1. Applewhite B, Cankaya Z, Heiderscheit A, Himmerich H. A Systematic Review of Scientific Studies on the Effects of Music in People with or at Risk for Autism Spectrum Disorder. Int J Environ Res Public Health;2022 (Apr 23);19(9)

The prevalence of autism spectrum disorders (ASD) is globally increasing, and the current available interventions show variable success. Thus, there is a growing interest in additional interventions such as music therapy (MT). Therefore, we aimed to provide a comprehensive and systematic review of music and people with, or at risk of, ASD. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and used PubMed, PsycINFO, and Web of Science as databases, with « music », « music therapy », « autism spectrum disorder », and « ASD » as search terms. Among the identified and screened articles, 81 out of 621 qualified as scientific studies involving a total of 43,353 participants. These studies investigated the peculiarities of music perception in people with ASD, as well as the effects of music and MT in this patient group. Most of the music-based interventions were beneficial in improving social, emotional, and behavioural problems. However, the availability of studies utilizing a rigorous randomized controlled trial (RCT) design was scarce. Most of the studies had a small sample size, and the applied therapeutic and scientific research methods were heterogeneous.

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2. Carey M, Sheehan D, Healy S, Knott F, Kinsella S. The Effects of a 16-Week School-Based Exercise Program on Anxiety in Children with Autism Spectrum Disorder. Int J Environ Res Public Health;2022 (Apr 30);19(9)

Physical activity interventions have been shown to decrease anxiety in children with ASD. There is little known regarding the effects of an exercise program on anxiety in both home and school settings and the optimal dosage to reduce anxiety. Therefore, the aim of this study was to assess the effects of a 16-week exercise program on the anxiety levels of children with moderate to severe symptoms of ASD in home and school settings, and to compare the effects at 8 and 16 weeks. This study was a within-subject, non-controlled design, intervention study. Twenty-four children (5-18 years) with moderate to severe ASD were included. A school-based exercise program was implemented three days a week for 16 weeks. Parents and teachers completed the Anxiety Scale for Children for ASD (ASC-ASD) at baseline, week 8, and week 16. A one-way repeated-measure ANOVA with post hoc analysis using Bonferroni adjustment was used to test for a significant effect for time (p < 0.05), with Cohen’s d used to calculate the effect size. For teacher-reported anxiety, there were significant decreases from baseline to week 16 for total ASC-ASD (p < 0.001), performance anxiety (p < 0.001), anxious arousal (p < 0.001), and uncertainty (p < 0.001). There was no significant decrease in parent-reported anxiety. The findings demonstrate that a 16-week exercise program can reduce anxiety in children with ASD in school settings. Results demonstrate that 16 weeks, as opposed to 8, may be necessary to have a significant effect on in-school anxiety.

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3. Cheng Y, Tang B, Zhang G, An P, Sun Y, Gao M, Zhang Y, Shan Y, Zhang J, Liu Q, Lai CSW, de Villers-Sidani É, Wang Y, Zhou X. Degraded cortical temporal processing in the valproic acid-induced rat model of autism. Neuropharmacology;2022 (May 15);209:109000.

Hearing disorders, such as abnormal speech perception, are frequently reported in individuals with autism. However, the mechanisms underlying these auditory-associated signature deficits in autism remain largely unknown. In this study, we documented significant behavioral impairments in the sound temporal rate discrimination task for rats prenatally exposed to valproic acid (VPA), a well-validated animal model for studying the pathology of autism. In parallel, there was a large-scale degradation in temporal information-processing in their primary auditory cortices (A1) at both levels of spiking outputs and synaptic inputs. Substantially increased spine density of excitatory neurons and decreased numbers of parvalbumin- and somatostatin-labeled inhibitory inter-neurons were also recorded in the A1 after VPA exposure. Given the fact that cortical temporal processing of sound is associated with speech perception in humans, these results in the animal model of VPA exposure provide insight into a possible neurological mechanism underlying auditory and language-related deficits in individuals with autism.

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4. Colizzi M, Bortoletto R, Costa R, Bhattacharyya S, Balestrieri M. The Autism-Psychosis Continuum Conundrum: Exploring the Role of the Endocannabinoid System. Int J Environ Res Public Health;2022 (May 5);19(9)

Evidence indicates shared physiopathological mechanisms between autism and psychosis. In this regard, the endocannabinoid system has been suggested to modulate neural circuits during the early stage of neurodevelopment, with implications for both autism and psychosis. Nevertheless, such potential common markers of disease have been investigated in both autism and psychosis spectrum disorders, without considering the conundrum of differentiating the two groups of conditions in terms of diagnosis and treatment. Here, we systematically review all human and animal studies examining the endocannabinoid system and its biobehavioral correlates in the association between autism and psychosis. Studies indicate overlapping biobehavioral aberrancies between autism and schizophrenia, subject to correction by modulation of the endocannabinoid system. In addition, common cannabinoid-based pharmacological strategies have been identified, exerting epigenetic effects across genes controlling neural mechanisms shared between autism and schizophrenia. Interestingly, a developmental and transgenerational trajectory between autism and schizophrenia is supported by evidence that exogenous alteration of the endocannabinoid system promotes progression to inheritable psychosis phenotypes in the context of biobehavioral autism vulnerability. However, evidence for a diametral association between autism and psychosis is scant. Several clinical implications follow from evidence of a developmental continuum between autism and psychosis as a function of the endocannabinoid system dysregulation.

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5. Cooper SA, Henderson A, Kinnear D, Mackay D, Fleming M, Smith GS, Hughes-McCormack LA, Rydzewska E, Dunn K, Pell JP, Melville C. Cohort profile: Scotland’s record-linkage e-cohorts of people with intellectual disabilities, and autistic people (SCIDA). BMJ Open;2022 (May 13);12(5):e057230.

PURPOSE: To investigate health, mortality and healthcare inequalities experienced by people with intellectual disabilities, and autistic people, and their determinants; an important step towards identifying and implementing solutions to reduce inequalities. This paper describes the cohorts, record-linkages and variables that will be used. PARTICIPANTS: Scotland’s Census, 2011 was used to identify Scotland’s citizens with intellectual disabilities, and autistic citizens, and representative general population samples with neither. Using Scotland’s community health index, the Census data (demography, household, employment, long-term conditions) were linked with routinely collected health, death and healthcare data: Scotland’s register of deaths, Scottish morbidity data 06 (SMR06: cancer incidence, mortality, treatments), Prescribing Information System (identifying asthma/chronic obstructive pulmonary disease; angina/congestive heart failure/hypertension; peptic ulcer/reflux; constipation; diabetes; thyroid disorder; depression; bipolar disorders; anxiety/sleep; psychosis; attention deficit hyperactivity disorder; epilepsy; glaucoma), SMR01 (general/acute hospital admissions and causes, ambulatory care sensitive admissions), SMR04 (mental health admissions and causes), Scottish Care Information-Diabetes Collaboration (diabetic care quality, diabetic outcomes), national bowel screening programme and cervical screening. FINDINGS TO DATE: Of the whole population, 0.5% had intellectual disabilities, and 0.6% were autistic. Linkage was successful for >92%. The resultant e-cohorts include: (1) 22 538 people with intellectual disabilities (12 837 men and 9701 women), 4509 of whom are children <16 years, (2) 27 741 autistic people (21 390 men and 6351 women), 15 387 of whom are children <16 years and (3) representative general population samples with neither condition. Very good general health was reported for only 3389 (15.0%) people with intellectual disabilities, 10 510 (38.0%) autistic people, compared with 52.4% general population. Mental health conditions were reported for 4755 (21.1%) people with intellectual disabilities, 3998 (14.4%) autistic people, compared with 4.2% general population. FUTURE PLANS: Analyses will determine the extent of premature mortality, causes of death, and avoidable deaths, profile of health conditions and cancers, healthcare quality and screening and determinants of mortality and healthcare.

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6. Elsabbagh M, Yusuf A, Zeidan J, Scorah J, Fombonne E, Durkin MS, Saxena S, Shih A. The time has come for living systematic reviews in autism research. Autism Res;2022 (May 15)

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7. Espelöer J, Proft J, Falter-Wagner CM, Vogeley K. Alarmingly large unemployment gap despite of above-average education in adults with ASD without intellectual disability in Germany: a cross-sectional study. Eur Arch Psychiatry Clin Neurosci;2022 (May 14)

For individuals with autism spectrum disorder (ASD), both getting access to as well as staying in the labor market are very challenging. However, the detailed educational, vocational, and employment characteristics of persons with ASD without intellectual disabilities are not yet studied. We conducted a retrospective study on a sample of 232 clinically late-diagnosed adults with ASD without intellectual disabilities. Data were compared to the general German population obtained from the public database of the German Federal Employment Agency. Results showed that the majority of persons with ASD graduated from high school and obtained a university entrance qualification (ASD: 50.4%; general population: 32.5%). Also, lower rates of basic secondary education were found in the ASD sample (ASD: 16.5%, general population: 29.6%). Significantly less individuals with ASD completed vocational training (40.1%) in comparison to the German population (56.3%). Despite the above-average level of education, the unemployment rate of the sample substantially exceeds that of the general population by the factor 5 (ASD: 25.2%; general population: 5.2%). Periods of unwanted unemployment of persons with ASD lasted on average 23 months with interpersonal problems being the main reason for contract termination. A higher level of educational qualification does not protect against a higher risk of unemployment for individuals with ASD presumably due to autism-specific interpersonal difficulties. Data emphasize the necessity to develop and spread both specific employment support activities for individuals with ASD as well as adequate awareness raising strategies. Funded by a public grant of the « Landschaftsverband Rheinland (LVR) ».

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8. González-Domenech PJ, Diaz-Atienza F, Gutiérrez-Rojas L, Fernández-Soto ML, González-Domenech CM. A Narrative Review about Autism Spectrum Disorders and Exclusion of Gluten and Casein from the Diet. Nutrients;2022 (Apr 25);14(9)

OBJECTIVE: Autism spectrum disorders (ASDs) appear in the early stages of neurodevelopment, and they remain constant throughout life. Currently, due to limitations in ASDs treatment, alternative approaches, such as nutritional interventions, have frequently been implemented. The aim of this narrative review is to gather the most relevant and updated studies about dietary interventions related to ASDs etiopathogenesis. RESULTS: Our literature search focused on the gluten- and casein-free (GFCF) diet. The literature found shows the inexistence of enough scientific evidence to support a general recommendation of dietary intervention in children with ASD. Protocols and procedures for assessing risk and safety are also needed. Future lines: Prospective and controlled research studies with larger sample sizes and longer follow-up times are scarce and needed. In addition, studies considering an assessment of intestinal permeability, bacterial population, enzymatic, and inflammatory gastrointestinal activity are interesting to identify possible responders. Besides brain imaging techniques, genetic tests can also contribute as markers to evaluate the comorbidity of gastrointestinal symptoms.

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9. Halls D, Leppanen J, Kerr-Gaffney J, Simic M, Nicholls D, Mandy W, Williams S, Tchanturia K. Examining the relationship between autistic spectrum disorder characteristics and structural brain differences seen in anorexia nervosa. Eur Eat Disord Rev;2022 (May 15)

Cortical differences have been reported in Anorexia Nervosa (AN) compared with healthy controls (HC); however, it is unclear if Autism Spectrum Disorder (ASD) characteristics are related to these cortical differences. The aim of this study was to examine if structural measures were correlated to ASD traits in AN. In total 184 female participants participated in the study; 57 acutely underweight AN participants (AAN), 59 weight-restored participants (WR) and 68 HC. Participants underwent structural magnetic resonance imaging as well as completing the Autism Diagnostic Observation schedule, second edition to examine ASD characteristics. Group differences in curvature, gyrification, surface area, thickness, global grey matter and white matter were measured. Correlation and regression analysis were conducted to examine the relationship between cortical measures and ASD characteristics. Two decreased gyrification clusters in the right post central and supramarginal gyrus and decreased global grey matter were observed in the AAN group compared to HC and WR. No correlations between ASD traits and structural measures existed. Our results suggest structural differences seen in individuals with AN do not appear to be related to ASD characteristics.

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10. Larson C, Rivera-Figueroa K, Thomas HR, Fein D, Stevens MC, Eigsti IM. Structural language impairment in Autism Spectrum Disorder versus Loss of Autism Diagnosis: Behavioral and neural characteristics. Neuroimage Clin;2022 (May 10);34:103043.

This study probed for structural language impairment using behavioral and functional neuroimaging methods in individuals with Autism Spectrum Disorder (ASD) and those diagnosed with ASD in childhood who no longer meet criteria for ASD, referred to as Loss of Autism Diagnosis (LAD(1)). Participants were drawn from Fein et al. (2013): ASD (n = 35), LAD (n = 31), and Neurotypical (NT; n = 34). Criteria for structural language impairment were: Scores ≤ 82 on Clinical Evaluation of Language Fundamentals-4 (CELF) Core Language, an omnibus measure of language; and scores ≤ 7 on CELF Recalling Sentences, a clinical marker of structural language impairment. Task-based fMRI examined lateralization of significantly activated language-related brain regions in groups with structural language impairment (LI(2)) versus normal-range language (LN(3)), collapsed across ASD, LAD(1), and NT status. Results showed no ASD versus LAD group differences in the proportion of participants with structural language impairment according to either metric (Recalling Sentences or Core Language). Functional MRI results indicated greater left hemisphere lateralization within significantly activated regions in the LI(2) group. Structural language abilities were not meaningfully associated with either social abilities or lifetime ADHD symptoms in LI(2) subgroups, further suggesting the presence of structural language impairment. Findings indicate the presence of persistent structural language difficulty even in the absence of ASD symptoms in some individuals within the LAD(1) group and unique patterns of language-related neural specialization for language function in LI(2) relative to LN(3).

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11. Levante A, Petrocchi S, Colombi C, Keller R, Narzisi A, Masi G, Lecciso F. The Effect of Sleep-Wake Routines on the Negative Emotional States and Aggressive Behaviors in Adults with Autism Spectrum Disorders (ASD) during the COVID-19 Outbreak. Int J Environ Res Public Health;2022 (Apr 19);19(9)

Disruption in routine may be related to experiencing negative emotional states and to aggressive behaviors in individuals with Autism Spectrum Disorder (ASD). The lockdown because of COVID-19 contributed to the disruption of individuals’ routines, including the sleep-wake cycle. The current study tested a relationship between the adherence to the sleep-wake routine and aggressive behaviors via the mediation role of negative emotional states (i.e., anxiety and anger). Forty-three parents of adults with ASD completed a web-based questionnaire about their life condition during the first lockdown (April-May 2020). Preliminary analyses showed a worsening in the adults’ aggressive behaviors during the lockdown in comparison to before it (Z = -3.130; p = 0.002). In the mediation models, the relationship between the adherence to the sleep-wake routines and aggressive behaviors was significant. The models showed the hypothesized mediated relationships among the adherence to the sleep-wake routines, negative emotional states, and aggressive behaviors (Model 1: F ((1, 41)) = 10.478, p < 0.001; Model 2: F((1, 41)) = 9.826, p = 0.003). The findings confirmed the potential protective role of the adherence to the sleep-wake routines for the emotional and behavioral adjustment of adults with autism. Theoretical and practical contributions of the study were discussed; indeed, our results may inform parent-coaching as well as intervention programs for individuals with ASD given that adequate sleep hygiene may contribute to improvements in internalizing/externalizing behaviors.

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12. Roman-Urrestarazu A, van Kessel R. Inaccurate prevalence estimates impacts autism policy: A letter to the editor in relation to « Global prevalence of autism: A systematic review update » by Zeidan et al. (2022). Autism Res;2022 (May 15)

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13. Song W, Nonnemacher SL, Miller KK, Anderson K, Shea LL. Living arrangements and satisfaction of current arrangement among autistic adults reported by autistic individuals or their caregivers. J Appl Res Intellect Disabil;2022 (May 15)

BACKGROUND: Living arrangements is an essential component of the social environments for autistic adults. The need to understanding the status and experience of living arrangements has been highlighted. AIM: This study examined living arrangements and satisfaction with current arrangements of autistic adults reported by autistic adults or caregivers of autistic adults. METHODS: This study used data from a statewide survey of autistic adults or caregivers. RESULTS: Older autistic adults and those employed and had higher financial resources were more likely to live alone or with a roommate or spouse than to live with family or in a supervised setting. Correlates of greater satisfaction included being young, either men or women (vs. non-binary adults), public insurance, fewer service needs, no or one mental health diagnosis (vs. two or more), no psychiatric emergency room or hospitalisation history, and living with a roommate or spouse (vs. living with family). CONCLUSION: This cross-sectional study adds to the literature on the status of living arrangements and satisfaction with living arrangements among autistic adults. Future research is needed to investigate contributing factors to the satisfaction of living arrangements and quality of life among autistic adults.

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14. Vakili Shahrbabaki SS, Jonaidi H, Sheibani V, Bashiri H. Early postnatal handling alters social behavior, learning, and memory of pre- and postnatal VPA-induced rat models of autism in a context-based manner. Physiol Behav;2022 (May 15);249:113739.

Early life events are known to greatly affect brain development, cortical neurogenesis, and Hypothalamic-pituitary-adrenal activity. Mainly characterized by impairment in social communication, language, and cognitive development, autism spectrum disorder (ASD) refers to a class of neuropsychiatric disorders with numerous genetic and environmental risk factors. In the early handling (EH) method, daily separation of infants from their mother, physical touching, and exposure to a new environment occur. Here, we studied the effect of EH on Social interaction, learning, and memory in rats exposed pre-or post-natally to valproic acid (VPA). Gestational VPA exposure (600 mg/kg) led to some severe autistic-like traits, more notable in the social behavior of the male sex, along with unchanged to partially altered spatial learning and memory function and reduced avoidance memory. In comparison, while causing a sex-dependent increase in spatial memory, subcutaneous injection of VPA (400 mg/kg) in infancy resulted in limited adverse autistic features, including a decrease in males’ social preference, as well as reduced avoidance memory. The results indicated that neonatal handling significantly improved multiple social behavior and memory deficits in prenatally injected rats. In contrast, EH in rats receiving postnatal VPA elicited a restricted advantage on social novelty tendency; while negatively affecting some other social behavior criteria and spatial learning of males and encouraging sex-dependent repetitive behaviors in the social setting. The controversial influence of postnatal handling on juvenile rats of postnatal VPA treatment vs. prenatal VPA treatment opens up the potential for future research on the context-based consequence of early-life handling stress using different behavioral tasks and to benefit therapeutic procedures through understanding the sex- and age-specific neurobiology of short-term environmental manipulation in animal models of autism.

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15. Veneruso M, Varallo G, Franceschini C, Mercante A, Rossetti M, Rebuttini A, Mantovani A, Musetti A, Castelnuovo G, Nobili L, Nardocci F, Plazzi G. Short report. Cooking for autism: a pilot study of an innovative culinary laboratory for Italian adolescents and emerging adults with autism spectrum disorder. Res Dev Disabil;2022 (May 11);126:104259.

BACKGROUND: Adolescence and emerging adulthood are critical periods for young people with autism spectrum disorder (ASD). However, there is a lack of appropriate and affordable services available. AIMS: The Il Tortellante® is an Italian project aimed at promoting adaptive behavior and social skills, and at reducing the severity of symptomatology through a culinary group intervention in which young people with ASD learn to make fresh pasta by hand. METHODS: A longitudinal study was conducted. PROCEDURE: Before and after the intervention, 20 participants were assessed based on the severity of symptoms, social skills, and adaptive behaviors. OUTCOME AND RESULTS: According to our findings, severity of symptoms and daily living skills improved significantly. CONCLUSION: A culinary intervention may be useful for adolescents and young adults with ASD to improve daily living skills and reduce ASD-related symptomatology. IMPLICATION: Services and associations may consider developing a culinary laboratory for people with ASD to improve group intervention proposals for adolescents and emerging adults. WHAT THIS PAPER ADDS?: This paper offers one of the first investigations of the impact of a culinary laboratory on ASD symptoms, social skills, and adaptive behavior in adolescents and young adults diagnosed with ASD. This group intervention could contribute to expand the range of interventions targeted at adolescents and young adults with ASD, to reduce the severity of symptoms, and to promote adaptive behaviors.

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16. Vermudez SAD, Buch A, Weiss K, Gogliotti RG, Niswender CM. Exploration of group II metabotropic glutamate receptor modulation in mouse models of Rett syndrome and MECP2 Duplication syndrome. Neuropharmacology;2022 (May 15);209:109022.

Rett syndrome (RTT) and MECP2 Duplication syndrome (MDS) have opposing molecular origins in relation to expression and function of the transcriptional regulator Methyl-CpG-binding protein 2 (MeCP2). Several clinical and preclinical phenotypes, however, are shared between these disorders. Modulation of MeCP2 levels has recently emerged as a potential treatment option for both of these diseases. However, toxicity concerns remain with these approaches. Here, we focus on pharmacologically modulating the group II metabotropic glutamate receptors (mGlu), mGlu(2) and mGlu(3), which are two downstream targets of MeCP2 that are bidirectionally affected in expression in RTT patients and mice (Mecp2(Null/+)) versus an MDS mouse model (MECP2(Tg1/o)). Mecp2(Null/+) and MECP2(Tg1/o) animals also exhibit contrasting phenotypes in trace fear acquisition, a form of temporal associative learning and memory, with trace fear deficiency observed in Mecp2(Null/+) mice and abnormally enhanced trace fear acquisition in MECP2(Tg1/o) animals. In Mecp2(Null/+) mice, treatment with the mGlu(2/3) agonist LY379268 reverses the deficit in trace fear acquisition, and mGlu(2/3) antagonism with LY341495 normalizes the abnormal trace fear learning and memory phenotype in MECP2(Tg1/o) mice. Altogether, these data highlight the role of group II mGlu receptors in RTT and MDS and demonstrate that both mGlu(2) and mGlu(3) may be potential therapeutic targets for these disorders.

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17. Yu X, Rahman MM, Wang Z, Carter SA, Schwartz J, Chen Z, Eckel SP, Hackman D, Chen JC, Xiang AH, McConnell R. Evidence of susceptibility to autism risks associated with early life ambient air pollution: A systematic review. Environ Res;2022 (May 15);208:112590.

BACKGROUND: Many studies have found associations between early life air pollution exposure and subsequent onset of autism spectrum disorder (ASD). However, characteristics that affect susceptibility remain unclear. OBJECTIVE: This systematic review examined epidemiologic studies on the modifying roles of social, child, genetic and maternal characteristics in associations between prenatal and early postnatal air pollution exposure and ASD. METHODS: A systematic literature search in PubMed and Embase was conducted. Studies that examined modifiers of the association between air pollution and ASD were included. RESULTS: A total of 19 publications examined modifiers of the associations between early life air pollution exposures and ASD. In general, estimates of effects on risk of ASD in boys were larger than in girls (based on 11 studies). Results from studies of effects of family education (2 studies) and neighborhood deprivation (2 studies) on air pollution-ASD associations were inconsistent. Limited data (1 study) suggest pregnant women with insufficient folic acid intake might be more susceptible to ambient particulate matter less than 2.5 μm (PM(2.5)) and 10 μm (PM(10)) in aerodynamic diameter, and to nitrogen dioxide (NO(2)). Children of mothers with gestational diabetes had increased risk of ozone-associated ASD (1 study). Two genetic studies reported that copy number variations may amplify the effect of ozone, and MET rs1858830 CC genotype may augment effects of PM and near-roadway pollutants on ASD. CONCLUSIONS: Child’s sex, maternal nutrition or diabetes, socioeconomic factors, and child risk genotypes were reported to modify the effect of early-life air pollutants on ASD risk in the epidemiologic literature. However, the sparsity of studies on comparable modifying hypotheses precludes conclusive findings. Further research is needed to identify susceptible populations and potential targets for preventive intervention.

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18. Zwilling M, Levy BR. How Well Environmental Design Is and Can Be Suited to People with Autism Spectrum Disorder (ASD): A Natural Language Processing Analysis. Int J Environ Res Public Health;2022 (Apr 21);19(9)

The quality of life of people diagnosed as having Autistic Spectrum Disorder (ASD) is essential for increasing their self-reliance and reducing their communication problems in order to allow them to work, take care of themselves, and develop a capacity to intercommunicate with their surroundings. Their need to organize their day-to-day and workplace surroundings has been addressed in the literature via long-term intervention programs aimed to imbue people with ASD with interpersonal communication capabilities. Yet, there is still a gap in the literature regarding new design methods aimed at creating a safe and friendly environment adapted to the needs of people with ASD. Therefore, this study has two objectives: (1) to shed light on the existing factors and methods related to workplaces designed to be friendly to people with ASD, specifically adults, through a natural language processing (NLP) analysis of existing scientific papers in the field of architecture and design; and (2) to explore the factors that might assist in improving the design and architecture of adaptive spaces for people with ASD by analyzing a corpus of experts’ documents. The study findings and their implications are analyzed and discussed.

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