure ME/CFS (yes, that's cure as in complete recovery) for the people concerned, but society also benefits. I'm also minded to suggest that when and where people with ME/CFS are disabled to such an extent by their symptoms, we (society) owe it to them to ensure that they are properly supported both medically and also, financially (see here).

Any questions?

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[1] Kingdon CC. et al. Functional Status and Well-Being in People with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Compared with People with Multiple Sclerosis and Healthy Controls. PharmacoEconomics. 2018. March 13.

[2] Falk Hvidberg M. et al. The Health-Related Quality of Life for Patients with Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME/CFS). PLoS One. 2015 Jul 6;10(7):e0132421.

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Walking as an intervention for good psychological health: number of steps or just enjoyment?

I'm once again returning to the topic of walking for health on this blog (see here) and some rather intriguing findings reported by Karen Hallam and colleagues [1] suggesting that adoption of a 100-day 10,000 steps a day program might have some bearing on aspects of mental and psychological health and wellbeing. But there's a bit of a twist...

The activity program in question was something called Stepathlon which, from what I gather, is a corporate initiative to promote health and fitness among employees. I might add that some employees in some occupations probably don't need such initiatives (see here). Various steps (pardon the pun!) are listed on the Stepathlon website including 'forming a team of 5 with your colleagues', getting yourself a pedometer or other fitness tracker that measures steps and then uploading your daily data on to their platform where it is compared with other groups across the world.

Hallam et al report results for nearly 2000 participants based on 'de-identified' data; also including participant reports based on the completion of the "short form of the Depression, Anxiety Stress Scales (DASS)" and the "Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS)." The various strands of data were analysed, correlated and the like.

Results: "The results of this study highlight some psychological and wellbeing benefits of being engaged in work based 10,000 step programs." The authors talk about observing a nearly 9% reduction in stress levels, 8% reduction in 'signs of depression' and a 5% reduction in anxiety when comparing pre-program with post-program data. They add: "This reinforces the benefits of this type of exercise regimen as playing a small yet significant role in improving mental as well as physical health."

But...

Things were not however completely straight-forward as the authors also talk about a "lack of a dose response" in terms of the number of steps completed and those psychological health and well being parameters being assessed. This could denote a few things: (a) participation in a program that encourages walking - walking in a group setting - may be beneficial irrespective of the number of steps that are actually taken, and/or (b) the wide variability in the number of daily steps taken over the course of the program - remember it lasted 100 days - scuppers any chance of getting meaningful correlation data between walking and psychological health. Indeed on that last point, authors mention that future work should really take into account things like the self-report nature of uploading daily activity levels and also the fact that within the sample there were "clearly individuals who were more active before commencing the program" and for whom such an intervention might not be all that effective given their already raised starting activity levels.

Still, I do think that this is a good piece of research that should encourage further investigation. Aside from the significant physical health benefits associated with getting more active, I'd also like to think that such a program could be further adapted for various groups, particularly when things like stress, depression and anxiety are considered a part of the clinical picture. Autism springs to mind as one such avenue for further study, based on various evidence [2] including result similarly using the DASS-21 tool. Indeed, on another blogging occasion where I critically discussed the suggestion that "
autism acceptance could contribute to mental health in autism" (see here) again based on DASS scores, I wonder if a group walking 'intervention' (although I'm not so sure about medicalising such an activity) could also be the topic of more study too, added to other research?

And finally... bearing in mind that exercise might have some nootropic value for some (see here and see this recent study [3]), it seems that much of the chatter about sitting around video game playing fostering "a broad range of cognitive abilities such as visual processing, attention, spatial ability, and cognitive control" is not readily supported by the current peer-reviewed evidence...

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[1] Hallam K. et al. “Happy feet”: evaluating the benefits of a 100-day 10,000 step challenge on mental health and wellbeing. BMC Psychiatry. 2018; 18: 19.

[2] Nah YH. et al. Brief Report: Screening Adults with Autism Spectrum Disorder for Anxiety and Depression. J Autism Dev Disord. 2017 Dec 2.

[3] Gmiąt A. et al. Improvement of cognitive functions in response to a regular Nordic walking training in elderly women - A change dependent on the training experience. Exp Gerontol. 2018 Feb 9. pii: S0531-5565(17)30663-0.

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Anxiety disorder is rife in 'high-functioning' autism

"Lifetime prevalence rates of 53.5% for depressive disorder 73.5% for anxiety disorders and 37.5% for ADHD [attention-deficit hyperactivity disorder] were found."

Those were the figures arrived at by Alexandru Gaman and colleagues [1] who set about investigating the "prevalence rates of psychiatric co-morbidities" among other things in a cohort of over a hundred adults diagnosed with "high-functioning" autism via the quite recently revised DSM-5 criteria. I've stressed the words 'high-functioning' to denote this being the authors' words not mine (personally, I'm not so sure that general level of functioning is all that good as a descriptor).

Various other observations were made by authors such as the finding that: "Subjects with psychotic co-morbid symptoms had a more severe social deficit" which might tap into some other discussions being had on how some of the screening instruments talked about with autism in mind are seemingly not adverse from potentially picking up other labels with a psychosis element to them (see here). I say that also with the understanding that at least for some, autism and psychosis are not diagnostically unstrange bedfellows (see here).

I've zoomed in on the anxiety disorder(s) bit to the Gaman findings because of their very high lifetime prevalence and because, day-to-day, anxiety disorders can be absolutely disabling for many people on the autism spectrum (see here). Indeed, with all the very positive talk about things like employment and further education opportunities [slowly] increasing for autistic young people and adults, one of the details that does not seem to be talked about as much is how issues like anxiety can significantly hinder not only efforts to get a job/student place but also keeping that job/student place in the longer term (see here). Talent is being outshone by crushing anxiety in some cases.

Gaman and colleagues concluded by talking about how identification of something like anxiety disorder is "a crucial clinical issue." I would very definitely agree with this viewpoint but more than that, efforts now need to go into what can be done about treating/managing such anxiety to make people's lives easier (see here); accepting that we still have some distance to go in this process [2]. I'd also like to see some kind of research parity being arrived at specifically with regards to the question: how prevalent and what effects does anxiety have for those NOT described as having 'high-functioning' autism?

To close, having recently been party to some interesting debate on social media about the ins-and-outs, rights-and-wrongs and positives-and-negatives of [exclusive] self-diagnosis with autism in mind, I'd like to link to a paper by Ashwood and colleagues [3] on how one of the premier 'are you autistic?' self-report schedules is not necessarily fit for purpose when it comes to a self-diagnosis of autism. Indeed pertinent to today's post, how "generalized anxiety disorder may ‘mimic’ ASD [autism spectrum disorder] and inflate AQ [Autism-Spectrum Quotient] scores, leading to false positives" echos a viewpoint that I championed: identity, emotions and politics aside, there is no substitute for a thorough professional assessment when autism is suspected. Outside of such an assessment being potentially pertinent to the idea that autism rarely appears in some sort of diagnostic vacuum (see here), it is perhaps even more important as the DSM-5 criteria for ASD and SCD [social (pragmatic) communication disorder] start to become even more mainstream and what it means/will mean to the concept of autistic identity too...

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[1] Gaman A. et al. Psychiatric co-morbidities in a French cohort of adults with high-functioning autism (HFA). European Psychiatry. 2017; 41: S136.

[2] Lorenc T. et al. Support for adults with autism spectrum disorder without intellectual impairment: Systematic review. Autism. 2017 Jun 1:1362361317698939.

[3] Ashwood KL. et al. Predicting the diagnosis of autism in adults using the Autism-Spectrum Quotient (AQ) questionnaire. Psychological Medicine. 2016;46(12):2595-2604.

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The inflammatory effects of unemployment?

"Our study demonstrates that systemic inflammation is associated with an important but little-studied aspect of the social environment, as it is elevated in unemployed compared to employed survey participants."

So said the results of the meta-analysis produced by Amanda Hughes and colleagues [1] (open-access) including data from "12 national studies, incorporating data collected between 1998 and 2012 from all countries in Great Britain" looking at two markers of systemtic inflammation: C-reactive protein (CRP) and fibrinogen. The numbers of participants available for study complete with biological data were "30,037 for CRP analyses and 28,661 for fibrinogen analyses" aged between 22-64 years old.

Alongside the biological information on CRP and/or fibrinogen, researchers also importantly analysed for employment status including "unemployment as commonly understood – the state of being in the labour force and available for work, but currently without it" as distinct from "non-employment categories such as retirement, homemaking or sickness/disability." Data from various other potentially confounding variables were also collected and included in the statistic mix including: age, gender, "socioeconomic position", tobacco smoking status and body mass index (BMI).

Bearing in mind the correlative nature of this research, various potentially important results emerged, not least that "markers of systemic inflammation were elevated for unemployed compared to employed participants." Authors undertook 'robustness checks' to see whether the various potentially confounding variables might have exerted a significant effect on their results and concluded that: "Associations were robust to adjustment for age, gender, education, long term illness, smoking classified using both heaviness and duration, adiposity specified using three BMI-based measures, and mental health, indicating these factors did not explain differences."

What does this research mean then? Well, based on the idea that something like elevations in CRP might be a risk factor for cardiovascular mortality in the general population [2] authors suggest that unemployment might be of 'clinical significance' when it comes to adverse health conditions associated with such an employment status.

There are a few other key points to emerge from the Hughes findings, not least that they may have turned up evidence for "a stronger inflammation-unemployment association in higher-unemployment areas." Their data for example, suggested that unemployment rates were lower in England than in Wales or Scotland over the study period, and that this may have been reflected in their combined data analysis. Different age groups also seemed to show some differences as per the observation that "associations were stronger in the 45–54 group than for younger participants or those approaching retirement."

Stressing again the correlational nature of this meta-analysis, these are potentially informative results. They suggest that, for whatever reasons, the state of being unemployed may not just have social and psychological effects on a person (and their families) but also a somatic element too. I assume one further stage of any research in this area would be to see whether a switch from unemployment to employment has any effects on those inflammatory measures and what element of employment might produce any reductions [3]. Another area of interest might be to see whether factors such as socio-economic status (SES) might also be an important correlate to inflammatory measures [4]. Alongside implications for the general population, I might also advance the idea that where specific groups are 'under-employed', similar inflammatory effects and onward elevated risks for various inflammatory-derived conditions could be something in need of investigation and intervention.

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[1] Hughes A. et al. Unemployment and inflammatory markers in England, Wales and Scotland, 1998–2012: Meta-analysis of results from 12 studies. Brain, Behavior, and Immunity. 2017. March 30.

[2] Li Y. et al. Hs-CRP and all-cause, cardiovascular, and cancer mortality risk: A meta-analysis. Atherosclerosis. 2017 Apr;259:75-82.

[3] Kim S. & Ferraro KF. Do productive activities reduce inflammation in later life? Multiple roles, frequency of activities, and C-reactive protein. Gerontologist. 2014 Oct;54(5):830-9.

[4] Liu RS. et al. Socioeconomic status in childhood and C reactive protein in adulthood: a systematic review and meta-analysis. J Epidemiol Community Health. 2017. 10 May.

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Hughes A, Kumari M, McMunn A, & Bartley M (2017). Unemployment and inflammatory markers in England, Wales and Scotland, 1998-2012: Meta-analysis of results from 12 studies. Brain, behavior, and immunity PMID: 28365380

A (bleedin' obvious) guide to happiness

Happy New Year!

Welcome back to Questioning Answers in 2017. While we wait to see just what this year will offer in [autism research] blogging terms, I open proceedings with the answer to happiness. Yes, you heard me right, I can officially unveil the Questioning Answers guide to happiness...

Drum roll please... and "Mental health and relationships 'key to happiness'."

As I unclutch my hands from my face and those opening 'bleedin' obvious' words included in the title of this post resonate once more alongside the question: 'how much did this research cost?' I direct you to some further discussion about the Origins of Happiness study (see here) from where results were derived.

Taken from: http://voxeu.org/article/origins-happiness

"So in short. If your suffering from depression your not very happy. Dontcha just love the intellectual elite" and "So in a nutshell, have the report's authors found that people not suffering with depression are generally happier than those that are suffering with it? How much are these geniuses paid?" are just two of the comments following that BBC coverage of the study results. With all due respect to the study authors and their introduction of new watchwords like 'wellbeing creation' over wealth creation, I am kinda reeling from the idea that we actually needed a study/report like this given the lack of surprising outcomes noted.

As per Figure 1 and the 'determinants of adult life satisfaction' is anyone really that surprised that having an education, a job, an income, being in rude health, having a special someone or even special 'some people', not being incarcerated or exposed to criminality and not suffering from depression and/or anxiety actually makes people more satisfied with their lives? No, and neither should you be.

I've little more to say on this topic aside from mentioning that (a) happiness is perhaps a relative term and something that includes both short-term and long-term elements to it and (b) the focus on treating mental health issues such as depression and anxiety with 'psychological therapies' (made by the author(s)) should not necessarily be to the exclusion of other well-validated treatment measures. Indeed, I might advance the position of a greater 'correlation' between physical health and mental health in light of other research findings (see here).

So: Be Happy! (I promise that my blogging this year will get better).

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Long-term outcome and autism continued

"The long-term outcome of almost half of all individuals with autistic disorders is poor."

I know that opening sentence doesn't make great reading, but when reported as part of the "systematic review and meta-analysis of studies reporting on the overall outcome in terms of a global measure of adjustment in children with autistic disorders followed up in adolescence and adulthood" by Steinhausen and colleagues [1], there are potential lessons to be learned. That some 20% of those participants included in the various studies by Steinhausen et al were said to have a "good outcome" offers a template for further investigation as to how science and practice might increase such an outcome status among the wider autism spectrum.

Outcome is a bit of a fuzzy term but is something that has been discussed before on this blog (see here). In that instance as in this, the idea that there is (a) "strong evidence for heterogeneity" when it comes to long-term outcome in autism and (b) "little is known about the pathways and predictors" of outcome, are important points. I might also add that overall outcome as gauged by factors such as living arrangements, degree of independence and/or education/employment status does not automatically mean that a person leads a 'happy' or 'unhappy' life. Even those who gain employment for example, might not necessarily have a great quality of life (see here). Likewise a dependency on others for day-to-day support is to expected for some people on the autism spectrum, particularly for those where routine tasks cannot be accomplished alone or where core and/or comorbid issues can be sometimes utterly disabling [2]. This does not mean a person is necessarily unhappy. I'm adverse to the idea that there is one-size-fits-all instruction manual for 'good' long-term outcome for everyone on the autism spectrum just as there isn't for those not on the autism spectrum.

With all that in mind, the area of outcome and autism and specifically the idea that we know little about the 'pathways and predictors' of it is perhaps a slight misnomer. If we happen to look at that group of people who have been headed under the label of 'optimal outcome' we can see important signals emerging (see here) including the idea that early communicative behaviours and general cognitive ability might be important behavioural variables for later outcome with autism in mind. I say this in the context of newer research also [3]. The suggestion that such cases of optimal outcome might have implications for psychiatric comorbidity outside of the presentation of core autism (see here) will no doubt also impact on perceptions/experiences of long-term outcome.

Although I don't want to get too bogged down in this area, I'd like to think that there are a few, quite simple, accommodations that could be made to improve overall long-term outcome for people on the autism spectrum. From a clinical perspective, some of the first things I'd like to see are moves to addressing the numerous health inequalities that seem to be popping up quite frequently with autism in mind and some rather distressing news on the extreme that is early mortality for example (see here and see here). Preferential screening for potentially 'over-represented' comorbidity might be a good start (see here and see here) and importantly, treating/managing what can be treated as and when it is identified (see here). The days of saying that every ailment experienced by a person on the autism spectrum is 'just down to their autism' are passing by very, very quickly.

Enabling individuals on the autism spectrum to further participate in society is perhaps another route towards better long-term outcome. I've talked before about research suggesting that greater societal inclusion is quite a big desire for quite a few people on the autism spectrum (see here) and what it might mean to them in terms of outcome. Of course this includes aspects such as getting a job (and not necessarily a job in the technology industry! [4]) and participating in activities such as sports or hobbies relevant to a person. More than that however are the opportunities to make and have friends and perhaps even meeting that special someone. If we've learned anything generally about favourable long-term outcome, it is that social and familial support are also paramount.

I'd finally like to add in the findings reported by Gotham and colleagues [5] and the notion that "understanding and acceptance of adults with ASD [autism spectrum disorder]" might also be something pretty important to outcome. As per the suggestion from Gotham on "calls for survey and qualitative research to ascertain what “understanding and acceptance” mean to individuals with ASD and their families" I do think more needs to be known about what expectations and requirements are included under such fuzzy terminology. In these days when autism awareness has its own day many people will know something about autism even if it is just sweeping generalisations (see here). Of course more needs to be done to inform the masses about how 'if you've met one person with autism, you've met one person with autism' and the like, but over and above that issue is a question to put out there: what more can be done to improve elements related to long-term outcome in autism?

And (once again) as if to prove a point...

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[1] Steinhausen HC. et al. A systematic review and meta-analysis of the long-term overall outcome of autism spectrum disorders in adolescence and adulthood. Acta Psychiatr Scand. 2016 Jan 13.

[2] Posserud M. et al. Autism traits: The importance of “co-morbid” problems for impairment and contact with services. Data from the Bergen Child Study. Research in Developmental Disabilities. 2016. Jan 27.

[3] Eigsti IM. et al. Language comprehension and brain function in individuals with an optimal outcome from autism. Neuroimage Clin. 2015 Dec 2;10:182-91.

[4] Lorenz T. & Heinitz K. Aspergers – Different, Not Less: Occupational Strengths and Job Interests of Individuals with Asperger’s Syndrome. Dichter GS, ed. PLoS ONE. 2014;9(6):e100358.

[5] Gotham K. et al. Characterizing the daily life, needs, and priorities of adults with autism spectrum disorder from Interactive Autism Network data. Autism. 2015 Oct;19(7):794-804.

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Steinhausen HC, Mohr Jensen C, & Lauritsen MB (2016). A systematic review and meta-analysis of the long-term overall outcome of autism spectrum disorders in adolescence and adulthood. Acta psychiatrica Scandinavica PMID: 26763353

"People with ASD had lower odds of employment in the community"

The title of this quite brief post refers to an important finding detailed by Derek Nord and colleagues [1] who, when analysing data from the "2008–09 National Core Indicators Adult Consumer Survey", concluded that there were some important inequalities when it came to employment rates for those diagnosed on the autism spectrum.

Employment rates and work opportunities for people diagnosed with an autism spectrum disorder (ASD) is a hot topic at the moment. The Nord findings build upon report after report published in the peer-reviewed domain and beyond basically telling everyone what was already quite widely known: "despite their capacity and willingness to work, [people with autism / autistic people] face significant disadvantages in the labour market." [2] Like many others, I am happy to see that things are [slowly] changing insofar as increasingly more resources being put into highlighting this issue and most importantly, the translation of talk into action. But such change is not happening everywhere for everyone and, as if to prove a point...

Appreciating that the autism spectrum includes a whole tapestry of skills and disabilities that might affect both the ability and desire to seek employment (and no, not everyone with autism automatically wants to work in IT or engineering), there is still quite a lot more to do in this area. Things like making the job application and interview a little more 'friendly' is a good start (see here) and also not assuming that getting someone a job is the end of the process [3] no matter how many 'feel good' boxes this might tick. Indeed, I'm particularly interested in the factors that are linked to the sustainability of employment and how making the workplace 'work' for people on the autism spectrum might be a key part of the benefits employment can bring to the person themselves, their family and society in general.

Now, about making the labour market also 'work' for parents of children with autism too (see here)...

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[1] Nord DK. et al. Employment in the community for people with and without autism: A comparative analysis. Research in Autism Spectrum Disorders. 2016; 24: 11-16.

[2] Baldwin S. et al. Employment activities and experiences of adults with high-functioning autism and Asperger’s Disorder. J Autism Dev Disord. 2014 Oct;44(10):2440-9.

[3] Holwerda A. et al. Predictors of sustainable work participation of young adults with developmental disorders. Res Dev Disabil. 2013 Sep;34(9):2753-63.

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Nord, D., Stancliffe, R., Nye-Lengerman, K., & Hewitt, A. (2016). Employment in the community for people with and without autism: A comparative analysis Research in Autism Spectrum Disorders, 24, 11-16 DOI: 10.1016/j.rasd.2015.12.013

Quality of life of parents of children with autism systematically reviewed

"This review verified previous reports on lower QoL [quality of life] among parents of children with ASD [autism spectrum disorder] and highlighted potential areas of support."

So said the findings reported by Eleni Vasilopoulou & Joy Nisbet [1] who surveyed the available peer-reviewed literature looking at "QoL among parents of children with ASD (<18 years)". They also reported on various factors potentially contributory to the reported lower QoL including "child behavioural difficulties, unemployment, being a mother and lack of social support."

Being careful not to generalise nor stigmatise, these are important results. On a previous blogging occasion I talked about the issue of parental stress in relation to raising a child with additional needs (see here) and how there may be evidence-based ways and means of reducing stress so helping allow parents to focus on being parents. Certainly the potentially contributory factors cited by Vasilopolou & Nisbet accord with some of tenets in that post (i.e. the positive impact of social support including respite and the need to tackle the more disruptive aspects of behaviour more likely to lead to greater stress for person and parent).

As per my recent ramblings on supporting other family members when a diagnosis of autism is received (see here), there are additional lessons to be learned. By all means focus attention and services on the person diagnosed in order to improve their quality of life (see here). Try and ensure that their personal, social and medical needs are met (see here) and that meaningful opportunities are offered, mindful that sweeping generalisations don't tend to work too good when it comes to the autism spectrum (see here). Snowflakes, people, snowflakes.

But also don't forget about families and other significant others. Don't forget about the mothers, fathers and other caregivers and their day-to-day and longer term needs and concerns (see here). Parents are the foundations of families. Those foundations need to be tended every once in a while in order to ensure the family home stays strong and upright.

Music: Red Hot Chili Peppers - Higher Ground.

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[1] Vasilopoulou E. & Nisbet J. The quality of life of parents of children with autism spectrum disorder: A systematic review. Research in Autism Spectrum Disorders. 2016; 23: 36-49.

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Vasilopoulou, E., & Nisbet, J. (2016). The quality of life of parents of children with autism spectrum disorder: A systematic review Research in Autism Spectrum Disorders, 23, 36-49 DOI: 10.1016/j.rasd.2015.11.008

Sick leave and income levels for parents of children with autism

"Parents of children with ASD [autism spectrum disorder] living in Stockholm, Sweden in 2006 were more likely to be on sick leave, not in the labor force, or earning low income when compared to parents who did not have a child with ASD and these results remained after adjusting for familial socioeconomic factors and parental psychiatric care."

That was the rather grim conclusion reached by Miranda McEvilly and colleagues [1] (open-access) following their analysis of families taking part in the Stockholm Youth Cohort (SYC) initiative [2] - "a record-linkage study comprising all individuals aged 0–17 years, ever resident in Stockholm County in 2001–2007 (N = 589,114)." From the huge number of participants, researchers identified 2,982 mothers/fathers with a child diagnosed on the autism spectrum: "1,207 had ASD with ID [intellectual disability] (or more than one child with ASD where at least one of the children had ASD with ID) and 1,685 had ASD without ID."

"Four outcomes, two for sick leave and two for work participation, were obtained using data from LISA in 2006." LISA by the way, refers to "the longitudinal integration database for health insurance and labor market studies (LISA)" based in Sweden and carries quite a bit of information about employment and related parameters. Participant data were analysed according to the presence of offspring autism and whether or not said autism was accompanied by ID or not. Various potential confounding variables were also added into the statistical mix as per the headline sentence above.

Results: well, we already know that parents with a child (or children) with autism were quite a bit more likely to be taking sick leave or not to be in work or to be on a low income compared to those without. This trend was particularly notable in mothers of children with autism. Researchers also reported that when comparing families with a child with autism and ID with those with a child with autism but no ID, several differences were also apparent. So: "Increased sick leave (15–365 days) is associated with parents of children with ASD without ID but not ASD with ID" (again, with mothers faring worse than fathers).

"Parents who have a child with ASD are more likely to experience stress, depression, and fatigue. Therefore it is not surprising that these parents take sick leave more frequently or participate less in the work force." As per this excerpt, the authors frame their findings within the perspective that parenting a child diagnosed with an ASD can carry its own particular stresses and strains outside of those more generally associated with parenting. I've covered this topic before on this blog and how, without blaming or stigmatising, there is a growing recognition of the need for additional support services for those parents (see here). The fact that Sweden has specific policies "aimed at helping families of children with ASD, both with well-being and with ability to work" also seemed not to be as effective as perhaps initially thought as "these parents remain a vulnerable group for which additional support might be warranted."

This is valuable data that adds to previous discussions about how the presence of familial autism can [variably] impact well beyond individuals and contribute to some of the societal inequalities that have been noted. One might quibble with some of the study mechanics such as the inclusion of "parents with children with other disabilities" in the comparison group or the lack of emphasis on other autism-associated comorbidities (in these days of ESSENCE) outside of ID and how they may impact on parental employment and earnings, but this is perhaps research fodder for a different time.

"It can also be noted that being on sick leave, outside of the work force or earning a low income will have long reaching impact on these parents because of Sweden’s pension system which is based on an individual’s life time earnings." This is another potential outcome that the authors focus in on as a consequence of their findings. One might put forward the viewpoint that where noted both inside and outside of Sweden, further preferential economic policies could be put in place as and when a child is diagnosed to secure both their future and that of their parents too. Also: "It is recommended that further studies be done to see what support mothers and fathers would find most beneficial and what support they are lacking." I cannot disagree with that last sentiment.

Music: David Bowie - Five Years.

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[1] McEvilly M. et al. Sick Leave and Work Participation Among Parents of Children with Autism Spectrum Disorder in the Stockholm Youth Cohort: A Register Linkage Study in Stockholm, Sweden. Journal of Autism and Developmental Disorders. 2015; 45: 2381.

[2] Idring S. et al. Autism Spectrum Disorders in the Stockholm Youth Cohort: Design, Prevalence and Validity. PLoS One. 2012; 7(7): e41280.

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McEvilly M, Wicks S, & Dalman C (2015). Sick Leave and Work Participation Among Parents of Children with Autism Spectrum Disorder in the Stockholm Youth Cohort: A Register Linkage Study in Stockholm, Sweden. Journal of autism and developmental disorders PMID: 25697737

Autism, higher education and employment: what happens long-term?

Note: I wish I knew who to attribute this fantastic picture to.

I want to draw your attention to the paper by Julie Lounds Taylor and colleagues [1] in today's post and some slightly worrying findings based on their longitudinal investigation of postsecondary (higher) education and employment experiences for a group of 73 adults diagnosed as being on the autism spectrum.

To quote: "Although two-thirds of adults with autism spectrum disorder participated in competitive employment/postsecondary education during the study, fewer than 25% maintained these activities over the study period."

I was interested in this specific sentence given some recent discussions with colleagues about how quite a lot of the conversations about employment and/or higher education access for those on the autism spectrum seemed to be missing some important elements including: (a) 'what factors successfully 'keep' a person in employment/education?' and (b) 'does long-term participation in education/employment really improve quality of life for everyone on the autism spectrum?'

Before anyone gets any ideas about me being somehow opposed to employment and higher education access for anyone and everyone who wants it, I'm not. As per some previous ramblings on this topic, I do think there are plenty of ways that the jobs market for example, can be opened up for those on the autism spectrum (see here) and society is poorer by not recognising the talents available. What I am slightly concerned about is quite a typical feature for autism research and practice with some of the sweeping generalisations that are often made that there is some sort of one-size-fits-all 'life plan' for everyone on the autism spectrum. There isn't and when it comes to jobs and education, there certainly isn't [2].

Appreciating that discussions about education and employment are quite prevalent in the research literature these days, I would very much like to see quite a bit more science done on the various reasons why higher education and/or employment in their current form might not necessarily be right for everyone on the autism spectrum and what can be done about it. Things like anxiety - which can be extremely disabling for some on the autism spectrum - affecting a person's ability to hold down a job for example, and the additional pressures that it can result in for both employees and employers. In these times of Governments striving for full employment, compassion for those not able to hold employment (including on the topic of benefits sanctions) should be extended at the same time as striving for improvements in offering opportunities. Drawing also on the idea that higher education might invoke certain stresses and strains that may uniquely affect some on the autism spectrum (see here) I'd like to see more investigations on what can be done to mitigate such issues and improve the learning experience for those on the spectrum who choose this particular direction.

"Women were considerably less likely than men to maintain employment/postsecondary education over time." This is another worrying finding reported by Taylor et al reiterating other work coming to similar conclusions [3]. I don't yet have any specific ideas why men with autism were more likely to hold down employment/education compared with women with autism but it strikes me that some further investigation should be quickly forthcoming.

To reiterate, I am by no means opposed to increasing access / participation in higher education and employment for those on the autism spectrum; society owes all it's citizens equal rights and importantly justice (see attached picture). What I do have a problem with is when equality assumes 'one-size-fits-all' and fails to understand the individual needs, wants and wishes of individuals [4]. This also includes the further requirement to debunk the idea that "natural science, engineering and IT" are the only educational / occupational courses 'right' for people on the autism spectrum [5].

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[1] Taylor JL. et al. Longitudinal patterns of employment and postsecondary education for adults with autism and average-range IQ. Autism. 2015 May 27. pii: 1362361315585643.

[2] Marshall D. & Goodall C. The Right to Appropriate and Meaningful Education for Children with ASD. JADD. 2015. June 3.

[3] Holwerda A. et al. Predictors of sustainable work participation of young adults with developmental disorders. Res Dev Disabil. 2013 Sep;34(9):2753-63.

[4] Griffith GM. et al. 'I just don't fit anywhere': support experiences and future support needs of individuals with Asperger syndrome in middle adulthood. Autism. 2012 Sep;16(5):532-46.

[5] Lorenz T. & Heinitz K. Aspergers--different, not less: occupational strengths and job interests of individuals with Asperger's Syndrome. PLoS One. 2014 Jun 20;9(6):e100358.

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Taylor JL, Henninger NA, & Mailick MR (2015). Longitudinal patterns of employment and postsecondary education for adults with autism and average-range IQ. Autism : the international journal of research and practice PMID: 26019306