Alyssa Orinstein

Intervention for optimal outcome in children and adolescents with a history of autism.

Objective: Autism spectrum disorders (ASDs) were once considered lifelong disorders, but recent findings indicate that some children with ASDs no longer meet diagnostic criteria for any ASD and reach normal cognitive function. These children are considered to have achieved “optimal outcomes” (OO). The present study aimed to retrospectively examine group differences in the intervention history of children and adolescents with OO and those with high-functioning autism (HFA). Method: The current study examined intervention histories in 25 individuals with OO and 34 individuals with HFA (current age, 8–21 years), who did not differ on age, sex, nonverbal intelligence, or family income. Intervention history was collected through detailed parent questionnaires. Results: Children in the OO group had earlier parental concern, received earlier referrals to specialists, and had earlier and more intensive intervention than those in the HFA group. Substantially more children with OO than HFA received applied behavior analysis (ABA) therapy, although for children who received ABA, the intensity did not differ between the groups. Children in the HFA group were more likely to have received medication, especially antipsychotics and antidepressants. There were no group differences in the percent of children receiving special diets or supplements. Conclusion: These data suggest that OO individuals generally receive earlier, more intense interventions, and more ABA, whereas HFA individuals receive more pharmacologic treatments. Although the use of retrospective data is a clear limitation to the current study, the substantial differences in the reported provision of early intervention, and ABA in particular, is highly suggestive and should be replicated in prospective studies.

Academic abilities in children and adolescents with a history of autism spectrum disorders who have achieved optimal outcomes

This study examines the academic abilities of children and adolescents who were once diagnosed with an autism spectrum disorder, but who no longer meet diagnostic criteria for this disorder. These individuals have achieved social and language skills within the average range for their ages, receive little or no school support, and are referred to as having achieved “optimal outcomes.” Performance of 32 individuals who achieved optimal outcomes, 41 high-functioning individuals with a current autism spectrum disorder diagnosis (high-functioning autism), and 34 typically developing peers was compared on measures of decoding, reading comprehension, mathematical problem solving, and written expression. Groups were matched on age, sex, and nonverbal IQ; however, the high-functioning autism group scored significantly lower than the optimal outcome and typically developing groups on verbal IQ. All three groups performed in the average range on all subtests measured, and no significant differences were found in performance of the optimal outcome and typically developing groups. The high-functioning autism group scored significantly lower on subtests of reading comprehension and mathematical problem solving than the optimal outcome group. These findings suggest that the academic abilities of individuals who achieved optimal outcomes are similar to those of their typically developing peers, even in areas where individuals who have retained their autism spectrum disorder diagnoses exhibit some ongoing difficulty.

Executive functioning in individuals with a history of ASDs who have achieved optimal outcomes

Executive functioning (EF) is examined among children and adolescents once diagnosed with an autism spectrum disorder (ASD), but who no longer meet diagnostic criteria. These individuals have average social and language skills, receive minimal school support and are considered to have achieved “optimal outcomes” (OOs). Since residual impairments in these individuals might be expected in deficits central to autism, and in developmentally advanced skills, EF was examined in 34 individuals who achieved OOs, 43 individuals with high-functioning autism (HFA), and 34 typically developing (TD) peers. Groups were matched on age (M = 13.49), gender, and nonverbal IQ (NVIQ) but differed on verbal IQ (VIQ; HFA < TD, OO). On direct assessment, all three groups demonstrated average EF; however, the OO and HFA groups exhibited more impulsivity and less efficient planning and problem-solving than the TD group, and more HFA participants exhibited below average inhibition than did OO and TD participants. Parent-report measures revealed average EF among the OO and TD groups; however, the OO group exhibited more difficulty than the TD group on set-shifting and working memory. HFA participants demonstrated more difficulty on all parent-reported EF domains, with a clinical impairment in attention-shifting. Results suggest that EF in OO appears to be within the average range, even for functions that were impaired among individuals with HFA. Despite their average performance, however, the OO and TD groups differed on measures of impulsivity, set-shifting, problem-solving, working memory, and planning, suggesting that the OO group does not have the above-average EF scores of the TD group despite their high-average IQs.

Language and Verbal Memory in Individuals with a History of Autism Spectrum Disorders Who Have Achieved Optimal Outcomes

Some individuals who lose their autism spectrum disorder diagnosis may continue to display subtle weaknesses in language. We examined language and verbal memory in 44 individuals with high-functioning autism (HFA), 34 individuals with “optimal outcomes” (OO) and 34 individuals with typical development (TD). The OO group scored in the average range or above on all measures and showed few differences from the TD group. The HFA group performed within the average range but showed significantly lower mean performance than the other groups on multiple language measures, even when controlling for verbal IQ. Results also indicate that OO individuals show strong language abilities in all areas tested, but that their language may show greater reliance on verbal memory.

Social Function and Communication in Optimal Outcome Children and Adolescents with an Autism History on Structured Test Measures

Youth who lose their ASD diagnosis may have subtle social and communication difficulties. We examined social and communication functioning in 44 high-functioning autism (HFA), 34 optimal outcome (OO) and 34 typically developing (TD) youth. Results indicated that OO participants had no autism communication symptoms, no pragmatic language deficits, and were judged as likable as TD peers. Some group differences were found: OO youth had less insight into social relationships and poorer friendship descriptions than TD youth. OO participants had attention, self-control, and immaturity difficulties that may impact social abilities. However, OO participants were most engaged, friendliest, warmest, and most approachable. Overall, OO participants had no social and communicative impairments, although some exhibited mild social difficulties that often accompany attentional problems.

Psychiatric Symptoms in Youth with a History of Autism and Optimal Outcome

Since autism spectrum disorder (ASD) is often comorbid with psychiatric disorders, children who no longer meet criteria for ASD (optimal outcome; OO) may still be at risk for psychiatric disorders. A parent interview for DSM-IV psychiatric disorders (K-SADS-PL) for 33 OO, 42 high-functioning autism (HFA) and 34 typically developing (TD) youth, ages 8–21, showed that OO and HFA groups had elevated current ADHD and specific phobias, with tics in HFA. In the past, the HFA group also had elevated depression and ODD, and the OO group had tics. The HFA group also showed subthreshold symptoms of specific and social phobias, and generalized anxiety. Psychopathology in the OO group abated over time as did their autism, and decreased more than in HFA.

Language comprehension and brain function in individuals with an optimal outcome from autism

Although Autism Spectrum Disorder (ASD) is generally a lifelong disability, a minority of individuals with ASD overcome their symptoms to such a degree that they are generally indistinguishable from their typically-developing peers. That is, they have achieved an Optimal Outcome (OO). The question addressed by the current study is whether this normalized behavior reflects normalized brain functioning, or alternatively, the action of compensatory systems. Either possibility is plausible, as most participants with OO received years of intensive therapy that could alter brain networks to align with typical function or work around ASD-related neural dysfunction. Individuals ages 8 to 21 years with high-functioning ASD (n = 23), OO (n = 16), or typical development (TD; n = 20) completed a functional MRI scan while performing a sentence comprehension task. Results indicated similar activations in frontal and temporal regions (left middle frontal, left supramarginal, and right superior temporal gyri) and posterior cingulate in OO and ASD groups, where both differed from the TD group. Furthermore, the OO group showed heightened “compensatory” activation in numerous left- and right-lateralized regions (left precentral/postcentral gyri, right precentral gyrus, left inferior parietal lobule, right supramarginal gyrus, left superior temporal/parahippocampal gyrus, left middle occipital gyrus) and cerebellum, relative to both ASD and TD groups. Behaviorally normalized language abilities in OO individuals appear to utilize atypical brain networks, with increased recruitment of language-specific as well as right homologue and other systems. Early intensive learning and experience may normalize behavioral language performance in OO, but some brain regions involved in language processing may continue to display characteristics that are more similar to ASD than typical development, while others show characteristics not like ASD or typical development.

Brain activity in predominantly-inattentive subtype attention-deficit/hyperactivity disorder during an auditory oddball attention task

Previous functional neuroimaging studies have found brain activity abnormalities in attention-deficit/hyperactivity disorder (ADHD) on numerous cognitive tasks. However, little is known about brain dysfunction unique to the predominantly-inattentive subtype of ADHD (ADHD-I), despite debate as to whether DSM-IV-defined ADHD subtypes differ in etiology. This study compared brain activity of 18 ADHD-I adolescents (ages 12-18) and 20 non-psychiatric age-matched control participants on a functional magnetic resonance image (fMRI) auditory oddball attention task. ADHD-I participants had significant activation deficits to infrequent target stimuli in bilateral superior temporal gyri, bilateral insula, several midline cingulate/medial frontal gyrus regions, right posterior parietal cortex, thalamus, cerebellum, and brainstem. To novel stimuli, ADHD-I participants had reduced activation in bilateral lateral temporal lobe structures. There were no brain regions where ADHD-I participants had greater hemodynamic activity to targets or novels than controls. Brain activity deficits in ADHD-I participants were found in several regions important to attentional orienting and working memory-related cognitive processes involved in target identification. These results differ from those in previously studied adolescents with combined-subtype ADHD, who had a lesser magnitude of activation abnormalities in frontoparietal regions and relatively more discrete regional deficits to novel stimuli. The divergent findings suggest different etiological factors might underlie attention deficits in different DSM-IV-defined ADHD subtypes, and they have important implications for the DSM-V reconceptualization of subtypes as varying clinical presentations of the same core disorder.

Early Manifestations of Autism Spectrum Disorders

Autism is a neuro-developmental disorder defined by deficits in social interaction and communication, and restricted interests and repetitive behaviors. Identification of the earliest signs of the disorder has important implications for understanding the developmental course and potential underlying neural mechanisms. It may also facilitate earlier identification of affected children and more timely and effective intervention. This chapter reviews the literature from both retrospective and prospective studies that identify early biomarkers and behavioral symptoms of atypical social motivation, delayed development of functional communication, and the onset of repetitive behaviors. The data suggest that signs of the disorder are not evident in the first six months of life, but emerge in the second half of the first year. The chapter closes with consideration of potential theoretical models of the available data and a brief discussion of the implications of these data for early diagnosis.