On 'negative first impressions' and autism: even those on the autism spectrum are prone to them

The findings reported by Ruth Grossman and colleagues [1] talking about 'perceptions of self and others' in the context of autism are really quite intriguing. Researchers reported that when adolescents, either diagnosed with or without autism, were shown brief video clips of adolescents with and without autism (and not explicitly being told about whether actors were autistic or not), "all participants provided more negative judgments of autistic than neurotypical adolescents in the videos." I've hyperlinked that mention of the word 'neurotypical' to some previous discussions on this blog about how this term really is a misnomer...

OK, let's rewind a little. Grossman et al mention that: "Neurotypical adults often form negative first impressions of individuals with autism spectrum disorder and are less interested in engaging with them socially." Such sweeping sentiments are based on other research that she has been involved in (see here) observing that "the social presentations of individuals with ASD, particularly their non-verbal cues, including prosody, facial expressions, and body posture, are perceived less favorably and are associated with reluctance on the part of observers to pursue social engagement" [2]. I should add that 'undergraduates' were the "rating participants" on that research occasion; a participant group who may not be as representative of the general population [3] as many people might think.

Further study in this area [4] revealed that diagnostic disclosure and "increased autism understanding" seemed to improve such first impressions. They also revealed that once again, the diagnosis known as schizophrenia was viewed even less favourably; heaping yet more stigma and misery on to this label and those diagnosed with it.

The most recent Grossman findings added a new dimension to such 'first impression' research by including young adults with autism into their study. They specifically started out by mentioning that: "individuals with autism spectrum disorder actively seek out the company of others who share their diagnosis", I assume, on the basis that 'like attracts like' across various types of relationship, and 'shared' characteristics might be more likely to provide shared viewpoints and shared understanding. That's the [sweeping] theory anyway. The fact however that those on the autism spectrum were seemingly not immune to those initial negative judgements "without being explicitly informed of a shared diagnosis" kinda implies that at least when it comes to first impressions, those on the autism spectrum aren't so dissimilar from those results from the not-autism cohort.

Should anyone be surprised by these findings? Well, I was initially taken aback by them, particularly when so much was (and still is) made of the idea that society and it's 'reactions' to autism is part of the reason why some of those on the autism spectrum feel disabled. I don't want to get into any ideological debates or discussions about the application of the social model of disability to autism ("disability is caused by the way society is organised, rather than by a person’s impairment or difference") but I can think of some occasions where those original 'first impression' findings were suggested to be supportive of such a model. The Grossman findings also don't discount the social model of disability; indeed they're supportive of it from a first-impressions point of view. But they do blur the distinction between autism and 'neurotypical' in terms of who makes those first impression responses. In short, a diagnosis of autism does not seemingly mean prejudice-free nor does it necessarily mean that everyone on the autism spectrum probably wants to, or necessarily seeks out, the company of like-minded spectrum people. Yet again, sweeping generalisations about autism falls...

I would like to see more investigations done in this area. I've talked about the use of the student population in this post already, so the next step would be talking to your average Joe or Josephine who doesn't rely on getting a 'class credit' for their study participation to gauge their views. It's also important to see whether variables like baseline 'familiarity' with autism (if there is such a thing!) or chronological age of raters are also consistent with such findings: are older folk for example, who've lived a little longer and experienced a bit more in their lives, more or less likely to hold a particular 'first impression' view of autism? Does it also vary according to the 'severity' of autism presentation?

Assuming also that it is rather difficult to significantly impact on one persons first impression of another, I'd like to know further details about why those negative judgments were formed. 'Social skills' were part-and-parcel of the Grossman analyses but this covers quite a lot of ground. We are also told that: "Both participant groups spent less time gazing at videos of autistic adolescents" implying that poise, posture and other physical features/characteristics might similarly be important in grabbing and keeping someones (positive) attention. Going back to the previous research where the (mis)label of schizophrenia was mentioned, I'd also like to see the inclusion of autistic voices when it comes to this area too. So, do the same prejudices about something like schizophrenia hold for those on the autism spectrum? What about other mental issues and illnesses such as depression and/or anxiety? I say this also bearing in mind that labels like schizophrenia, depression and anxiety are sometimes not unfamiliar facets of the autism spectrum (see here and see here), in a world where autism typically does not exist in a diagnostic vacuum (see here)...

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[1] Grossman RB. et al. Perceptions of self and other: Social judgments and gaze patterns to videos of adolescents with and without autism spectrum disorder. Autism. 2017. July 17.

[2] Sasson N. et al. Neurotypical Peers are Less Willing to Interact with Those with Autism based on Thin Slice Judgments. Scientific Reports. 2017; 7: 40700.

[3] Hanel PHP. & Vione KC. Do Student Samples Provide an Accurate Estimate of the General Public? PLoS ONE. 2016;11(12):e0168354.

[4] Sasson NJ. & Morrison KE. First impressions of adults with autism improve with diagnostic disclosure and increased autism knowledge of peers. Autism. 2017 Oct 1:1362361317729526.

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Robot-mediated intervention and autism: fun but is it genersalisable?

For any Sci-Fi fan like me, mention of the word 'robot' conjures up various iconic images. Outside of the obvious, you have lovable robots like Twiki from the 1980s film/series that was Buck Rogers in the 25th Century. You also have the not-so-lovable robots like the Cylons from the original (and best) film/series that was Battlestar Galactica or even the spider robots designed (on screen) by a member of Kiss (yep, you heard me right). There are lots of examples.

These days the early dreams that robots might become an integral part of modern living have kinda come true albeit typically without the homicidal intent that their portrayal almost always seemed to imply. These days robots are our friends and helpers and are seemingly present in many areas of our modern infrastructure...

Set in this context the paper by Clare Huijnen and colleagues [1] provides a welcome analysis of the "roles, strengths and challenges of robot-mediated interventions using robot KASPAR [Kinesics and Synchronisation in Personal Assistant Robotics]  for children with autism spectrum disorder (ASD)." Authors concluded that there are some strengths to the application of robots to intervention with autism in mind, but also a few 'be careful' issues too...

Just in case you might not know, KASPAR is a social robot designed to "act as a social companion" to improve quality of life for children on the autism spectrum [2]. He/she/it is a little jarring to initially see (Leatherface sprung to mind) but works on the premise that as a robot he's 'safe and predictable' and because of that predictability, he might provide a good opportunity to help children on the spectrum learn certain skills, particularly around social interaction and communication. Noble sentiments.

Huijnen and colleagues decided to ask various care and education professionals - presumably with an interest in autism - about their views on KASPAR. Specifically: what role he/she/it might play, alongside the strengths and potential challenges around the use of such technology. The results were interesting insofar as positives like "personalisation possibilities, its playfulness... its neutral expression,... and repetitive application of actions." There's potentially lots that a robot could do that might be useful for some children, particularly children who crave predictability.

But just as interesting and important were the down-sides to such robot use, and in particular: "difficulties with generalisation or transfer and finally potential dependence on KASPAR." In other words, we're not yet living in the 'I, Robot' world where autonomous robots walk among us, and so one has to be quite careful that children aren't just being 'trained' to interact with KASPAR or similar robots rather than real people.

I've watched the emerging 'robots for autism' scene play out in the peer-reviewed science domain. I've watched various groups proudly showcase their technology and the promises that it holds. It's great to see this embracing of tech in many areas of autism research and practice but it has, I have to admit, always left me with niggling questions and doubts. Questions/doubts about whether this is just 'cosmetic' research or whether there is real potential for such technology...

I am particularly concerned that using robot-mediated intervention in the context of autism does one thing and one thing only: it 'teaches' children to interact with a robot. It provides a false reality that, whilst initially, might produce some gains for some children, does not in the longer-term prepare children for the very complicated social world. Interacting with a robot is not the same as interacting with children in a school playground or later, interacting with people in the workplace and beyond. Interacting with a robot is not the same as sitting in a job interview or interacting with the human face(s) of our very complicated social benefits systems to ensure suitable allowances are (rightfully) provided. Interacting with a robot is, well, interacting with a robot.

I'm not totally poo-pooing this work. There may yet be potential from such robot interactions that may provide transferable skills. At the moment however, we have little to no scientific data to backup the idea that robot-mediated intervention is anything more than a fun addition to the learning experience over some long-term meaningful teaching tool. Certainly, we have nothing to suggest that social interactive skills for example, are going to be significantly improved in the longer-term by sitting down and interacting with a robot.

To close, kids, don't be swayed by your robot companions...

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[1] Huijnen CAGJ. et al. Roles, Strengths and Challenges of Using Robots in Interventions for Children with Autism Spectrum Disorder (ASD). J Autism Dev Disord. 2018. July 17.

[2] Huijnen CAGJ. et al.  How to Implement Robots in Interventions for Children with Autism? A Co-creation Study Involving People with Autism, Parents and Professionals. J Autism Dev Disord.  2017;47(10):3079-3096.

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Effects of pregnancy vitamin D deficiency on social behaviours of offspring rats

I note the findings reported by Nathanael Yates and colleagues [1] have garnered a few lay and science media headlines recently (see here) as authors concluded that "early life levels of vitamin D are an important consideration for maternal behavioural adaptations as well as offspring neuropsychiatry." Further coverage of their findings is provided in a helpful article for The Conversation (see here), where some authors - including the autism research powerhouse that is Andrew Whitehouse - provide a little more interpretation of their findings. I might also add that Whitehouse is no stranger to the vitamin D - autism research story (see here).

So, what's all the current discussion about?

Well, vitamin D - the 'sunshine' vitamin/hormone - is front and centre of this latest research, and some investigation into "how early life vitamin D deficiency during rat pregnancy and lactation alters maternal care and influences neurodevelopment and affective, cognitive and social behaviours in male adult offspring." This is set within the context that vitamin D seems to be doing a lot more than just contributing to bone health (see here). You'll of course note the use of the word 'rat' in the above text, and in particular what happened to offspring baby rats in terms of "offspring neurodevelopmental markers, ultrasonic vocalisations and adult behavioural outcomes including social, cognitive and affective-like behaviours" when mummy rat diets are loaded up with enough vitamin D as opposed to those mummy rats who were provided with a vitamin D deficient diet. The theory behind those vitamin D loaded vs. vitamin D deficient mummy rat diets is that: "In both humans and rats, a baby developing in the womb is completely reliant on the mother’s vitamin D stores." Probably something to do with the lack of sunlight exposure in the womb(!)...

Results: there did seem to be some difference across various 'test a rat / test an offspring rat' measures as a function of vitamin D status, looking across behaviour, brain scans (yes, rats did meet some MRI equipment) and also "plasma corticosterone levels and neural expression of genes associated with language, dopamine and glucocorticoid exposure." So for example, authors describe how "males that had been exposed to vitamin D deficiency in early life exhibited decreased social behaviour, impaired learning and memory outcomes and increased grooming behaviour, but unaltered affective behaviours." It's not difficult to see the 'decreased social behaviour' links that *could* be made with a condition / label / diagnosis like autism; particularly when vitamin D has quite the peer-reviewed research history with autism in mind (see here).

Interestingly too, but not made too much of in the chatter about this study for obvious reasons, were the observations made around maternal care as a function of vitamin D status, bearing in mind that vitamin D deficiency will probably impact both mummy rat and baby rat. So: "the quality of maternal care was decreased in dams consuming a vitamin D-deficient diet." Mmm...

Whilst this is important work, and adds to our understanding that appropriate nutrition throughout the lifespan is important to various aspects of functioning, I'll reiterate that this was research using rats. Rats not humans. It is perhaps timely that at around the same time that the Yates paper was published, I also chanced upon some discussion over at Spectrum on how we all need to be a little bit careful when talking about modelling autism in various animals (see here) and their relevance to real, often much more complicated, people (see here) and their [multiple] labels (see here).

I note that in their piece for the The Conversation, authors caution that their findings don't mean everyone who is pregnant (or could become pregnant) should rush out and load up on vitamin D so as to potentially influence offspring developmental course. I would second that view; but would also direct your attention to some Government advice quite recently (at least here in Blighty) that we should perhaps all be thinking about vitamin D supplementation (see here) and the many and varied ways that this vitamin/hormone *might* impact on our physiology and beyond (see here).

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[1] Yates NJ. et al. Vitamin D is crucial for maternal care and offspring social behaviour in rats. J Endocrinol. 2018 May;237(2):73-85.

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Music therapy for social skills in autism: RCT says not...

"Adding IMT [improvisational music therapy] to the treatment received by children with ASD [autism spectrum disorder] did not improve social affect or parent-assessed social responsiveness."

So said the report published by Crawford and colleagues [1] commenting on recent research [2] observing that IMT might be 'music to the ears' but seemingly not so when it comes to altering symptom severity in the social affect domain of autism.

I'm no expert on IMT in any context so approach this topic with some caution. I remember quite a few years back watching and hearing about sessions where IMT was used as part of a schedule of interventions in the context of autism (see here) and thinking at the time, that it's inclusion seemed like quite a good idea. The data from Bieleninik and colleagues [2] perhaps urge caution that 'sounding good' might not necessarily translate into better outcomes when put under the scientific microscope.

So, 360 or so children diagnosed with ASD were randomised to receive either 'enhanced standard care' (ESC) or ESC + IMT (IMT delivered at high- and low-frequency among this group). I have to say that whilst ESC initially sounded pretty good, I was a little disappointed to hear that it meant "usual care as locally available plus parent counseling to discuss parents' concerns and provide information about ASD." Parent counselling? Remind me what year we're in if this is all we've got under the label of ESC.

After 5 months of ESC and ESC+IMT the scores on the Autism Diagnostic Observation Schedule (ADOS) social affect domain showed... no significant difference between the groups. Even most of the secondary outcomes (17 of 20) showed no significant difference. In short, IMT added to that ESC failed to significantly impact on social affect compared to ESC alone.

An accompanying editorial on the Bieleninik findings [3] talked about the implications of the trial results particularly in light of a previous Cochrane review [4] which suggested that "music therapy may help children with ASD to improve their skills in primary outcome areas that constitute the core of the condition including social interaction, verbal communication, initiating behaviour, and social-emotional reciprocity." The authors urge caution that the previous Cochrane review examined various different types of music therapies for example and whilst coming out on the side of music therapy for autism, determined the scientific quality of available research at that time to be "as either moderate or low quality."

Where next for IMT? Well, I'm going to be a bit more up-beat about this intervention that usual. I say that on the basis that music therapy is probably going to be one of the more 'risk-averse' interventions put forward for autism (first, do no harm and all that). Whilst social affect was not seemingly 'statistically' affected by its inclusion as an intervention option, this does not mean that other facets of autism - whether core or peripheral - might not benefit from its use with some people on the autism spectrum. On this note, I'll refer you to the paper by Pavlicevic and colleagues [5] and the suggestion that "long-term shared therapeutic musicking provides young adults with ongoing opportunities for experiencing confidence and self-esteem, with feelings of shared acceptance and success." Music to the ears eh?

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[1] Crawford MJ. et al. International multicentre randomised controlled trial of improvisational music therapy for children with autism spectrum disorder: TIME-A study. Health Technol Assess. 2017 Oct;21(59):1-40.

[2] Bieleninik L. et al. Effects of Improvisational Music Therapy vs Enhanced Standard Care on Symptom Severity Among Children With Autism Spectrum Disorder: The TIME-A Randomized Clinical Trial. JAMA. 2017 Aug 8;318(6):525-535.

[3] Broder-Fingert S. et al. Music Therapy for Children With Autism Spectrum Disorder. JAMA. 2017; 318(6): 523-524.

[4] Geretsegger M. et al. Music therapy for people with autism spectrum disorder. Cochrane Database Syst Rev. 2014 Jun 17;(6):CD004381.

[5] Pavlicevic M. et al. Making music, making friends: Long-term music therapy with young adults with severe learning disabilities. J Intellect Disabil. 2014 Mar;18(1):5-19.

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Maternal immune history and autism (social) symptom severity

"Pregnant mothers' asthma and allergies linked to more severe autism in their children" went one of the media headlines discussing the findings reported by Patel and colleagues [1]. Drawing on data derived from the "Western Australian Autism Biological Registry (WAABR)" researchers set out to examine whether "having an immune or autoimmune-driven MIA [maternal immune activation] is associated with increased severity of ASD [autism spectrum disorder] symptoms for the child."

The conclusions arrived at: "a positive immune history (allergies or asthma) was associated with increased severity of social symptoms in child." Said data derived from 220 families/children who were quizzed about "the medical history of the biological mother, where details regarding any diagnosed illnesses or chronic conditions were reported, along with age of any diagnosis" alongside the use of more direct measures to ascertain autistic traits in children: Autism Diagnostic Observation Schedule-Generic (ADOS-G) and the Social Responsiveness Scale (SRS).

One obviously has to be a little cautious about such results where the study was conducted 'retrospectively' and what this could mean in terms of recall [2] (although, I hasten to add, other studies of maternal recall vs. medical records in the context of autism are actually quite promising). That no objective confirmation of the presence of allergy or autoimmune disease via direct testing for example, were included in this publication is also something to be a little careful about (I'm pretty sure however, someone would know if they had received a diagnosis of coeliac disease or not for example).

So what do the results mean and what are the implications? Well, MIA - maternal immune activation - in the context of offspring autism risk is not something new (see here and see here for examples) as the authors mention in their paper. Added to work talking about how inflammation, a process that is part-and-parcel of immune function, might have the ability to 'affect' social cognitive processing (see here) one might see further evidence for how the immune system seems to be doing quite a bit more than just protecting us from the odd pathogen or two. This might be particularly relevant during pregnancy; a time when a reprogrammed immune system is in place to prevent mum's body from 'rejecting' the developing foetus and associated systems.

"Findings support the role of an immune system-mediated subtype in ASD, which may be driven by MIA and changes in levels immune markers. Identification of such a subtype in ASD will enable more streamlined diagnosis and management in clinical environments." Yes, alongside acknowledgement that there may be an 'immune phenotype' of autism (see here), the authors do mention the potential future use of "immune-modulating pharmacotherapies" in the context of the growing evidence base for MIA and risk of offspring autism. Such options are already being explored in the animal research domain as per those findings from Vuillermot and colleagues [3] and how "early dietary supplementation with vitamin D may open new avenues for a successful attenuation or even prevention of neurodevelopmental disorders following maternal inflammation during pregnancy." Vitamin D and autism is already quite a hot topic (see here for example). And things don't just stop at vitamin D neither (see here for another example) as further investigations are warranted with the hope that children with possible 'MIA autism' (if I can use that term) are "able to function and integrate into the world... [and] have a level of independence" required to do so successfully (and of course, happily).

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[1] Patel S. et al. Social impairments in autism spectrum disorder are related to maternal immune history profile. Molecular Psychiatry. 2017. Oct 10.

[2] Ozonoff S. et al. Reliability of parent recall of symptom onset and timing in autism spectrum disorder. Autism. 2017 Sep 1:1362361317710798.

[3] Vuillermot S. et al. Vitamin D treatment during pregnancy prevents autism-related phenotypes in a mouse model of maternal immune activation. Mol Autism. 2017 Mar 7;8:9.

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How helpful is a 'geek index'?

A quote to begin: "male offspring of older fathers had higher ‘geek index’ scores, a composite measure of high IQ, strong focus on the subject of interest and social aloofness."

So said the findings published by Magdelena Janecka and colleagues [1] (open-access) who set out to determine whether "having an older father is associated with certain beneficial traits" in offspring. Their use of the term 'geek index' (GI) was derived from a "composite measure of non-verbal intelligence, restrictive interests and reduced need to fit in with the peer group" based on data derived from the TEDS (Twin Early Development Study) initiative (something that has cropped up before on this blog). As one might imagine, use of the term 'geek index' in a science article was always likely to make some media headlines (see here for example).

In terms of study design and numbers, this was a biggie with study participants in the thousands. The geek index was derived from scores "of (i) non-verbal intelligence, (ii) restrictive and repetitive behaviours (RRBs) and (iii) social aloofness." Further: "Scores on the Raven’s Standard Progressive Matrices test were used to obtain (i). Childhood Autism Spectrum Test (CAST) scores were used to obtain both (ii) and (iii)." Various statistical 'transformations' were conducted on said scores to give that geek index sum and, not forgetting the parental age bit, paternal age was also thrown into the statistical mix.

As per the opening sentence, those children born to older fathers (but not older mothers) seemed to more frequently present with a higher geek index. This association persisted after controlling for various potentially confounding variables: "maternal age, sex, zygosity and SES [socio-economic status]." Researchers further observed that: "GI was positively linked with future academic attainment—including the key predictors of future SES—suggesting a phenotypic advantage in the offspring of older fathers."

These are interesting results and notwithstanding some study limitations i.e. "It was not possible to determine whether the advantageous effects of GI extend beyond secondary education, and correlate with future SES" require further independent investigation. Offspring being born to older fathers has generally been associated with various less-than-positive outcomes so this article kinda paints a more positive picture for children and families. Indeed, one of the commentators talking about these findings suggests that "perhaps we are destined for future society of geniuses that are going to help us solve all the world's problems." One would hope so.

As per the title of this post, I would however question how useful/helpful the term 'geek index' is when it comes to outcomes and implications. Yes, I know there is such a thing as 'geek chic' these days, but let's not forget that the word 'geek' has it's primary origins as a term of ridicule in many languages. To quote one definition: "the word typically connotes an expert or enthusiast or a person obsessed with a hobby or intellectual pursuit, with a general pejorative meaning of a "peculiar person, especially one who is perceived to be overly intellectual, unfashionable, or socially awkward."" I'm not so sure that every child (youngster or teenager) would be particularly happy to be labelled as scoring high on a geek index. Surely something a little more scientific could replace such a term?

Going also back to those study caveats provided by the authors, I might also raise the idea that just because someone shows an intellectual advantage when it comes to something like STEM (science, technology, engineering and mathematics) subjects does not necessarily mean that their future is going to be a rosy one in terms of employment, income or other markers of SES. “If you look at who does well in life right now, it’s geeks” is one of the quotes attributed to the first author of the paper; and with it as massive a sweeping generalisation as you will ever see.

If we for example, assume that strengths in STEM might be over-represented when it comes to the autism spectrum (see here) we should be seeing lots and lots of people either diagnosed with autism or possessing significant autistic traits thriving in such roles and in life in general. The reality however is that skills pertinent to STEM often do not appear in a vacuum (see here) as I would put forward the suggestion that future research might also consider the possibility of a relationship between the geek index (or other term) and the presentation of something like anxiety or depression and how that might also impact on later adult outcomes for example. The additional idea that social aloofness also makes up part of the geek index is something else that needs quite a lot more work on as part of any 'advantage' arguments being put forward...

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[1] Janecka M. et al. Advantageous developmental outcomes of advancing paternal age. Translational Psychiatry. 2017. 7; e1156.

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[Objective] exposure to flame retardants and social behaviours

Although a few details of the study reported by Shannon Lipscomb and colleagues [1] (open-access) interested me, I was particularly taken by their use of "a silicone passive wristband sampler [worn] around his/her wrist or ankle" to "assess the child’s exposure to flame retardants" as part of their investigation "to determine if flame retardant exposure was associated with measurable differences in social behaviors among children ages 3–5 years."

I've covered the topic of potential adverse effects associated with exposure to flame retardants such as brominated diphenyl ethers (BDE) before on this blog (see here and see here for examples). Such compounds are listed as POPs (persistent organic pollutants) because of their ability to endure in the environment, accumulate in the body and potentially [adversely] affect various biological systems. In other words, these are compounds that might well have served an important purpose at one time - flame retardants - but are now realised to have quite a risk profile attached to them. Sounds familiar doesn't it?

Anyhow, Lipscomb et al relied on other research [2] suggesting that various compounds/chemicals can be sequestered from silicone wristbands - those plastic things that many people wear for various causes - with the right equipment and under the right circumstances. To any analytical chemist, this is probably scientific music to their ears. They "extracted and analyzed for 41 different flame retardant compounds using gas chromatography mass spectrophotometry" and focused on 11 compounds "PBDE-47, PBDE-99, PBDE-153, PBDE-154, PBDE-49, PBDE28 + 33, tris(1,3-dichloro-2-propyl) phosphate], TPP [e.g. triphenylphosphate], TCPP [e.g tris(1-chloro-2-propyl) phosphate], and TCEP [e.g. tris(2-chloroethyl) phosphate" that were quite readily present in 60% or more of wristbands. For some of the compounds the authors generated a 'sum of' score; for example: "ƩPBDEs is the total amount of PBDE-47, PBDE-99, PBDE-153, PBDE-154, PBDE-49, and PBDE28." Social behaviours by the way, were scored by teachers in the preschool setting of participants using the Social Skills Improvement System - Rating Scales.

Results: 92 children were initially recruited onto the study but only 77 children returned their wristbands intact (i.e. some of them 'went through the laundry'). Further: "a final sample size of 69 children with complete data... were included in the final analyses." Then: "Bivariate analysis revealed modest correlations between flame retardant exposure and some of the social behavior subscales." What this suggests is that there may be some evidence that such compounds (including organophosphate-based flame retardants (OPFRs)) might impact on aspects of social skills development but there are constraints based on the sample size used and the reliance on one primary measure of social skills for examples.

As per the previous sentence, I'm not totally convinced by this data but am still really interested in the use of wristband samplers described by Lipscomb and colleagues. I can see how this kind of objective measure of exposure could really add another dimension to lots of different areas of research on environmental exposures in relation to various labels. Take for example the quite complicated area of research talking about maternal air pollution exposure and offspring autism risk (see here). Instead of just relying on postcode (zip code) in relation to mapping (estimating) pollution exposure, one could potentially adapt the chemical assay to screen for particulate matter for example, as collected on those wristbands. Certainly an easier way than lugging around a portable air monitor I would have thought. No doubt there are also other uses for such simple solutions...

Music: Europe - The Final Countdown. 80s rock hairstyles at their best and perhaps an apt song given what happened here in Blighty yesterday...

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[1] Lipscomb ST. et al. Cross-sectional study of social behaviors in preschool children and exposure to flame retardants. Environmental Health 2017; 16: 23.

[2] O'Connell SG. et al. Silicone Wristbands as Personal Passive Samplers. Environ. Sci. Technol. 2014; 48: 3327–3335.

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Lipscomb ST, McClelland MM, MacDonald M, Cardenas A, Anderson KA, & Kile ML (2017). Cross-sectional study of social behaviors in preschool children and exposure to flame retardants. Environmental health : a global access science source, 16 (1) PMID: 28274271

Subgroups in autism (without intellectual disability)

"Children with ASD [autism spectrum disorder] without ID [intellectual disability] could be differentiated into Moderate and Severe Social Impairment subgroups when core ASD symptoms were more closely examined."

So said the findings reported by Felicity Klopper and colleagues [1] looking at an important part of the autism research scene related to the 'plurality' of the term autism and the seemingly vast range of presentations included under the label. Reliant on data obtained from "the ‘gold standard’ ASD diagnostic instruments" (including the ADOS and ADI), researchers looked at the "presence of phenotypic subgroups" in their cohort.

As per the opening sentence to this post, there were some differences to be seen in the cohort, and in particular, how social interaction issues might be a key part of any differentiation. The authors talk about how social interaction issue differences seemed to tie into other core behavioural features such as communication and the presence of restricted/repetitive behaviours. They concluded: "both categorical and dimensional approaches may be useful in classifying ASD, with neither alone being adequate."

It is not necessarily new news that the label of autism is good for diagnosis but seemingly says little about the range of presentation included under the heading (see here for example). Indeed, in these days of ESSENCE I might forward the view that even the label autism might be part of a wider heterogeneous presentation (see here) and one should further expand those subgroup notions at the label as well as symptom level. The focus on overt behaviour (as assessed by those gold-standard instruments) in the Klopper study is but one part of looking at such 'heterogeneity' (see here for example) as the authors argue that: "The dissociated profiles of ASD features could represent different underlying neurobiological mechanisms for each subgroup." At least one of the authors on the Klopper paper probably, more than most, realises that fact (see here).

There are other key areas to this focus on the presentation of autism that also need to be factored in: sex differences and comorbidity profiles. Specifically, the growing realisation that girls and boys on the autism spectrum probably show subtle differences in presentation (see here) and, minus any sweeping generalisations, should be considered in future studies in this area. Oh, and keep in mind that those diagnosed with autism with an intellectual disability (ID) could also be 'sub-grouped' according to symptom presentation too with similar caveats. The question is: how many sub-groups of autism will we eventually end up with?

Music, and because Spring has Sprung... In Bloom.

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[1] Klopper F. et al. A cluster analysis exploration of autism spectrum disorder subgroups in children without intellectual disability. Research in Autism Spectrum Disorders. 2017; 36: 66-78.

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Felicity Klopper, Renee Testa, Christos Pantelis, & Efstratios Skafidas (2017). A cluster analysis exploration of autism spectrum disorder subgroups in children without intellectual disability Research in Autism Spectrum Disorders : 10.1016/j.rasd.2017.01.006

Social interaction and autism: it takes two to tango

Psychology experiments are not generally fodder for this blog when it comes to autism. The main reason being that quite a few appearing in the peer-reviewed literature tend to look at quite abstract features perhaps somewhat removed from the daily lives of autistic people and their significant others. A few also seem to struggle with the idea that grand over-arching psychological theories (that seem to inevitably follow psychological findings in particular) are not required when it comes to autism in these days of heterogeneity and plurality.

I am making an exception today however with the paper by Noah Sasson and colleagues [1] (open-access) and their findings suggesting advocating "for a broader perspective of social difficulties in ASD [autism spectrum disorder] that considers both the individual’s impairments and the biases of potential social partners." In other words, it takes two to [socially, interactively] tango. I might add that a doctoral thesis by one of the co-authors on the Sasson paper (Daniel Faso) is also available for further inspection too (see here).

Based on the idea that issues with social interaction "quantity and quality" might not be something exclusively under the control of those diagnosed with autism, Sasson et al devised a series of experiments to test their hypothesis: "three studies conceived and conducted independently by three research groups assessing observers’ first impressions of—and intentions to socially engage with— children and adults with ASD based upon “thin slices” of their real-world social behavior." I'm not going to go into too much detail about the experiments because the paper is open-access and you can read about them for yourselves. 'Thin slices' in the context of the experiments carried out referred to media that were rated pertinent to "observers’ first impressions of individuals with ASD engaging in real-world social behavior."

The results make for some important reading as across the different experiments undertaken the key messages were that: "first impressions of individuals with ASD are significantly less favorable than those of matched TD [typically developing] controls, and are associated with greater reluctance on the part of observers to pursue social engagement." Further: "social interaction difficulties in ASD are not solely an individual impairment but also a relational one, and consideration of both of these factors is necessary for a full understanding of social impairment in ASD." I relay all of that bearing in mind that these were experiments carried out under controlled conditions (I don't know about you, but I don't generally rate people at first contact using a "0-3" Likert scale or a "non-graduated slider" on 'how approachable' they were or the likelihood of a friendship developing).

Although important, I don't think anyone should be too surprised by the results reported in the context of how first impressions count and how people are generally quick to judge from "personality and character traits" whether social engagement with a person or group of people is going to be a short or longer-term thing. I say this also bearing in mind that minus any psychobabble, people generally take into account things like context, familiarity and similarity when it comes to their social interaction decisions too [if for example, you happen to be a fan of Star Wars or a Shotokan karateka, I might be more inclined to chat with you than say if you talked about the goings-on on various reality TV shows]. Indeed, the authors note: "these studies present only group-wise comparisons and do not address individual differences among those with ASD, nor whether individual characteristics of the raters (e.g., gender, personality, etc.) affect the results reported here." I'd also forward the idea that they might also include important concepts such as self-monitoring for example when it comes to future studies in this area. Similarly, it would also be handy to see if 'comorbidity counts' when it comes to further investigations on this topic in light of expanding links between different labels and traits (see here).

The question of what to do about the Sasson findings similarly provide some food for thought. The authors suggest that: "intervention and education approaches that target both those with ASD as well as their TD [typically developing] peers may offer a more comprehensive approach for improving social and functional outcomes in autism." In the context of other studies looking at social interaction and autism particularly in the school setting (see here) I can see how this might work in terms of raising awareness of how people are not always the same when it comes to the presentation of their social persona. Intervening with a wider group (i.e. peers) and taking the onus off 'just the person with autism' is a win-win situation and will no doubt have other positive knock-on effects in terms of self-esteem and helping to remove barriers around the 'disability' framing of autism. I might add that in these days of the potential virality of personality traits, it makes sense to include everyone.

In a wider context - outside of school - and in the big, wide [adult] world however, I'm slightly less sure of how such intervention is going to be achieved. Yes, we would all love people to be more understanding and less 'judgemental' in their first (and subsequent) impressions, but when it comes to influencing aspects such as views on "awkwardness, attractiveness, [and] likability" I'm not so sure that this can be universally achieved. Indeed, facets such as attractiveness and likability are probably going to be influenced by lots of variables outside of those just linked to an autism diagnosis and its presentation (frank or not). By saying all that, I'm not suggesting that we shouldn't try to educate and perhaps even move people away from the whole 'first impressions last' [2] thing, but rather am looking at the realistic prospect of achieving such a societal goal, mindful that it takes two to tango...

And on the topic of first impressions, at least get the handshake right (i.e. let go)...

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[1] Sasson NJ. et al. Neurotypical Peers are Less Willing to Interact with Those with Autism based on Thin Slice Judgments. Sci Rep. 2017 Feb 1;7:40700.

[2] Gunaydin G. et al. Impressions Based on a Portrait Predict, 1-Month Later, Impressions Following a Live Interaction. Social Psychological and Personality Science. 2017. 8: 36-44.

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Sasson NJ, Faso DJ, Nugent J, Lovell S, Kennedy DP, & Grossman RB (2017). Neurotypical Peers are Less Willing to Interact with Those with Autism based on Thin Slice Judgments. Scientific reports, 7 PMID: 28145411

On "socially successful elementary school-aged children with autism"

"School-based interventions should address malleable factors such as the number of peer connections and received friendships that predict the best social outcomes for children with ASD [autism spectrum disorder]."

So said the study findings reported by Jill Locke and colleagues [1] looking at "the stable (unlikely to change) and malleable (changeable) characteristics of socially successful children with ASD."

Mindful that the phrase 'socially successful children' is perhaps not one that I'm particularly enamoured with, and certainly not one that necessarily opens the doors to 'successful' academic outcomes in childhood for example (see here), the Locke paper makes for interesting reading.

Looking at nearly 150 "elementary-aged children with ASD" authors listed a number of factors linked to 'playground peer engagement' and 'social network salience ' a.k.a playing with other children in the school yard and "inclusion in informal peer groups." The severity of autistic symptoms was unsurprisingly a key feature as was those numbers of 'peer connections' and 'received friendships'.

What do these results mean? Well, minus sweeping generalisations, there may be some pretty easy ways that 'social outcomes' can be positively influenced for at least some children on the autism spectrum; not least one important variable: friends. Yes, a shocker I know.

I've used the term 'easy ways' and 'friends' in that previous sentence to denote how [sometimes] complicated and expensive/resource intensive interventions to 'increase social outcomes' when it comes to the label of autism really might not be the most effective use of resources. I however understand that friends, real friends, are not just something that can be magically produced on demand and that also friendships, whilst in the end generally worthwhile, are not without their own stresses and strains (some of which might be even more stressful and strainful(!) for a child on the autism spectrum).

One approach that does seem to be finding some favour in the peer-reviewed domain at least is that of employing a buddy system. The findings reported by Laushey & Heflin [2] whilst not without their methodological issues, provide some important assertions that a peer buddy approach might be something for schools to consider for some pupils with autism. I know some people might argue that a buddy is not the same as a friend but I'm not one of the them: opportunity (not necessity) is the mother of invention. Visit most schools (at least in here in the UK) and you will see similar arrangements being made for pupils whether diagnosed with autism or not. That and use of 'buddy/friendship stops' in certain parts of the playground and you'll see how important socialisation is viewed for all school pupils.

I'm also a greater believer that sport and exercise can be an important part of inclusion practices when it comes to autism - something equally applicable to school. Y'know, those team games that help build and forge important bonds between children particularly when it comes to competitive team games, also introducing the important concept of 'belonging'. I appreciate that finding the right sport is important in terms of likes/dislikes and ability but there are quite a few options out there. Indeed, drilling further down into the concept of 'belonging', one can perhaps see how even at elementary school age, finding your social niche can open up a whole world of new friends/associates thus implying that school clubs (e.g. Lego club, ICT club) might also be an important intervention tool too.

I don't want to come across too formulaic or mechanical when it comes to how to improve social outcomes for children on the autism spectrum because there is not one-size-fits-all 'flowchart' to this issue. Appreciating also that some children on the autism spectrum might not necessarily want to be 'social butterflies' there has to be some indication from the child as to the extent of their wants and wishes when it comes to social interaction also taken into account.

I should also remind readers that when it comes to friendships, children can be a rather fickle bunch...

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[1] Locke J. et al. Characteristics of socially successful elementary school-aged children with autism. J Child Psychol Psychiatry. 2016 Sep 13.

[2] Laushey KM. & Heflin LJ. Enhancing social skills of kindergarten children with autism through the training of multiple peers as tutors. J Autism Dev Disord. 2000 Jun;30(3):183-93.

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Locke J, Williams J, Shih W, & Kasari C (2016). Characteristics of socially successful elementary school-aged children with autism. Journal of child psychology and psychiatry, and allied disciplines PMID: 27620949

Lactobacillus reuteri rescuing [mouse] social behaviours: relevance to autism?

Continuing a recent 'probiotic theme' on this blog I've decided to talk a little about the study results reported by Shelly Buffington and colleagues [1] on how a "single species of gut bacteria can reverse autism-related social behavior in mice." I say 'talk about' but my conversations on this topic should be viewed in light of what others have also said about this study (see here for example) including the lead author (see here).

To summarise the findings: authors started from the idea that maternal obesity during pregnancy might have some implications for offspring in terms of their risk of "neurodevelopmental disorders including autism spectrum disorder (ASD)." It's something that has been covered before on this blog (see here) including the idea that inflammation or response to inflammation in-utero might be an important part of any risk mechanism (see here).

Conversations then progressed towards the possibility that the gut microbiome might play a role in that elevated risk of offspring autism following pregnancy obesity. To test this theory out, researchers fed female mice a high fat or 'normal diet' for 8 weeks, paired them for mating and gave all their offspring a regular diet. They studied social behaviour of offspring mice and observed that "MHFD [maternal high-fat diet] offspring had impaired sociability and showed no preference for social novelty."

To examine whether those mouse social behaviours were linked to the gut microbiome, researchers looked at the "bacterial composition and community structure in the feces" of offspring mice to ascertain any differences. They did find differences; indeed in one write-up of the study the authors note: "We found a clear difference in the microbiota of the two maternal diet groups." Could such bacterial differences account for the social differences noted between the groups? Quite possibly as Buffington et al reported that "co-housing one MRD [maternal regular diet] with three MHFD offspring was sufficient to rescue both the social behaviors and microbiota phylogenetic profile of MHFD offspring." Further, researchers transplanted the faecal microbiota from the MRD and MHFD offspring into germ-free mice providing "causal evidence that an imbalanced microbial ecology in the mice born to mothers on a high-fat diet is responsible for their social deficits."

Then came a big question: what was it about the maternal high-fat diet offspring microbiome that might be 'responsible' for the social issues observed? The answer or at least one answer: "L. reuteri [Lactobacillus reuteri] was the most drastically reduced (>9-fold) in the MHFD microbiota population, compared to the MRD microbiota." Subsequent addition of L. reuteri to the drinking water of MHFD offspring was instigated and: "Remarkably, treatment with L. reuteri significantly improved sociability and preference for social novelty in MHFD offspring."

As if all that wasn't enough researchers also looked at the old gut-brain axis and subsequently noted that: "L. reuteri treatment restores oxytocin levels, VTA [ventral tegmental area] plasticity and social behaviors." Oxytocin has something of an interesting possible connection to [some] autism (see here).

And rest.

As you can perhaps appreciate, this piece of research is fairly comprehensive both in terms of the methodologies used and also the findings in relation to maternal pregnancy obesity, offspring social behaviour, gut microbiome and the gut-brain axis. Certainly quite compelling evidence for some kind of effect including the concept of foetal programming allied to the idea of possible intervention.

Of course you'd be right to question whether the processes described in this mouse model would necessarily map on to the human experience and indeed the very heterogeneous autism spectrum characterised by [variable] issues with social affect for example. Similar questioning is asked of all animal studies trying to model the complexities of autism (see here). But added to other research where mouse modelling of autism 'deficits' has been to some degree 'changed' as the result of the addition of a particular bacterial species (see here) there is some reason for potential excitement. More so when one considers other research on the gut microbiome in relation to specific preparations potentially modifying the risk of 'neurospychiatric disorder' (see here) for example, and potentially affecting mood and/or behaviour (see here). Don't even get me started on toddler temperament being linked to the inner workings of the gut (see here) minus any hype.

But just before sales of Lactobacillus reuteri increase markedly there is further research to be done. Not least is the translation of elements of the Buffington research into studies of humans. Set within the idea that mapping exactly what kinds of wee beasties are residing in the gut is now fairly commonplace and has already stretched into autism research (see here) I would have thought that looking for the presence or absence of L. reuteri in certain groups (and sub-groups) on the autism spectrum and beyond should be fairly easy to do. If and when issues are found with this particular species, supplementing could be indicated bearing in mind some of the potential effects [2] noted already on this bacterium might already show indication in some cases of autism (see here). One might also see a way to look at this and other bacteria in conjunction with levels of oxytocin and possibly other important compounds too as part of that gut-brain axis. Given also that the Buffington study was a study of offspring of obese mice in terms of their sociability, does this also mean that kids born to overweight or obese mums are less likely to have age-appropriate social skills outside of any talk of autism?

There is still a research journey to be travelled in this area of investigation and, I might add, potentially linking various areas together including the idea that not all fats in a high-fat diet are necessarily the one and the same (see here)...

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[1] Buffington SA. et al. Microbial Reconstitution Reverses Maternal Diet Induced Social and Synaptic Deficits in Offspring. Cell.2016; 165: 1762-1775.

[2] Coccolrullo P. et al. Lactobacillus reuteri (DSM 17938) in Infants with Functional Chronic Constipation: A Double-Blind, Randomized, Placebo-Controlled Study. J Peds. 2010; 157: 598-602.

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Buffington, S., Di Prisco, G., Auchtung, T., Ajami, N., Petrosino, J., & Costa-Mattioli, M. (2016). Microbial Reconstitution Reverses Maternal Diet-Induced Social and Synaptic Deficits in Offspring Cell, 165 (7), 1762-1775 DOI: 10.1016/j.cell.2016.06.001

Interest in romantic relationships is high in autism

It's official: "the vast majority of high-functioning adults with ASD [autism spectrum disorder] are interested in romantic relationships." Yes, the scientific findings reported by Sandra Strunz and colleagues [1] have said as much.

Sorry to be so sarcastic about them but coming from a place where the words 'the bleedin' obvious' are commonly used, I couldn't believe that in 2016 anyone would genuinely believe otherwise. Yes, I know the autism awareness et al message still has some distance to go, but underneath every diagnostic label including autism there are people: people with hopes, dreams, wants, needs and yes, even desires...

With all due respect to the authors and the work they put into doing this study - "total sample comprised 229 high-functioning adults with ASD (40% males, average age: 35 years)" - there is an interesting detail included in their paper such that: "7% had no desire to be in a romantic relationship." What this perhaps tells us is that when it comes to reporting on issues like quality of life and long-term outcome (see here) with autism in mind, people should be wary of making sweeping generalisations. But 7% means that 93% did have a desire for romance in their lives...

Insofar as where next with this area of research, well, there are a few avenues to suggest. Intimacy as one part of a 'romantic relationship' is something still in need of a lot more discussion as and when autism is included in the mix, in terms of education and aspects like safety and sexual health for example (see here). As difficult as it might be for some to acknowledge, people are generally 'designed' for relationships with others, and even those who might present with sometimes extreme disability as a result of their autism or related issues should not necessarily be seen as asexual in terms of their wants and needs. I know this issue has crossed into the legal domain in past times and intersects with other important areas such as competence and vulnerability. There are no easy answers.

Perhaps another important area for further research concerns how romantic relationships might affect the presentation of autism or other important (over-represented) comorbidities. Y'know, in the context of how relationships might be protective against certain things and how these manifest when it comes to the autism spectrum particularly where issues like depression and anxiety are over-represented (see here). That also the 'products' of some romantic relationships (yes, the brood) can also impact on health and wellbeing is another important area requiring quite a bit more investigation with autism in mind particularly in the context of parenting experiences.

But let's not complicate matters too much and turn the wants and desires of people into something that needs to be continually scrutinised and experimentally analysed. People generally want to be close to other people and autism should not necessarily be seen as a barrier to this...

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[1] Strunz S. et al. Romantic Relationships and Relationship Satisfaction Among Adults With Asperger Syndrome and High-Functioning Autism. J Clin Psychol. 2016 May 16.

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Strunz S, Schermuck C, Ballerstein S, Ahlers CJ, Dziobek I, & Roepke S (2016). Romantic Relationships and Relationship Satisfaction Among Adults With Asperger Syndrome and High-Functioning Autism. Journal of clinical psychology PMID: 27196958

Is empathising rather than systemising linked to maths achievement?

"Contrary to our hypothesis, we found no relationship between systemizing and math achievement after controlling for domain general abilities and no relationship between the systemizing brain type (greater discrepancy between systemizing and empathizing) and math achievement."

That quote taken from the study published by Emily Escovar and colleagues [1] (open-access available here) provides some blogging fodder today. Based on some ideas proposed in autism research circles that "mathematics is purported to be an example of an ability requiring systemizing" and some rather sweeping claims about facets of autism being explained "as a high tendency to systemize" researchers set about testing the idea that being a good systemiser might make for good maths ability. I might add that previous research has demonstrated that a diagnosis of autism (and comorbidities) does not necessarily equal 'maths genius' (see here).

Drawing on data from a cohort of 112 "typically developing children" (authors words not mine) aged between 7 and 12 years old, researchers set about assessing various functions. "Intelligence was assessed using the full-scale intelligence quotient (FSIQ) of the Wechsler Abbreviated Scale of Intelligence (WASI)." Various facets of maths ability were also included for study as a function of the use of "the Woodcock Johnson III, Form A" and specifically "the Calculation, Math Fluency, and Applied Problems subtests as measures of math achievement." Researchers also sensibly included a measure of maths anxiety - the Scale for Early Mathematics Anxiety - as part of their protocol. Alongside the use of the Social Responsiveness Scale (SRS) to provide some background on presented autistic-like traits, the main event was the that: "The primary guardian of each child completed the Combined Empathy Quotient-Child (EQ-C) and Systemizing Quotient-Child (SQ-C)."

Results: from the point of view of proponents of the whole systemising-empathising thing with gender in mind, there was some good news: "There was a marginally significant gender difference on SQ-C, with boys scoring higher than girls. In contrast, boys and girls differed significantly on EQ-C with girls scoring higher than boys." This follows other work in this area (see here). But it was not all one-way traffic as per the opening statement to this post and the conclusion that "SQ-C is not an independent predictor of math achievement in children."

One particularly interesting detail did emerge from the study findings: "results demonstrate that empathizing is a previously unknown predictor of math skills in TD [typically developing] children." This was specifically based on the results of the Calculation skills subtest but was independent of gender (as an effect) and neither was explained by maths anxiety scores. Some further analysis taking into account SRS scores was undertaken and the idea that "children with higher social abilities tended to have lower math skills" emerged. Finally, just in case you might think that 'autistic behaviours' might be the driving force between empathising and maths ability, the authors have something to say about this too: "the link between empathizing and math achievement may be related to social awareness and cognition rather than autistic behaviors."

I am cautious that the Escovar findings do require replication and further investigation before any grand claims are made about autism, empathising/systemising and maths ability; not least because of the cohort used and, although a decent sized number, the requirement for even greater participant numbers. That other categories of behaviour can seemingly affect maths performance should also not be forgotten [2]. That being said, I'd like to think that there could be some really important issues to come from such work if the relationships proposed holds out. Not least is the idea that reinforcing empathising skills *might* have a knock-on effect for something like maths ability and perhaps equally important, the possibility of a downside to being a classroom 'social butterfly' from a maths perspective...

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[1] Escovar E. et al. The Empathizing-Systemizing Theory, Social Abilities, and Mathematical Achievement in Children. Sci Rep. 2016 Mar 14;6:23011.

[2] May T. et al. The role of attention in the academic attainment of children with autism spectrum disorder. J Autism Dev Disord. 2013 Sep;43(9):2147-58.

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Escovar E, Rosenberg-Lee M, Uddin LQ, & Menon V (2016). The Empathizing-Systemizing Theory, Social Abilities, and Mathematical Achievement in Children. Scientific reports, 6 PMID: 26972835

Substance use disorder and autism: a case report

Minus any sweeping generalisations, I want to bring your attention to the recent paper by Ashy Rengit and colleagues [1] today, continuing a theme of case reports discussing autism co-occurring with a substance use disorder (SUD). A SUD is generally defined as where the use of one or more substances (drugs) with psychoactive properties leads to significant impairment or distress for a person. Although some people might envisage the use of illicit drugs as being the only way to receiving a diagnosis like SUD, the label also covers more 'everyday' drugs such as problematic alcohol use for example. Indeed, alcohol use disorder (AUD) has its very own category in DSM-5.

I appreciate that this topic is generally neither good dinner-table conversation nor particularly great when it comes to the public image of autism, but as per other discussions overlapping with this topic (see here) it would be folly to ignore it. That some of the characteristics accompanying the diagnosis of autism *might* play a hand in increasing the risk of developing a SUD [2] provides an important message on the value of screening for risk of SUD and where appropriate, educating and intervening early.

Rengit et al provide some useful discussions on the "risk factors which predispose individuals with ASD [autism spectrum disorder] to developing SUD" but I hasten to reiterate that sweeping generalisations are to be avoided, including the ideas of "a positive family history for substance misuse" and the suggestion that autism might be one 'phenotype' "previously reported to be associated with cannabis use" [3] for example.

"It is relaxing in general and provides an amount of happiness" is the explanation offered by Mr. A, the participant under inspection, when it came to explaining his history of alcohol use and abuse. His relationship with alcohol, we are told, began after he graduated from high school and thereafter escalated from "one or two beers per week in solitude" to "hard liquor and wine on a daily basis." There is a familiar theme included in the Rengit paper on how a 'vicious cycle' of anxiety and depression are "perpetuated by his psychosocial limitations" and how combined with chronic worry, a pattern related to his alcohol use may be emerging in conjunction with social circumstances "eliminating his motivation to leave the house." That some of the traditional strategies for overcoming depression and anxiety only previously "showed limited benefit" also provides a rationale for how alcohol might be part and parcel of a self-medication strategy in this case. Similar sentiments have been noted in other research on this topic [4]. I might also bring to your attention the history of suicide attempt(s) reported by the authors as a consequence of "feeling overwhelmed by the new environment and social challenges" that college life brought and how it may also be relevant to discussions on the pathway to SUD in relation to autism. This is particularly relevant to some important discussions recently.

Accepting that different people have different ways and means bringing them to something like a diagnosis of SUD, the Rengit paper brings to light a potentially important but difficult issue linked to some autism. Given the increasing numbers of people being diagnosed with autism (some of them quite late in life) and how in these times of continued austerity many are being left to fend for themselves, one might appreciate that cases of SUD linked to autism are only likely to increase further. This is on top of the idea that certain comorbidity that is over-represented in cases of autism might also increase the chances of something like SUD [5]. That a SUD may further disadvantage people on the autism spectrum not just in terms of health but also in relation to obtaining and sustaining employment for example - "He was also fired from his job for being suspected of being intoxicated" - requires further study and action on both screening vulnerable populations and also managing/treating such issues quickly as and when they occur [6]. Oh, and don't forget the burden of such additional issues on caregivers too [7]...

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[1] Rengit AC. et al. Brief Report: Autism Spectrum Disorder and Substance Use Disorder: A Review and Case Study. J Autism Dev Disord. 2016 Mar 5.

[2] Tabata K. et al. Three cases of alcoholism with autism spectrum disorder. Alcohol Alcoholism. 2014 Sep;49 Suppl 1:i54.

[3] Stringer S. et al. Genome-wide association study of lifetime cannabis use based on a large meta-analytic sample of 32 330 subjects from the International Cannabis Consortium. Transl Psychiatry. 2016 Mar 29;6:e769.

[4] Clarke T. et al. Substance use disorder in Asperger syndrome: An investigation into the development and maintenance of substance use disorder by individuals with a diagnosis of Asperger syndrome. Int J Drug Policy. 2016 Jan;27:154-63.

[5] Pedersen SL. et al. The Indirect Effects of Childhood ADHD on Alcohol Problems in Adulthood through Unique Facets of Impulsivity. Addiction. 2016 Mar 21.

[6] Kronenberg LM. et al. Personal recovery in individuals diagnosed with substance use disorder (SUD) and co-occurring attention deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD). Arch Psychiatr Nurs. 2015 Aug;29(4):242-8.

[7] Kronenberg LM. et al. Burden and Expressed Emotion of Caregivers in Cases of Adult Substance Use Disorder with and Without Attention Deficit/Hyperactivity Disorder or Autism Spectrum Disorder. Int J Ment Health Addict. 2016;14:49-63.

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Rengit AC, McKowen JW, O'Brien J, Howe YJ, & McDougle CJ (2016). Brief Report: Autism Spectrum Disorder and Substance Use Disorder: A Review and Case Study. Journal of autism and developmental disorders PMID: 26944591