Mental health comorbidities in adults with Autism Spectrum Disorder: prevalence rates and the role of adverse life events and parental mental health and wellbeing

Introduction: Adults with autism spectrum disorders (ASD) are at heightened risk for several comorbid mental health conditions. However, the prevalence of common co-occurring difficulties such as anxiety and depression and associated risk factors are poorly understood. Aim: The aim of this thesis was to both quantify the prevalence of anxiety and depression in adults with ASD and to investigate how internalising (anxiety and depression) and externalising (conduct problems) symptoms in adulthood are related longitudinally to symptoms in childhood, quantifying any additional impact of exposure to adverse life events and poor parental mental health. Method: The prevalence of anxiety and depression was estimated by conducting a systematic review and meta-analysis consisting of 36 studies, including 30 studies measuring anxiety (n=26,070) and 29 measuring depression (n=26,117). The empirical study included 115 young adults with ASD who were assessed at three time-points (at 12,15 and 23 years of age) on measures of internalizing and externalizing symptoms. Structural Equation Modelling was used to investigate the impact of adverse life events and parental mental health on internalizing and externalizing symptoms. Results: The estimated current and lifetime prevalence for anxiety and depression in adults with ASD was 27% and 42%, and 23% and 37%, respectively. Results of the empirical study indicated that internalizing and externalizing symptoms in young adults with ASD are significantly related to exposure to adverse life events and mental health symptoms in childhood and adolescence. Additionally, poor parental mental health and wellbeing was found to predict a higher frequency of externalising problems but did not moderate the impact of adverse life events. Discussion: The results of this thesis suggest that anxiety and depression are highly prevalent in adults with ASD and that symptom severity in childhood and adolescence, exposure to life events and poorer parent mental health are all independent predictors of symptom severity

The Brief Memory and Executive Test (BMET) for detecting vascular cognitive impairment in small vessel disease: a validation study.

Cognitive impairment is common in patients with cerebral small vessel disease, but is not well detected using common cognitive screening tests which have been primarily devised for cortical dementias. We developed the Brief Memory and Executive Test (BMET); a rapid screening measure sensitive to the impaired executive function and processing speed characteristic of small vessel disease (SVD). To assess the BMET's validity for general use, we evaluated it when administered by non-psychologists in a multicentre study and collected control data to derive normative scores.The BMET study was funded by The Stroke Association (TSA2010/08). Recruitment to BMET was supported by the NIHR Stroke Clinical Research Network. Hugh Markus is supported by an NIHR Senior Investigator award and his work is supported by the Cambridge University Hospitals NIHR Comprehensive BRC. Matthew Hollocks is supported by a Stroke Association/British Heart Foundation Grant (TSA BHF 2010/01). Robin Morris receives consultancy fees for P1Vital Limited. The authors disclose no competing interests financial or otherwise

The Brief Memory and Executive Test (BMET) for detecting vascular cognitive impairment in small vessel disease: a validation study

Background: Cognitive impairment is common in patients with cerebral small vessel disease, but is not well detected using common cognitive screening tests which have been primarily devised for cortical dementias. We developed the Brief Memory and Executive Test (BMET); a rapid screening measure sensitive to the impaired executive function and processing speed characteristic of small vessel disease (SVD). To assess the BMET’s validity for general use, we evaluated it when administered by non-psychologists in a multicentre study and collected control data to derive normative scores. Methods: Two-hundred participants with SVD, defined as a clinical lacunar stroke and a corresponding lacunar infarct on MRI, and 303 healthy controls aged between 40–90 years old were recruited. The BMET, as well as the Montreal Cognitive Assessment (MoCA) and Mini Mental State Examination (MMSE), were performed. Overall, 55 SVD participants underwent repeat testing at 3 months to assess the BMET test-retest reliability. Results: Administering the BMET took a mean (SD) of 12.9 (4.7) in cases and 9.5 (2.6) minutes in controls. Receiver Operator Curve analysis showed the BMET was a good predictor of cognitive impairment in SVD (AUC = 0.94) and performed significantly better than both the MoCA (AUC = 0.77) and the MMSE (AUC = 0.70). Using a cut-off score of 13, the BMET had a sensitivity of 93% and specificity of 76% for detecting cognitive impairment in SVD. Conclusions: The BMET is a brief and sensitive tool for the detection of cognitive impairment in patients with SVD.The BMET study was funded by The Stroke Association (TSA2010/08). Recruitment to BMET was supported by the NIHR Stroke Clinical Research Network. Hugh Markus is supported by an NIHR Senior Investigator award and his work is supported by the Cambridge University Hospitals NIHR Comprehensive BRC. Matthew Hollocks is supported by a Stroke Association/British Heart Foundation Grant (TSA BHF 2010/01). Robin Morris receives consultancy fees for P1Vital Limited. The authors disclose no competing interests financial or otherwise.This is the final published version. It first appeared at http://www.biomedcentral.com/content/pdf/s12916-015-0290-y.pdf

Brief Report: An Evaluation of the Social Communication Questionnaire as a Screening Tool for Autism Spectrum Disorder in Young People Referred to Child & Adolescent Mental Health Services

The SCQ is a widely used screening measure for the assessment of autism spectrum disorder (ASD). However, its sensitivity and specificity when used with older children in the context of community Child & Adolescent Mental Health services is unclear. Seventy-seven (Mean age = 12.8 years) young people with suspected ASD were screened using parent- and teacher-reported SCQ’s before completing a comprehensive diagnostic assessment. Of the 77 young people included, 44 (57%) met criteria for an ASD diagnosis. Our results indicated that regardless of informant, SCQ scores did not significantly predict the outcome of the diagnostic assessment. Based on the published cut-off score for the SCQ, Receiver Operating Characteristic curve analyses revealed a lower than expected sensitivity and specificity. This suggests that the SCQ is not an effective screening tool when used in the context of community Child & Adolescent Mental Health service

Apathy, but not depression, is associated with executive dysfunction in cerebral small vessel disease.

OBJECTIVE: To determine the prevalence of apathy and depression in cerebral small vessel disease (SVD), and the relationships between both apathy and depression with cognition. To examine whether apathy is specifically related to impairment in executive functioning and processing speed. METHODS: 196 patients with a clinical lacunar stroke and an anatomically corresponding lacunar infarct on MRI were compared to 300 stroke-free controls. Apathy and depression were measured using the Geriatric Depression Scale, and cognitive functioning was assessed using an SVD cognitive screening tool, the Brief Memory and Executive Test, which measures executive functioning/processing speed and memory/orientation. Path analysis and binary logistic regression were used to assess the relation between apathy, depression and cognitive impairment. RESULTS: 31 participants with SVD (15.8%) met criteria for apathy only, 23 (11.8%) for both apathy and depression, and 2 (1.0%) for depression only. In the SVD group the presence of apathy was related to global cognition, and specifically to impaired executive functioning/processing speed, but not memory/orientation. The presence of depression was not related to global cognition, impaired executive functioning/processing speed or memory/orientation. CONCLUSIONS: Apathy is a common feature of SVD and is associated with impaired executive functioning/processing speed suggesting the two may share biological mechanisms. Screening for apathy should be considered in SVD, and further work is required to develop and evaluate effective apathy treatment or management in SVD.This work was supported by a Priority Program Grant from the Stroke Association (TSA PPA 2015-02; www.stroke.org.uk). The BMET Study was supported by a grant from the Stroke Association (TSA2008/10). Valerie Lohner is supported by a Stroke Association/British Heart Foundation Program Grant (TSA BHF 2010/01; www.bhf.org.uk). Rebecca Brookes is supported by a BHF Project Grant (PG/13/30/30005). Recruitment to the BMET Study was supported by the English National Institute of Health Research (NIHR) Clinical Stroke Research Network (www.crn.nihr.ac.uk/stroke). Hugh Markus is supported by an NIHR Senior Investigator award (www.nihr.ac.uk) and his work is supported by the Cambridge University Hospital Comprehensive NIHR Biomedical Research Unit (www.cambridge-brc.org.uk)

Brief Screening of Vascular Cognitive Impairment in Patients With Cerebral Autosomal-Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy Without Dementia.

BACKGROUND AND PURPOSE: Cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a monogenic form of cerebral small vessel disease leading to early-onset stroke and dementia, with younger patients frequently showing subclinical deficits in cognition. At present, there are no targeted cognitive screening measures for this population. However, the Brief Memory and Executive Test (BMET) and the Montreal Cognitive Assessment (MoCA) have shown utility in detecting cognitive impairment in sporadic small vessel disease. This study assesses the BMET and the MoCA as clinical tools for detecting mild cognitive deficits in CADASIL. METHODS: Sixty-six prospectively recruited patients with CADASIL, and 66 matched controls completed the BMET, with a subset of these also completing the MoCA. Receiver operating characteristic curves were calculated to examine the sensitivity and specificity of clinical cutoffs for the detection of vascular cognitive impairment and reduced activities of daily living. RESULTS: Patients with CADASIL showed more cognitive impairment overall and were poorer on both executive/processing and memory indices of the BMET relative to controls. The BMET showed good accuracy in predicting vascular cognitive impairment (85% sensitivity and 84% specificity) and impaired instrumental activities of daily living (92% sensitivity and 77% specificity). The MoCA also showed good predictive validity for vascular cognitive impairment (80% sensitivity and 78% specificity) and instrumental activities of daily living (75% sensitivity and 76% specificity). The most important background predictor of vascular cognitive impairment was a history of stroke. CONCLUSIONS: The results indicate that the BMET and the MoCA are clinically useful and sensitive screening measures for early cognitive impairment in patients with CADASIL.Stroke Association (Grant ID: TSA2008/10), British Heart Foundation (Grant ID: PG/13/30/30005), Stroke Association/British Heart Foundation (Grant ID: TSA BHF 2010/01), Agency for Science, Technology and Research, Singapore, National Institute for Health Research (Senior Investigator award), Cambridge University Hospital Comprehensive National Institute for Health Research Biomedical Research UnitThis is the final version of the article. It first appeared from Wolters Kluwer via http://dx.doi.org/10.1161/STROKEAHA.116.01376

Anxiety and Depression in Adults with Autism Spectrum Disorder: A Systematic Review and Meta-analysis

Adults with autism spectrum disorder (ASD) are thought to be at disproportionate risk of developing mental health comorbidities, with anxiety and depression being considered most prominent amongst these. Yet, no systematic review has been carried out to date to examine rates of both anxiety and depression focusing specifically on adults with ASD. This systematic review and meta-analysis examined the rates of anxiety and depression in adults with ASD and the impact of factors such as assessment methods and presence of comorbid intellectual disability (ID) diagnosis on estimated prevalence rates. Electronic database searches for studies published between January 2000 and September 2017 identified a total of 35 studies, including 30 studies measuring anxiety (n = 26 070; mean age = 30.9, s.d. = 6.2 years) and 29 studies measuring depression (n = 26 117; mean age = 31.1, s.d. = 6.8 years). The pooled estimation of current and lifetime prevalence for adults with ASD were 27% and 42% for any anxiety disorder, and 23% and 37% for depressive disorder. Further analyses revealed that the use of questionnaire measures and the presence of ID may significantly influence estimates of prevalence. The current literature suffers from a high degree of heterogeneity in study method and an overreliance on clinical samples. These results highlight the importance of community-based studies and the identification and inclusion of well-characterized samples to reduce heterogeneity and bias in estimates of prevalence for comorbidity in adults with ASD and other populations with complex psychiatric presentations

Increasing compliance with wearing a medical device in children with autism

Health professionals often recommend the use of medical devices to assess the health, monitor the well-being, or improve the quality of life of their patients. Children with autism may present challenges in these situations as their sensory peculiarities may increase refusals to wear such devices. To address this issue, we systematically replicated prior research by examining the effects of differential reinforcement of other behavior (DRO) to increase compliance with wearing a heart rate monitor in 2 children with autism. The intervention increased compliance to 100% for both participants when an edible reinforcer was delivered every 90 s. The results indicate that DRO does not require the implementation of extinction to increase compliance with wearing a medical device. More research is needed to examine whether the reinforcement schedule can be further thinned

Brief Report: Testing the Psychometric Properties of the Spence Children’s Anxiety Scale (SCAS) and the Screen for Child Anxiety Related Emotional Disorders (SCARED) in Autism Spectrum Disorder

Anxiety is a prevalent and impairing co-morbidity among individuals with autism spectrum disorder (ASD), yet assessment measures, including screening tools, are seldom validated with autism samples. We explored the psychometric properties of the child and parent reports of the Spence Children’s Anxiety Scale (SCAS) and the Screen for Anxiety Related Disorder-71 (SCARED-71) with 49 males with ASD (10–16 years, 63% co-occurring anxiety). Both measures had excellent internal consistency and fair-good parent–child agreement. The SCAS has a higher proportion of items evaluating observable behaviors. Predictive power of the measures did not differ. Higher cut-points in the parent reports (SCARED only) and lower cut-points in the child reports may enhance prediction in this sample. Choice of measure and cut-points should be considered alongside intended purpose