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 Mar 26, · Levy, A. and A. Perry, Outcomes in adolescents and adults with autism: A review of the literature. Research in Autism Spectrum Disorders, 5(4): p. Taylor, J.L. and M.M. Seltzer, Employment and post-secondary educational activities for young adults with autism spectrum disorders during the transition to adulthood Jan 08, · Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by markedly impaired social interaction, impaired communication, and restricted/repetitive patterns of behavior, interests, and activities. 1 In addition to challenges caused by core symptoms of the disorder, maladaptive behaviors such as aggression can be associated with ASD and can further disrupt
Evidenced-Based Interventions for Children With Autism Spectrum Disorder
Try out PMC Labs and tell us what you think. Learn More. In addition to challenges caused by core symptoms, maladaptive behaviors such as aggression can be associated with ASD and can further disrupt functioning and quality of life.
For adults with ASD, these behaviors can portend adverse outcomes e. This article reviews the scientific literature to provide an literature review on autism spectrum disorder on evidence-based interventions for aggression in adults with ASD.
A search of the electronic databases CINAHL, EMBASE, and PsycINFO was conducted using relevant search terms. After reviewing titles, abstracts, full-length articles, and reference lists, 70 articles were identified and reviewed. Additional randomized, controlled trials using consistent methodology that adequately addresses sources of bias are needed to determine which treatments are reliably effective in addressing aggression in adults with ASD.
The Diagnostic and Statistical Manual of Mental Disorders 5th edition DSM-5 criteria for ASD require enduring deficits in social communication and interaction, along with restricted patterns of behavior, interests, or activities, starting in the early developmental period and causing significant functional impairment; intellectual and language impairment may or may not be present.
Efforts in this regard have been under way for over two decades, using a variety of research approaches. Current clinical approaches to the management of aggression in adults with ASD largely reflect the limited scientific literature in this area to date.
A previous review by Kwok 10 focused on the use of medications to treat certain symptoms in individuals with ASD. Although accumulating evidence was noted for the use of second-generation antipsychotics and selective serotonin reuptake inhibitors to treat aggression and repetitive and self-injurious behavior in ASD, most 14 of 16 of the referenced studies pertained to children with ASD.
A review by Matson and colleagues 4 focused on applied behavior analysis ABA and pharmacotherapy to treat aggression and self-injury associated with ASD. The authors noted that because such behaviors usually have clear environmental antecedents, literature review on autism spectrum disorder, behavioral interventions, such as ABA, should be used to address them, with concurrent pharmacotherapy employed when environmental factors are unidentifiable or when challenging behaviors are very severe.
They noted that only risperidone and aripiprazole were Food and Drug Administration FDA —approved for treating irritability associated with ASD in children not adults. Another literature review by Matson and Jang 5 examining treatment of aggression in ASD found that, of 27 papers reviewed, only 5 explored this issue in adults with ASD, and no comment was made on the findings of these studies.
The authors noted that the literature seemed to support using functional assessments and efforts to improve coping skills and competing behaviors in individuals with ASD and aggression, though this recommendation was based mostly on studies of children with ASD. Eight systematic reviews have also been published regarding the treatment of aggression in individuals with ASD. However, the limited number of randomized, controlled trials, small sample sizes, and bias risks make it difficult to draw firm conclusions regarding the efficacy of specific treatments based on these reviews.
Seven of these reviews focused solely on medication interventions, 11 — 17 and one focused exclusively on psychoeducational interventions.
Thus, to date, previous literature reviews have focused primarily on controlled treatment studies of aggression in children with Literature review on autism spectrum disorder, and prior systematic reviews have limited their scope to either studies of medication interventions or non-pharmacologic interventions, but not both, for treating aggression in adults with ASD.
The present review aims to examine and summarize the scientific literature to provide a comprehensive update on all evidence-based interventions for aggression in adults with ASD.
To our knowledge, this is the first attempt to summarize the evidence base on both non-pharmacologic and pharmacologic interventions for aggression in adults with ASD looking at a broad array of study designs. The review also considers implications of the findings for clinical practice. Of note, literature review on autism spectrum disorder, this review focuses specifically on treating aggression in adults with ASD, rather than treating general or core symptoms of ASD, the latter of which has been extensively studied and reported on in the current literature, and is beyond the scope of this review.
A search of the databases CINAHL, EMBASE, and PsycINFO from January to February was conducted using the following search terms: autism, autistic, Asperger, pervasive developmental disorder, adult, aggression, violence, offending, treatment, and intervention. Citations not meeting all of these inclusion criteria were excluded from review.
The initial electronic search yielded a total of reports. Three hundred fifty-nine of these were excluded after a review of titles and abstracts, leaving 70 records. Nineteen of these were subsequently excluded after reviewing full-length articles 3 for not being treatment focused, 3 for not involving adult subjects, 5 for not including subjects diagnosed with ASD, 5 for not having aggression as a focus of treatment, and 3 for not meeting study design criterialeaving 51 citations.
A review of reference lists and corresponding full-length articles yielded an additional 19 articles, resulting in a total of 70 articles included in this review. In this review, aggression is defined as intentional threats, attempts, or infliction of bodily harm on another person, or intentional destruction of property. Self-injurious behavior is not included in the definition of aggression for the purposes of this article.
Of the 70 studies reviewed, 33 used standardized assessment instruments e. The remaining studies assessed aggression via reports by caregivers, hospital staff, residential treatment staff, trained work counselors, day program staff, or study personnel on the observed frequency or intensity of aggressive behavior, with most of these studies employing a specific definition of aggression for purposes of the study.
These definitions all included an element of inflicting or intending to inflict physical harm on another person, with some variability as to the inclusion of self-injurious behavior or property destruction in the definition. The specific instruments and their reliability and validity in assessing aggression are briefly reviewed below.
The Aberrant Behavior Checklist ABC 30 is a item checklist that measures six areas of behavior: irritability, literature review on autism spectrum disorder, lethargy, withdrawal, stereotyped behavior, hyperactivity, and inappropriate speech, and gives a total composite that has confirmed reliability and validity in regard to the factor structure, distribution of scores, and sensitivity to change.
The Irritability subscale ABC-I 30 consists of 15 items on temper tantrums, aggression, mood swings, irritability, property destruction, and self-injury.
The Behavior Problems Inventory BPI 31 is a item, informant-based, behavior-rating instrument for individuals with intellectual disabilities. The Behavioral Summarized Evaluation Scale for Autistic Disorder 33 is a item, observer-rated instrument for assessing the presence of various behaviors including aggression toward others in individuals with ASD. The specific categories include: 1 temper tantrums, 2 nonspecific fighting, 3 specific assaults on people or property, but not suicidal attempts4 school discipline, 5 relationship with supervisors civilian jobs6 antisocial behavior not involving police, 7 antisocial behavior involving police, 8 military disciplinary problems not involving military judicial system, and 9 difficulty with military judicial system.
The scale has been demonstrated to have high interrater reliability and acceptable validity in measuring aggressive behavior. The CGI 35 has been shown to correlate well with standard, well-known research drug-efficacy scales across a wide range of psychiatric indications, and has been shown to have reasonable reliability and validity in assessing and tracking changes in the severity of psychiatric symptoms such as aggression over time.
The Conners Abbreviated Parent-Teacher Questionnaire APTQ 36 is a item instrument that has been widely used to assess inattentive-hyperactive behaviors and the effects of medication on behavioral change.
The items also elicit observations of behaviors associated with emotional lability, including temper outbursts and explosive behavior. Despite its wide usage, the psychometric properties of the Conners APTQ as a stand-alone behavioral rating instrument have received limited study, and concern has literature review on autism spectrum disorder raised regarding methodological issues, such as limitations associated with teacher reports e.
This schedule was based on a review of the aggression literature, existing interview schedules and scales, and input from service providers working in a range of community and hospital facilities, and has demonstrated reasonable inter-informant, between-interviewer, and test-retest reliability. The Maladaptive Behavior Scale MBS 39 is an observer-rated instrument that rates the frequency of assaultive behavior toward others, self-injurious behavior, and property destruction, and assesses the response of these behaviors to pharmacologic intervention at various time points.
The scale is unpublished, literature review on autism spectrum disorder, and its psychometric properties, including reliability and validity for use in measuring aggression in a variety of contexts e. The Overt Aggression Scale OAS 40 is an instrument designed to measure categorical as opposed to covert aggression, including physical assaults on others, verbal threats of violence to others, self-injurious behavior, and explosive outbursts of property destruction, literature review on autism spectrum disorder.
The OAS documents the frequency, intensity, and duration of an aggressive incident as well as any interventions taken with the subject because of aggressive behavior. This scale was developed using institutionalized child and adult psychiatric subjects.
Reliability has been demonstrated by intra-class correlation coefficients ranging from. The Positive and Negative Syndrome Scale PANSS 42 is a item rating scale that combines 18 items from the Brief Psychiatric Rating Scale BPRS 43 and 12 items from the Psychopathology Rating Schedule PRS.
Factor analyses have converged on five major factors assessed by literature review on autism spectrum disorder PANSS: positive symptoms, negative symptoms, disorganization, affect, and resistance or activation including hostility, poor impulse control, excitement, and uncooperativeness.
Psychometric testing of the PANSS has demonstrated good test-retest reliability, moderate to good interrater reliability, and reasonable validity for the above subscales. The Self-Injurious Behavior Questionnaire SIB-Q 46 is a item, clinician-rated instrument that assesses self-injurious behavior, physical aggression toward others, destruction of property, and other maladaptive behaviors.
Each item is assigned a score ranging from 0 not a problem to 4 severe problemresulting in a total score ranging from 0 to Despite its use in three of the studies reviewed, 46 — 48 the SIB-Q is an unpublished instrument, literature review on autism spectrum disorder, and as such, its psychometric properties, including reliability and validity, are unclear.
The Vineland Adaptive Behavior Scale—Maladaptive Behavior Subscale 49 consists of two parts, one pertaining to symptoms of aggression, withdrawal, tantrums, inattention, emotionality, and defiance, and the other related to self-injury, literature review on autism spectrum disorder, property destruction, mannerisms, preoccupations, and rocking.
The instrument is completed by a qualified professional and has been shown to have reasonable reliability and validity in assessing maladaptive behavior including aggressiveness in individuals with ASD. It has been employed in studies of response to pharmacologic intervention in individuals with ASD. A small proportion 5 of 70 of the studies reviewed here used standardized assessment instruments to assess for comorbid psychiatric diagnoses, which have been shown to be a frequent factor associated with aggressive behavior in individuals with ASD, literature review on autism spectrum disorder.
The specific instruments used included the Millon Multiaxial Personality Inventory MCMI-III59 Positive and Negative Syndrome Scale PANSS42 Mini Psychological Assessment Scale for Adults with Developmental Disabilities Mini PAS—ADD60 Health of the Nation Outcome Survey—Learning Disabilities HoNOS-LD61 and Structured Clinical Interview for DSM-IV Axis I Disorders SCID-I. It is designed to match the DSM-IV diagnostic criteria for each personality disorder and clinical syndrome cited.
However, the reliability and validity of the MCMI-III in individuals with ASD, as with all self-report personality measures for individuals with ASD, remains unknown. The Mini Psychological Assessment Scale for Adults with Developmental Disabilities 60 is an assessment schedule for psychiatric disorders in individuals with intellectual disability.
It comprises 86 psychiatric symptoms generating a series of subscores on the following diagnostic areas: depression, anxiety, mania, obsessive-compulsive disorder, psychosis, unspecified disorder including dementiaand pervasive developmental disorder autism.
It has been shown to have good validity and interrater reliability in identifying possible co-occurring depression, anxiety, and mania in intellectually disabled individuals.
The Health of the Nation Outcome Survey—Learning Disabilities 61 is a widely used, item measure of mental health status in people with intellectual disability. The scale measures a wide range of behavioral and psychiatric symptoms, as well as independent functioning and relationships-based indicators of mental health functioning. Each of the 18 scales is scored from 0 to 4, with 0 indicating no problem; 1, minor problem requiring no action; 2, mild problem but definitely present; 3, moderately severe problem; and 4, severe to very severe problem.
The scale has been shown to have high interrater reliability and strong internal consistency. The Structured Clinical Interview for DSM-IV Axis I Disorders 62 is a semistructured interview guide for making diagnoses of Axis I psychiatric disorders according to DSM-IV 21 diagnostic criteria.
It is designed to be administered by a mental health professional, although trained research assistants may also administer the tool. It has been shown to have good reliability and fair validity, at least in research settings. Those studies not utilizing a standardized assessment instrument to assess for comorbid psychiatric diagnoses either used clinical interviews, record reviews, or other sources of collateral information with or without DSM-III, 19 DSM-III-R, 20 or DSM-IV 21 criteria applied to this information literature review on autism spectrum disorder ascertain the presence of such comorbidity 19 studiesor did not clearly assess for such comorbidity 46 studies.
In this review, the presence of comorbid psychiatric diagnoses did not appear to have a substantial impact on the outcomes i. To date, there have been 21 case reports, 525455literature review on autism spectrum disorder, 67 — 84 17 N of 1 nonrandomized trials, 565785 — 99 16 prospective open trials, 41464758literature review on autism spectrum disorder, — 8 retrospective reviews, 39— 1 naturalistic case-control study, and 7 randomized, controlled trials 48— of treatments for aggression literature review on autism spectrum disorder adults with ASD, literature review on autism spectrum disorder.
These reports describe various interventions of potential benefit, including behavioral interventions such as differential reinforcement of other behavior DRO schedules, 67 community interventions such as integrated assessment and treatment services, 81 pharmacologic interventions such as risperidone, 72 — 74 aripiprazole, 767782 clozapine, 5255 buspirone, 7178 propranolol, 68 clonidine, 70 riluzole, 80 and literature review on autism spectrum disorder, 75 and electroconvulsive therapy ECT.
Similarly, the one case report describing the use of propranolol 68 contained descriptions of 5 subjects; the case report on clomipramine described 2 subjects; 69 the report on riluzole described 2 subjects; 80 the Jordan and colleagues report 82 on aripiprazole described 2 subjects; and the report on ECT described 2 subjects. Most of the studies, however, did not randomly allocate subjects to intervention conditions or to the order of conditions to which subjects were exposedblind participants and personnel, blind outcome assessment, or ensure dependent-variable reliability i.
Moreover, the uncontrolled nature of these reports makes it difficult to draw firm conclusions about the efficacy of the interventions described, literature review on autism spectrum disorder, and the small sample sizes limit the generalizability of the findings. Nonetheless, such reports suggest interventions that may merit controlled study. N of 1 Nonrandomized Trials of Treatments for Aggression in Adults with Autism Spectrum Disorder. ASD, autism spectrum disorder; DRA-O, Differential Reinforcement of Alternative and Other Appropriate Behavior; DRO, Differential Reinforcement of Other Behavior; DSM, Diagnostic and Statistical Manual of Mental Disorders ; ID, intellectual disability; IQ, intelligence quotient; y.
All but two of the studies, 8996 however, were judged to be at moderate to serious risk of bias involving measurement of outcome data i. In the Cohen and colleagues 89 study demonstrating reduced frequency of aggressive behavior with long-acting propranolol compared to placebo in an adult with ASD and fragile X syndrome, the subject and assessors were blind to which intervention the subject received, according a low risk of bias regarding measurement of outcome data to this study.
However, the study examined a single subject with fragile X syndrome, possibly limiting its generalizability to adults with ASD without this genetic condition. In the Kaplan and colleagues 96 study showing a slight reduction in aggressive behavior following exposure to a multisensory Snoezelen environment in 2 of 3 adults with ASD and intellectual disability, the use of blinded outcome assessors conferred a low risk of bias involving measurement of outcome data to this study.
Its small sample size, however, may limit the generalizability of the results. Finally, 10 of the 17 studies 565785 — 8890919398 were judged to be at serious risk of bias literature review on autism spectrum disorder to baseline or time-varying confounding i.
Overall, the nonrandomized nature of most of these studies makes it difficult to firmly conclude that the interventions studied were responsible for literature review on autism spectrum disorder effects observed and to exclude other factors that could have accounted for the outcomes. Within the constraints imposed by these bias and design limitations, evidence from nonrandomized, N of 1 studies provides preliminary support for propranolol and multisensory environments, and to a somewhat lesser extent, behavioral interventions, in addressing aggressive behavior in adults with ASD.
Demographic information for the samples in each study including sex distribution and mean age is included in the table. These trials suggest potential usefulness of multisensory environments, beta blockers, 41, clomipramine, sertraline, 46risperidone, — olanzapine, 47 paliperidone, and the Japanese herbal preparation yokukansan.
Prospective Open Trials of Treatments for Aggression in Adults with Autism Spectrum Disorder.
An alternative approach to Autism:Review of Literature
, time: 29:50Autism Spectrum Disorder in Teenagers & Adults | Autism | NCBDDD | CDC
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 Jan 08, · Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by markedly impaired social interaction, impaired communication, and restricted/repetitive patterns of behavior, interests, and activities. 1 In addition to challenges caused by core symptoms of the disorder, maladaptive behaviors such as aggression can be associated with ASD and can further disrupt Background. Autism spectrum disorders (ASD) is a gathering of neurological disorders with severe developmental disability that create problems with thinking, feeling, language and interaction with others. This is a lifelong developmental disability that limit social, educational, occupational and other important demands in every stage of life
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