Blythe A. Corbett, Ph.D., discusses her lab’s research on puberty, adolescence, and mental health in autistic individuals. She emphasizes puberty as a period of significant biological maturation involving several physical, biological, hormonal, and social factors. The speaker details her lab’s latest research on pubertal onset, mental health, hormonal changes, and gender identity in autistic young people compared to allistic (non-autistic) groups. Corbett repeatedly emphasizes how puberty can be particularly complex for autistic youth (especially those assigned female at birth), who are already vulnerable to change and stress. She summarizes the presentation and underscores the importance of exploring how puberty’s hormonal, psychological, and social changes interact with the autism phenotype before the Q&A.

Handouts are online HERE

In this webinar:

1:15 – Outline
5:10 – Adolescence, puberty & associated risks
9:25 – Measuring puberty
13:15 – Autistic vs. allistic pubertal onset
19:00 – Cortisol levels in autistic young people
25:25 – Depression in young people with autism
32:15 – Testosterone and development
37:00 – Gender identity
43:00 – Conclusions & future research
47:30 – Q&A

Adolescence & puberty in autism

Corbett describes autism as a neurodevelopmental condition characterized by differences in social communication (e.g., social-emotional reciprocity, non-verbal communication) and restricted, repetitive patterns of behavior, interests, or activities (e.g., insistence on sameness, sensory sensitivities) (01:35). Adolescence, she explains, is a transformative stage characterized by significant psychological, social, emotional, and hormonal shifts, typically spanning ages 10 to 24. Within this broader period of adolescence, puberty specifically marks the biological maturation that leads to reproductive capacity and further psychosocial development (5:10). For autistic individuals, who often experience challenges with social communication, adaptability to change, and sensory sensitivities, navigating these developmental milestones can be particularly complex.

The presenter explains that early onset puberty can increase the risk for mental health problems, such as anxiety, depression, and suicidality, which are already more prevalent in adolescents with autism (05:58). Until recently, research on puberty and autism has been limited. Some recent studies suggest that while social cognition might improve during puberty, social withdrawal can intensify, and about a third of youth experience significant psychosocial problems. Further, female-presenting autistic people have reported challenges with emotion regulation and heightened sensory experiences during menstruation (08:06).

• A Two-Hit Model of Autism: Adolescence as the Second Hit (Picci & Scherf, 2015)
• Changes in Maladaptive Behaviors From Midchildhood to Young Adulthood in Autism Spectrum Disorder (Anderson et al., 2011)
• Autism after Adolescence: Population-based 13- to 22-year Follow-up Study of 120 Individuals with Autism Diagnosed in Childhood (Billstedt et al., 2005)
• Autism spectrum disorders and menstruation (Hamilton et al., 2011)
• In Search of Explanations for Early Pubertal Timing Effects on Developmental Psychopathology (Ge & Natsuaki, 2009)
• Pubertal Timing, Depression, and Externalizing Problems: A Framework, Review, and Examination of Gender Differences (Negriff & Susman, 2011)
• Other-Sex Relationship Stress and Sex Differences in the Contribution of Puberty to Depression (Llewellyn et al., 2012)
• Depressive and Anxiety Symptom Trajectories From School Age Through Young Adulthood in Samples With Autism Spectrum Disorder and Developmental Delay (Gotham et al., 2015)

Puberty onset and measurements

Corbett briefly describes methods for measuring puberty, including Tanner staging (physical exam), parent report (e.g., Pubertal Development Scale), and self-report (e.g., gender-specific self-assessment questionnaire) (09:27). She outlines a recent publication by her team which found that pubertal assessments by parent or child are not reliable indices of precise pubertal staging, compared to physical exams (11:05). Corbett and her team use all three methods of measurement in their studies to compare perceived development with physical indices. The speaker touches on models and frameworks used to help understand the links between mental health, puberty, and autism.

A study published by Corbett and colleagues in 2020 shows that autistic females experience significantly earlier breast development and onset of menses compared to typically developing females, while pubertal onset for autistic males is similar to neurotypical males (13:15). A longitudinal study assessing the progression of puberty in the same participants between 10 and 15 years of age verified these findings. Corbett reiterates that pubertal onset “sets into motion a cascade of events which may magnify and further complicate an already vulnerable trajectory, especially in females (17:00).” 

• Pubertal Development Measurement in Children With and Without Autism Spectrum Disorder: A Comparison Between Physical Exam, Parent- and Self-Report (Corbett et al., 2019)
• Pubertal Timing During Early Adolescence: Advanced Pubertal Onset in Females with Autism Spectrum Disorder (Corbett et al., 2020)
• Examination of pubertal timing and tempo in females and males with autism spectrum disorder compared to typically developing youth (Corbett et al., 2022)

Altered cortisol levels in autism

The speaker describes the Hypothalamic-Pituitary-Adrenal (HPA) axis, which plays a vital role in our stress response by triggering a neuroendocrine cascade to produce cortisol. Cortisol, she continues, is a widely used biological marker found in blood and saliva (19:00). Normally, cortisol levels peak in the morning and decline throughout the day. However, Corbett’s research consistently shows that autistic children exhibit significant variability in cortisol levels, with persistently elevated evening cortisol and a “blunted slope” compared to their allistic peers. This means their cortisol doesn’t rise or drop to the same level, impacting their ability to feel energized during the day and rest well during the night (20:30). Another longitudinal study on cortisol trajectory further revealed that HPA axis maturation is impacted by age, puberty, sex, and an autism diagnosis, where females had higher overall cortisol and higher evening cortisol than the males in both groups (22:00). 

• The developmental trajectory of diurnal cortisol in autistic and neurotypical youth (Corbett et al., 2023)

Psychological well-being: depression in autistic adolescence

The presenter notes that half of all people who will suffer from mental illnesses have their onset by age 14, making adolescence a critical period for mental health, especially for autistic youth. A study conducted by Corbett and Dr. Jessica Schwarzman found that depressive symptoms are significantly higher in both autistic males and females as early as 10-13 years of age. Parents corroborated these findings, reporting higher depressive symptoms in their autistic children, especially in females (25:25). The presenter therefore asserts that screening and intervention for depressive symptoms for autistic individuals should begin very early in adolescence. She notes that symptoms were often related to interpersonal problems and feelings of worthlessness, which are crucial intervention targets (28:00).

Corbett outlines a recent longitudinal study on the trajectory of depressive symptoms which revealed that while autistic individuals reported significantly higher depression symptoms at age 10, their symptoms actually decrease through adolescence, contrasting with an increase seen in allistic youth around ages 14-15 (30:00). The speaker notes that if replicated, this data warrants significant attention, potentially pointing to earlier identification and treatment for autistic youth.

• Higher depressive symptoms in early adolescents with Autism Spectrum Disorder by self- and parent-report compared to typically-developing peers (Schwartzman & Corbett, 2020)
• Diagnostic- and sex-based differences in depression symptoms in autistic and neurotypical early adolescents (Schwartzman et al., 2022)
• Trajectory of depressive symptoms over adolescence in autistic and neurotypical youth (Corbett et al., 2024)

Hormonal differences

Corbett explains that imbalances in hormones such as testosterone may modulate autism phenotypes. However, there is limited research regarding variations in testosterone during adolescence in autism (34:15). She details a recent study comparing salivary testosterone between autistic and allistic groups and male vs. female participants, with considerations of developmental stage. Data show that in autistic youth, both males and females exhibited significantly elevated testosterone compared to allistic youth. While male testosterone levels rapidly increased as expected during adolescence, females initially had higher testosterone until around 11.5 years of age before plateauing. Corbett states that these findings may suggest testosterone does play a role in autism, especially during periods of hormonal change (36:00). 

• Salivary testosterone in male and female youth with and without autism spectrum disorder: considerations of development, sex, and diagnosis (Muscatello et al., 2022)

Gender diversity in autistic young people

Adolescence is a time of profound self-exploration, including gender identity, or a person’s innate sense of gender. The speaker highlights recent research suggesting a higher prevalence of gender diversity in individuals diagnosed with autism or having autistic traits compared to their allistic peers. Corbett’s team used both self-report and parent report questionnaires to confirm this finding in autistic children (37:00). Parents of autistic children reported significantly greater “gender body incongruence” in their children compared to parents of allistic children. Furthermore, within the autistic group, those assigned female at birth reported significantly more experiences of gender body incongruence than those assigned male. Self-reports from autistic youth also indicated significantly more reports of both “gender diversity” and “non-binary diversity” (40:00).

A follow-up study assessing gender diversity throughout adolescence found that gender incongruence was relatively stable across puberty in males (autistic and allistic). In contrast, autistic females endorsed greater incongruence around age 10, followed by a short plateau and then another increase. Allistic females reported the opposite pattern. Corbett summarizes these findings, highlighting the sex-based differences that indicate greater gender diversity in autistic females assigned at birth (AFAB). She also reiterates that gender identity formation is nuanced and likely influenced by pubertal progression, hormone patterns, and psychosocial factors (42:00). 

• Greater Gender Diversity among Autistic Children by Self Report and Parent Report (Corbett et al., 2023)
• Gender diversity in autistic and neurotypical youth over adolescence and puberty: A longitudinal study (Corbett et al., 2024)

Conclusions & future research

Corbett summarizes the presentation, highlighting that autistic females enter puberty earlier than autistic males and allistic groups. Autistic young people also have a higher rate and earlier onset of depression and a greater prevalence of gender diversity, especially in females. The speaker underscores the need for comprehensive measurements of psychological variables based on self-report, parent-report, and clinical-report. She emphasizes the need to identify risks and opportunities for resilience to elucidate and support the dynamic transition of puberty (43:00). 

Corbett and her team recently received funding to renew their longitudinal study of pubertal development. The renewed study aims to examine pubertal development through age 17 by observing physical development, hormones, menstruation, social communication, and internalizing symptoms. It also aims to observe the nervous system during these periods in a group of more than 300 participants (45:00). She notes an ongoing female development study before the Q&A (47:30). 

Originally published January 29th, 2025

Beth Malow, MD, shares current research updates on sleep and autism. She highlights the multifactorial nature of sleep patterns and how they affect daily functioning and core autism traits like emotion regulation. The speaker provides helpful sleep questionnaires and tips for minimizing sleep resistance and night waking. Malow outlines preliminary work from ongoing sleep education trials for parents and therapists and emphasizes the efficacy of behavior-based interventions. She provides contact information for potential study participants and notes the lack of research surrounding common medications before the Q&A. 

• Handouts are online HERE
• Articles on melatonin are HERE
• Interested in participating in research at locations described i Save n the webinar? Email the research team at sleeped@vumc.org

In this webinar:

1:00 – Introduction and case study
6:45 – Multifactorial sleep problems
12:13 – Emotion regulation and sleep
17:20 – Parent trainings for insomnia
23:00 – Sleep resistance and night waking
29:30 – Sleep education multicenter trials
36:30 – Medications
37:45 – Summary
39:00 – Q&A

Sleep in Autism

Dr. Malow notes the high prevalence of sleep problems in autistic children and how they impact both nighttime rest and daytime functioning (1:00). Various factors contribute to sleep issues in autism, which can generally be divided into biological, medical, and behavioral categories (7:45). 

Case Study

To illustrate the multifactorial nature of sleep issues, Malow presents a case study of Alex, a 10-year-old boy with autism, epilepsy, and anxiety. It takes him hours to fall asleep because he “cannot shut his brain down,” and he takes methylphenidate (Ritalin) in the morning and afternoon and lamotrigine (Lamictal) at night. Alex enjoys a soda and video games after dinner. He has restless sleep, snores loudly, and wakes multiple times at night. It’s also nearly impossible to wake Alex up in the morning for school. His teacher describes him as being sleepy as well as hyperactive in class. All of this leaves his parents exhausted and very overwhelmed (2:40). 

Due to his snoring, practitioners treated him for sleep apnea by removing his adenoids and tonsils. This helped his seizures and snoring, but the restlessness and night wakings continued (6:45). The speaker emphasizes a comprehensive approach to sleep issues that identifies co-occurring conditions, prioritizes behavioral strategies wherever possible, and uses medications sparingly. She reiterates the benefits of routines for people with autism (10:15)

Sleep, emotional regulation, behavior, and core symptoms

All daily functioning is improved when we sleep better; it’s like “hitting the reset button,” especially for emotion regulation. Malow outlines fMRI studies that show increased amygdala activation (fear and anxiety) and decreased connectivity between different parts of the brain after sleep deprivation (12:13). Similarly, in a study with more than 2,500 kids, those getting less than seven hours of sleep per night had higher severity scores for social communication and emotion regulation (15:15). The presenter asserts the significant relationship between sleep and behavior and suggests that if we improve sleep, daytime behaviors will also improve (16:35). 

Parent training for insomnia supports

In 2009, Malow published the Sleep Habits Questionnaire for Children With Autism Spectrum Disorders to help parents and caregivers manage sleep issues in autistic children (17:20). The questionnaire assesses components of successful sleep and daytime habits including exercise, abundant light, limited caffeine, limited naps, and selective bedroom use (using the bedroom only for sleeping) (19:18). The speaker describes the interaction of homeostatic and circadian rhythms throughout the day and emphasizes the importance of having the proper bedtime. For example, in Alex’s case study, 8 pm may be too early for his body to enter sleep mode, so she suggests pushing it back half an hour (21:00). 

Sleep resistance and night waking

For many autistic children, the “crying it out” method doesn’t work because the child doesn’t understand what is going on. If a child needs company to fall asleep, Malow suggests the rocking chair method, where you sit in the rocking chair with your back to the child, moving closer to the door each night until you have left the room (23:00). 

The first step in minimizing night waking is to help the child fall asleep on their own – “A child who can fall asleep on their own can go back to sleep on their own.’. It’s essential to respond quickly to distress and comfort and reassure but avoid over responding – be “brief and boring” (25:00). “Bedtime passes” can also be used as a ticket for a hug or class of water during the night. In this case, the child can use the pass or turn it in in the morning for a reward. This gives the child control over the situation and comfort, knowing they can have help if needed (26:30).

Malow notes that all of these learning materials are available for free at https://www.autismspeaks.org/tool-kit/strategies-improve-sleep-children-autism

Sleep education multicenter trials

Malow outlines a two-phased study in parents of autistic children with sleep onset delay at least 3 nights/week. In phase 1, parents were given sleep education, a pamphlet, or no intervention. In phase 2, parents were randomized into either group or individualized classes with a trained community therapist (29:30). The therapist training portion includes a manual, videos, and weekly Zoom meetings for practice and support. Following training, therapists identify families who could benefit from the program, and after consent is given, baseline assessments are completed. Therapists meet virtually to discuss challenging cases and billing issues (34:44). 

Preliminary results show that therapists achieved fidelity goals during training sessions and that parents achieved high scores in understanding, comfort, and implementation. Sleep patterns and core symptoms improved, and parents were delighted with the training overall (32:55). 

This training is now available in TN, NH, VT, GA, and CO. For more information, email the research team at sleeped@vumc.org

Medications

Malow expresses her reservations about medications due to the many side effects and unknown long-term implications. However, sometimes they are necessary. They can help manage parental overwhelm initially, but it’s good to wean off slowly as behavioral habits are adopted. Gabapentin, alpha-adrenergic agonists (clonidine), and mirtazapine are common medications that have been studied, but most others have not (36:30).

 The presenter summarizes her talk, reiterating the prevalence of sleep problems in autism and their impact on daily functioning. She emphasizes that once the root cause is identified, sleep problems are highly treatable, especially with behavioral strategies. Personalized, family-centered interventions are the most effective  (37:45). Malow touches on future research directions before the Q&A (39:00). 

Originally published March 18, 2025

Laurie A. Vismara, Ph.D., BCBA-D, R.B.A. (Ont.) details caregiver strategies for building infant social interaction. She introduces the Infant Start Manual, an extension of the Early Start Denver Model. The speaker outlines contemporary research on early-in-life autism support strategies and underscores the need for collaborative, family-centered support tactics for parents and caregivers. Vismara details six (6) infant learning characteristics, how they present, and what caregivers can do to foster these social communication skills during infancy.

Handouts are online HERE (.zip)

In this webinar: 

1:30 – Introduction
6:10 – Infant Start Manual
11:40 – Research findings
17:55 – Infant learning characteristics
20:25 – Attentional flexibility
27:10 – Object use
33:00 – Prelinguistic development
36:55 – Combined, pragmatic communication
42:25 – Speech
47:30 – Social attention and engagement
54:20 – Tips for baby learning
58:00 – Resources

Introduction

Vismara introduces the Infant Start Manual, an extension of the Early Start Denver Model that focuses on infant social interactions (1:30). She highlights the need for innovative, flexible approaches to support strategies that match the needs, goals, and priorities of parents and caregivers. The speaker outlines specific language used in the talk and notes presentation learning objectives (4:20). The vision of the Infant Start Manual is to facilitate families in their caregiving journey with interactive early-in-life topics aimed at infant social communication vulnerabilities (6:10). The manual provides supports through family-centered coaching and does not substitute for a diagnosis, fix, or cure. The Infant Start Model can be accessed freely at esdmonline.com/about in the Encouraging Infant Communication and Play Manual (Rogers & Vismara). Free access is for personal use only and should not be posted online. 

What the research says

Research on the efficacy of early-in-life autism supports is still emerging. Studies show mixed results across high (10-15 hrs/week) and low-intensity (0.5 – 3 hrs/week) supports delivered by parents and clinicians. All studies aim to teach caregiving skills for social and joint engagement through play and other activities. Results show improvements in caregiving domains, infant proximal behaviors, and interactive styles for caregivers. In contrast, infant autism domains show minimal changes (13:00). One pilot study of the Infant Start has been published. Overall, caregivers shared positive perspectives on content and delivery techniques, and infant vulnerability around social characteristics diminished over time compared to families that did not participate (11:40). 

Vismara posits that the cumulative benefits of small initial changes in interaction become more apparent over time, meaning the full impact of these interventions cannot yet be measured. However, these studies provide an opportunity to understand the acceptability of these support mechanisms from diverse caregiver perspectives, which will allow for the creation of individualized, culturally aligned support systems (15:00). 

Autism Treatment in the First Year of Life: A Pilot Study of Infant Start, a Parent-Implemented Intervention for Symptomatic Infants (Rogers et al., 2014)

Autistic and autism community perspectives on infant and family support in the first two years of life: Findings from a community consultation survey (Bent et al., 2024)

A Developmental Social Neuroscience Perspective on Infant Autism Interventions (Dawson et al., 2023)

Feasibility and acceptability of a caregiver-mediated early support program, delivered online, for infants at elevated familial likelihood for autism: A feasibility randomized controlled trial (Meera et al., 2024)

The Earlier, the Better? An In-Depth Interview Study on the Ethics of Early Detection with Parents of Children at an Elevated Likelihood for Autism (Jan-Vanaken et al., 2023)

Preemptive interventions for infants and toddlers with a high likelihood for autism: A systematic review and meta-analysis (Hampton et al., 2021)

Efficacy of very early interventions on neurodevelopmental outcomes for infants and toddlers at increased likelihood of or diagnosed with autism: A systematic review and meta-analysis (McGlade et al., 2023)

Parent-Mediated Interventions for Infants under 24 Months at Risk for Autism Spectrum Disorder: A Systematic Review of Randomized Controlled Trials (Law et al., 2022)

Infant learning characteristics

The presenter emphasizes that babies come ready to explore, learn, and respond just as caregivers have intuitive skills to nurture, love, and protect. Both shape and influence the others’ actions, resulting in a communication “dance” of synchronized rhythmic steps and movements. No matter who is leading, both sides must be aware of the other and sensitive to each other’s movements and what they mean (17:55). When there is a “misstep,” the dance may stop, and working to regain that attention and engagement is where the Early Start Manual comes in. Vismara outlines six (6) infant learning characteristics, how they present in infants, and how to strengthen caregiver-baby social interactions. 

Attentional flexibility

Attentional flexibility refers to babies’ ability to pay attention to people, objects, and experiences that they find interesting, even when there are distractions. Babies do this when they pick up and explore objects, move from one toy to the next, watch people doing things, or shift focus when something new is introduced (20:25). Attentional flexibility helps babies gather information, build on their learning experiences, and filter out distractions to stay on task.

The speaker provides play recommendations for supporting attentional flexibility (23:15). She suggests offering toys or materials that encourage exploration and interactive play. Holding pieces to your face and naming or commenting about them before you give them to the baby can help them orient your voice to your face. She suggests helping babies complete goals, adding playful sounds, hand gestures, or body movements to help call attention back to you, and giving babies choices for which objects they want to play with (25:15). 

Object use

Babies are naturally curious about objects, and playing with them allows them to explore, try out new behaviors, express ideas, and receive feedback. Vismara explains that babies develop play through patterns of repeated actions, called schemas, which are constantly changing and overlapping (27:10). During play, she suggests taking turns with the same object(s) to create a back-and-forth dance (baby does, you do – repeat) which encourages skill adoption and lets babies know that you are part of the activity/conversation. It is also helpful to be face-to-face during play, to set up toys and spaces in visually clear ways that are not over-stimulating, and to follow babies’ play before leading with your own (29:10). The speaker provides a resource table with play schema definitions and ideas (31:20).

Prelinguistic development

Vismara explains that baby communication begins with crying, which lets caregivers know the baby is hungry, uncomfortable, or upset. This quickly develops into “talking bodies” communication, where babies use their facial expressions, bodies, actions, and gestures to communicate in many different ways (33:00). We chat back to babies when we name and describe things, hold or point to things, copy sounds and expressions, and add silly sounds, hand gestures, or movements to play routines.

To support prelinguistic development, the speaker again suggests playing face-to-face with the baby and talking about everything. Describe what you are doing as you go through routines and make your own “talking body” stand out to babies with playful sounds and exaggerated facial expressions and movements (34:15). It is important to give babies time to respond and for you to put words to their communication methods (35:35). The presenter shows a resource table with activity ideas for strengthening talking bodies.

 Combined, pragmatic communication

Bundling communication behaviors is a critical step in the infant communication journey. Combining face, body, and voice makes communication more efficient and complex, allowing for information retention, skill expansion, and relationship building. Caregivers naturally encourage bundling when we model back-and-forth conversations with babies. For example, when a baby smiles and makes a sound, a caregiver can comment on what excited them (36:55). Vismara suggests giving babies time to think of what they want to say and going with the communication methods that the baby is naturally using. The speaker suggests starting with any two bundles (voice and body, face and voice, etc.) and being flexible, remembering you can always try again later. She warns against holding out for specific communication bundles and underscores working with the babies’ strengths (39:30). The speaker provides another resource table on encouraging bundling through daily routines. 

Speech

Baby babbling is a universal aspect of early speech development that unfolds across several stages and serves as a stepping stone to first words. Babbling is a continuous string of sounds that express babies’ emotions and desire to talk. They often mimic words and language qualities such as tone, pitch, and accent (42:25). To support speech development, Vismara suggests talking to babies and then pausing for them to listen and respond. It’s essential to interpret the intent of what babies say and to keep the conversation going as long as they wish to babble. Helpful tips include mouthing games, imitating baby, and using props to encourage sounds (44:45). The presenter shares a resource table with activities that encourage baby sounds and potential props that you can use to promote conversations. 

Social attention and engagement

Human beings are born with the need and desire to connect with the people around us. We can see this social-emotional connection through babies’ visual attention to people, desire for attention, and drive to start interactions (47:30). Early signs of the social-emotional journey include turning toward familiar faces, turning away when overwhelmed, following faces or objects, and responding to people in their environment. Caregivers can foster this bonding by pausing an activity to cue a response from the baby. For example, hold out a toy, show the play action, and wait for baby to say, “I like this, do it again” (reach, look, smile, move body, make sound) (50:00). 

The speaker reminds viewers to respect babies’ preferences and that it may take some detective work to find their comfort zone inside activities. It helps to repeat your actions when babies are watching and read their cues for what makes them smile. Tips for finding their comfort zone include changing movement pace, adjusting voice and animation, and moving closer or backing up until they feel comfortable. Once you find their smile, create a predictable routine for setting up the fun and pausing for a reaction from the baby before continuing the action (51:15). 

Tips for baby learning

The presenter reminds viewers to build on babies’ interests and experiences with other ideas only after you can follow their play patterns. Building on their preferences can include showing different ways to play with their favorite toys, increasing interaction, and introducing new toys and songs they may like. She notes that not all ideas are winners on the first try but that bridging their interests with new ideas will create understanding and participation through which their skills can expand. Vismara underscores the importance of active play and urges caregivers to expand their involvement in baby interactions (54:20). 

The speaker reiterates that the Infant Start Model is about supporting families with programs and resources that build off of dynamic, authentic early learning experiences. She asserts the need for researchers, families, and clinicians to think deeply about what early autism care looks like and to listen intently to what families are telling us to create collaborative, culturally-informed strategies (55:41). Vismara provides links to manuals, videos, and other resources as well as an Infant Start workshop for professionals (58:55).

Originally posted on October 8, 2024

Dr. Waizbard-Bartov discusses changes in autism symptoms across childhood. She outlines the Autism Phenome Project and study methods for her recent work. The speaker presents findings on the frequency, patterns, and predictors of symptom severity changes across childhood periods in autism. Waizbard-Bartov touches on the intersection of autism symptom severity, assigned sex, and environmental factors. She summarizes presentation findings and considers pathways of future research before the Q&A. 

In this webinar:

1:09 – What is autism
5:00 – Social communication and RRB
12:06 – Autism Phenome Project
16:15 – Study methods
20:15 – Changes in autism symptom severity across childhood
24:30 – Variations in patterns of symptom change
28:05 – Predictors of changes in severity across childhood
30:25 – Sex differences
35:40 – Adaptive function
37:44 – Parental characteristics
39:10 – Co-occurring mental health conditions

What is autism?

Waizbard-Bartov describes autism as a neurodevelopmental condition broadly defined by difficulties with social communication and restrictive, repetitive behaviors (RRB) (1:09). For an autism assessment, social communication differences are subcategorized into social-emotional behavior, atypical nonverbal social behavior, and difficulty creating and maintaining relationships (2:15). RRBs are also subcategorized into stereotyped repetitive speech or actions, excessive adherence to non-functional routines, restricted/fixated interests, and atypical sensory behaviors (4:19). The speaker draws on her time working with preschoolers to illustrate how core characteristics/symptoms of autism range in presentation and severity across individuals and time (8:00). 

Study methods

The presenter outlines the Autism Phenome Project (APP), a longitudinal study of nearly 700 autistic and non-autistic children across five time points from early childhood to early adulthood (12:06). At each time point, the ongoing study assesses blood, MRI, language development, memory and attention, co-occurring conditions, and parental perspectives (14:20). Waizbard-Bartov describes her recent work on autism symptom trajectories across early (ages 3 – 6) and middle childhood (ages 6 – 11.5) (11:25). Her team used APP data for 183 autistic children (30% female-presenting) at three times points: between ages two and three and a half (2 – 3.5 yrs), between ages four and six (4 – 6 yrs), and again between ages nine and twelve (9 – 12 yrs) (16:15). Researchers used the calibrated severity scores from the Autism Diagnostic Observation Schedule (ADOS) to track symptom severity across time and domains (17:50). 

Q1: How common is change in autism symptom severity across childhood?

Researchers divided children into three groups based on observed changes in symptom severity across the first two time points (early childhood; ages 3 – 6). Of these, 54% remained stable, 29% significantly decreased, and 17% increased dramatically in symptom severity across early childhood (20:15). Correlations between behaviors and brain development were also found, where children with increased severity had slower white matter development compared to those with decreased symptom severity (21:43). When assessments were extended to the third time point (middle childhood; around age 11.5), the same three groups were identified, where 49% remained stable, 27% experienced a consistent decrease, and 24% experienced a consistent increase in symptom severity (22:55). Waizbard-Bartov reiterates that about half of children in the study demonstrated changes in severity across early and middle childhood, suggesting that such changes may be expected in autism (24:00). 

Q2: Do patterns of change vary across periods of childhood?

To understand patterns of symptom change across time, the presenter and her team compared early childhood severity changes to those of middle childhood (third time point). Results showed increases in symptom severity are equally as likely to occur during early and middle childhood, while decreases in severity are significantly more likely to occur in early childhood only (24:30). Researchers also found that more than 60% of the sample showed different patterns of change across childhood periods (i.e., decreased in early childhood and stable or increasing during middle childhood) (25:35). Waizbard-Bartov summarizes these findings, asserting that patterns of severity change across periods of childhood in autism (27:15). 

Q3: What predicts directional changes in symptoms across childhood?

To assess predictors of symptom severity changes in autism, Waizbard-Bartov and her team assessed related variables:

Cognitive ability/IQ

Results showed that children with decreased severity in early childhood had a higher IQ at the first two time points and exhibited IQ gains over time (28:45). Comparatively, those with increased severity had lower IQ at both time points that remained stable across time (29:30). The speaker asserts that these findings suggest a strong association between cognitive abilities and symptom severity during early development. 

Sex differences

Researchers found in female-presenting participants, symptom severity is likely to decrease or remain stable. However, for male-presenting participants, increases and decreases in severity are equally likely to occur (30:25). Further, calibrated severity scores revealed that female-presenting individuals show significant severity decreases in total symptoms and, more specifically, in RRB, especially during middle school. Conversely, male-presenting individuals show stable total symptom and RRB scores across childhood (31:15). The presenter discusses sex-compared changes across ADOS items, highlighting the stark trajectory differences between sex groups (33:15).  

Adaptive function

Adaptive functioning is meaningful for everyday life, and all three groups had the same score at age one. However, by age six, those experiencing decreases in severity had significantly higher adaptive functioning than those with increasing severity (35:40). The presenter explains how those with increasing severity did not necessarily lose adaptive function skills but that their rate of progress steadily slowed over time (36:40). 

Parental characteristics

Waizbard-Bartov and her team also found that fathers and mothers of children with decreasing severity were generally older and more educated. Contrastingly, parents of children with increasing severity were younger and less educated. The speaker notes the intersectionality of education and socioeconomic status and its impact on resource accessibility and self-advocacy (37:44). 

Co-occurring mental health conditions

Results showed a significant correlation between aspects of mental health and autism symptom domains (39:10). For example, 21% of participants had significant increases in both the severity of social communication issues and anxiety as they entered elementary school. ADHD levels also rose across middle school, and by age eleven, 84% of participants met the clinical requirements for an anxiety disorder (41:25). In female-presenting participants, improvements in RRB overtime ran parallel to increases in anxiety, where 94% had clinical anxiety disorders by age eleven (44:26). Waizbard-Bartov and her team found no evidence that initial symptom severity can predict changes across childhood, meaning everyone has the same potential for change (45:05). The presenter summarizes the findings for question three, noting that severity changes are correlated with assigned sex, IQ, adaptive functioning, parental characteristics, and mental health conditions (46:45).

• Trajectories of Autism Symptom Severity Change During Early Childhood (Waizbard-Bartov et al., 2021)
• Identifying autism symptom severity trajectories across childhood (Waizbard-Bartov et al., 2022)
• Changes in the severity of autism symptom domains are related to mental health challenges during middle childhood (Waizbard-Bartov et al., 2023)

Conclusion

Waizbard-Bartov summarizes research findings, underscoring that the severity of autism symptoms can change substantially across childhood periods and that patterns of change are not linear. She highlights that a child’s characteristics and environment can predict directional changes and that children have the potential for different severity trajectories regardless of their initial levels (47:55). 

She outlines future research directions, including how severity is affected during adolescence and how interactions between symptom severity and other characteristics play out over time (49:15). The presenter highlights current research around the impact of sex on symptom severity, underscoring the potential effects of camouflaging specific to female-presenting individuals (51:10). The speaker provides thanks and acknowledgments before the Q&A (53:25). 

Originally published on May 15, 2024