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Funder: European Union's Horizon 2020 research and innovation programme, Funder: EFPIA; Id: http://dx.doi.org/10.13039/100013322, Funder: AUTISM SPEAKS; Id: http://dx.doi.org/10.13039/100000073, Funder: Autistica; Id: http://dx.doi.org/10.13039/100011706, Funder: SFARI; Id: http://dx.doi.org/10.13039/100014370, Funder: Templeton World Charitable Fund, Funder: MRC, Funder: NIHR Cambridge Biomedical Research Centre; Id: http://dx.doi.org/10.13039/501100018956, Funder: National Institute for Health Research (NIHR) Applied Research Collaboration East of England, We investigate whether autistic people's vulnerability is taken into account at each stage of the criminal justice system (CJS). Defense lawyers from 12 nations were included in the study although the sample was predominantly from the UK. Lawyers completed an online survey regarding one case in which they had defended an autistic client between January 2015 and January 2020; and on one case in which they had defended a nonautistic client charged with a similar offense, to provide a comparison group. Ninety‐three lawyers (85% in the UK) reported on one autistic case, and 53 also reported on one nonautistic case. 75% of autistic clients were not given reasonable adjustments during the process. Only 43% were offered an appropriate adult during police investigations, even though they had an existing diagnosis of autism. 59% of prosecution barristers and 46% of judges said or did something during the trial that made the lawyers concerned that they did not have an adequate understanding of autism. Lawyers were 7.58 times more likely to be concerned about their autistic client's effective participation in court and were 3.83 times more likely to be concerned that their autistic clients would engage in self‐harm, compared with their nonautistic clients. There is a failure to identify and address autistic peoples' disability within the CJS. There is a need for mandatory autism training for police officers and the judiciary, with a focus on identifying autism and understanding the needs of autistic people so that reasonable adjustments are offered in all cases. Lay Summary: This study sought to investigate if the needs of autistic people are being overlooked by the police and other professionals within the CJS. Results show that autistic people are not always given the support they need during police questioning or in court. The experience of being involved with the police may also have a more negative impact on autistic peoples' mental health than that of nonautistic people.

Funder: Applied Health Research and Care (ARC‐EoE); Id: http://dx.doi.org/10.13039/501100012358, Funder: Corbin Charitable Trust, Funder: Medical Research Council; Id: http://dx.doi.org/10.13039/501100000265, Funder: National Institute of Health Research (NIHR), Funder: Templeton World Charity Foundation; Id: http://dx.doi.org/10.13039/501100011730, Funder: University of Cambridge; Id: http://dx.doi.org/10.13039/501100000735, Funder: Department of Health; Id: http://dx.doi.org/10.13039/501100003921, Funder: Health Research; Id: http://dx.doi.org/10.13039/100005622, Funder: National Institute for Health Research; Id: http://dx.doi.org/10.13039/501100000272, Funder: Biomedical Research Centre; Id: http://dx.doi.org/10.13039/100014461, Funder: AUTISM SPEAKS; Id: http://dx.doi.org/10.13039/100000073, Funder: Horizon 2020; Id: http://dx.doi.org/10.13039/100010661, Funder: European Union; Id: http://dx.doi.org/10.13039/501100000780, Funder: Innovative Medicines Initiative; Id: http://dx.doi.org/10.13039/501100010767, Funder: Wellcome Trust; Id: http://dx.doi.org/10.13039/100010269, Small studies suggest significant differences between autistic and nonautistic individuals regarding sexual orientation and behavior. We administered an anonymized, online survey to n = 2386 adults (n = 1183 autistic) aged 16–90 years to describe sexual activity, risk of sexually transmitted infections (STIs), and sexual orientation. Autistic individuals are less likely to report sexually activity or heterosexuality compared to nonautistic individuals, but more likely to self‐report asexuality or an ‘other’ sexuality. Overall, autistic, and nonautistic groups did not differ in age of sexual activity onset or contraction of STIs. When evaluating sex differences, autistic males are uniquely more likely to be bisexual (compared to nonautistic males); conversely, autistic females are uniquely more likely to be homosexual (compared to nonautistic females). Thus, both autistic males and females may express a wider range of sexual orientations in different sex‐specific patterns than general population peers. When comparing autistic males and females directly, females are more likely to have diverse sexual orientations (except for homosexuality) and engage in sexual activity, are less likely to identify as heterosexual, and have a lower mean age at which they first begin engaging in sexual activity. This is the largest study of sexual orientation of autistic adults. Sexual education and sexual health screenings of all children, adolescents, and adults (including autistic individuals) must remain priorities; healthcare professionals should use language that affirms a diversity of sexual orientations and supports autistic individuals who may have increased risks (affecting mental health, physical health, and healthcare quality) due to stress and discrimination from this intersectionality.

OBJECTIVE: There is limited evidence about the cross-cultural validity of autistic symptoms in school-aged children in Brazil. We used data from a large school survey to evaluate the factor structure of autism symptoms in community-dwelling children and adolescents. METHODS: We translated the Childhood Autism Spectrum Test to Brazilian Portuguese and performed factor analyses to investigate the factor structure of parent-reported autistic symptoms in a large sample (n=8,571) of children/adolescents from a school survey in the metropolitan area of São Paulo. RESULTS: Autistic symptoms were best conceptualized under a correlated-factors model with two factors: one predominantly characterized by social-communication symptoms and the other by symptoms of inflexible/restricted language, behaviors, and interests. CONCLUSIONS: These findings provide evidence that the structure of autistic symptoms in Brazil is similar to that described in other countries, indicating the cross-cultural validity of autism in Brazil.

Background We aimed to assess whether autistic individuals were able to generalise across contexts when building statistical expectations of their environment to the same extent as non-autistic individuals. We did this by assessing the implicit awareness of statistical regularities in a sequence of naturalistic scene images in both autistic and non-autistic individuals. Methods125 participants (61 participants with an autism diagnosis and 64 non-autistic controls) were presented with a fast serial presentation sequence of images and given a cover task to avoid attention being explicitly drawn to patterns in the underlying sequences. This was followed by a two-alternative forced choice task to assess participants’ implicit recall. Participants were presented with 1 of 3 unique versions of the task, in which the presentation and assessment of statistical regularities was done at either a low feature-based level or a high semantic-based level. ResultsThere were no significant group differences in how performance varied across the 3 conditions, but there was an overall significant reduction in visual statistical learning in the autistic group. There was also a lack of statistical significant effect of learning for the autistic participants who completed the generalisation condition.LimitationsWhile the overall sample was fairly large, the sample sizes for the subgroups within the study were modest, so the lack of statistically significant effect of learning for the autistic participants who completed the generalisation condition may be due to a lack of power rather than an true absence of learning. Additionally, this study did not directly assess if semantic information was being processed to a similar extent by both autistic and non-autistic participants.ConclusionsThese results do not support the claim that autistic individuals experience difficulties in either acquiring or generalising statistic regularities at the category-level, but suggest that differences in visual statistical learning occur in autistic people.

The “Reading the Mind in the Eyes” Test (Eyes Test) is a widely used assessment of “theory of mind.” The NIMH Research Domain Criteria recommends it as one of two tests for “understanding mental states.” Previous studies have demonstrated an on-average female advantage on the Eyes Test. However, it is unknown whether this female advantage exists across the lifespan and across a large number of countries. Thus, we tested sex and age differences using the English version of the Eyes Test in adolescents and adults across 57 countries. We also tested for associations with sociodemographic and cognitive/personality factors. We leveraged one discovery dataset ( N = 305,726) and three validation datasets ( N s = 642; 5,284; and 1,087). The results show that: i) there is a replicable on-average female advantage in performance on the Eyes Test; ii) performance increases through adolescence and shallowly declines across adulthood; iii) the on-average female advantage is evident across the lifespan; iv) there is a significant on-average female advantage in 36 out of 57 countries; v) there is a significant on-average female advantage on translated (non-English) versions of the Eyes Test in 12 out of 16 countries, as confirmed by a systematic review; vi) D-scores, or empathizing-systemizing, predict Eyes Test performance above and beyond sex differences; and vii) the female advantage is negatively linked to “prosperity” and “autonomy,” and positively linked to “collectivism,” as confirmed by exploratory country-level analyses. We conclude that the on-average female advantage on the Eyes Test is observed across ages and most countries.

La teoría de la mente (ToM) es un proceso cognitivo central de la cognición social, con gran importancia en la investigación en neurociencia y los trastornos neuropsiquiátricos. Un método usado para evaluar la ToM avanzada en adultos es la prueba de lectura de la mente a través de la mirada (RMET), que pese a ser ampliamente conocido en Perú aún carece de medidas estandarizadas y adecuadamente validadas para su aplicación en el área clínica y no clínica. Objetivos: 1. explorar las propiedades psicométricas del test de lectura de la mente a través de la mirada en los peruanos, así como el porcentaje de precisión para cada ítem entre las diferentes versiones del RMET; 2. obtener la fiabilidad test-retest tras un año de seguimiento. Se reclutaron 288 participantes de entre 17 y 55 años, de ambos sexos. Resultados: El RMET muestra una validez y consistencia media según la prueba KR-20, Alpha de Cronbach y Omega (0.645 – 0.666). Las mujeres tienen mejor rendimiento que hombres (p

BACKGROUND: Understanding how certain factors affect autism incidence can help to identify inequities in diagnostic access. We aimed to investigate the incidence of autism in England as a function of geography and sociodemographics, examining spatial distribution across health service boundaries.METHODS: In this retrospective, longitudinal, school registry study, we sourced data for the years 2014-17 from the summer school census, which is a component of the National Pupil Database, a government registry of pupils under state education in England. Our main outcome was the incidence of autism in the English state-funded education system, defined by the amount of new autism-specific Education, Health and Care Plans or autism-specific special education needs and disability support recorded during each summer school census year since the 2014 baseline. After excluding prevalent cases in 2014, we calculated unadjusted incidence and age-adjusted, sex-adjusted incidence per 100 000 person-years per subsequent school year and by various sociodemographic categories and local authority districts. We report spatial effects using local indicators of spatial association. We used a three-level mixed-effects logistic regression model with two random intercepts (lower-layer super output area [a geographical area in England containing 1000-3000 residents] and pupil identifier) to calculate odds ratios (ORs) for autism incidence, adjusting for age, sex, ethnicity, claimed eligibility for free school meals, ethnic density quintile, Index of Multiple Deprivation quintile, first language spoken at home, and year, with our reference category being White girls without claimed eligibility for free school meals who speak English as their first language.FINDINGS: Between 2014 and 2017, our total sample included 31 580 512 person-years and 102 338 newly diagnosed autistic pupils, corresponding to an unadjusted annual autism incidence of 429·1 cases per 100 000 person-years (95% CI 426·4-431·7) and an age-adjusted, sex-adjusted annual incidence of 426·9 cases per 100 000 person-years (423·5-430·4). The adjusted incidence of autism was slightly higher in 2014-15 than in 2015-16 or 2016-17, and, of the age groups, pupils aged 1-3 years, 4-6 years, and 10-12 years had the highest incidence of autism. Adjusted autism incidence in boys was 3·9-times the incidence in girls (668·6 cases per 100 000 person-years [95% CI 662·5-674·6] vs 173·2 cases per 100 000 person-years [170·1-176·3]). Across ethnic groups, adjusted incidence was highest in pupils who had an unclassified ethnicity (599·4 cases per 100 000 person-years [574·5-624·3]) or were Black (466·9 cases per 100 000 person-years [450·8-483·0]). However, in our fully adjusted mixed-effects logistic regression model, we observed lower odds of autism among Asian (OR 0·65 [0·59-0·71]), Black (0·84 [0·77-0·92]), and Chinese (0·62 [0·42-0·92]) girls compared with White girls when these groups had not claimed free school meals and spoke English as a first language. Boys from all ethnicities irrespective of first language spoken and free school meals status had increased odds of autism compared with White girls with no claimed eligibility for free school meals who spoke English as their first language. We also found that claimed free school meal eligibility, first language spoken, sex, and ethnicity differentially impacted the odds of autism. Our spatial analysis showed significant spatial autocorrelation across lower-layer super output areas in England, with 2338 hotspots (high-incidence areas surrounded by other high-incidence areas).INTERPRETATION: The incidence of autism varies across sex, age, ethnicity, and geographical location. Environmental and social factors might interact with autism aetiology. Speaking a language other than English and economic hardship might increase access barriers to autism diagnostic services, autism-specific Education, Health and Care Plans, and school-level support.FUNDING: The Commonwealth Fund, the Institute for Data Valorization, the Fonds de recherche du Québec-Santé, Calcul Quebec, the Digital Research Alliance of Canada, the Wellcome Trust, the Innovative Medicines Initiative, the Autism Centre of Excellence, the Simons Foundation Autism Research Initiative, the Templeton World Charitable Fund, the Medical Research Council, the National Institute for Health and Care Research Cambridge Biomedical Research Centre, and the National Institute for Health and Care Research Applied Research Collaboration East of England-Population Evidence and Data Science.

Peer reviewed: True, Funder: NIHR Cambridge Biomedical Research Centre; FundRef: https://doi.org/10.13039/501100018956, Funder: Autism Research Trust, Funder: Autistica; FundRef: https://doi.org/10.13039/501100008161, Funder: Templeton World Charity Foundation; FundRef: https://doi.org/10.13039/501100011730, Funder: NIHR Collaboration for Leadership in Applied Health Research and Care East of England at Cambridgeshire and Peterborough NHS Foundation Trust, Funder: Medical Research Council; FundRef: https://doi.org/10.13039/501100000265, Assortative mating is a phenomenon in which romantic partners typically resemble each other at a level greater than chance. There is converging evidence that social behaviours are subject to assortative mating, though less is known regarding social cognition. Social functioning requires the ability to identify and understand the mental states of others, i.e., theory of mind. The present study recruited a sample of 102 heterosexual couples via an online survey to test if theory of mind as measured using facial expressions (Reading the Mind in the Eyes Test) or language (Stiller-Dunbar Stories Task) is associated with assortative mating. Results provide evidence of assortative mating for theory of mind via facial expressions, though there was no such effect for theory of mind via language. Assortative mating for theory of mind via facial expressions was not moderated by length of relationship nor by partner similarity in age, educational attainment, or religiosity, all variables relevant to social stratification. This suggests assortative mating for theory of mind via facial expressions is better explained by partners being alike at the start of their relationship (initial assortment) rather than becoming similar through sustained social interaction (convergence), and by people seeking out partners that are like themselves (active assortment) rather than simply pairing with those from similar demographic backgrounds (social homogamy).

This pilot study compared autistic (N = 15) and non-autistic (N = 19) adults in a systemizing (physics reasoning) task using observational measures of attention, reasoning, and communication. Autistic adults mentioned more non-salient details (autistic; M = 4.43, non-autistic; M = 0.89) and had a greater ratio of attention to non-social versus social stimuli (autistic; M = 5.70, non-autistic; M = 3.27). Misunderstandings were more frequent (autistic; M = 2.07, non-autistic; M = 0.47) and longer (autistic; M = 64.63 seconds, non-autistic; M = 5.89 seconds) for autistic adults. However, the form of reasoning employed in the task was similar for both groups. The results suggest that the autistic adults experienced the task differently and had more difficulties. Implications for inclusive educational environments are discussed. This pilot study is presented to encourage a larger scale study using these novel methods.

Funder: RCUK | Engineering and Physical Sciences Research Council, A significant proportion of the personal and economic burden of schizophrenia can be attributed to the late diagnosis or misdiagnosis of the disorder. A novel, objective diagnostic approaches could facilitate the early detection and treatment of schizophrenia and improve patient outcomes. In the present study, we aimed to identify robust schizophrenia-specific blood biomarkers, with the goal of developing an accurate diagnostic model. The levels of selected serum and peripheral blood mononuclear cell (PBMC) markers relevant to metabolic and immune function were measured in healthy controls (n = 26) and recent-onset schizophrenia patients (n = 36) using multiplexed immunoassays and flow cytometry. Analysis of covariance revealed significant upregulation of insulin receptor (IR) and fatty acid translocase (CD36) levels in T helper cells (F = 10.75, P = 0.002, Q = 0.024 and F = 21.58, P = 2.8 × 10-5, Q = 0.0004, respectively), as well as downregulation of glucose transporter 1 (GLUT1) expression in monocytes (F = 21.46, P = 2.9 × 10-5, Q = 0.0004). The most robust predictors, monocyte GLUT1 and T helper cell CD36, were used to develop a diagnostic model, which showed a leave-one-out cross-validated area under the receiver operating characteristic curve (AUC) of 0.78 (95% CI: 0.66-0.92). The diagnostic model was validated in two independent datasets. The model was able to distinguish first-onset, drug-naïve schizophrenia patients (n = 34) from healthy controls (n = 39) with an AUC of 0.75 (95% CI: 0.64-0.86), and also differentiated schizophrenia patients (n = 22) from patients with other neuropsychiatric conditions, including bipolar disorder, major depressive disorder and autism spectrum disorder (n = 68), with an AUC of 0.83 (95% CI: 0.75-0.92). These findings indicate that PBMC-derived biomarkers have the potential to support an accurate and objective differential diagnosis of schizophrenia.

Social cognition includes understanding the mental states (thoughts, feelings, intentions, desires, and beliefs) of others – so-called ‘theory of mind’ or ‘mindreading’. Recent studies have shown an impact of age and sex. Here, we applied the ‘Reading the Mind in the Eyes’ Test (RMET) that measures the ability to identify mental states from the eye region of the face. RMET accuracy was measured and analyzed in a large population-based sample (N = 1603) across the whole adult age-range from 19 to 79 years with effect size analyses (Hedges' g). Overall test performance was lower in older than younger women and men, whereas differences between women and men were almost negligible across the whole cohort. In a further analysis focusing on age-specific sex differences, RMET accuracy was higher for women below 45 years compared to men. This sex effect nearly vanished in older people above 45 years of age. Results were verified in a sub-cohort after excluding participants with neurological and psychiatric conditions, and with another cut-off, i.e. 50 years of age. In conclusion, results suggest that mindreading declines with age. Overall sex effects were small and results suggest that age-related hormonal and social factors may impact mental state perception. Future mega-analyses and longitudinal studies including hormonal and social measures are needed to validate the interaction between RMET performance, aging and sex.

Funder: NIHR Cambridge Biomedical Research Centre; doi: http://dx.doi.org/10.13039/501100018956, Funder: NIHR Brain Injury MedTech Co-operative, Funder: Autism Research Trust, Funder: Simons Foundation Autism Research Initiative; doi: http://dx.doi.org/10.13039/100014370, Funder: Templeton World Charitable Fund, Funder: Medical Research Council; doi: http://dx.doi.org/10.13039/501100000265, Funder: NIHR Collaboration for Leadership in Applied Health Research and Care East of England at Cambridgeshire and Peterborough NHS Foundation Trust, Funder: Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No 777394 for the project AIMS-2-TRIALS, The ratio of index to ring finger (2D:4D) has been hypothesised to indicate prenatal androgen exposure, yet evidence for its validity is lacking. We report the first pre-registered study to investigate mothers’ early pregnancy sex hormone concentrations in relation to their children’s digit ratios measured at 18–22-month follow-up. Although the testosterone (T) to estradiol (E) ratio correlated negatively with right hand digit ratio (R2D:4D) and directional asymmetry (right-minus-left) in digit ratio (D[R−L]), neither effect remained statistically significant once demographic and obstetric covariates were controlled for. Nevertheless, the multivariate level of analysis did reveal that T correlated positively with left hand digit ratio (L2D:4D) and negatively with D[R−L]. However, the first of these effects is in the opposite direction to that predicted by theory. Taken together, the results of our study suggest research with larger samples is required to determine whether digit ratios are valid proxies for maternal sex hormone exposure.

Background Non-suicidal self-injury (NSSI) has been linked with a higher risk of suicide attempts in autistic and non-autistic people. In the general population, NSSI may confer acquired capability for suicide by eroding one’s fear and avoidance of pain and death. The present study aimed to explore acquired capability as the mediator of increased suicide risk conferred by NSSI in autistic and non-autistic adults. Methods Autistic and non-autistic adults (n = 314, n = 312) completed an online survey exploring lifetime suicide attempts, experience with NSSI, and acquired capability for suicide. We explored relationships between lifetime incidence of NSSI and lifetime suicide attempts via three facets of acquired capability (pain tolerance, reduced fear of death, and mental rehearsal of suicide). In self-harming participants (224 autistic and 156 non-autistic), we explored whether particular types and features of NSSI might be especially associated with capability and through that with suicide: namely engagement in scratching, cutting, and self-hitting, and engaging in more numerous forms of NSSI. Results While a higher frequency of NSSI was associated with all three facets of acquired capability, only reduced fear of death and mental rehearsal of suicide mediated an indirect relationship with lifetime suicide attempts. NSSI also directly predicted more numerous suicide attempts. Autistic people tended towards reduced fear of death and mental rehearsal regardless of NSSI status. Among self-harming autistic and non-autistic participants, cutting and an increased number of NSSI behaviours were associated with lifetime suicide attempts directly and indirectly via acquired capability. In both groups, self-hitting was associated with lifetime suicide attempts only via acquired capability. Limitations Our cross-sectional methodology negates inferences of directionality. While we controlled for age, our samples were poorly matched, with the autistic group two times older on average. The autistic sample, predominantly late-diagnosed, female and highly qualified, were unrepresentative of the whole autistic community. Conclusions Our data suggest that acquired capability, as measured herein, is an incomplete explanation for the association between NSSI and suicide risk. A broader construct with stable and transient facets may offer greater explanatory power, but it is probable that other variables explain or provide additional means through which this association arises.

The cognitive representation of oneself is central to other sociocognitive processes, including relations with others. It is reflected in faster, more accurate processing of self-relevant information, a “self-prioritisation effect” (SPE) which is inconsistent across studies in autism. Across two tasks with autistic and non-autistic participants, we explored the SPE and its relationship to autistic traits, mentalizing ability and loneliness. A SPE was intact in both groups, but together the two tasks suggested a reduced tendency of late-diagnosed autistic participants to differentiate between familiar and unfamiliar others and greater ease disengaging from the self-concept. Correlations too revealed a complex picture, which we attempt to explore and disentangle with reference to the inconsistency across self-processing studies in autism, highlighting implications for future research.

BackgroundFace individual identity recognition skill is heritable and independent of intellectual ability. Difficulties in face individual identity recognition are present in autistic individuals and their family members and are possibly linked to oxytocin polymorphisms in families with an autistic child. While it is reported that developmental prosopagnosia (i.e., impaired face identity recognition) occurs in 2–3% of the general population, no prosopagnosia prevalence estimate is available for autism. Furthermore, an autism within-group approach has not been reported towards characterizing impaired face memory and to investigate its possible links to social and communication difficulties.MethodsThe present study estimated the prevalence of prosopagnosia in 80 autistic adults with no intellectual disability, investigated its cognitive characteristics and links to autism symptoms’ severity, personality traits, and mental state understanding from the eye region by using standardized tests and questionnaires.ResultsMore than one third of autistic participants showed prosopagnosia. Their face memory skill was not associated with their symptom’s severity, empathy, alexithymia, or general intelligence. Face identity recognition was instead linked to mental state recognition from the eye region only in autistic individuals who had prosopagnosia, and this relationship did not depend on participants’ basic face perception skills. Importantly, we found that autistic participants were not aware of their face memory skills.LimitationsWe did not test an epidemiological sample, and additional work is necessary to establish whether these results generalize to the entire autism spectrum.ConclusionsImpaired face individual identity recognition meets the criteria to be a potential endophenotype in autism. In the future, testing for face memory could be used to stratify autistic individuals into genetically meaningful subgroups and be translatable to autism animal models.

Funder: Indonesia Endowment Fund for Education, BACKGROUND: Many empirical studies suggest that higher maternal age increases the likelihood of having an autistic child. However, little is known about factors that may explain this relationship or if higher maternal age is related to the number of autistic-like traits in offspring. One possibility is that mothers who have a higher number of autistic-like traits, including greater challenges performing mentalizing skills, are delayed in finding a partner. The goal of our study is to assess the relationship between maternal age, mentalizing skills and autistic-like traits as independent predictors of the number of autistic-like traits in offspring. METHODS: In a population-based study in the Netherlands, information on maternal age was collected during pre- and perinatal enrolment. Maternal mentalizing skills and autistic-like traits were assessed using the Reading the Mind in the Eyes Test and the Autism Spectrum Quotient, respectively. Autistic-like traits in children were assessed with the Social Responsiveness Scale. A total of 5718 mother/child dyads had complete data (Magechild = 13.5 years; 50.2% girls). RESULTS: The relationship between maternal age and autistic-like traits in offspring best fits a U-shaped curve. Furthermore, higher levels of autistic features in mothers are linked to higher levels of autistic-like traits in their children. Lower mentalizing performance in mothers is linked to higher levels of autistic-like traits in their children. LIMITATIONS: We were able to collect data on both autistic-like traits and the mentalizing skills test in a large population of mothers, but we did not collect these data in a large number of the fathers. CONCLUSIONS: The relationships between older and younger mothers may have comparable underlying mechanisms, but it is also possible that the tails of the U-shaped curve are influenced by disparate mechanisms.

Funder: Simons Foundation Autism Research Initiative; doi: http://dx.doi.org/10.13039/100014370, Funder: Templeton World Charity Foundation; doi: http://dx.doi.org/10.13039/501100011730, Funder: Medical Research Council; doi: http://dx.doi.org/10.13039/501100000265, Funder: NIHR Biomedical Research Centre, Funder: NIHR Collaboration for Leadership in Applied Health Research and Care - East of England, Funder: Queen Anne's Gate Foundation, Funder: Corbin Charitable Trust, BACKGROUND: Recent research suggests that autistic individuals have shorter lifespans and experience worse health (greater health burden) than non-autistic individuals. Small, qualitative studies suggest that autistic adults also experience poor self-reported healthcare quality. METHODS: An anonymized, cross-sectional, self-report questionnaire was administered to n = 4158 individuals. The study assessed prevalence of chronic health conditions, healthcare quality, differences in overall health inequality score, and effects of the coronavirus pandemic on healthcare quality. We used Fisher's exact tests, binomial logistic regression, and predictive machine learning tools, as appropriate. RESULTS: The final sample included n = 2649 participants (n = 1285 autistic) aged 16-96 years. Autistic adults reported lower quality healthcare than non-autistic adults across 50/51 items, including poorer access to healthcare and poorer communication, alongside increased anxiety, sensory sensitivity, system-level problems, shutdowns, and meltdowns. Differences between groups were stark: aggregated health inequality scores predicted autism diagnosis, even after stratifying by sex. Autistic adults were also more likely to have chronic health conditions than non-autistic adults. There were no significant differences in healthcare quality for autistic adults before and during the pandemic, although they received relatively poorer quality healthcare than non-autistic adults across both periods. LIMITATIONS: The study's sampling methods are not likely to capture the perspectives of all autistic individuals, especially those with intellectual disability. Both the autistic and control samples are biased towards UK residents, white individuals, those assigned female at birth, and those who completed an undergraduate degree or higher education. As such, these results may limit their generalizability to other groups. Finally, these results relate to self-reported differences in healthcare quality between autistic and non-autistic adults. The observed group differences may in part reflect differences in perception and communication rather than differences in actual healthcare quality. CONCLUSIONS: Autistic adults are more likely to have chronic health conditions alongside self-reported lower quality healthcare than others. Health inequalities between these groups are widespread and dramatic; unfortunately, they existed before and have persisted after the onset of the coronavirus pandemic.

Maternal immune activation (MIA) is mediated by activation of inflammatory pathways resulting in increased levels of cytokines and chemokines that cross the placental and blood-brain barriers altering fetal neural development. Maternal viral infection is one of the most well-known causes for immune activation in pregnant women. MIA and immune abnormalities are key players in the etiology of developmental conditions such as autism, schizophrenia, ADHD, and depression. Experimental evidence implicating MIA in with different effects in the offspring is complex. For decades, scientists have relied on either MIA models or human epidemiological data or a combination of both. MIA models are generated using infection/pathogenic agents to induce an immunological reaction in rodents and monitor the effects. Human epidemiological studies investigate a link between maternal infection and/or high levels of cytokines in pregnant mothers and the likelihood of developing conditions. In this review, we discuss the importance of understanding the relationship between virus-mediated MIA and neurodevelopmental conditions, focusing on autism and schizophrenia. We further discuss the different methods of studying MIA and their limitations and focus on the different factors contributing to MIA heterogeneity.

Over the past few decades, neuroimaging has become a ubiquitous tool in basic research and clinical studies of the human brain. However, no reference standards currently exist to quantify individual differences in neuroimaging metrics over time, in contrast to growth charts for anthropometric traits such as height and weight1. Here we assemble an interactive open resource to benchmark brain morphology derived from any current or future sample of MRI data ( http://www.brainchart.io/ ). With the goal of basing these reference charts on the largest and most inclusive dataset available, acknowledging limitations due to known biases of MRI studies relative to the diversity of the global population, we aggregated 123,984 MRI scans, across more than 100 primary studies, from 101,457 human participants between 115 days post-conception to 100 years of age. MRI metrics were quantified by centile scores, relative to non-linear trajectories2 of brain structural changes, and rates of change, over the lifespan. Brain charts identified previously unreported neurodevelopmental milestones3, showed high stability of individuals across longitudinal assessments, and demonstrated robustness to technical and methodological differences between primary studies. Centile scores showed increased heritability compared with non-centiled MRI phenotypes, and provided a standardized measure of atypical brain structure that revealed patterns of neuroanatomical variation across neurological and psychiatric disorders. In summary, brain charts are an essential step towards robust quantification of individual variation benchmarked to normative trajectories in multiple, commonly used neuroimaging phenotypes., R.A.I.B. was supported by a British Academy Postdoctoral fellowship and by the Autism Research Trust. J. Seidlitz was supported by NIMH T32MH019112-29 and K08MH120564. S.R.W. was funded by UKRI Medical Research Council MC_UU_00002/2 and was supported by the NIHR Cambridge Biomedical Research Centre (BRC-1215-20014). E.T.B. was supported by an NIHR Senior Investigator award and the Wellcome Trust collaborative award for the Neuroscience in Psychiatry Network. A.F.A.-B. was supported by NIMH K08MH120564. Data were curated and analysed using a computational facility funded by an MRC research infrastructure award (MR/M009041/1) to the School of Clinical Medicine, University of Cambridge and supported by the mental health theme of the NIHR Cambridge Biomedical Research Centre.

Funder: Autism Research Trust, Funder: Autistica; doi: http://dx.doi.org/10.13039/501100008161, Funder: Medical Research Council; doi: http://dx.doi.org/10.13039/501100000265, Funder: Cambridge Biomedical Research Centre; doi: http://dx.doi.org/10.13039/501100018956, Funder: National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care East of England at Cambridgeshire and Peterborough NHS Foundation Trust, Funder: Templeton World Charity Foundation; doi: http://dx.doi.org/10.13039/501100011730, It has been hypothesised that romantic partners are more similar than chance in relation to autistic traits. To test this theory, we recruited n = 105 heterosexual couples and examined within-couple correlations for autistic traits [measured using the Autism Spectrum Quotient (AQ)], empathizing [measured using the Empathy Quotient (EQ)], and systemizing [measured using the Systemizing Quotient-Revised (SQ-R)]. For a subsample that attended the lab (n = 58 couples), we also investigated theory of mind via facial expressions using the Reading the Mind in the Eyes Test (RMET) and attention to detail, a component within systemizing, using the Embedded Figures Task (EFT). Variable-centred analyses revealed positive within-couple correlations for all measures except EQ, although these effects were only statistically significant for unmarried couples and not for married/engaged couples. Follow-up analyses indicated that the observed couple similarity effects are likely consistent with people pairing with those more similar than chance (initial assortment) rather than becoming alike over time (convergence), and to seeking out self-resembling partners (active assortment) rather than pairing in this manner via social stratification processes (social homogamy). Additionally, a significant within-couple correlation for autistic traits was observed at the meta-analytic level. However, it should be noted that the meta-analytic effect size estimate was small (r = 0.153) and indicates that only ~ 2% of variance in a person’s score on a phenotypic measure of autistic traits can be predicted by that of their partner.

Background: Posttraumatic stress disorder (PTSD) is triggered by environmental stressors. Empathy may predispose an individual to respond to life events differently if high empathizers are emotionally more sensitive to trauma. For the first time, we test this hypothesis using genetic information. Methods: We applied polygenic scoring (PGS) to investigate the shared genetics linking empathy (measured using the Empathy Quotient (EQ), a self-report measure of empathy; N = 46,861) and PTSD symptom severity (measured using the 6-item PTSD Checklist 6-item (PCL-6)) in the UK Biobank (N = 126,219). Follow-up analyses were performed in the context of (1) experiencing any of 16 potential traumas, (2) the total number of traumas endorsed, and (3) the context of trauma. Autism, depression, generalized anxiety, and PCL-17 PGS were included as covariates to verify the specificity of the effect. Results: EQPGS associated with PCL-6 (R 2 = 0.012%, P = 9.35 �� 10-5). This effect remained significant after accounting for autism, depression, PTSD, and anxiety PGS but was observed only in those who endorsed experiencing at least one traumatic event. EQPGS showed the strongest effect on PCL-6 (�� = 2.32, s.e. = 0.762, P = 0.002) among those who endorsed childhood neglect/abuse (felt hated as a child). With respect to case status, the highest probability of PTSD was 17.93% and 10.04% for those who endorsed "feeling hated as a child" and those who did not, respectively (P diff = 0.011; Cohen's d = 1.951, 95%CI 1.70-2.20). Conclusions: A genetic predisposition to higher empathy, which may index greater emotional sensitivity, predisposes an individual to more severe PTSD symptoms, especially after early-life adversity.

Funder: Silmo Research Academy grant 2018, Sensory differences between autism and neuro-typical populations are well-documented and have often been explained by either weak-central-coherence or excitation/inhibition-imbalance cortical theories. We tested these theories with perceptual multi-stability paradigms in which dissimilar images presented to each eye generate dynamic cyclopean percepts based on ongoing cortical grouping and suppression processes. We studied perceptual multi-stability with Interocular Grouping (IOG), which requires the simultaneous integration and suppression of image fragments from both eyes, and Conventional Binocular Rivalry (CBR), which only requires global suppression of either eye, in 17 autistic adults and 18 neurotypical participants. We used a Hidden-Markov-Model as tool to analyze the multistable dynamics of these processes. Overall, the dynamics of multi-stable perception were slower (i.e. there were longer durations and fewer transitions among perceptual states) in the autistic group compared to the neurotypical group for both IOG and CBR. The weighted Markovian transition distributions revealed key differences between both groups and paradigms. The results indicate overall lower levels of suppression and decreased levels of grouping in autistic than neurotypical participants, consistent with elements of excitation/inhibition imbalance and weak-central-coherence theories.

Oxytocin is hypothesized to promote social interactions by enhancing the salience of social stimuli. While previous neuroimaging studies have reported that oxytocin enhances amygdala activation to face stimuli in autistic men, effects in autistic women remain unclear. In this study, the influence of intranasal oxytocin on activation and functional connectivity of the basolateral amygdala – the brain’s “salience detector” – while processing emotional faces vs. shapes was tested in 16 autistic and 21 non-autistic women by fMRI in a placebo-controlled, within-subjects, cross-over design. In the placebo condition, minimal activation differences were observed between autistic and non-autistic women. However, significant drug × group interactions were observed for both basolateral amygdala activation and functional connectivity. Oxytocin increased left basolateral amygdala activation among autistic women (35 voxel cluster, MNI coordinates of peak voxel= -22 -10 -28; mean change=+0.079%, t=3.159, ptukey=0.0166), but not non-autistic women (mean change =+0.003%, t=0.153, ptukey=0.999). Furthermore, oxytocin increased functional connectivity of the right basolateral amygdala with brain regions associated with socio-emotional information processing in autistic women, but not non-autistic women, attenuating group differences in the placebo condition. Taken together, these findings extend evidence of oxytocin’s effects on the amygdala to specifically include autistic women and specify the subregion of the effect.

Recent data has revealed dissociations between social and non-social skills in both autistic and neurotypical populations. In the present study, we investigated whether specific visuospatial abilities, such as figure disembedding and mental rotation, are differently related to social and non-social autistic traits, in neurotypical women and men. University students (N = 426) completed the Autism Spectrum Quotient (AQ), figure disembedding and mental rotation of two-dimensional figures tasks. AQ social skills (AQ-social) and attention-to-details (AQ-attention) subscales were used as measures of social and non-social autistic traits, respectively. Mental rotation was affected by a significant interaction between sex, social and non-social traits. When non-social traits were above the mean (+ 1 SD), no sex differences in mental rotation were found. Instead, below this value, sex differences depended on the social traits, with men on average outperforming women at middle-to-high social traits, and with a comparable performance, and with women on average outperforming men, at lower social traits. A small positive correlation between figure disembedding and social traits was observed in the overall sample. These results are interpreted in terms of the hyper-systemizing theory of autism and contribute to the evidence of individual differences in the cognitive style of autistic people and neurotypical people with autistic traits.

Contains fulltext : 288245.pdf (Publisher’s version ) (Open Access) BACKGROUND: The cerebellum contains more than 50% of the brain's neurons and is involved in social cognition. Cerebellar anatomical atypicalities have repeatedly been reported in individuals with autism. However, studies have yielded inconsistent findings, likely because of a lack of statistical power, and did not capture the clinical and neuroanatomical diversity of autism. Our aim was to better understand cerebellar anatomy and its diversity in autism. METHODS: We studied cerebellar gray matter morphology in 274 individuals with autism and 219 control subjects of a multicenter European cohort, EU-AIMS LEAP (European Autism Interventions-A Multicentre Study for Developing New Medications; Longitudinal European Autism Project). To ensure the robustness of our results, we conducted lobular parcellation of the cerebellum with 2 different pipelines in addition to voxel-based morphometry. We performed statistical analyses with linear, multivariate (including normative modeling), and meta-analytic approaches to capture the diversity of cerebellar anatomy in individuals with autism and control subjects. Finally, we performed a dimensional analysis of cerebellar anatomy in an independent cohort of 352 individuals with autism-related symptoms. RESULTS: We did not find any significant difference in the cerebellum when comparing individuals with autism and control subjects using linear models. In addition, there were no significant deviations in our normative models in the cerebellum in individuals with autism. Finally, we found no evidence of cerebellar atypicalities related to age, IQ, sex, or social functioning in individuals with autism. CONCLUSIONS: Despite positive results published in the last decade from relatively small samples, our results suggest that there is no striking difference in cerebellar anatomy of individuals with autism.

Prenatal testosterone (pT) is a crucial component in physiological masculinization in humans. In line with the Prenatal Sex Steroid Theory of autism, some studies have found a positive correlation between pT and autistic traits in childhood. However, effects in adolescence have not been explored. Hormonal and environmental changes occurring during puberty may alter the strength or the nature of prenatal effects on autistic traits. The current study examines if pT relates to autistic traits in a non-clinical sample of adolescents and young adults (N = 97, 170 observations; age 13–21 years old). It also explores pT interactions with pubertal stage and timing. PT concentrations were measured from amniotic fluid extracted in the 2nd trimester of gestation via amniocentesis conducted for clinical purposes. Autistic traits were measured by self- and parent-reports on the Autism Spectrum Quotient (AQ) which provides a total score and 5 sub-scores (social skills, communication, imagination, attention switching and attention to detail). Self-reported pubertal stage was regressed on age to provide a measure of relative timing. We found no statistical evidence for a direct association between pT and autistic traits in this adolescent sample (males, females or full sample). Exploratory analyses suggested that pT correlated positively with autistic traits in adolescents with earlier puberty-onset, but statistical robustness of this finding was limited. Further exploratory post-hoc tests suggested the pT-by-pubertal timing interaction was stronger in males relative to females, in self-reported compared to parent-reported AQ and specifically for social traits. These findings require replication in larger samples. Findings have implications for understanding the effects of pT on human behavior, specifically existence of effects in adolescence., Highlights • High prenatal testosterone (pT) may be associated with autistic traits in children. • An association was not observed in our adolescent sample. • The association between pT and autistic traits may be moderated by pubertal factors. • Higher pT related to higher autistic traits in adolescents with earlier-onset/faster puberty. • This interaction of pT and pubertal timing was most evident for social traits.

Background The neurocognitive mechanisms underlying autism spectrum disorder (ASD) remain unclear. Progress has been largely hampered by small sample sizes, variable age ranges and resulting inconsistent findings. There is a pressing need for large definitive studies to delineate the nature and extent of key case/control differences to direct research towards fruitful areas for future investigation. Here we focus on perception of biological motion, a promising index of social brain function which may be altered in ASD. In a large sample ranging from childhood to adulthood, we assess whether biological motion preference differs in ASD compared to neurotypical participants (NT), how differences are modulated by age and sex and whether they are associated with dimensional variation in concurrent or later symptomatology. Methods Eye-tracking data were collected from 486 6-to-30-year-old autistic (N = 282) and non-autistic control (N = 204) participants whilst they viewed 28 trials pairing biological (BM) and control (non-biological, CTRL) motion. Preference for the biological motion stimulus was calculated as (1) proportion looking time difference (BM-CTRL) and (2) peak look duration difference (BM-CTRL). Results The ASD group showed a present but weaker preference for biological motion than the NT group. The nature of the control stimulus modulated preference for biological motion in both groups. Biological motion preference did not vary with age, gender, or concurrent or prospective social communicative skill within the ASD group, although a lack of clear preference for either stimulus was associated with higher social-communicative symptoms at baseline. Limitations The paired visual preference we used may underestimate preference for a stimulus in younger and lower IQ individuals. Our ASD group had a lower average IQ by approximately seven points. 18% of our sample was not analysed for various technical and behavioural reasons. Conclusions Biological motion preference elicits small-to-medium-sized case–control effects, but individual differences do not strongly relate to core social autism associated symptomatology. We interpret this as an autistic difference (as opposed to a deficit) likely manifest in social brain regions. The extent to which this is an innate difference present from birth and central to the autistic phenotype, or the consequence of a life lived with ASD, is unclear.

IntroductionSpecialist gender services for children and young people (CYP) worldwide have experienced a significant increase in referrals in recent years. As rates of referrals increase, it is important to understand the characteristics and profile of CYP attending these services in order to inform treatment pathways and to ensure optimal outcomes.Methods and analysisA retrospective observational study of clinical health records from specialist gender services for CYP in the UK and the Netherlands. The retrospective analysis will examine routinely collected clinical and outcome measures data including demographic, clinical, gender identity-related and healthcare resource use information. Data will be reported for each service and also compared between services. This study forms part of a wider programme of research investigating outcomes of gender identity in children (the Longitudinal Outcomes of Gender Identity in Children study).Ethics and disseminationThe proposed study has been approved by the Health Research Authority and London—Hampstead Research Ethics Committee as application 19/LO/0181. The study findings will be published in peer-reviewed journals and presented at both conferences and stakeholder events.

Autistic individuals experience significantly elevated rates of childhood trauma, self-harm and suicidal behaviour and ideation (SSBI). Is this purely the result of negative environmental experiences, or does this interact with genetic predisposition? In this study we investigated if a genetic predisposition for autism is associated with childhood trauma using polygenic scores (PGS) and genetic correlations in the UK Biobank (105,222 N R2 = 0.096%, P −16), self-harm ideation (max R2 = 0.108%, P −16), and self-harm (max R2 = 0.13%, P −16). Supporting this, we identified significant genetic correlations between autism and childhood trauma (rg = 0.36 ± 0.05, P = 8.13 × 10−11), self-harm ideation (rg = 0.49 ± 0.05, P = 4.17 × 10−21) and self-harm (rg = 0.48 ± 0.05, P = 4.58 × 10−21), and an over-transmission of PGS for the two SSBI phenotypes from parents to autistic probands. Male sex negatively moderated the effect of autism PGS on childhood trauma (β = −0.023 ± 0.005, P = 6.74 × 10−5). Further, childhood trauma positively moderated the effect of autism PGS on self-harm score (β = 8.37 × 10−3 ± 2.76 × 10−3, P = 2.42 × 10−3) and self-harm ideation (β = 7.47 × 10−3 ± 2.76 × 10−3, P = 6.71 × 10−3). Finally, depressive symptoms, quality and frequency of social interactions, and educational attainment were significant mediators of the effect of autism PGS on SSBI, with the proportion of effect mediated ranging from 0.23 (95% CI: 0.09–0.32) for depression to 0.008 (95% CI: 0.004–0.01) for educational attainment. Our findings identify that a genetic predisposition for autism is associated with adverse life-time outcomes, which represent complex gene-environment interactions, and prioritizes potential mediators and moderators of this shared biology. It is important to identify sources of trauma for autistic individuals in order to reduce their occurrence and impact.

UNSTRUCTURED The COVID-19 pandemic accelerated the uptake of digital health worldwide and highlighted many benefits of these innovations. However, it also stressed the magnitude of inequalities regarding accessing digital health. Using a scoping review, this article explores the potential benefits of digital technologies for the global population, with particular reference to people living with disabilities, using the autism community as a case study. We ultimately explore policies in Sweden, Australia, Canada, Estonia, the United Kingdom, and the United States to learn how policies can lay an inclusive foundation for digital health systems. We conclude that digital health ecosystems should be designed with health equity at the forefront to avoid deepening existing health inequalities. We call for a more sophisticated understanding of digital health literacy to better assess the readiness to adopt digital health innovations. Finally, people living with disabilities should be positioned at the center of digital health policy and innovations to ensure they are not left behind.

The coronavirus disease 2019 (COVID-19) pandemic will have a high impact on older adults and people with Alzheimer's disease and other dementias. Social cognition enables the understanding of another individual's feelings, intentions, desires and mental states, which is particularly important during the COVID-19 pandemic. To prevent further spread of the disease face masks have been recommended. Although justified for prevention of this potentially devastating disease, they partly cover the face and hamper emotion recognition and probably mindreading. As social cognition is already affected by aging and dementia, strategies must be developed to cope with these profound changes of communication. Face masking even could accelerate cognitive decline in the long run. Further studies are of uppermost importance to address face masks' impact on social cognition in aging and dementia, for instance by longitudinally investigating decline before and in the pandemic, and to design compensatory strategies. These issues are also relevant for face masking in general, such as in medical surroundings—beyond the COVID-19 pandemic.

Funder: Autism Research Trust, Funder: Templeton World Charitable Fund, Funder: NIHR Cambridge Biomedical Research Centre; doi: http://dx.doi.org/10.13039/501100018956, Funder: National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research, Funder: Care East of England at Cambridgeshire and Peterborough NHS Foundation Trust, Recent data has revealed dissociations between social and non-social skills in both autistic and neurotypical populations. In the present study, we investigated whether specific visuospatial abilities, such as figure disembedding and mental rotation, are differently related to social and non-social autistic traits, in neurotypical women and men. University students (N = 426) completed the Autism Spectrum Quotient (AQ), figure disembedding and mental rotation of two-dimensional figures tasks. AQ social skills (AQ-social) and attention-to-details (AQ-attention) subscales were used as measures of social and non-social autistic traits, respectively. Mental rotation was affected by a significant interaction between sex, social and non-social traits. When non-social traits were above the mean (+ 1 SD), no sex differences in mental rotation were found. Instead, below this value, sex differences depended on the social traits, with men on average outperforming women at middle-to-high social traits, and with a comparable performance, and with women on average outperforming men, at lower social traits. A small positive correlation between figure disembedding and social traits was observed in the overall sample. These results are interpreted in terms of the hyper-systemizing theory of autism and contribute to the evidence of individual differences in the cognitive style of autistic people and neurotypical people with autistic traits.

To date, neuroimaging research has had a limited focus on non-social features of autism. As a result, neurobi- ological explanations for atypical sensory perception in autism are lacking. To address this, we quantitively condensed findings from the non-social autism fMRI literature in line with the current best practices for neu- roimaging meta-analyses. Using activation likelihood estimation (ALE), we conducted a series of robust meta- analyses across 83 experiments from 52 fMRI studies investigating differences between autistic (n = 891) and typical (n = 967) participants. We found that typical controls, compared to autistic people, show greater activity in the prefrontal cortex (BA9, BA10) during perception tasks. More refined analyses revealed that, when compared to typical controls, autistic people show greater recruitment of the extrastriate V2 cortex (BA18) during visual processing. Taken together, these findings contribute to our understanding of current theories of autistic perception, and highlight some of the challenges of cognitive neuroscience research in autism

Summary Background Autistic individuals might be more likely to misuse substances than non-autistic individuals. Better understanding of these patterns can help clinicians identify strategies to reduce substance use, protecting physical and mental health. The aim of this study was to compare the experiences of substance use between autistic and non-autistic adolescents and adults. Methods This study is a mixed-methods study, including both quantitative (closed-ended questions) and qualitative (one open-ended question) online assessments. Data were collected as part of a larger study, the Autism and Physical Health Survey, in which we administered an anonymised, online questionnaire to autistic and non-autistic individuals aged 16–90 years. In the present study, we investigated data on substance use or misuse, using two overlapping but separate samples from the survey (one sample with complete quantitative responses and one sample with complete qualitative responses). Binary measures of substance use were investigated using unadjusted and adjusted binomial logistic regression models. Content analysis was used to compare experiences of autistic and non-autistic adolescents and adults. We used Fisher's exact tests to assess differences in frequency of reporting particular qualitative themes and subthemes. Findings Survey recruitment was done between Feb 7, 2018, and Aug 26, 2019. At the end of the recruitment, 3657 individuals had accessed the survey. After excluding duplicates as well as participants with missing or incomplete responses, we had data from 2386 participants (1183 autistic and 1203 non-autistic participants; 1571 female and 815 male participants) for the quantitative analyses and data from 919 participants (429 autistic and 490 non-autistic participants; 569 female and 350 male participants) in the qualitative analyses. The samples for the quantitative and qualitative analyses were predominantly composed of female individuals, White individuals, UK residents, and those without intellectual disability. Autistic individuals were less likely than non-autistic individuals to report consuming alcohol regularly (16·0% of autistic individuals vs 22·2% of non-autistic individuals; adjusted model: odds ratio [OR] 0·69, 95% CI 0·55–0·86; p=0·0022) or binge-drinking (3·8% vs 8·2%; adjusted model: OR 0·38, 0·26–0·56; p

Background Marked sex differences in autism prevalence accentuate the need to understand the role of biological sex-related factors in autism. Efforts to unravel sex differences in the brain organization of autism have, however, been challenged by the limited availability of female data. Methods We addressed this gap by using a large sample of males and females with autism and neurotypical (NT) control individuals (ABIDE; Autism: 362 males, 82 females; NT: 409 males, 166 females; 7–18 years). Discovery analyses examined main effects of diagnosis, sex and their interaction across five resting-state fMRI (R-fMRI) metrics (voxel-level Z > 3.1, cluster-level P Results Discovery analyses in ABIDE revealed significant main effects of diagnosis and sex across the intrinsic functional connectivity of the posterior cingulate cortex, regional homogeneity and voxel-mirrored homotopic connectivity (VMHC) in several cortical regions, largely converging in the default network midline. Sex-by-diagnosis interactions were confined to the dorsolateral occipital cortex, with reduced VMHC in females with autism. All findings were robust to different pre-processing steps. Replicability in independent samples varied by R-fMRI measures and effects with the targeted sex-by-diagnosis interaction being replicated in the larger of the two replication samples—EU-AIMS LEAP. Limitations Given the lack of a priori harmonization among the discovery and replication datasets available to date, sample-related variation remained and may have affected replicability. Conclusions Atypical cross-hemispheric interactions are neurobiologically relevant to autism. They likely result from the combination of sex-dependent and sex-independent factors with a differential effect across functional cortical networks. Systematic assessments of the factors contributing to replicability are needed and necessitate coordinated large-scale data collection across studies.

BackgroundAutism is a heterogenous collection of disorders with a complex molecular underpinning. Evidence from post-mortem brain studies using adult brains have indicated that early prenatal development may be altered in autism. Induced pluripotent stem cells (iPSCs) generated from autistic individuals with macrocephaly also indicate prenatal development as a critical period for this condition. But little is known about early altered cellular events during prenatal stages in autism.MethodsIPSCs were generated from 9 unrelated autistic individuals without macrocephaly and with heterogeneous genetic backgrounds, and 6 typically developing, control, individuals. IPSCs were differentiated towards either cortical or midbrain fates. Gene expression and high throughput cellular phenotyping was used to characterise iPSCs at different stage of differentiation.ResultsA subset of autism-iPSC cortical neurons were RNA-sequenced to reveal autism-specific signatures similar to post-mortem brain studies, indicating a potential common biological mechanism. Autism-iPSCs differentiated towards a cortical fate displayed impairments in the ability to self-form into neural rosettes. In addition, autism-iPSCs demonstrated significant differences in rate of cell type assignment of cortical precursors, and dorsal and ventral forebrain precursors. These cellular phenotypes occurred in the absence of alterations in cell proliferation during cortical differentiation, differing from previous studies. Acquisition of cell fate during midbrain differentiation was not different between control- and autism-iPSCs.ConclusionsTaken together, our data indicate that autism-iPSCs diverge from control-iPSCs at a cellular level during early stage of neurodevelopment. This suggests that unique developmental differences associated with autism may be established at early prenatal stages.

Background There is inconsistent evidence for a clear pattern of association between ‘camouflaging’ (strategies used to mask and/or compensate for autism characteristics during social interactions) and mental health. Methods This study explored the relationship between self-reported camouflaging and generalised anxiety, depression, and social anxiety in a large sample of autistic adults and, for the first time, explored the moderating effect of gender, in an online survey. Results Overall, camouflaging was associated with greater symptoms of generalised anxiety, depression, and social anxiety, although only to a small extent beyond the contribution of autistic traits and age. Camouflaging more strongly predicted generalised and social anxiety than depression. No interaction between camouflaging and gender was found. Limitations These results cannot be generalised to autistic people with intellectual disability, or autistic children and young people. The sample did not include sufficient numbers of non-binary people to run separate analyses; therefore, it is possible that camouflaging impacts mental health differently in this population. Conclusions The findings suggest that camouflaging is a risk factor for mental health problems in autistic adults without intellectual disability, regardless of gender. We also identified levels of camouflaging at which risk of mental health problems is highest, suggesting clinicians should be particularly aware of mental health problems in those who score at or above these levels.

Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder that is accompanied by neurodevelopmental differences in regional cortical volume (CV), and a potential layer-specific pathology. Conventional measures of CV, however, do not indicate how volume is distributed across cortical layers. In a sample of 92 typically developing (TD) controls and 92 adult individuals with ASD (aged 18–52 years), we examined volumetric gradients by quantifying the degree to which CV is weighted from the pial to the white surface of the brain. Overall, the spatial distribution of Frustum Surface Ratio (FSR) followed the gyral and sulcal pattern of the cortex and approximated a bimodal Gaussian distribution caused by a linear mixture of vertices on gyri and sulci. Measures of FSR were highly correlated with vertex-wise estimates of mean curvature, sulcal depth, and pial surface area, although none of these features explained more than 76% variability in FSR on their own. Moreover, in ASD, we observed a pattern of predominant increases in the degree of FSR relative to TD controls, with an atypical neurodevelopmental trajectory. Our findings suggest a more outward-weighted gradient of CV in ASD, which may indicate a larger contribution of supragranular layers to regional differences in CV.

SB-C was funded by the Autism Research Trust, the Wellcome Trust, the Templeton World Charitable Foundation, and the NIHR Biomedical Research Centre in Cambridge, during the period of this work. SB-C received funding from the Innovative Medicines Initiative 2 Joint Undertaking (JU) under grant agreement No 777394. The JU receives support from the European Union's Horizon 2020 research and innovation programme and EFPIA and AUTISM SPEAKS, Autistica, SFARI. The research conducted by SB-C was supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care East of England at Cambridgeshire and Peterborough NHS Foundation Trust. The views expressed are those of the author(s) and not necessarily those of the NHS, NIHR, or Department of Health and Social Care., Introduction: The literature has demonstrated how the relationship between cognitive or emotional intelligence and age exhibits an inverted-U-shape and that this decline can be mitigated by an individual’s cognitive reserve (CR). Rather less is known, however, about the pattern of changes in cognitive empathy or the ability to recognize the thoughts or feelings of others. Objectives: The aim of the present study was firstly to analyze the effect of age, gender, and CR (measured through educational level), on the capacity to show cognitive empathy. Secondly, we aimed to evaluate what type of relationship—linear or quadratic—exists between age and cognitive empathy. We finally aimed to analyze the moderator role of educational level on the relationship between age and cognitive empathy. Participants: Totally, 902 Spanish adults aged between 18 and 79 years (M= 43.53, SD = 11.86; 57% women). Measurements: Participants were asked to indicate their educational level (primary, high school, or college education) and their cognitive empathy was assessed using the Eyes test. Results: Women scored higher than men on cognitive empathy. Participants with a college education had higher scores on cognitive empathy than those with a lower educational level. Additionally, the relationship between age and cognitive empathy fit an inverted-U-shaped curve, consistent with the data found for cognitive and emotional intelligence. Finally, the age-related decrease in cognitive empathy appeared to be mitigated by a higher educational level, but only in those individuals aged 35 years and above. Limitations and clinical implications are discussed., Autism Research Trust, Wellcome Trust, Templeton World Charitable Foundation, NIHR Biomedical Research Centre in Cambridge, Innovative Medicines Initiative 2 Joint Undertaking (JU) 777394, European Commission, EFPIA, AUTISM SPEAKS, Autistica, SFARI, National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care East of England at Cambridgeshire and Peterborough NHS Foundation Trust

Funder: Wellcome Trust (Wellcome); doi: https://doi.org/10.13039/100004440, Funder: SBC was funded by the Wellcome Trust and the Autism Research Trust during the period of this work., Funder: DM was supported by the NIHR Maudsley Biomedical Research Centre., Autism is a complex neurodevelopmental condition with substantial phenotypic, biological, and etiologic heterogeneity. It remains a challenge to identify biomarkers to stratify autism into replicable cognitive or biological subtypes. Here, we aim to introduce a novel methodological framework for parsing neuroanatomical subtypes within a large cohort of individuals with autism. We used cortical thickness (CT) in a large and well-characterized sample of 316 participants with autism (88 female, age mean: 17.2 ± 5.7) and 206 with neurotypical development (79 female, age mean: 17.5 ± 6.1) aged 6–31 years across six sites from the EU-AIMS multi-center Longitudinal European Autism Project. Five biologically based putative subtypes were derived using normative modeling of CT and spectral clustering. Three of these clusters showed relatively widespread decreased CT and two showed relatively increased CT. These subtypes showed morphometric differences from one another, providing a potential explanation for inconsistent case–control findings in autism, and loaded differentially and more strongly onto symptoms and polygenic risk, indicating a dilution of clinical effects across heterogeneous cohorts. Our results provide an important step towards parsing the heterogeneous neurobiology of autism.

Background: Autistic adults are more likely to engage in suicidal thoughts and behaviors, but there is little research to explore the underlying reasons. It is unclear whether self-report suicide scales that have been designed for non-autistic people accurately measure suicide risk constructs in autistic people. Therefore, this study explored, for the first time, whether the measurement properties of the self-report scales of the Interpersonal Theory of Suicide are equivalent in autistic and non-autistic adults. Methods: In this study, responses from 342 autistic and 353 non-autistic people on the Interpersonal Needs Questionnaire-10 (INQ-10) and Acquired Capability for Suicide Scale–Fearlessness about Death (ACSS–FAD) were compared by using measurement invariance analysis. Data were gathered through an online cross-sectional survey of the self-report measures. Results: Results suggest that measurement properties of the INQ-10 were different in autistic people. Autistic characteristics, such as different theory of mind and preference for concrete language, may have led the scale items to load differently on the factors in the autistic group than in the non-autistic group. The measurement properties of the ACSS–FAD were invariant between autistic and non-autistic people. Conclusions: Scores on the INQ-10 cannot be meaningfully compared between autistic and non-autistic people due to different measurement properties. Future research could explore how autistic people experience the concepts of burdensomeness and belonging, to consider how measures could accurately capture this. This would allow researchers to explore the role of these constructs in the development of suicidal thoughts and behaviors in autistic people. Clinicians should be aware that suicide risk factors may present differently in autistic people. Scores on the ACSS-FAD can be meaningfully compared, but the negatively worded scale items may pose similar response difficulties to autistic and non-autistic people., Lay summary What was the purpose of this study? The purpose of this study was to explore whether two questionnaires designed for non-autistic people create response difficulties for autistic people. If autistic people experience difficulties interpreting the questions, this can mean that the scales do not work in the same way, which means that scores between autistic and non-autistic people cannot be compared. This is important, as these questionnaires are designed to measure risk factors for suicide: feeling like a burden on others, feeling as if you don't belong, and not fearing death. We know that for non-autistic people these feelings increase the risk of suicide, but we do not yet know whether this is the case for autistic people. What did the researchers do? We collected questionnaire responses online from 342 autistic people and 335 non-autistic people. We then used statistical analyses to identify whether the questionnaires operated differently in autistic and non-autistic people. A steering group of autistic adults identified which questions were likely to be interpreted differently by autistic people. What were the results of the study? We found that on the questionnaire designed to test feeling like a burden, autistic people appeared to have interpreted all items differently. This means that we cannot compare scores on this scale between autistic and non-autistic people. We found that on the questionnaire designed to test feelings of not belonging total scores could not be compared, because autistic people seemed to have interpreted two items differently. On the questionnaire measuring a reduced fear of death, total scores can be compared as all items appear to have been interpreted similarly between autistic and non-autistic people. What do these findings add to what was already known? These findings provide evidence that the questions in these questionnaires may be differently interpreted by autistic people, meaning that scores cannot be meaningfully compared. This could mean that feelings of burdensomeness and belonging are experienced differently by autistic people. What are the potential weaknesses in the study? This study has not investigated whether other factors, such as other neurodevelopmental conditions, may influence how someone responds to these scales. Also, future research should also include the experiences of autistic people with intellectual disability. How will these findings help autistic adults now or in the future? These findings will alert clinicians immediately to the fact that autistic people may show risk factors for suicide differently from non-autistic people. They may need to ask different questions or look out for different signs. In future, this may help us to understand how different factors may contribute to suicidal thoughts and behaviors for autistic and non-autistic people.

© 2020 The Authors. The 'Reading the Mind in the Eyes' test (Eyes Test) has been widely used to measure theory of mind (ToM) or the ability to recognize the thoughts and feelings of others. Although previous studies have analysed its relationship with the ability to perceive emotions, the potential links with more complex emotional abilities remain unclear. The aim of the present research was to analyse the relationship between the Eyes Test and each of the emotional intelligence (EI) branches: perceiving, facilitating, understanding and managing emotions. In addition, we were interested in studying these relationships as a function of the Eyes Test difficulty. Eight hundred and seventy-four participants completed the Eyes Test and the Mayer-Salovey-Caruso Emotional Intelligence Test. A stepwise multiple regression analysis for the total score on the Eyes Test revealed that the best fitting model included the understanding, perceiving and managing emotion branches, with the understanding branch being the one most strongly associated with performance on the Eyes Test. Interestingly, stepwise multiple regression analysis for the easiest items of the Eyes Test revealed the same predictors, but, in the case of the most difficult items only the understanding branch was a predictor. These outcomes were not moderated by the influence of gender. Our findings support the notion that the Eyes Test can be used as a ToM task and that it is associated with complex EI abilities. Limitations and future lines of investigation are discussed.

The Soviet occupation of the Baltic States followed by joining the United Nations (UN) and European Union make these countries an interesting point of comparison in the development of autism and education policy. This study investigates how policies changed following the transition and how the right and access to education are facilitated for autistic children by performing a path dependence analysis. All Baltic States created new education policies following the transition out of the Soviet era, with their accession to the UN and their appetite to follow internationally available guidance. The right to education for all children in was adopted in all education systems. Education facilities for children with disabilities were implemented in all countries. Afterward, all countries started toward the development of more inclusive systems. Nevertheless, the majority of policies did not specify for autism, yet covered special education needs in general. A development in Latvia should be noted, where various special education needs are outlined in national policy, along with provisions and professional assistance required to address them in mainstream or special classrooms. Ultimately, education policy flourished after the transition. Their development caught up to other European Union countries and they are currently working on implementing inclusive education.

Background It has been hypothesised that the ratio of length between the second and fourth fingers (2D:4D), commonly employed as an indicator of foetal sex hormone exposure, may be positively correlated between heterosexual partners. Aims As previous evidence has been conflicting, our study aimed to determine whether intra-couple correlations exist for digit ratio variables, and if so, to estimate the size and direction of these effects. Study design We present a preregistered (osf.io/6jg8p) correlational study and quantitative meta-analysis of the available literature, and attempted to locate further published and unpublished data (i.e. ‘grey literature’) by contacting n = 248 researchers in the 2D:4D and related fields. Subjects n = 58 heterosexual dating couples from the UK took part in our empirical study, and the meta-analysis included data from k = 11 samples. Outcome measures We measured digit ratio for the right hand (R2D:4D), left hand (L2D:4D), and average of both hands (M2D:4D), as well as the right-left-difference (D[R-L]). Results We found no evidence of significant positive intra-couple correlations in our own data, but a significant (positive) meta-analytic effect size estimate emerged for R2D:4D (r = 0.072, p = 0.014). The meta-analytic effects for L2D:4D (r = 0.043, p = 0.303), M2D:4D (r = 0.070, p = 0.225), and D[R-L] (r = 0.028, p = 0.649) were all in the same direction but not statistically significant. However, if the sample from Klimek et al. (2014, 2016) were omitted, meta-analysis would also yield a significant positive correlation for M2D:4D (r = 0.128, p = 0.001). Conclusions Although our findings are based on a fairly small range of studies, which themselves provide a relatively small sample of participants, they do imply the intriguing possibility of small effects of positive assortment in relation to characteristics associated with the prenatal hormonal environment.

Excitation-inhibition (E:I) imbalance is theorized as an important pathophysiological mechanism in autism. Autism affects males more frequently than females and sex-related mechanisms (e.g., X-linked genes, androgen hormones) can influence E:I balance. This suggests that E:I imbalance may affect autism differently in males versus females. With a combination of in-silico modeling and in-vivo chemogenetic manipulations in mice, we first show that a time-series metric estimated from fMRI BOLD signal, the Hurst exponent (H), can be an index for underlying change in the synaptic E:I ratio. In autism we find that H is reduced, indicating increased excitation, in the medial prefrontal cortex (MPFC) of autistic males but not females. Increasingly intact MPFC H is also associated with heightened ability to behaviorally camouflage social-communicative difficulties, but only in autistic females. This work suggests that H in BOLD can index synaptic E:I ratio and that E:I imbalance affects autistic males and females differently., eLife digest Autism is a condition that is usually diagnosed early in life that affects how a person communicates and socializes, and is often characterized by repetitive behaviors. One key theory of autism is that it reflects an imbalance in levels of excitation and inhibition in the brain. Excitatory signals are those that make other brain cells more likely to become active; inhibitory signals have the opposite effect. In non-autistic individuals, inhibitory activity outweighs excitatory activity. In people with autism, by contrast, an increase in excitatory activity is believed to produce an imbalance in excitation and inhibition. Most of the evidence to support this excitation-inhibition imbalance theory has come from studies of rare mutations that cause autism. Many of these mutations occur on the sex chromosomes or are influenced by androgen hormones (hormones that usually play a role on typically male traits). However, most people with autism do not possess these particular mutations. It was thus unclear whether the theory could apply to everyone with autism or, for example, whether it may better apply to specific groups of individuals based on their sex or gender. This is especially important given that about four times as many men and boys compared to women and girls are diagnosed with autism. Trakoshis, Martínez-Cañada et al. have now found a way to ask whether any imbalance in excitation and inhibition in the brain occurs differently in men and women. Using computer modeling, they identified a signal in brain scans that corresponds to an imbalance of excitation and inhibition. After showing that the technique works to identify real increases in excitation in the brain scans of mice, Trakoshis, Martínez-Cañada et al. looked for this signal, or biomarker, in brain scans of people with and without autism. All the people in the study identified with the gender that matched the sex they were assigned at birth. The results revealed differences between the men and women with autism. Men with autism showed an imbalance in excitation and inhibition in specific ‘social brain' regions including the medial prefrontal cortex, but women with autism did not. Notably, many of these brain regions are strongly affected by androgen hormones. Previous studies have found that women with autism are sometimes better at hiding or ‘camouflaging’ their difficulties when socializing or communicating than men with autism. Trakoshis, Martínez-Cañada et al. showed that the better a woman was at camouflaging her autism, the more her brain activity in this region resembled that of non-autistic women. Excitation-inhibition imbalance may thus affect specific brain regions involved in socializing and communication more in men who have autism than in women with the condition. Balanced excitation and inhibition in these brain areas may enable some women with autism to camouflage their difficulties socializing or communicating. Being able to detect imbalances in activity using standard brain imaging could be useful for clinical trials. Future studies could use this biomarker to monitor responses to drug treatments that aim to adjust the balance between excitation and inhibition.

Funder: Wellcome Trust (Wellcome); doi: https://doi.org/10.13039/100004440, Funder: Templeton World Charity Foundation (Templeton World Charity Foundation, Inc.); doi: https://doi.org/10.13039/501100011730, The substantial phenotypic heterogeneity in autism limits our understanding of its genetic etiology. To address this gap, here we investigated genetic differences between autistic individuals (nmax = 12,893) based on core and associated features of autism, co-occurring developmental disabilities and sex. We conducted a comprehensive factor analysis of core autism features in autistic individuals and identified six factors. Common genetic variants were associated with the core factors, but de novo variants were not. We found that higher autism polygenic scores (PGS) were associated with lower likelihood of co-occurring developmental disabilities in autistic individuals. Furthermore, in autistic individuals without co-occurring intellectual disability (ID), autism PGS are overinherited by autistic females compared to males. Finally, we observed higher SNP heritability for autistic males and for autistic individuals without ID. Deeper phenotypic characterization will be critical in determining how the complex underlying genetics shape cognition, behavior and co-occurring conditions in autism.

Objective: Many existing tests of social cognition are not appropriate for clinical use, due to their length, complexity or uncertainty in what they are assessing. The Edinburgh Social Cognition Test (ESCoT) is a new test of social cognition that assesses affective and cognitive Theory of Mind as well as inter- and intrapersonal understanding of social norms using animated interactions.Method: To support the development of the ESCoT as a clinical tool, we derived cut-off scores from a neurotypical population (n = 236) and sought to validate the ESCoT in a sample of Autism Spectrum Disorder (ASD; n = 19) adults and neurotypical controls (NC; n = 38) matched on age and education. The ESCoT was administered alongside established tests and questionnaire measures of ASD, empathy, systemizing traits and intelligence.Results: Performance on the subtests of the ESCoT and ESCoT total scores correlated with performance on traditional tests, demonstrating convergent validity. ASD adults performed poorer on all measures of social cognition. Unlike the ESCoT, performance on the established tests was predicted by verbal comprehension abilities. Using a ROC curve analysis, we showed that the ESCoT was more effective than existing tests at differentiating ASD adults from NC. Furthermore, a total of 42.11% of ASD adults were impaired on the ESCoT compared to 0% of NC adults.Conclusions: Overall these results demonstrate that the ESCoT is a useful test for clinical assessment and can aid in the detection of potential difficulties in ToM and social norm understanding.

Background Previous research using the Sensory Perception Quotient (SPQ) has reported greater sensory hypersensitivity in people with autism spectrum condition (ASC) compared to controls, consistent with other research. However, current scoring of the SPQ does not differentiate between hyper and hyposensitivity, making it uncertain whether individuals with ASC might also show differences in hyposensitivity. Furthermore, no research to date has focused on sensory differences in females, and whether differences in sensory sensitivity extend to the broader autism phenotype (BAP). The present study aimed to fill these gaps. Methods The present study developed and validated a Revised Scoring of the Sensory Perception Quotient (SPQ-RS) in order to investigate self-reported hypersensitivity and hyposensitivity in three groups of adults: a female ASC group (n = 152), mothers of children with ASC (BAP mothers group; n = 103), and a control mothers group (n = 74). All participants completed the SPQ as a self-report measure of sensory processing and the Autism-Spectrum Quotient (AQ) as a measure of the degree of autism traits. Results The female ASC group reported significantly more hypersensitivity, but not more hyposensitivity, compared to the control female and BAP mothers groups. The BAP mothers group did not differ from the control mothers group in either reported hypersensitivity (p = .365) or hyposensitivity (p = .075), suggesting atypical sensory sensitivity is not a BAP trait within females. SPQ-RS hypersensitivity scores positively correlated with autistic traits in the female ASC (r = .266) and BAP mothers groups (r = .350). Conclusions The present findings revealed greater sensory hypersensitivity, but not hyposensitivity, in females with ASC compared to BAP and control female groups, and that a greater degree of autism traits relates to higher hypersensitivity in ASC females. The results offer support for the enhanced perceptual functioning model using large samples of females, who are an understudied population, and demonstrate the validity of the SPQ-RS as a valuable new research tool for exploring self-reported hypersensitivity and hyposensitivity.

BACKGROUND: Autism is a lifelong neurodevelopmental difference and disability, yet there is limited research examining parenting in autistic mothers. OBJECTIVE: To explore autistic mothers' experience of the perinatal period and parenthood. This includes pregnancy, childbirth, the postpartum period, self-perception of parenting strengths and weaknesses, communication with professionals in relation to one's child, mental health difficulties and the social experience of motherhood. It also includes disclosing one's diagnosis of autism in parenting contexts. METHODS: We used a community-based participatory research model, and recruited an advisory panel, with whom we co-developed an anonymous, online survey for autistic mothers. The online survey was completed by autistic and non-autistic mothers, and we compared their responses using Chi-squared analysis. SAMPLE: Autistic mothers (n = 355), and non-autistic mothers (n = 132), each of whom had at least one autistic child, were included in our final analysis. RESULTS: There were differences in education, gender identity and age of mother at birth of first child. Autistic mothers were more likely to have experienced additional psychiatric conditions, including pre- or post-partum depression, and reported greater difficulties in areas such as multi-tasking, coping with domestic responsibilities and creating social opportunities for their child. They were also more likely to report feeling misunderstood by professionals, and reported greater anxiety, higher rates of selective mutism, and not knowing which details were appropriate to share with professionals. They were also more likely to find motherhood an isolating experience, to worry about others judging their parenting, or feel unable to turn to others for support in parenting. However, despite these challenges, autistic mothers were able to act in the best interest of their child, putting their child's needs first. CONCLUSIONS: Autistic mothers face unique challenges and the stigma associated with autism may further exacerbate communication difficulties. Greater understanding and acceptance amongst individuals who interact with autistic mothers is needed, and autistic mothers would benefit from additional and better-tailored support.

Background Special education provides an array of support that can advantageously meet special education needs (SEN) of children with autism. This report maps autism and SEN policies, and tension of international legislation in Malta, Cyprus, Luxembourg and Slovenia. Methods A policy path analysis was performed using a scoping review as fundamental methodological framework. Results Education for children with SEN developed from limited education towards segregation, and further to integration, and inclusion in mainstream education. International policy has greatly influenced the education systems under study. The rights to education and to have SEN addressed have been adopted in all countries. Inclusion is seen to be gradually incorporated by Malta, Cyprus and Luxembourg—closely following values of international documents through concise SEN policies. Slovenia’s education system remains segregated, indicating potential tension. Conclusions It appears that mainstream schools offer SEN services until no longer feasible for the child in the majority of investigated countries. Inclusion has become a guiding principle for most education systems under study. Finally, small states either commit to the implementation of inclusion or delay it and attempt to improve the education system for children with SEN in different ways.