Psychiatric symptoms in minimally verbal kids with autism: filling a gap

The findings reported by Daniela Plesa Skwerer and colleagues [1] (open-access available here) provide the blogging fodder today. They include some important information on an under-studied group on the autism spectrum (see here) with regards to the "overall burden of psychiatric comorbidities and emotion dysregulation" in those diagnosed with an autism spectrum disorder (ASD) "who had limited verbal abilities (i.e., few to no words used spontaneously)." Such work follows the recent publication of a paper by Ginny Russell and colleagues [2] who observed that those diagnosed with autism + intellectual (learning) disability were not exactly well-represented in the peer-reviewed autism research arena.

The Plesa Skwerer paper started with the observation that various psychiatric symptoms and conditions seem to be over-represented when it comes to a diagnosis of autism (see here for example). They noted that much of the research on this topic tended look at those who could be considered to be at the 'more able end' of the autism spectrum based on skills like self-report ability. They noted that "the population most severely affected, the ~30% of individuals with ASD who remain non- or minimally verbal beyond school-age" are not particularly well-represented in such comorbidity studies. The specific words they use are the "neglected “severe end of the spectrum”."

So: "Sixty-five participants diagnosed with ASD who had limited verbal abilities" were invited to participate in their study. They were already part of a larger research initiative. When I say 'invited' what I really meant is that: "Informed consent was obtained from the parents." All were diagnosed with an autism spectrum disorder (ASD) and the group was fairly equally split between children (5-11 years old) and young adults (12-18 years old). Parents/caregivers had a big role to play in the Plesa Skwerer study as we told that they were asked to complete various questionnaires about their children, including the Child and Adolescent Symptom Inventory (CASI-5) to "examine the frequency and severity of comorbid psychiatric symptoms." Completing the CASI-5 is no mean feat as per it having "173 items, which rate behaviors as occurring never, sometimes, often and very often."

Results: "All participants met cutoff criteria for at least one CASI-5 classification, and the number of categorical classifications parents endorsed ranged from 1 to 15, with a mode and a median of 6 classifications." This is an important detail. It tells us that, based on proxy reporting, every participant, child or young adult, presented with potentially clinically significant symptoms for one or more psychiatric/behavioural disorder. Some of the most popular labels that featured were things like vocal tics, phobia and the various types of attention-deficit hyperactivity disorder (ADHD). Further: "except oppositional defiant disorder and conduct disorder, more participants showed clinically concerning severity scores than expected based on general population norms." Authors concluded that: "The overall picture to emerge from this study is that minimally verbal children and adolescents present with extremely heterogeneous profiles of co-morbid psychopathology that are not easily predicted by autism symptom severity, intellectual disability, or limitations in communication."

There are some important caveats to the Plesa Skwerer findings, not least that proxy-reporting was the method used to ascertain the presence of not of such psychiatric comorbidity. This point tells us that a lot more needs to be done to help those who are minimally-verbal to be able to communicate much more readily. Yes, it's a tall order but where there's a will, there's a way. Also, researchers admit that they "excluded those with the most severe behavior problems including aggression, self-injury or non-compliance, and therefore our findings must be viewed in the context of whom our participants represent." Personally I see this is being a pretty issue across quite a lot of research on autism. Indeed, in light of legal rulings here in the UK (see here) talking about aggression 'not being a choice for children with autism' I daresay that by excluding those who present with such issues means that many, many children and adults on the autism spectrum are under-represented in autism research as it stands.

Still, the important message from Plesa Skwerer et al stands: those with autism who are described (defined?) as minimally-verbal seem to show a similar profile of psychiatric comorbidity and a "high degree of maladaptive behavior" as that identified in other parts/regions of the autism spectrum. Screening is implied and, so as to ensure that health inequalities are minimised, access to intervention is also indicated.

Bravo to the researchers who look at the under-studied parts of the autism spectrum.

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[1] Plesa Skwerer D. et al. Prevalence and Correlates of Psychiatric Symptoms in Minimally Verbal Children and Adolescents With ASD. Front Psychiatry. 2019 Feb 18;10:43.

[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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Sub-threshold autistic traits and creativity

I was intrigued by the results reported by Catherine Best and colleagues [1] recently and the suggestion that yet another sweeping generalisation attributed to autism (or at least autistic traits) might turn out to be not as accurate or universal as we might have all been led to believe.

Based on the analysis of data from over 300 people who completed an on-line questionnaire (anonymously) measuring autistic traits, researchers reported that creative ideas as measured by a divergent thinking task might show some connection to self-reported autistic traits. Further: "autistic traits were associated with high numbers of unusual responses on the divergent thinking tasks." Ergo, thinking outside of the box may show something of a relationship to autistic traits and creativity may not be an alien concept for those on the autism spectrum (a shocker I know).

Bearing in mind headlines such as 'Scientists discover people with autism have 'fewer ideas but are more creative and think outside the box'' that don't really reflect the study design and findings in their entirety (only 75 of the study participants said they had received a diagnosis of autism), I do think that the Best study findings call for quite a bit more research inspection in this area. Previous investigations have for example, suggested that there may be quite a bit more to see when it comes to verbal creativity and [some] autism [2] bearing in mind the small participant numbers included in such trials.

Divergent thinking and it's links to creativity is not necessarily a new concept when it comes to autism despite the increasing recent popularisation of this phenomenon. Viewers in the UK might have already seen the Channel 4 series 'The Autistic Gardener' detailing how a diagnosis of autism may not be a hurdle to good design skills; also over-turning other generalisations about perceived interests and vocations for those on the autism spectrum too (see here).

Caution does need to applied to the Best findings as they stand bearing in mind the study methodology used and the application of their findings to "a non-clinical sample." As per other commentary on the paper, it is still a little unclear as to how listing alternative uses for a brick or paper clip actually translates into a real-world setting. That also aspects of creativity have been previously associated with other labels (see here) and the lack of information on study participants with some of these other aspects in mind (e.g. comorbidity), and one needs to be mindful not to push the findings beyond their original scope however desirable they may be.

Still, the study results do make for some interesting reading and reiterate that all minds potentially have something rich to offer to society. Indeed, playing to strengths is a key theme of other recent research as per the concept of 'attention to detail' and threat detection [3] for example.

Music: Daft Punk - One More Time.

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[1] Best C. et al. The Relationship Between Subthreshold Autistic Traits, Ambiguous Figure Perception and Divergent Thinking. Journal of Autism & Developmental Disorders. 2015. August 14.

[2] Kasirer A. & Mashal N. Verbal creativity in autism: comprehension and generation of metaphoric language in high-functioning autism spectrum disorder and typical development. Front Hum Neurosci. 2014 Aug 11;8:615.

[3] Rusconi E. et al. XRIndex: a brief screening tool for individual differences in security threat detection in x-ray images. Front Hum Neurosci. 2015 Aug 10;9:439.

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Best, C., Arora, S., Porter, F., & Doherty, M. (2015). The Relationship Between Subthreshold Autistic Traits, Ambiguous Figure Perception and Divergent Thinking Journal of Autism and Developmental Disorders DOI: 10.1007/s10803-015-2518-2