"anxiety occurring as a consequence of ASD symptoms"

Although not necessarily a popular idea, I have for a while been coming around to the possibility that various 'comorbidities' associated with a diagnosis of autism or autism spectrum disorder (ASD) represent more than just 'comorbidity'. I'm not specifically talking about medical comorbidity such as epilepsy or seizure disorder being intricately related to autism (although there is evidence for such a relationship) but rather that co-occurring clinical and sub-clinical psychiatric issues such as depression and anxiety potentially 'come about' partially as a result of the presence of autistic traits and characteristics (see here and see here).

As I said, this is not a universally popular idea. In the age of the emergence of an 'autistic identity' and an increasingly vocal group of people wanting to discuss what role societal factors play with regards to quality of life in the context of autism (see here), the idea that autistic traits themselves might in some way predispose for various other, often very disabling conditions, is not easy to reconcile. Even more so if the implication for managing things like anxiety and/or depression might mean 'targeting' core autistic features for intervention...

The findings such as those reported by Elizabeth Shephard and colleagues [1] "testing the specificity of early-life (infant and toddler) predictors of mid-childhood ADHD [attention-deficit hyperactivity disorder] and anxiety symptoms compared to ASD symptoms" provide however, another tier of evidence that (a) autism rarely exists in some sort of diagnostic vacuum (see here), and (b) something like the symptoms of anxiety appearing alongside autism could "reflect the presence of common developmental pathways or convergence in early behavioural manifestations."

Shephard et al discuss results obtained from the British Autism Study of Infant Siblings (BASIS) initiative, a collaboration based here in Blighty aiming to "provide a platform for the study of infants at-risk for autism in the UK and to facilitate collaborative links between scientists working in the area." High-risk (i.e. having a sibling diagnosed with ASD) and low-risk infants were followed and tested for various symptoms and traits covering autism and also ADHD and anxiety at various points during their childhood development: "7, 14, 24 and 38 months, and 7 years of age." Importantly, because measuring things like anxiety in young children is still quite a challenge, researchers used other soft signs and symptoms - fearfulness and shyness - as "early-life predictors of anxiety symptoms." Some nifty statistical methods were applied to the collected data.

Results: "Increased activity levels and poor inhibitory control were correlated with ADHD symptoms and not ASD or anxiety; these associations were unchanged in path models controlling for risk-group and ASD symptoms." The authors interpreted these findings as evidence that "these disorders may have distinct developmental origins and are therefore unlikely to reflect a common condition" with a specific focus on autism and ADHD. Ergo, when one sees the data pointing to a rather large over-representation of ADHD in the context of autism (see here), this does not necessarily translate into autism being ADHD or vice-verse or them sharing a common developmental pathway.

Additionally: "early‐life markers of anxiety (without ASD) were associated with later anxiety..., but were also associated with later ASD symptoms." When looking at those early-life markers of [possible] anxiety, and how they *linked* to the symptoms of autism, authors highlighted how "these disorders are difficult to differentiate early in life, which could reflect the presence of common developmental pathways or convergence in early behavioural manifestations of these disorders." In other words, there may be some intricate links between them.

Of course, lots more research is needed in this area, as authors mention about the use of "parent‐rated measures of early‐life predictors and mid‐childhood symptoms of ADHD, anxiety and ASD" and what that could mean for the quality of the information obtained. Personally, I'd be inclined to suggest that parents are often 'under-rated' in their contributions to autism research (see here for example) including on the specific issue of anxiety and autism (see here). But I guess every study can be improved in some respect.

What's more to say on this topic? Well, I'm minded to bring in some other, rather 'left-field' evidence for how autism and anxiety might be more intricately linked than hitherto suggested, in the form of some work looking at selective mutism and autism (see here). How, a condition centrally identifying with anxiety (selective mutism), also seemingly heightens the risk of autism being subsequently diagnosed well beyond what would be expected. I don't doubt that there other examples of anxiety-related conditions also potentially increasing the likelihood of autism presenting clinically further strengthening the 'beyond just comorbidity' sentiments.

And set within this emerging research/clinical picture [2], we then go back to the idea that some autistic traits might be 'promoters' of something like anxiety in the context of autism, and back to the important question of what to do about them...

----------

[1] Shephard E. et al. Early developmental pathways to childhood symptoms of attention-deficit hyperactivity disorder, anxiety and autism spectrum disorder. J Child Psychol Psychiatry. 2018 Jul 2.

[2] Spain D. et al. Social anxiety in autism spectrum disorder: A systematic review. Research in Autism Spectrum Disorders. 2018; 52: 51-68.

----------

Once more... listen to parents: on the identification of the early behavioural signs of autism

"The results suggest that parents may detect some clinically informative behaviors based on their day-to-day observations more readily than do clinicians during brief clinical assessments."

So said the findings reported by Lori-Ann Sacrey and colleagues [1] who compared the views of parents "of children at high-risk of autism spectrum disorder (ASD; have an older sibling with ASD)" with clinicians opinions when it came to reporting on around 20 clinical signs that could indicate the presence of autism.

Clinicians relied on the Autism Observational Scale for Infants (AOSI) to make their judgements and parents used the Autism Parent Screen for Infants (APSI) (a sort of parent-version of the AOSI) for theirs when infants were between 12 and 18 months of age. Infants being 'observed' subsequently underwent "a blind independent diagnostic assessment for ASD at 36 months of age" to see how accurate those earlier parent and clinician observations were.

The old adage that 'parents generally know their children best' shines through in the Sacrey results with "parent-reported symptoms being better able to differentiate between children with and without ASD at both 12 and 18 months of age compared to clinician observations during a brief office visit." No, most parents aren't experts when it comes to child development and no, typically they aren't seeing lots of children on a day-to-day basis who may present with various developmental issues including autism. But... compared with an often "brief clinical assessment", all those day-in day-out observations that are made - particularly when autism is 'already a part of the family' - do seem to count for quite a bit. Once again, we would all do well to listen to parents (see here) and any concerns they have about their child's development. I might add that combined with the recording technology available to most people these days and the tendency for many parents to document their child's every developmental move, there is potentially plenty of data available for further analysis (see here).

There are a few other issues that could come into play as a result of the Sacrey and other, related but independent findings. I tend to go on quite a bit on this blog about how various 'comorbidities' (if I can still call them that) seem to be over-represented when it comes to a diagnosis of autism. One of the more prevalent ones is that of bowel / gastrointestinal (GI) issues (see here) which is becoming more readily accepted in various circles as being a part of the clinical picture for quite a few people on the autism spectrum. I've talked before about how parents were/are typically the first ones to pick up the bowel-side of things and how, their observations of their own child's bowel symptoms, can on many occasions, provide some important 'pointers' to the professionals (see here). I see the Sacrey work as an extension of this other research, as the message 'listen to parents' continues to be a consistent theme.

----------

[1] Sacrey LR. et al. Parent and clinician agreement regarding early behavioral signs in 12- and 18-month-old infants at-risk of autism spectrum disorder. Autism Res. 2018 Jan 22.

----------

Could early sleep characteristics "constitute one clinical sign of ASD risk"?

Could problematic early sleep behaviours constitute one sign of autism?

That was the question asked and partially answered in the paper by A. K. Danny Nguyen and colleagues [1] who set out to "estimate prospective associations between infant sleep characteristics at 12 months and later ASD [autism spectrum disorder] screening scores at 24 months."

Based on data obtained for over a thousand children and their mothers enrolled on the "Conditions Affecting Neurocognitive Development and Learning in Early Childhood longitudinal birth cohort study" (CANDLE study), researchers measured several sleep characteristics in young infants at approximately a year old ("nighttime and daytime sleep, night wakings, and sleep onset latency") and then at 2 years of age, screened them for the signs and symptoms of autism.

Researchers reported that: "The number of night wakings was the only sleep characteristic at 12 months to be significantly associated with the development of early ASD symptoms at 24 months." Whilst an important finding, this suggests that despite the authors' claims that: "Infants with more sleep problems by 12 months, especially those waking more often during the night, showed an increased number of early ASD symptoms a year later", early sleep behaviours are perhaps not yet ready to go 'mainstream' as a clinical sign of autism. I say this also because once again (see here), we have two variables being measured at two different time periods in the Nguyen study...

But just before anyone thinks I'm poo-pooing sleep as a potentially important factor when it comes to autism, I'm not. I've for example, covered other (independent) research suggesting that infant sleep duration at 3-4 months objectively measured via actigraphy might be important for girls in particular when it comes to autism (see here). I've also talked about issues such as sleep apnoea as being important to some autism too (see here). Sleep (perhaps alongside other issues) is worthy of a lot more research and clinical attention in the context of autism.

But as a specific 'clinical sign of ASD risk'? I stand by initial reaction for now...

----------

[1] Nguyen AKD. et al. Prospective Associations Between Infant Sleep at 12 Months and Autism Spectrum Disorder Screening Scores at 24 Months in a Community-Based Birth Cohort. J Clin Psychiatry. 2018 Jan 2;79(1). pii: 16m11127.

----------

Various symptoms cluster around psychosis but...

The findings reported by Abigail Livny and colleagues [1] provide some [brief] blogging fodder today. Looking to "characterize the symptoms of patients later hospitalized for psychotic disorders in primary mental health outpatient settings" researchers found several variables seemed to be *correlated* in their target population (N=1092).

So: "thought disorder, perceptual abnormalities, poor orientation, and suicidality was associated with an increased risk for hospitalization for nonaffective psychotic disorder" as a function of various time periods. The hazard ratios (HRs) produced were not to be sniffed at. The authors concluded however that: "Despite the increased risk, the positive predictive values of this symptom cluster were low" suggesting that looking for such a symptom cluster does not necessarily guarantee prediction of "later hospitalization for nonaffective psychotic disorder."

It remains the holy grail of psychiatry to be able to 'predict' who might go on to develop something like a clinical diagnosis of psychosis or other related condition and onward, target those vulnerable groups/people with appropriate screening and other required services. Whilst there is seemingly no end of potential 'behaviours to watch for' (indeed, conditions/labels to watch for too), the fact of the matter is that we still don't [reliably] know who will or won't go to develop psychosis. And I doubt that position will change very much without some greater focus on biological 'risk' markers also added to the mix (see here and see here for examples)...

----------

[1] Livny A. et al. A Population-Based Longitudinal Study of Symptoms and Signs Before the Onset of Psychosis. Am J Psychiatry. 2017 Nov 28: appiajp201716121384.

----------