Publications by authors named "Emily Simonoff"

149 Publications

Behavioural and physiological response to frustration in autistic youth: associations with irritability.

J Neurodev Disord 2021 Jul 19;13(1):27. Epub 2021 Jul 19.

Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.

Background: Irritability is a common and impairing occurrence in autistic youth, yet the underlying mechanisms are not well-known. In typically developing populations, differences in frustration response have been suggested as important driver of the behavioural symptoms of irritability. Research exploring the role of frustration response as a risk factor for irritability in autistic populations is limited and often uses parent report or observer ratings; objective measures of frustration response appropriate for use in autistic populations are required to advance the field.

Methods: In the current study, fifty-two autistic adolescents aged 13-17 years from a population-based longitudinal study completed an experimental task designed to induce frustration through exposure to periods of unexpected delay. Behavioural (number of button presses) and physiological (heart rate; HR) metrics were collected during delay periods. Irritability was measured using the parent-rated Affective Reactivity Index (ARI). Analyses used mixed-level models to test whether irritability was associated with different slopes of behavioural and physiological response to experimentally induced frustration during the task. Age and baseline HR (for the physiological data only) were included as covariates.

Results: Analyses showed a marginal association between irritability and the slope of behavioural response (incident rate ratio (IRR) =.98, p=.06), and a significant association with the slope of physiological response (b=-.10, p=.04); higher levels of irritability were associated with a dampened behavioural and physiological response, as indicated by flatter slopes of change over the course of the task. The pattern of results largely remained in sensitivity analyses, although the association with physiological response became non-significant when adjusting for IQ, autism symptom severity, and medication use (b=-.10, p=.10).

Conclusions: Results suggest that the current experimental task may be a useful objective measure of frustration response for use with autistic populations, and that a non-adaptive response to frustration may be one biological mechanism underpinning irritability in autistic youth. This may represent an important target for future intervention studies.
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http://dx.doi.org/10.1186/s11689-021-09374-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8287810PMC
July 2021

The association of adverse life events and parental mental health with emotional and behavioral outcomes in young adults with autism spectrum disorder.

Autism Res 2021 Jun 2. Epub 2021 Jun 2.

Department of Child and Adolescent Psychiatry, King's College London, Institute of Psychiatry, Psychology & Neuroscience, and South London and Maudsley Foundation Trust, London, UK.

People with autism spectrum disorder (ASD) are at increased risk of developing co-occurring mental health difficulties across the lifespan. Exposure to adverse life events and parental mental health difficulties are known risk factors for developing a range of mental health difficulties. This study investigates the association of adverse life events, parental stress and mental health with emotional and behavioral problems in young adults with ASD. One hundred and fifteen young adults with ASD derived from a population-based longitudinal study were assessed at three time-points (12-, 16-, and 23-year) on questionnaire measures of emotional and behavioral problems. Parent-reported exposure to adverse life events and parental stress/mental health were measured at age 23. We used structural equation modeling to investigate the stability of emotional and behavioral problems over time, and the association between adverse life events and parental stress and mental health and emotional and behavioral outcomes at 23-year. Our results indicate that exposure to adverse life events was significantly associated with increased emotional and behavioral problems in young adults with ASD, while controlling for symptoms in childhood and adolescence. Higher reported parental stress and mental health difficulties were associated with a higher frequency of behavioral, but not emotional problems, and did not mediate the impact of adverse life events. These results suggest that child and adolescent emotional and behavioral problems, exposure to life events and parent stress and mental health are independently associated, to differing degrees, with emotional or behavioral outcomes in early adulthood. LAY SUMMARY: People with autism experience high rates of mental health difficulties throughout childhood and into adult life. Adverse life events and parental stress and mental health may contribute to poor mental health in adulthood. We used data at three time points (12-, 16-, and 23-year) to understand how these factors relate to symptoms at 23-year. We found that emotional and behavioral problems in childhood, adverse life events and parent mental health were all associated with increased emotional and behavioral problems in adulthood.
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http://dx.doi.org/10.1002/aur.2548DOI Listing
June 2021

COVID-19 health and social care access for autistic people: European policy review.

BMJ Open 2021 05 17;11(6):e045341. Epub 2021 May 17.

Department of Forensic and Neurodevelopmental Sciences, King's College London, London, UK.

Background: The global COVID-19 pandemic has had an unprecedented impact on European health and social care systems, with demands on testing, hospital and intensive care capacity exceeding available resources in many regions. This has led to concerns that some vulnerable groups, including autistic people, may be excluded from services.

Methods: We reviewed policies from 15 European member states, published in March-July 2020, pertaining to (1) access to COVID-19 tests; (2) provisions for treatment, hospitalisation and intensive care units (ICUs); and (3) changes to standard health and social care. In parallel, we analysed survey data on the lived experiences of 1301 autistic people and caregivers.

Results: Autistic people experienced significant barriers when accessing COVID-19 services. First, despite being at elevated risk of severe illness due to co-occurring health conditions, there was a lack of accessibility of COVID-19 testing. Second, many COVID-19 outpatient and inpatient treatment services were reported to be inaccessible, predominantly resulting from individual differences in communication needs. Third, ICU triage protocols in many European countries (directly or indirectly) resulted in discriminatory exclusion from lifesaving treatments. Finally, interruptions to standard health and social care left over 70% of autistic people without everyday support.

Conclusions: The COVID-19 pandemic has further exacerbated existing healthcare inequalities for autistic people, probably contributing to disproportionate increases in morbidity and mortality, mental health and behavioural difficulties, and reduced quality of life. An urgent need exists for policies and guidelines on accessibility of COVID-19 services to be updated to prevent the widespread exclusion of autistic people from services, which represents a violation of international human rights law.
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http://dx.doi.org/10.1136/bmjopen-2020-045341DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8130751PMC
May 2021

A Novel Group Parenting Intervention for Emotional and Behavioral Difficulties in Young Autistic Children: Autism Spectrum Treatment and Resilience (ASTAR): A Randomized Controlled Trial.

J Am Acad Child Adolesc Psychiatry 2021 May 6. Epub 2021 May 6.

King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, United Kingdom; South London and Maudsley NHS Foundation Trust, London, United Kingdom.

Objective: To examine the feasibility and preliminary efficacy of a group behavioral parenting intervention for emotional and behavioral problems (EBPs) in young autistic children.

Method: This was a feasibility pilot randomized controlled trial comparing a 12-week group behavioral parenting intervention (Predictive Parenting) to an attention control (Psychoeducation). Parents of 62 autistic children 4 to 8 years of age were randomized to Predictive Parenting (n = 31) or Psychoeducation (n = 31). The primary outcome was a blinded observational measure of child behaviors that challenge. Secondary outcomes were observed child compliance and parenting behaviors; parent- and teacher-reported child EBPs; self-reported parenting practices, stress, self-efficacy, and well-being. Cost-effectiveness was also explored.

Results: Recruitment, retention, completion of measures, treatment fidelity, and parental satisfaction were high for both interventions. There was no group difference in primary outcome: mean log of rate 0.18 lower (d, 90% CI = -0.44 to 0.08) in Predictive Parenting. Differences in rates of child compliance (0.44, 90% CI = 0.11 to 0.77), facilitative parenting (0.63, 90% CI = 0.33 to 0.92) and parent-defined target symptom change (-0.59, 90% CI -0.17 to -1.00) favored Predictive Parenting. There were no differences on other measures. Predictive Parenting was more expensive than Psychoeducation, with a low probability of being more cost-effective.

Conclusion: Feasibility was demonstrated. There was no evidence from this pilot trial that Predictive Parenting resulted in reductions in child EBPs beyond those seen following Psychoeducation; in addition, the effect size was small, and it was more expensive. However, it showed superiority for child compliance and facilitative parenting with moderate effect sizes. Future, definitive studies should evaluate whether augmented or extended intervention would lead to larger improvements.

Clinical Trial Registration Information: Autism Spectrum Treatment and Resilience (ASTAR); https://www.isrctn.com/ISRCTN91411078.
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http://dx.doi.org/10.1016/j.jaac.2021.03.024DOI Listing
May 2021

Autism Spectrum Disorder and Mental Health Problems: Patterns of Difficulties and Longitudinal Trajectories in a Population-Based Twin Sample.

J Autism Dev Disord 2021 Apr 17. Epub 2021 Apr 17.

Social, Genetic, and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, PO80, Denmark Hill, London, SE5 8AF, UK.

There is increasing concern regarding additional psychiatric problems that co-occur with Autism Spectrum Disorder (ASD), as reflected in recent changes to diagnostic schemes. However, there remains little research with population-based samples across childhood. We report on additional problems, as measured by the Strengths and Difficulties Questionnaire, in a population-based sample of 135 twins with ASD, 55 non-ASD co-twins, and 144 comparison twins low in ASD traits. Frequencies, associated demographic factors, and changes in mental health difficulties from age 4 to 13 years are presented. Our data confirm the high rates of additional difficulties reported in previous studies, and suggest that the profile, associated risk factors and longitudinal course of additional difficulties in ASD may differ from those in typically-developing populations.
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http://dx.doi.org/10.1007/s10803-021-05006-8DOI Listing
April 2021

Inspecting the Glass Half-Full Identifies Strengths in the Development of Children With Autism Spectrum Disorder.

JAMA Netw Open 2021 03 1;4(3):e213155. Epub 2021 Mar 1.

Department of Child and Adolescent Psychiatry, King's College London, Institute of Psychiatry, Psychology, and Neuroscience and Maudsley Biomedical Research Centre for Mental Health, London, United Kingdom.

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http://dx.doi.org/10.1001/jamanetworkopen.2021.3155DOI Listing
March 2021

Editors' Note and Special Communication: Research Priorities in Child and Adolescent Mental Health Emerging From the COVID-19 Pandemic.

J Am Acad Child Adolesc Psychiatry 2021 05 17;60(5):544-554.e8. Epub 2021 Mar 17.

Dr. Zima, Consulting Editor, is with University of California, Los Angeles.

Over the last year, the coronavirus disease 2019 (COVID-19) pandemic has resulted in profound disruptions across the globe, with school closures, social isolation, job loss, illness, and death affecting the lives of children and families in myriad ways. In an Editors' Note in our June 2020 issue, our senior editorial team described this Journal's role in advancing knowledge in child and adolescent mental health during the pandemic and outlined areas we identified as important for science and practice in our field. Since then, the Journal has published articles on the impacts of the pandemic on child and adolescent mental health and service systems, which are available in a special collection accessible through the Journal's website. Alongside many opinion papers, the pace of publication of empirical research in this area is rapidly expanding, covering important issues such as increased frequency of mental health symptoms among children and adolescents and changes in patterns of clinical service use such as emergency department visits. As the Senior Editors prepared that Editors' Note, they were acutely aware that the priorities that they identified were broad and generated by only a small group of scientists and clinicians. Although this had the advantage of enabling us to get this information out to readers quickly, we decided that a more systematic approach to developing recommendations for research priorities would be of greater long-term value. We were particularly influenced by the efforts of the partnership between the UK Academy of Medical Scientists and a UK mental health research charity (MQ: Transforming Mental Health) to detail COVID-19-related research priorities for "Mental Health Science" that was published online by Holmes et al. in The Lancet Psychiatry in April 2020. Consistent with its focus on mental health research across the lifespan, several recommendations highlighted child development and children's mental health. However, a more detailed assessment of research priorities related to child and adolescent mental health was beyond the scope of that paper. Furthermore, the publication of that position paper preceded the death of George Floyd at the hands of Minneapolis police on May 25, 2020, which re-energized efforts to acknowledge and to address racism and healthcare disparities in the United States and many other countries. To build upon the JAACAP Editors' Note and the work of Holmes et al., we conducted an international survey of professionals-practitioners and researchers-working on child and adolescent development and pediatric mental health to identify concerns about the impact of the pandemic on children, adolescents, and their families, as well as what is helping families navigate these impacts, and the specific research topics that are of greatest importance.
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http://dx.doi.org/10.1016/j.jaac.2021.03.005DOI Listing
May 2021

Neural Correlates of Theory of Mind in Autism Spectrum Disorder, Attention-Deficit/Hyperactivity Disorder, and the Comorbid Condition.

Front Psychiatry 2020 6;11:544482. Epub 2020 Nov 6.

Department of Child and Adolescent Psychiatry, King's College London (KCL), Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London, United Kingdom.

Theory of mind (ToM) or mentalizing difficulties is reported in attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD), but the mechanism underpinning these apparently shared deficits is relatively unknown. Eighty-three young adult males, 19 with ASD alone, 21 with ADHD alone, 18 with dual diagnosis of ASD and ADHD, and 25 typically developing (TD) controls completed the functional magnetic resonance imaging version of the Frith-Happé animated-triangle ToM task. We compared neural function during ToM with two non-ToM conditions, random and goal directed motions, using whole-brain and region-of-interest analysis of brain activation and functional connectivity analyses. The groups showed comparable ToM task performance. All three clinical groups lacked local connectivity increase shown by TD controls during ToM in the right temporoparietal cortex, a key mentalizing region, with a differentially activation pattern in both ASD and comorbid groups relative to ADHD. Both ASD groups also showed reduced connectivity between right inferior lateral prefrontal and posterior cingulate cortices that could reflect an atypical information transmission to the mentalizing network. In contrast, with mentalizing both ADHD groups showed decreasing connectivity between the medial prefrontal and left temporoparietal cortices when compared to TD controls. Therefore, despite the complex pattern of atypical brain function underpinning ToM across the three disorders, some neurofunctional abnormalities during ToM are associated with ASD and appeared differentiable from those associated with ADHD, with the comorbid group displaying combined abnormalities found in each condition.
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http://dx.doi.org/10.3389/fpsyt.2020.544482DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7677232PMC
November 2020

Development and Psychometric Properties of a New Questionnaire to Assess Mental Health and Concerning Behaviors in Children and Young People with Autism Spectrum Disorder (ASD): The Assessment of Concerning Behavior (ACB) Scale.

J Autism Dev Disord 2021 Aug 14;51(8):2812-2828. Epub 2020 Oct 14.

Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.

Although 70% of autistic children and young people meet criteria for co-occurring psychiatric conditions, there are few screening measures specifically for autistic individuals. We describe the development and validation of the Assessment of Concerning Behavior (ACB), an instrument co-developed with the autistic community to assess mental health and problematic/risky behaviors. Items include descriptions to facilitate symptom recognition by autistic people, and carers/professionals. The ACB was completed by 255 parents, 149 autistic children and young people and 30 teachers. Internal consistency, stability and validity was assessed. The ACB parent-version fit a two-factor model (internalizing and externalizing problems) and showed adequate test-retest reliability, internal consistency and construct validity. The ACB is a promising new measure for research and clinical use in autism.
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http://dx.doi.org/10.1007/s10803-020-04748-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8254716PMC
August 2021

User Perspectives of Mood-Monitoring Apps Available to Young People: Qualitative Content Analysis.

JMIR Mhealth Uhealth 2020 10 10;8(10):e18140. Epub 2020 Oct 10.

Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, United Kingdom.

Background: Mobile health apps are increasingly available and used in a clinical context to monitor young people's mood and mental health. Despite the benefits of accessibility and cost-effectiveness, consumer engagement remains a hurdle for uptake and continued use. Hundreds of mood-monitoring apps are publicly available to young people on app stores; however, few studies have examined consumer perspectives. App store reviews held on Google and Apple platforms provide a large, rich source of naturally generated, publicly available user reviews. Although commercial developers use these data to modify and improve their apps, to date, there has been very little in-depth evaluation of app store user reviews within scientific research, and our current understanding of what makes apps engaging and valuable to young people is limited.

Objective: This study aims to gain a better understanding of what app users consider useful to encourage frequent and prolonged use of mood-monitoring apps appropriate for young people.

Methods: A systematic approach was applied to the selection of apps and reviews. We identified mood-monitoring apps (n=53) by a combination of automated application programming interface (API) methods. We only included apps appropriate for young people based on app store age categories (apps available to those younger than 18 years). We subsequently downloaded all available user reviews via API data scraping methods and selected a representative subsample of reviews (n=1803) for manual qualitative content analysis.

Results: The qualitative content analysis revealed 8 main themes: accessibility (34%), flexibility (21%), recording and representation of mood (18%), user requests (17%), reflecting on mood (16%), technical features (16%), design (13%), and health promotion (11%). A total of 6 minor themes were also identified: notification and reminders; recommendation; privacy, security, and transparency; developer; adverts; and social/community.

Conclusions: Users value mood-monitoring apps that can be personalized to their needs, have a simple and intuitive design, and allow accurate representation and review of complex and fluctuating moods. App store reviews are a valuable repository of user engagement feedback and provide a wealth of information about what users value in an app and what user needs are not being met. Users perceive mood-monitoring apps positively, but over 20% of reviews identified the need for improvement.
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http://dx.doi.org/10.2196/18140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7585773PMC
October 2020

How do core autism traits and associated symptoms relate to quality of life? Findings from the Longitudinal European Autism Project.

Autism 2021 02 7;25(2):389-404. Epub 2020 Oct 7.

King's College London, UK.

Lay Abstract: Previous studies suggest that some autistic individuals report lower satisfaction, or well-being, with different aspects of everyday life than those without autism. It is unclear whether this might be partly explained by symptoms of anxiety and/or depression, which affect at least 20%-50% of autistic people. In this study, we measured individual differences in well-being in 573 six to thirty-year-olds with and without a diagnosis of autism. We investigated whether individual differences in well-being were explained by autism traits (e.g. social-communication difficulties) and/or anxiety and depression symptoms. We showed that, though well-being was lower for some autistic individuals, compared to those without autism, many autistic individuals reported good well-being. Where well-being was reduced, this was particularly explained by depression symptoms, across all ages. For children/adolescents, anxiety and social-communication difficulties were also related to some aspects of well-being. Our study suggests that support and services for improving mental health, especially depression symptoms, may also improve broader outcomes for autistic people.
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http://dx.doi.org/10.1177/1362361320959959DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7874383PMC
February 2021

Informing the development of an E-platform for monitoring wellbeing in schools: involving young people in a co-design process.

Res Involv Engagem 2020 3;6:51. Epub 2020 Sep 3.

King's College London, Department of Child & Adolescent Psychiatry, Institute of Psychology, Psychiatry and Neuroscience, London, UK.

Background: The use of new technologies and methodologies in young people's mental health research is needed to allow more frequent and reliable sampling. Mobile applications and e-platforms create exciting potential for the collection of large-scale cohort data, however there are various feasibility and ethical issues to consider. Consultation with young people is needed to inform the research agenda, and ensure these technologies are engaging, useful and safe. This article describes the process of Public and Patient Involvement (PPI) with a sample of young people in London, with the aim of i) informing the development of a mood-monitoring e-platform, and ii) providing feedback and advice for researchers developing web-based technologies in the mental health field.

Methods: A total of 26 young people were consulted across four advisory group co-design sessions. All young people were students enrolled at one of the participating London based sixth form colleges, and voluntarily attended a workshop session. Audio recordings of the sessions were analysed using a thematic analysis framework.

Results: We found that young people were engaged in discussions around mobile health technologies and valued the opportunity to collaborate throughout the early stages of the development process The advisory groups identified key considerations for future web-development work to encourage engagement and prolonged use, including, the promotion of trust and transparency, consideration of accessibility, provision of support, production of engaging and functional design, and acknowledgment of specific contextual influences surrounding young people's wellbeing.

Conclusions: Involving young people in the development process of e-health technologies contributes to optimising the successful adoption and prolonged usage of new methodologies. The thematic map and informant examples can be used to guide researchers interested in developing web-based technologies in the mental health field and will be directly applicable to the development of a mood-monitoring e-platform.
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http://dx.doi.org/10.1186/s40900-020-00219-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7470434PMC
September 2020

Is there an association between anxiety and depression prior to and during pregnancy and gestational diabetes? An analysis of the Born in Bradford cohort.

J Affect Disord 2020 11 18;276:345-350. Epub 2020 Jul 18.

Section of Women's Mental Health, King's College London and South London and Maudsley NHS Foundation Trust, PO31 King's College London, De Crespigny Park, London, SE5 8AF, UK.

Background: anxiety and depression are common in women with gestational diabetes but it is not clear whether they are more likely to precede the onset of gestational diabetes or to co-occur with it. Our aims were to compare the strength of association between common mental disorders of anxiety and depression (i) before pregnancy and (ii) during pregnancy in women with and without gestational diabetes.

Methods: the sample comprised 12,239 women with 13,539 pregnancies from the UK's Born in Bradford cohort. Gestational diabetes was diagnosed by oral glucose tolerance test (OGTT). Indicators of common mental disorders were obtained from linked primary care records. Multivariable robust Poisson and logistic regression were employed. Multiple imputation by chained equations was implemented to handle missing data. Models were adjusted for maternal age, ethnicity, education and obstetric complications. Analyses of common mental disorders during pregnancy were additionally adjusted for maternal smoking, pre-pregnancy BMI, multiple pregnancy and common mental disorders prior to pregnancy.

Results: there was no evidence for an association between common mental disorders prior to pregnancy and gestational diabetes (adjusted RR 0.96; 95% CI 0.80,1.15) or between gestational diabetes and common mental disorders during pregnancy (adjusted OR 0.91; 95% CI 0.73,1.12).

Limitations: high levels of deprivation and multi-ethnic composition of the cohort may limit generalisability of these findings to other populations.

Conclusions: routine primary care records did not identify an increased risk of gestational diabetes in women with common mental disorders prior to pregnancy or of gestational diabetes in women with common mental disorders during pregnancy.
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http://dx.doi.org/10.1016/j.jad.2020.07.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7477491PMC
November 2020

Associations between theory of mind and conduct problems in autistic and nonautistic youth.

Autism Res 2021 02 21;14(2):276-288. Epub 2020 Jul 21.

Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.

Many autistic young people exhibit co-occurring behavior difficulties, characterized by conduct problems and oppositional behavior. However, the causes of these co-occurring difficulties are not well understood. Impairments in theory of mind (ToM) are often reported in autistic individuals and have been linked to conduct problems in nonautistic individuals. Whether an association between ToM ability and conduct problems exists in autistic populations, whether this association is similar between individuals who are autistic versus nonautistic, and whether these associations are specific to conduct problems (as opposed to other domains of psychopathology) remains unclear. ToM ability was assessed using the Frith-Happé Triangles task in a pooled sample of autistic (N = 128; mean age 14.78 years) and nonautistic youth (N = 50; mean age 15.48 years), along with parent-rated psychiatric symptoms of conduct problems, hyperactivity/inattention and emotional problems. Analyses tested ToM ability between autistic versus nonautistic participants, and compared associations between ToM performance and conduct problems between the two groups. Where no significant group differences in associations were found, the pooled association between ToM and conduct problems was estimated in the combined sample. Results showed no evidence of moderation in associations by diagnostic status, and an association between poorer ToM ability and higher levels of conduct problems, hyperactivity/inattention and emotional problems across the total sample. However, these associations became nonsignificant when adjusting for verbal IQ. Results provide support for theoretical models of co-occurring psychopathology in autistic populations, and suggest targets for intervention for conduct problems in autistic youth. LAY SUMMARY: Many young people with autism spectrum disorder show co-occurring behavior problems, but the causes of these are not well understood. This paper found an association between difficulties recognizing what others think and intend (so-called "theory of mind") in a simple animated task, and emotional and behavioral problems in autistic and nonautistic young people. However, a substantial part of this association was explained by individual differences in verbal ability. These findings may have implications for intervention efforts to improve young people's mental health.
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http://dx.doi.org/10.1002/aur.2346DOI Listing
February 2021

Callous-unemotional traits in youth with autism spectrum disorder (ASD): replication of prevalence estimates and associations with gaze patterns when viewing fearful faces.

Dev Psychopathol 2020 Jun 29:1-9. Epub 2020 Jun 29.

Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.

Research suggests an increased prevalence of callous-unemotional (CU) traits in children with autism spectrum disorder (ASD), and a similar impairment in fear recognition to that reported in non-ASD populations. However, past work has used measures not specifically designed to measure CU traits and has not examined whether decreased attention to the eyes reported in non-ASD populations is also present in individuals with ASD. The current paper uses a measure specifically designed to measure CU traits to estimate prevalence in a large community-based ASD sample. Parents of 189 adolescents with ASD completed questionnaires assessing CU traits, and emotional and behavioral problems. A subset of participants completed a novel emotion recognition task (n = 46). Accuracy, reaction time, total looking time, and number of fixations to the eyes and mouth were measured. Twenty-two percent of youth with ASD scored above a cut-off expected to identify the top 6% of CU scores. CU traits were associated with longer reaction times to identify fear and fewer fixations to the eyes relative to the mouth during the viewing of fearful faces. No associations were found with accuracy or total looking time. Results suggest the mechanisms that underpin CU traits may be similar between ASD and non-ASD populations.
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http://dx.doi.org/10.1017/S0954579420000449DOI Listing
June 2020

Sociodemographic factors associated with routine outcome monitoring: a historical cohort study of 28,382 young people accessing child and adolescent mental health services.

Child Adolesc Ment Health 2021 Feb 16;26(1):56-64. Epub 2020 Jun 16.

South London and Maudsley NHS Foundation Trust, London, UK.

Background: Patient-reported outcome measures (PROMs) are important tools to inform patients, clinicians and policy-makers about clinical need and the effectiveness of any given treatment. Consistent PROM use can promote early symptom detection, help identify unexpected treatment responses and improve therapeutic engagement. Very few studies have examined associations between patient characteristics and PROM data collection.

Methods: We used the electronic mental health records for 28,382 children and young people (aged 4-17 years) accessing Child and Adolescent Mental Health Services (CAMHS) across four South London boroughs between the 1st of January 2008 to the 1st of October 2017. We examined the completion rates of the caregiver Strengths and Difficulties Questionnaire (SDQ), a ubiquitous PROM for CAMHS at baseline and 6-month follow-up.

Results And Conclusions: SDQs were present for approximately 40% (n = 11,212) of the sample at baseline, and from these, only 8% (n = 928) had a follow-up SDQ. Patterns of unequal PROM collection by sociodemographic factors were identified: males were more likely (aOR 1.07, 95% CI 1.01-1.13), whilst older age (aOR 0.87, 95% CI 0.87-0.88), Black (aOR 0.79 95% CI 0.74-0.84) and Asian ethnicity (aOR 0.75 95% CI 0.66-0.86) relative to White ethnicity, and residence within the most deprived neighbourhood (aOR 0.87 95% CI 0.80-0.94) were less likely to have a record of baseline SDQ. Similar results were found in the sub-group (n = 11,212) with follow-up SDQ collection. Our findings indicate systematic differences in the currently available PROMS data and highlights which groups require increased focus if we are to gain equitable PROM collection. We need to ensure representative PROM collection for all individuals accessing treatment, regardless of ethnic or socioeconomic background; biased data have adverse ramifications for policy and service level decision-making.
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http://dx.doi.org/10.1111/camh.12396DOI Listing
February 2021

Introducing 'Predictive Parenting': A Feasibility Study of a New Group Parenting Intervention Targeting Emotional and Behavioral Difficulties in Children with Autism Spectrum Disorder.

J Autism Dev Disord 2021 Jan;51(1):323-333

South London and Maudsley NHS Foundation Trust, London, UK.

Parent-mediated interventions can reduce behavioral and emotional problems in children with ASD. This report discusses the development of the first group parent intervention targeting behaviors and anxiety in children with ASD, across the spectrum of cognitive and language ability. 'Predictive Parenting' was developed from the clinical observation (and emerging evidence base) that children with ASD struggle with 'prediction' and anticipating change. It integrates well-established parenting strategies within an ASD-specific framework. The concept was co-created with patient and public involvement panels of parents and adults with ASD. A feasibility study found the programme is acceptable and accessible. Qualitative feedback from participants was largely positive, and critiques were used to inform a larger, pilot randomized controlled trial of the intervention.
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http://dx.doi.org/10.1007/s10803-020-04442-2DOI Listing
January 2021

Starting ADHD medications during the COVID-19 pandemic: recommendations from the European ADHD Guidelines Group.

Lancet Child Adolesc Health 2020 06 12;4(6):e15. Epub 2020 May 12.

Department of Child & Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

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http://dx.doi.org/10.1016/S2352-4642(20)30144-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7217636PMC
June 2020

Development of the Observation Schedule for Children with Autism-Anxiety, Behaviour and Parenting (OSCA-ABP): A New Measure of Child and Parenting Behavior for Use with Young Autistic Children.

J Autism Dev Disord 2021 Jan;51(1):1-14

Department of Psychology, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK.

Co-occurring emotional and behavioral problems (EBPs) frequently exist in young autistic children. There is evidence based on parental report that parenting interventions reduce child EBPs. More objective measures of child EBPs should supplement parent reported outcomes in trials. We describe the development of a new measure of child and parenting behavior, the Observation Schedule for Children with Autism-Anxiety, Behaviour and Parenting (OSCA-ABP). Participants were 83 parents/carers and their 4-8-year-old autistic children. The measure demonstrated good variance and potential sensitivity to change. Child and parenting behavior were reliably coded among verbal and minimally verbal children. Associations between reports from other informants and observed behavior showed the measure had sufficient convergent validity. The measure has promise to contribute to research and clinical practice in autism mental health beyond objective measurement in trials.
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http://dx.doi.org/10.1007/s10803-020-04506-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7810641PMC
January 2021

Comparative meta-analyses of brain structural and functional abnormalities during cognitive control in attention-deficit/hyperactivity disorder and autism spectrum disorder.

Psychol Med 2020 04 27;50(6):894-919. Epub 2020 Mar 27.

Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Background: People with attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) have abnormalities in frontal, temporal, parietal and striato-thalamic networks. It is unclear to what extent these abnormalities are distinctive or shared. This comparative meta-analysis aimed to identify the most consistent disorder-differentiating and shared structural and functional abnormalities.

Methods: Systematic literature search was conducted for whole-brain voxel-based morphometry (VBM) and functional magnetic resonance imaging (fMRI) studies of cognitive control comparing people with ASD or ADHD with typically developing controls. Regional gray matter volume (GMV) and fMRI abnormalities during cognitive control were compared in the overall sample and in age-, sex- and IQ-matched subgroups with seed-based d mapping meta-analytic methods.

Results: Eighty-six independent VBM (1533 ADHD and 1295 controls; 1445 ASD and 1477 controls) and 60 fMRI datasets (1001 ADHD and 1004 controls; 335 ASD and 353 controls) were identified. The VBM meta-analyses revealed ADHD-differentiating decreased ventromedial orbitofrontal (z = 2.22, p < 0.0001) but ASD-differentiating increased bilateral temporal and right dorsolateral prefrontal GMV (zs ⩾ 1.64, ps ⩽ 0.002). The fMRI meta-analyses of cognitive control revealed ASD-differentiating medial prefrontal underactivation but overactivation in bilateral ventrolateral prefrontal cortices and precuneus (zs ⩾ 1.04, ps ⩽ 0.003). During motor response inhibition specifically, ADHD relative to ASD showed right inferior fronto-striatal underactivation (zs ⩾ 1.14, ps ⩽ 0.003) but shared right anterior insula underactivation.

Conclusions: People with ADHD and ASD have mostly distinct structural abnormalities, with enlarged fronto-temporal GMV in ASD and reduced orbitofrontal GMV in ADHD; and mostly distinct functional abnormalities, which were more pronounced in ASD.
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http://dx.doi.org/10.1017/S0033291720000574DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7212063PMC
April 2020

Comparative meta-analyses of brain structural and functional abnormalities during cognitive control in attention-deficit/hyperactivity disorder and autism spectrum disorder.

Psychol Med 2020 04 27;50(6):894-919. Epub 2020 Mar 27.

Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Background: People with attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) have abnormalities in frontal, temporal, parietal and striato-thalamic networks. It is unclear to what extent these abnormalities are distinctive or shared. This comparative meta-analysis aimed to identify the most consistent disorder-differentiating and shared structural and functional abnormalities.

Methods: Systematic literature search was conducted for whole-brain voxel-based morphometry (VBM) and functional magnetic resonance imaging (fMRI) studies of cognitive control comparing people with ASD or ADHD with typically developing controls. Regional gray matter volume (GMV) and fMRI abnormalities during cognitive control were compared in the overall sample and in age-, sex- and IQ-matched subgroups with seed-based d mapping meta-analytic methods.

Results: Eighty-six independent VBM (1533 ADHD and 1295 controls; 1445 ASD and 1477 controls) and 60 fMRI datasets (1001 ADHD and 1004 controls; 335 ASD and 353 controls) were identified. The VBM meta-analyses revealed ADHD-differentiating decreased ventromedial orbitofrontal (z = 2.22, p < 0.0001) but ASD-differentiating increased bilateral temporal and right dorsolateral prefrontal GMV (zs ⩾ 1.64, ps ⩽ 0.002). The fMRI meta-analyses of cognitive control revealed ASD-differentiating medial prefrontal underactivation but overactivation in bilateral ventrolateral prefrontal cortices and precuneus (zs ⩾ 1.04, ps ⩽ 0.003). During motor response inhibition specifically, ADHD relative to ASD showed right inferior fronto-striatal underactivation (zs ⩾ 1.14, ps ⩽ 0.003) but shared right anterior insula underactivation.

Conclusions: People with ADHD and ASD have mostly distinct structural abnormalities, with enlarged fronto-temporal GMV in ASD and reduced orbitofrontal GMV in ADHD; and mostly distinct functional abnormalities, which were more pronounced in ASD.
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http://dx.doi.org/10.1017/S0033291720000574DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7212063PMC
April 2020

Trajectories of emotional and behavioral problems from childhood to early adult life.

Autism 2020 05 19;24(4):1011-1024. Epub 2020 Mar 19.

King's College London, UK.

Lay Abstract: Although mental health problems are common in autism, relatively little is known about their stability and the factors that influence their persistence or change over the life-course. To address this, we use data from the Special Needs and Autism Project (SNAP) cohort studied at three time-points from 12 to 23 years. Using the parent-reported Strengths and Difficulties Questionnaire (SDQ) domains of conduct, emotional, and ADHD symptoms, we evaluated the role of child, family, and contextual characteristics on these three trajectories. Symptoms decreased significantly over time for all three domains, but many participants still scored above the published disorder cutoffs. Individuals showed high levels of persistence. Higher initial adaptive function and language levels predicted a greater decline in conduct and ADHD symptoms. In contrast, higher language functioning was associated with higher levels of emotional symptoms, as was lower levels of autism symptom severity and higher parental education. Those with higher neighborhood deprivation had higher initial conduct problems but a steeper decline over time. Our findings highlight that it may be possible to accurately predict mental health trajectories over this time period, which could help parents and carers in planning and help professionals target resources more efficiently.
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http://dx.doi.org/10.1177/1362361320908972DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7521012PMC
May 2020

Exploring the cognitive, emotional and sensory correlates of social anxiety in autistic and neurotypical adolescents.

J Child Psychol Psychiatry 2020 12 1;61(12):1317-1327. Epub 2020 Mar 1.

Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Background: Social anxiety is common in autistic adolescents. While emerging evidence indicates the importance of several mechanisms (including intolerance of uncertainty (IU), alexithymia and sensory processing) for maintaining anxiety, limited research has explored how these factors are associated with social anxiety in autistic adolescents.

Methods: We investigated whether IU, emotional and sensory processing are related to social anxiety in autistic and neurotypical adolescents, gathering experimental and questionnaire data from 61 autistic and 62 neurotypical 11- to 17-year-olds recruited to have similarly high levels of anxiety.

Results: In autistic and neurotypical adolescents matched for social anxiety, similar significant associations were observed between social anxiety and IU, alexithymia, maladaptive emotion regulation, sensory hypersensitivity and interoceptive sensibility. Taking a dimensional approach, we found that child- and parent-reported IU, alexithymia and sensory hypersensitivity mediated the relationship between autistic traits and social anxiety symptoms in the combined group of adolescents.

Conclusions: Our findings indicate that similar correlates of social anxiety are evident in autistic and neurotypical youths experiencing social anxiety and further our understanding of mechanisms that may contribute towards social anxiety in both groups.
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http://dx.doi.org/10.1111/jcpp.13214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7116440PMC
December 2020

Trajectories in Symptoms of Autism and Cognitive Ability in Autism From Childhood to Adult Life: Findings From a Longitudinal Epidemiological Cohort.

J Am Acad Child Adolesc Psychiatry 2020 12 19;59(12):1342-1352. Epub 2019 Dec 19.

UCLA Semel Institute of Neuroscience and Human Behavior, Los Angeles, California; Newcomen Centre, Evelina Children's Hospital, Guys & St Thomas NHS Foundation Trust, London, United Kingdom.

Objective: For the first time, we use a longitudinal population-based autism cohort to chart the trajectories of cognition and autism symptoms from childhood to early adulthood and identify features that predict the level of function and change with development.

Method: Latent growth curve models were fitted to data from the Special Needs and Autism Project cohort at three time points: 12, 16, and 23 years. Outcome measures were IQ and parent-reported Social Responsiveness Scale autism symptoms. Of the 158 participants with an autism spectrum disorder at 12 years, 126 (80%) were reassessed at 23 years. Child, family, and contextual characteristics obtained at 12 years predicted intercept and slope of the trajectories.

Results: Both trajectories showed considerable variability. IQ increased significantly by a mean of 7.48 points from 12 to 23 years, whereas autism symptoms remained unchanged. In multivariate analysis, full-scale IQ was predicted by initial language level and school type (mainstream/specialist). Participants with a history of early language regression showed significantly greater IQ gains. Autism symptoms were predicted by Social Communication Questionnaire scores (lifetime version) and emotional and behavioral problems. Participants attending mainstream schools showed significantly fewer autism disorder symptoms at 23 years than those in specialist settings; this finding was robust to propensity score analysis for confounding.

Conclusion: Our findings suggest continued cognitive increments for many people with autism across the adolescent period, but a lack of improvement in autism symptoms. Our finding of school influences on autism symptoms requires replication in other cohorts and settings before drawing any implications for mechanisms or policy.
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http://dx.doi.org/10.1016/j.jaac.2019.11.020DOI Listing
December 2020

Anxiety in young people with autism spectrum disorder: Common and autism-related anxiety experiences and their associations with individual characteristics.

Autism 2020 07 19;24(5):1111-1126. Epub 2019 Dec 19.

National University of Singapore, Singapore.

Anxiety is common in autism spectrum disorder. Many anxiety symptoms in autism spectrum disorder are consistent with (5th ed.) anxiety disorders (termed "common" anxieties), but others may be qualitatively different, likely relating to autism spectrum disorder traits (herein termed "autism-related" anxieties). To date, few studies have examined both "common" and "autism-related" anxiety experiences in autism spectrum disorder. We explored caregiver-reported Spence Children's Anxiety Scale-Parent version data from a multi-site (United Kingdom, Singapore, and United States) pooled database of 870 6- to 18-year-old participants with autism spectrum disorder, of whom 287 provided at least one written response to the optional open-ended Spence Children's Anxiety Scale-Parent item 39 ("?"). Responses were thematically coded to explore (a) common and autism-related anxiety presentations and (b) their relationship with young people's characteristics. Nearly half of the responses were autism-related anxieties (mostly sensory, uncommon, or idiosyncratic specific phobias and worries about change and unpredictability). The other half described additional common anxieties not covered in the original measure (mostly social, weather and environmental disasters, and animals). Caregivers of participants who were more severely affected by autism spectrum disorder symptoms reported more autism-related, as compared to common, additional anxieties. Implications for the assessment and understanding of anxiety in autism are discussed.
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http://dx.doi.org/10.1177/1362361319886246DOI Listing
July 2020

Protocol for establishing a child and adolescent twin register for mental health research and capacity building in Sri Lanka and other low and middle-income countries in South Asia.

BMJ Open 2019 10 16;9(10):e029332. Epub 2019 Oct 16.

Institute for Research and Development in Health and Social Care, Colombo, Sri Lanka

Introduction: Worldwide, 10%-20% of children and adolescents experience mental health conditions. However, most such disorders remain undiagnosed until adolescence or adulthood. Little is known about the factors that influence mental health in children and adolescents, especially in low and middle-income countries (LMIC), where environmental threats, such as poverty and war, may affect optimal neurodevelopment. Cohort studies provide important information on risks and resilience across the life course by enabling tracking of the effects of early life environment on health during childhood and beyond. Large birth cohort studies, including twin cohorts that can be aetiologically informative, have been conducted within high-income countries but are not generalisable to LMIC. There are limited longitudinal birth cohort studies in LMIC.

Methods: We sought to enhance the volume of impactful research in Sri Lanka by establishing a Centre of Excellence for cohort studies. The aim is to establish a register of infant, child and adolescent twins, including mothers pregnant with twins, starting in the districts of Colombo (Western Province) and Vavuniya (Northern Province). We will gain consent from twins or parents for future research projects. This register will provide the platform to investigate the aetiology of mental illness and the impact of challenges to early brain development on future mental health. Using this register, we will be able to conduct research that will (1) expand existing research capacity on child and adolescent mental health and twin methods; (2) further consolidate existing partnerships and (3) establish new collaborations. The initiative is underpinned by three pillars: high-quality research, ethics, and patient and public involvement and engagement (PPIE).

Ethics And Dissemination: Ethical approval for this study was obtained from the Ethics Review Committee of Sri Lanka Medical Association and Keele University's Ethical Review Panel. In addition to journal publications, a range of PPIE activities have been conducted.
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http://dx.doi.org/10.1136/bmjopen-2019-029332DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6797400PMC
October 2019

A novel group parenting intervention to reduce emotional and behavioural difficulties in young autistic children: protocol for the Autism Spectrum Treatment and Resilience pilot randomised controlled trial.

BMJ Open 2019 06 27;9(6):e029959. Epub 2019 Jun 27.

Service for Complex Autism & Associated Neurodevelopmental Disorders, South London and Maudsley NHS Foundation Trust, London, UK.

Introduction: The majority of young autistic children display impairing emotional and behavioural difficulties that contribute to family stress. There is some evidence that behavioural parenting interventions are effective for reducing behavioural difficulties in autistic children, with less evidence assessing change in emotional difficulties. Previous trials have tended to use unblinded parent-report measures as primary outcomes and many do not employ an active control, limiting the conclusions that can be drawn.

Methods And Analysis: The Autism Spectrum Treatment and Resilience study is a pilot randomised controlled trial (RCT) testing the specific effect of a 12-week group parenting intervention (Predictive Parenting) on primary and secondary outcomes, in comparison to an attention control condition consisting of psychoeducation parent groups. Following a feasibility study to test research procedures and the interventions, the pilot RCT participants include 60 parents of autistic children aged 4-8 years who are randomised to Predictive Parenting versus the attention control. Measures are administered at baseline and post intervention to assess group differences in child and parent outcomes, costs and service use and adverse events. The primary outcome is an objective measure of child behaviours that challenge during interactions with their parent and a researcher. The trial aims to provide data on recruitment, retention, completion of measures and acceptability of the intervention and research protocol, in addition to providing a preliminary indication of potential efficacy and establishing an effect size that could be used to power a larger-scale efficacy trial. We will also provide preliminary estimates of the cost-effectiveness of the interventions.

Ethics And Dissemination: Ethical approval was granted from NHS Camden and Kings Cross Research Ethics Committee (ref: 16/LO/1769) along with NHS R&D approval from South London and Maudsley, Guy's and St Thomas', and Croydon Health Services NHS Trusts. The findings will be disseminated through publication in peer-reviewed journals and presentations at conferences.

Trial Registration Number: ISRCTN91411078.
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http://dx.doi.org/10.1136/bmjopen-2019-029959DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6597639PMC
June 2019

Emerging challenges in pharmacotherapy research on attention-deficit hyperactivity disorder-outcome measures beyond symptom control and clinical trials.

Lancet Psychiatry 2019 Jun;6(6):528-537

Departments of Paediatrics and Psychiatry, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, and Murdoch Children's Research Institute, Melbourne, VIC, Australia. Electronic address:

Although pharmacological therapies are recommended as a key component in the treatment of attention-deficit hyperactivity disorder, their use continues to prompt intense debate. Despite considerable research efforts, several gaps in the knowledge base and several questions over the quality of evidence exist. Particular issues surrounding pharmacological treatments include uncertainties about long-term effectiveness and safety, safety profiles in adults, and the comparative effectiveness of different medications. In this Review, we focus on four key methodological issues for future research: (1) the use of appropriate trial designs; the need for (2) outcome measures targeting effectiveness beyond symptom control and (3) safety outcome measures; and (4) the application of clinical and administrative research databases to assess real-world outcomes. Potential solutions include increased use of randomised placebo-controlled withdrawal trials and large pharmacoepidemiological studies that use electronic health-care records on the long-term effectiveness and safety of medications. Pragmatic head-to-head randomised trials would also provide direct evidence on comparative effectiveness and safety profiles.
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http://dx.doi.org/10.1016/S2215-0366(19)30096-3DOI Listing
June 2019

Editorial Perspective: Key issues in children with intellectual disability for practitioners.

Child Adolesc Ment Health 2019 May 6;24(2):194-198. Epub 2018 Oct 6.

Neuropsychiatry Service, Michael Rutter Centre, Maudsley Hospital, London, UK.

One in seven children with an impairing mental health disorder has intellectual disability (ID). Despite the ubiquity of ID, many clinicians are less confident in the assessment and management of mental disorders in youth with ID. Key to determining how to modify these is a good understanding of the child's developmental/cognitive strengths and weaknesses. There is very limited evidence for mental health interventions specific to children with ID. In this context, NICE guidelines generally recommend the same interventions identified for typically developing children. However, psychological interventions should be adapted for developmental level and communication ability. Medication should be selected carefully taking account of co-existing conditions, drug interactions and the greater sensitivity to adverse effects in this population. Assessment and intervention should always take account of the child's wider context, including education. There is little evidence regarding the best service models in relation to efficacy and efficiency, but the high prevalence of ID amongst youth with mental health problems suggests that all mental health professionals should have competence in working with youth with milder levels of ID.
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http://dx.doi.org/10.1111/camh.12293DOI Listing
May 2019