1. Attanasio M, Masedu F, Quattrini F, Pino MC, Vagnetti R, Valenti M, Mazza M. Are Autism Spectrum Disorder and Asexuality Connected?. Archives of sexual behavior. 2021.

Asexuality is a lack of sexual attraction to any gender. There is some evidence to suggest that many self-identified asexuals have a formal diagnosis of autism spectrum disorder which is characterized by deficits in social interaction and communication, as well as by restricted and repetitive interests and behaviors. Additionally, the literature shows that asexuality and lack of sexual attraction or low sexual interest is overrepresented in people with autism spectrum disorder compared with neurotypical samples. Nevertheless, no studies have been conducted to investigate the relationship between autism and asexuality in depth. We conducted a systematic review of the literature to examine whether asexuality and autism spectrum disorder are connected. We conclude that asexuality and autism share various aspects, such as a possible role of prenatal factors, reference to romantic dimensions of sexual attraction and sexual orientation, and non-partner-oriented sexual desire, but future research should explore and clarify this link.

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2. Bathje M, Conrad S, Medick M, Ross M, Fogg L. Differences in Hospital-Based Care for Patients With Intellectual and Developmental Disabilities. The American journal of occupational therapy : official publication of the American Occupational Therapy Association. 2021; 75(3).

IMPORTANCE: The number of adults with intellectual and developmental disabilities (IDD) seeking treatment in non-IDD-specific health care settings is growing. Little is known about how adults with IDD use health care services in specialty settings, including occupational therapy services. OBJECTIVE: To describe adults with IDD in hospitals and identify differences in utilization patterns compared with patients without IDD. DESIGN: Descriptive and correlational designs were used. PARTICIPANTS: Data were obtained from Vizient (Clinical Data Base/Resource Manager™), a national database of administrative discharge abstracts for adults admitted to hospitals for an orthopedic procedure. From this sample, subsamples of (1) patients diagnosed with IDD and (2) an age- and gender-matched sample of patients without IDD were identified. RESULTS: The study cohort with IDD experienced longer lengths of stay, t(2821.5) = -14.2, p < .001; were more likely to have Medicare coverage, χ2(3, N = 8,472) = 1,170.38, p < .001; and were more commonly discharged to subacute or skilled nursing facilities, χ2(5, N = 8,472) = 1,033.60, p < .001. Differences in occupational therapy services were also noted. CONCLUSIONS AND RELEVANCE: Despite similarities in orthopedic procedures, participants with IDD had different use patterns than those without IDD. Differences may be attributed to varying client factors and contexts. The results also indicate that practitioners in non-IDD-specific settings should expect to encounter clients with IDD. Occupational therapy practitioners have an opportunity to be leaders in adapting treatment protocols and providing education to caregivers and health care providers on behalf of people with IDD. What This Article Adds: This article provides novel information about a population that is known to experience disparities in health outcomes. It offers a basis on which future research can build to improve health care delivery and occupational therapy interventions to improve outcomes.

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3. Bathje M, Schrier M, Williams K, Olson L. The Lived Experience of Sexuality Among Adults With Intellectual and Developmental Disabilities: A Scoping Review. The American journal of occupational therapy : official publication of the American Occupational Therapy Association. 2021; 75(4).

IMPORTANCE: Sexuality is an important part of the human experience. However, little is known about the experience of sexuality from the perspective of adults with intellectual and developmental disabilities (IDD). OBJECTIVE: To review evidence about the lived experience of sexuality among adults with IDD to inform future research and practice. DATA SOURCES: We located articles using search terms summarized into three categories: intellectual disability, sexual activity, and feelings/opinions. Articles were indexed in the following electronic databases: CINAHL, Scopus, PubMed, and PsycINFO. Study Selection and Data Collection: Arksey and O’Malley’s methodology was used to review scientific literature published between 2008 and 2018. The studies were in English, were located in peer-reviewed journals, and described the experience of sexuality from the perspective of people with IDD or observations of expressed sexuality. FINDINGS: Seventeen articles met inclusion criteria. Four main themes emerged: intimate relationships, oppressed sexual activity, knowledge, and identity. Findings indicate that sexuality is a part of the lives of many adults with IDD, regardless of their engagement in sexual activity. CONCLUSIONS AND RELEVANCE: Barriers to expression of sexuality exist for people with IDD. Some of these barriers are internal, although many are external. The results provide support for addressing sexuality among adults with IDD. What This Article Adds: This review provides evidence to support occupational therapy practitioners in including sexuality as a part of their holistic view of clients and as an area for advocacy.

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4. Benson JD, Tokarski R, Blaskowitz MG, Geubtner A. Phenomenological Study of the Transition Process for Adolescents With Intellectual and Developmental Disabilities. The American journal of occupational therapy : official publication of the American Occupational Therapy Association. 2021; 75(3).

IMPORTANCE: Occupational therapy practitioners should understand the barriers faced by young adults with intellectual and developmental disabilities (IDD) who are attempting a successful transition to postsecondary work, higher education, community and social activities, and living opportunities so they can better advocate for them and tailor their involvement in the transition process. OBJECTIVE: To explore the lived experience of parents of adolescents with IDD participating in the transition process. DESIGN: Phenomenological design. SETTING: Community-based setting with interviews occurring face-to-face in the participants’ home or via telephone. PARTICIPANTS: Eleven parents of adolescents and young adults (ages 16-22 yr) with IDD. Outcomes and Measures: Semistructured interviews focusing on parent and family experiences with the transition process. RESULTS: Seven themes emerged from the data representing parent perceptions related to the use or lack of person-centered practices, needing more communication from the team, frustration with being the driving force of progress, feelings of defeat, gaps between programming options, positive team collaboration, and planning for the future. CONCLUSIONS AND RELEVANCE: Parents identified person-centered planning, guidance from school staff, and resource sharing as desired practices in the transition planning process. The outcomes indicate that some aspects of the transition process have not changed in several decades. What This Article Adds: Occupational therapy practitioners are optimally positioned to remediate transition issues; therefore, it is essential that they assert their integral role in the transition planning process to increase self-determination and quality of life for all adolescents and young adults with IDD.

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5. Bougeard C, Picarel-Blanchot F, Schmid R, Campbell R, Buitelaar J. Prevalence of Autism Spectrum Disorder and Co-morbidities in Children and Adolescents: A Systematic Literature Review. Frontiers in psychiatry. 2021; 12: 744709.

Objective: Individuals with autism spectrum disorder often present somatic and/or psychiatric co-morbid disorders. The DSM-5 allows for consideration of additional diagnoses besides ASD and may have impacted the prevalence of co-morbidities as well as being limited in capturing the true differences in prevalence observed between males and females. We describe the prevalence of ASD and frequently observed co-morbidities in children and adolescents (<18 years) in the United States and five European countries. Methods: Two systematic literature reviews were conducted in PubMed and Embase for the period 2014-2019 and focusing on the prevalence of ASD and nine co-morbidities of interest based on their frequency and/or severity: Attention Deficit Hyperactivity Disorder (ADHD), anxiety, depressive disorders, epilepsy, intellectual disability (ID), sleep disorders, sight/hearing impairment/loss, and gastro-intestinal syndromes (GI). Results: Thirteen studies on prevalence of ASD and 33 on prevalence of co-morbidities were included. Prevalence of ASD was 1.70 and 1.85% in US children aged 4 and 8 years respectively, while prevalence in Europe ranged between 0.38 and 1.55%. Additionally, current evidence is supportive of a global increase in ASD prevalence over the past years. Substantial heterogeneity in prevalence of co-morbidities was observed: ADHD (0.00-86.00%), anxiety (0.00-82.20%), depressive disorders (0.00-74.80%), epilepsy (2.80-77.50%), ID (0.00-91.70%), sleep disorders (2.08-72.50%), sight/hearing impairment/loss (0.00-14.90%/0.00-4.90%), and GI syndromes (0.00-67.80%). Studies were heterogeneous in terms of design and method to estimate prevalence. Gender appears to represent a risk factor for co-morbid ADHD (higher in males) and epilepsy/seizure (higher in females) while age is also associated with ADHD and anxiety (increasing until adolescence). Conclusion: Our results provide a descriptive review of the prevalence of ASD and its co-morbidities in children and adolescents. These insights can be valuable for clinicians and parents/guardians of autistic children. Prevalence of ASD has increased over time while co-morbidities bring additional heterogeneity to the clinical presentation, which further advocates for personalized approaches to treatment and support. Having a clear understanding of the prevalence of ASD and its co-morbidities is important to raise awareness among stakeholders.

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6. Burton C, Allan E, Eckhardt S, Le Grange D, Ehrenreich-May J, Singh M, Dimitropoulos G. Case Presentations Combining Family-Based Treatment with the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents for Comorbid Avoidant Restrictive Food Intake Disorder and Autism Spectrum Disorder. Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal de l’Academie canadienne de psychiatrie de l’enfant et de l’adolescent. 2021; 30(4): 280-91.

Avoidant Restrictive Food Intake Disorder (ARFID) is a Feeding and Eating Disorder newly added to the Diagnostic and Statistical Manual of Mental Disorders, 5 (th) Edition, which presents with high prevalence rates in community and clinical settings. Given its recent diagnostic recognition, validated and standardized treatments for this population are lacking. In addition, given the complexity, heterogeneity of symptoms, and high rates of psychiatric comorbidities in the ARFID population, new models of care are required. The current therapy model combines two evidence-based treatments – Family Based Treatment (FBT) and the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents (UP-C/A) – for young patients with ARFID plus Autism Spectrum Disorder (ASD), which allows clinicians to personalize care based on each patient’s unique presenting needs. This paper presents two distinct cases which showcase the use of the FBT+UP for ARFID approach for treating comorbid ARFID and ASD in a clinical setting. Case 1 demonstrates the application and reliance on FBT, while Case 2 draws upon UP to facilitate behavioural change in the patient. Case backgrounds, presenting problems, and treatment approaches combining the two evidence-based treatments are presented and discussed. The cases demonstrate the unique challenges of treating young patients with comorbid ARFID and ASD, along with the proposed benefits of the combined approach with this population.

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7. De Giacomo A, Gargano CD, Simone M, Petruzzelli MG, Pedaci C, Giambersio D, Margari L, Ruggieri M. B and T Immunoregulation: A New Insight of B Regulatory Lymphocytes in Autism Spectrum Disorder. Frontiers in neuroscience. 2021; 15: 732611.

Introduction: Autism Spectrum Disorder (ASD) is a heterogeneous neurodevelopmental disorder characterized by a complex pathogenesis, by impairment social communication and interaction, and may also manifest repetitive patterns of behavior. Many studies have recognized an alteration of the immune response as a major etiological component in ASDs. Despite this, it is still unclear the variation of the function of the immune response. Aim: Our aim is to investigate the levels of immunological markers in peripheral blood of children with ASD such as: regulatory B and T cells, memory B and natural killer (NK) cells. Materials and Methods: We assessed various subsets of immune cells in peripheral blood (regulatory B and T cells, B-cell memory and natural killer cells) by multi-parametric flow cytometric analysis in 26 ASD children compared to 16 healthy controls (HCs) who matched age and gender. Results: No significant difference was observed between B-cell memory and NK cells in ASDs and HCs. Instead, regulatory B cells and T cells were decreased (p < 0.05) in ASD subjects when compared to HCs. Discussion: Regulatory B and T cells have a strategic role in maintaining the immune homeostasis. Their functions have been associated with the development of multiple pathologies especially in autoimmune diseases. According to our study, the immunological imbalance of regulatory B and T cells may play a pivotal role in the evolution of the disease, as immune deficiencies could be related to the severity of the ongoing disorder.

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8. Geissler JM, Werner E, Dworschak W, Romanos M, Ratz C. German Law Reform Does Not Reduce the Prevalence of Coercive Measures in Residential Institutions for Children, Adolescents, and Young Adults With Intellectual and Developmental Disabilities. Frontiers in psychiatry. 2021; 12: 765830.

Background: Approximately 10% of children, adolescents and young adults with an intellectual and developmental disability (IDD) in Bavaria live in residential institutions. 2015 saw media reports raising suspicions about excessive use of coercive measures (cM) in those institutions. Until a law reform at the end of 2017 made permission from family courts mandatory for cM, their use was governed by parental consent. The REDUGIA project conducted a representative survey comparing cM and their relation to challenging behaviour (cB) and employee stress in Bavaria pre and post reform. Methods: We sent questionnaires to 65 residential institutions for children, adolescents and young adults with IDD in 2017 (pre reform, T1) and 2019 (post reform, T2). To assess changes, we analysed data from all available questionnaire pairs (T1 and T2, N = 43). We calculated paired t-test and correlative analyses concerning the relationship between cB, cM, and employee stress. Results: The number of residents overall (T1: N = 1,661; T2: N = 1,673) and per institution (T1: m = 38.6 ± 32.0; T2: m = 38.9 ± 34.5, p = 0.920) remained stable. We did not see any changes in the Index cB (p = 0.508) or the proportion of residents per institution displaying various types of challenging behaviour (all ps>0.220). There was no change in the Index cM (p = 0.089) or any indicator of employee stress, all ps > 0.323. At follow-up, the Index cB correlated positively with the Index cM (r = 0.519 p < 0.001). Regarding employee stress, the Index cB correlated positively with the frequency of sick leave (r = 0.322, p = 0.037) and physical attacks on employees (r = 0.552, p < 0.001). The Index cM also correlated positively with the frequency of sick leave (r = 0.340, p = 0.028) and physical attacks on employees (r = 0.492, p = 0.001). Discussion: Coercive measures are not a general phenomenon, but are focused on specialised institutions. The law reform did not lead to changes in the number of children, adolescents and young adults with IDD affected by coercive measures in residential institutions in Bavaria. There were still large discrepancies between institutions in the prevalence of challenging behaviour and coercive measures. Coercive measures were associated with challenging behaviour and employee stress. Taken together, findings from REDUGIA emphasise the need to prevent challenging behaviour and thus coercive measures.

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9. Ghaziuddin M. Catatonia: A Common Cause of Late Regression in Autism. Frontiers in psychiatry. 2021; 12: 674009.

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by social communication deficits and restricted interests and behaviors which begin very early in life. In about a quarter of cases, the symptoms emerge about 18-24 months after a period of normal development, a phenomenon commonly described as early regression. However, marked functional decline can also occur in persons with autism after a relatively stable childhood. As opposed to early regression, which occurs in normally developing children, late regression occurs typically in adolescents with an established diagnosis of autism. Apart from their occasional mention in the literature, these individuals have not been examined systematically. This Brief Report describes the presentation, comorbidity and short-term outcome of 20 persons with ASD who developed late regression. The mean age of onset of regression was 13 years. One of the earliest symptoms was an increase in obsessive slowing and compulsive rituals. Other symptoms included motor abnormalities, aggression and mood disturbance. The most common comorbid disorder was catatonia occurring in 17 patients. Despite treatment with several modalities, the outcome was often suboptimal. These findings suggest that catatonia is a common cause of late regression in persons with autism. Clinical and research implications are discussed.

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10. Halliwell N, Podvey M, Smith JD, Harris K, Sylvester L, DeGrace BW. Experience of Sleep for Families of Young Adults With Autism Spectrum Disorder. The American journal of occupational therapy : official publication of the American Occupational Therapy Association. 2021; 75(5).

IMPORTANCE: Children with autism spectrum disorder (ASD) may experience sleep difficulties that worsen into adulthood and negatively influence both child and family, yet the experience is not well understood. Understanding the family’s experience can inform occupational therapy providers, future research, and practice guidelines. OBJECTIVE: To examine experiences surrounding sleep for families raising a young adult with ASD (YA-ASD). DESIGN: Qualitative study in the phenomenological tradition of Moustakas (1994). Experienced researchers analyzed transcripts from in-depth, in-person interviews to triangulate data, distill themes, and construct the essence of family experience. Trustworthiness was established through member checking, audit trails, and epoché diaries that were maintained throughout data analyses. SETTING: Community setting (large city in the northeastern United States). PARTICIPANTS: People who self-identified as living in a family arrangement that included a YA-ASD age 15-21 yr, able to verbally participate in English. Families with children diagnosed with developmental disabilities other than ASD were excluded. RESULTS: Six eligible families identified through volunteer sampling participated. The participants’ sociodemographic diversity was limited across household income, education level, and ethnicity. All YA-ASD in this study were limited verbally and unable to contribute. Analyses of interview transcripts revealed five themes that form the essence of the families’ experience surrounding sleep. CONCLUSIONS AND RELEVANCE: Sleep issues for YA-ASD continue into adulthood and affect the entire family because of continuous co-occupation; occupational therapy support is therefore important for families of YA-ASD. The lack of effective evidence-based interventions supporting the YA-ASD population also reveals an area for growth. What This Article Adds: The results indicate the importance of addressing sleep for YA-ASD and their families in occupational therapy practice because of its considerable impact on family life.

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11. Johannessen J, Nærland T, Hope S, Torske T, Kaale A, Wirgenes KV, Malt E, Djurovic S, Rietschel M, Andreassen OA. Attitudes among parents of persons with autism spectrum disorder towards information about genetic risk and future health. European journal of human genetics : EJHG. 2021.

Clinical relevance of genetic testing is increasing in autism spectrum disorder (ASD). Information about genetic risk may contribute to improved diagnostics, treatment and family planning, but may also be perceived as a burden. Knowledge about the families’ preferences with regard to genetic risk information is important for both health care professionals and policy makers. We investigated attitudes towards sharing information about genetic risk of ASD and knowledge about future health among parent members of the Norwegian Autism Association (N = 1455) using a questionnaire, and the relationships with parent and child characteristics, such as age, gender and ASD severity. Most preferred autonomy in deciding whom to inform about genetic risk of ASD (74.4%) and a minority supported extensive intra-familial disclosure of the genetic risk (41.1%). The majority agreed that it is an obligation to know as much as possible relevant for future health (58.0%) and only 51.7% agreed to a principle of a ‘right not to know’. In regression models, the attitudes were associated with opinions about benefits and harms of genetic testing (e.g., treatment, family planning, understanding of ASD pathology, insurance discrimination and family conflict). In sum, the findings show that most parents want to know as much as possible relevant for their children’s future health and keep their autonomy and intra-familial confidentiality about genetic risk information. Nearly half of the parents were not concerned with a « right not to know ». These attitudes can inform development of guidelines and bioethics in the age of genomic precision medicine.

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12. Kinlin LM, Birken CS. Micronutrient deficiencies in autism spectrum disorder: A macro problem?. Paediatrics & child health. 2021; 26(7): 436-7.

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13. Kirby AV, Feldman KJC, Himle MB, Diener ML, Wright CA, Hoffman JM. Pilot Test of the Maximizing Adolescent Post-Secondary Success (MAPSS) Intervention: Supporting Parents of Autistic Youth. The American journal of occupational therapy : official publication of the American Occupational Therapy Association. 2021; 75(3): 7503180070p1-p11.

IMPORTANCE: Parents play an essential role in the transition to adulthood for autistic youth, yet often feel they do not have adequate training and resources. OBJECTIVE: To evaluate data on the preliminary efficacy of and collect participant feedback about the Maximizing Adolescent Post-Secondary Success (MAPSS) intervention. DESIGN: Single-group, pretest-posttest pilot study. SETTING: Clinic. PARTICIPANTS: Twenty-two families of autistic youth (ages 13-19 yr, 72.7% male). INTERVENTION: MAPSS is a group intervention for parent-youth dyads that is designed to guide parents in facilitating the development of independent skills for adulthood. Outcomes and Measures: Measures included the Transition Preparation Activities Measure (T-PAM), Family Empowerment Scale (FES), 10-item Perceived Stress Scale (PSS-10), Adulthood Expectations Questionnaire (AEQ), Adaptive Behavior Assessment System-Third Edition (ABAS-3), and a study-specific participant feedback survey. RESULTS: Frequency of transition preparation activities (T-PAM) significantly increased from before to after the intervention, and although the frequency of preparation activities decreased by 1-mo follow-up, it remained significantly higher than at baseline. Parent self-efficacy (FES), parent expectations (AEQ), and parent sense of control over outcomes (AEQ) also significantly increased from preintervention to follow-up; however, parent coping (PSS-10) was unchanged. Youth self-care skills (ABAS-3) demonstrated improvements 6 mo after the completion of the intervention, although other areas of adaptive behavior did not significantly change. Feedback from parents suggested they had positive experiences and felt the intervention was beneficial. CONCLUSIONS AND RELEVANCE: Our data suggest that the MAPSS intervention is an appropriate candidate for larger, controlled clinical trials. What This Article Adds: With additional evidence, this intervention can offer guidelines for occupational therapists to work with autistic youth and their parents to prepare for adulthood.

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14. Kornblau BL, Robertson SM. Special Issue on Occupational Therapy With Neurodivergent People. The American journal of occupational therapy : official publication of the American Occupational Therapy Association. 2021; 75(3).

The neurodiversity movement presents a significant opportunity for occupational therapy practitioners to meet the needs of neurodivergent people across the life course The term neurodiverse includes autistic people and people with intellectual disabilities, attention deficit hyperactivity disorder, obsessive-compulsive disorder, and several other mental health conditions. Research shows that neurodivergent people continue to need occupational therapy beyond the end of high school, when most supports and services end for them. Despite research showing that the needs of neurodiverse populations continue throughout the life course, research also shows that services for this population seem to taper as they progress through the public school system. The studies in this issue add to the body of literature supporting the role of occupational therapy practitioners in meeting the needs of neurodiverse people for services and supports through all stages of life.

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15. Larson SK, Nielsen S, Hemberger K, Klug MG. Addressing Puberty Challenges for Adolescents With Autism Spectrum Disorder: A Survey of Occupational Therapy Practice Trends. The American journal of occupational therapy : official publication of the American Occupational Therapy Association. 2021; 75(3).

IMPORTANCE: Understanding occupational therapy practice patterns for adolescents who have autism spectrum disorder (ASD) provides a baseline to determine areas of need and effective interventions. OBJECTIVE: To identify puberty-related challenges addressed and interventions used by occupational therapy practitioners with adolescents ages 8-16 yr with ASD. DESIGN: A nonexperimental survey design with a stratified random sample was used. SETTING: The Occupational Therapy-Autism and Puberty Survey was distributed in the United States online through the Qualtrics platform (available October 2017-January 2018). PARTICIPANTS: Occupational therapists (89%) or occupational therapy assistants with experience with adolescents who have ASD were included. The 71 eligible respondents were primarily White women with an average 16 yr of experience. Outcomes and Measures: Nine key challenges and 11 interventions regarding puberty and ASD were identified. Hypotheses were generated before data collection. RESULTS: More practitioners (>47%) addressed emotional regulation and personal hygiene, and fewer (<26%) addressed menstruation, safety, and masturbation. Nearly all practitioners (>92%) reported using social learning approaches and behavioral strategies, and most (>80%) reporting having received education in these interventions. Significant differences were found between reported education and use of behavioral skills training incorporating applied behavioral analysis (p < .001), parent training (p = .002), and technology (p = .003). CONCLUSIONS AND RELEVANCE: Practitioners are neglecting to address puberty-specific challenges with adolescents who have ASD. Opportunities exist to expand the interventions used and challenges addressed by occupational therapy practitioners for adolescents with ASD. What This Article Adds: This article expands occupational therapy literature by giving a baseline understanding of the puberty-related challenges that practitioners are addressing with adolescents who have ASD. This information can assist the profession in developing effective interventions and educational opportunities to allow practitioners to successfully address puberty-specific challenges.

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16. Le T, Rodrigues B, Hess LG. Video Modeling Use in Work Occupations for People With Autism: A Systematic Review. The American journal of occupational therapy : official publication of the American Occupational Therapy Association. 2021; 75(3).

IMPORTANCE: Occupational therapy practitioners should use evidence-based practices, such as video modeling, to address work occupations supporting people with autism spectrum disorder, including those with co-occurring intellectual and developmental disabilities. OBJECTIVE: To examine the evidence and relevance of video modeling supporting engagement in work occupations for people with autism and to translate these findings to occupational therapy practice. DATA SOURCES: Cochrane Collection Plus, CINAHL, PubMed, ERIC, ProQuest, and peer-reviewed occupational therapy literature from 2008 to 2018. Study Selection and Data Collection: This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study selection and data collection focused on occupational therapy scope of practice, autism spectrum disorder, co-occurring intellectual and developmental disabilities, video modeling, and work occupations for people age 16 yr and older. FINDINGS: A total of 464 articles were screened. Six articles met inclusion criteria. Results indicated moderate evidence for video modeling to support work occupations for people with autism, specifically employment seeking and acquisition and specific job-performance skills. Samples were limited to people younger than age 28 yr and represented varied intellectual abilities, indicating potential for benefits across the spectrum of cognitive functioning. CONCLUSIONS AND RELEVANCE: This systematic review highlights the promising potential of video modeling to address work occupations for people with autism. However, more rigorous effectiveness research is needed, including studies by occupational therapy practitioners. What This Article Adds: Occupational therapy expertise paired with video modeling, as a strengths-based, client-centered, customizable, socially acceptable intervention, can provide meaningful support for work occupations.

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17. Li D, Liu C, Huang Z, Li H, Xu Q, Zhou B, Hu C, Zhang Y, Wang Y, Nie J, Qiao Z, Yin D, Xu X. Common and Distinct Disruptions of Cortical Surface Morphology Between Autism Spectrum Disorder Children With and Without SHANK3 Deficiency. Frontiers in neuroscience. 2021; 15: 751364.

SH3 and Multiple Ankyrin Repeat Domains 3 (SHANK3)-caused autism spectrum disorder (ASD) may present a unique opportunity to clarify the heterogeneous neuropathological mechanisms of ASD. However, the specificity and commonality of disrupted large-scale brain organization in SHANK3-deficient children remain largely unknown. The present study combined genetic tests, neurobehavioral evaluations, and magnetic resonance imaging, aiming to explore the disruptions of both local and networked cortical structural organization in ASD children with and without SHANK3 deficiency. Multiple surface morphological parameters such as cortical thickness (CT) and sulcus depth were estimated, and the graph theory was adopted to characterize the topological properties of structural covariance networks (SCNs). Finally, a correlation analysis between the alterations in brain morphological features and the neurobehavioral evaluations was performed. Compared with typically developed children, increased CT and reduced nodal degree were found in both ASD children with and without SHANK3 defects mainly in the lateral temporal cortex, prefrontal cortex (PFC), temporo-parietal junction (TPJ), superior temporal gyrus (STG), and limbic/paralimbic regions. Besides commonality, our findings showed some distinct abnormalities in ASD children with SHANK3 defects compared to those without. Locally, more changes in the STG and orbitofrontal cortex were exhibited in ASD children with SHANK3 defects, while more changes in the TPJ and inferior parietal lobe (IPL) in those without SHANK3 defects were observed. For the SCNs, a trend toward regular network topology was observed in ASD children with SHANK3 defects, but not in those without. In addition, ASD children with SHANK3 defects showed more alterations of nodal degrees in the anterior and posterior cingulate cortices and right insular, while there were more disruptions in the sensorimotor areas and the left insular and dorsomedial PFC in ASD without SHANK3 defects. Our findings indicate dissociable disruptions of local and networked brain morphological features in ASD children with and without SHANK3 deficiency. Moreover, this monogenic study may provide a valuable path for parsing the heterogeneity of brain disturbances in ASD.

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18. McDaniel J, Brady NC, Warren SF. Effectiveness of Responsivity Intervention Strategies on Prelinguistic and Language Outcomes for Children with Autism Spectrum Disorder: A Systematic Review and Meta-Analysis of Group and Single Case Studies. Journal of autism and developmental disorders. 2021.

We conducted a systematic review to identify randomized controlled trials (RCTs) and single case research design (SCRD) studies of children with autism spectrum disorder that evaluate the effectiveness of responsivity intervention techniques for improving prelinguistic and/or language outcomes. Mean effect sizes were moderate and large for RCTs (33 studies; g = 0.36, 95% CI [0.21, 0.51]) and SCRD (34 studies; between-case standardized mean difference = 1.20, 95% CI [0.87, 1.54]) studies, respectively. Visual analysis (37 studies) revealed strong evidence of a functional relation for 45% of the opportunities and no evidence for 53%. Analyses of moderator effects and study quality are presented. Findings provide support for responsivity intervention strategies with more robust support for context-bound outcomes than more generalized outcomes.

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19. Miniarikova E, Vernhet C, Peries M, Loubersac J, Picot MC, Munir K, Baghdadli A. Anxiety and depression in parents of children with autism spectrum disorder during the first COVID-19 lockdown: Report from the ELENA cohort. Journal of psychiatric research. 2022; 149: 344-51.

BACKGROUND: The Covid-19 pandemic had a strong impact on mental health in the general population. This study conducted during the first lockdown in France considered parents of children with Autism Spectrum Disorder (ASD) prospectively followed in the ELENA Cohort. OBJECTIVES: We aimed to (1) compare the Anxiety and Depression (AaD) levels during the lockdown between mothers and fathers, (2) compare the parent’s AaD between the lockdown and the last ELENA follow-up visit, and (3) identify risk factors for parental AaD during lockdown among socio-demographic and children’s clinical characteristics. METHODS: The Hospital Anxiety and Depression Scale (HADS) was used to assess AaD in 134 parent’s pairs. Parents also completed the Questionnaire about their living conditions during COVID-19, their child’s interventions and perceived changes about their child’s behaviors and sleep. Child’s ASD severity, intellectual and socio-adaptive skills and parent’s socio-demographic characteristics were collected from ELENA follow-up. RESULTS: The parents’ AaD levels were lower during the lockdown compared to the last ELENA visit that coincided in 96% with the child’s ASD diagnosis. The AaD levels were more pronounced in mothers and significantly associated with the child’s challenging behaviors, parents’ teleworking and perceived knowledge about COVID-19. The perception of an insufficient knowledge was the only risk factor for mothers’ AaD. CONCLUSION: Our findings highlighted the pertinence for an assessment of the mental health of main caregivers of children with ASD, consideration of their gender characteristics, and the importance of providing relevant information during pandemic. Future studies examining the pandemic long-term effects are needed. TRIAL REGISTRATION NUMBER: NCT02625116.

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20. Myers RK, Carey ME, Bonsu JM, Yerys BE, Mollen CJ, Curry AE. Behind the Wheel: Specialized Driving Instructors’ Experiences and Strategies for Teaching Autistic Adolescents to Drive. The American journal of occupational therapy : official publication of the American Occupational Therapy Association. 2021; 75(3): 7503180110p1-p11.

IMPORTANCE: In the transition to adulthood, driving supports independence. For autistic adolescents, training provided by specialized driving instructors, including occupational therapists, may establish fitness to drive and continued independence. OBJECTIVE: To examine specialized driving instructors’ experiences providing behind-the-wheel instruction to autistic adolescents. DESIGN: We recruited participants through purposive and snowball sampling of members of ADED, the Association for Driver Rehabilitation Specialists. Interviews investigated experiences providing instruction, autistic students’ strengths and challenges, strategies used, and recommendations to improve the learning-to-drive process. We coded transcripts using a directed content analysis approach. SETTING: Telephone interviews. PARTICIPANTS: Specialized driving instructors (N = 17) trained as occupational therapists, driver rehabilitation specialists, or licensed driving instructors with recent experience providing behind-the-wheel training for autistic adolescents participated. RESULTS: Behind-the-wheel challenges included mental inflexibility, distractibility, and difficulties with social cues and motor coordination. Instructors acknowledged students’ strengths, including adherence to rules of the road, limited risk taking, and careful observations. Instructors scaffolded learning to help students develop skills. Although licensure and driving outcomes were sometimes unknown to instructors, students who became licensed frequently drove with supervision or restrictions. CONCLUSIONS AND RELEVANCE: Licensure is possible for autistic adolescents, although developing fitness to drive requires individualization and rigorous specialized instruction, which may culminate in delayed or restricted driving. What This Article Adds: This article highlights challenges and strengths encountered by specialized driving instructors teaching autistic adolescents. Despite requiring prolonged training, autistic adolescents can achieve licensure when supported by specialized instruction that is individualized to their needs and strengths.

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21. Nguyen J, Cardy RE, Anagnostou E, Brian J, Kushki A. Examining the effect of a wearable, anxiety detection technology on improving the awareness of anxiety signs in autism spectrum disorder: a pilot randomized controlled trial. Molecular autism. 2021; 12(1): 72.

BACKGROUND: Anxiety is prevalent in autism spectrum disorder (ASD) and can negatively impact physical and mental health. Self-awareness of anxiety signs is a key barrier to success of anxiety interventions for many children. METHODS: To address this, we conducted a randomized controlled trial to assess whether the Anxiety Meter, a wearable, real-time anxiety detection technology, can improve awareness of anxiety symptoms and the initiation of relaxation techniques in children with ASD. Twenty-eight children with ASD were trained on the use of the Anxiety Meter and taught a diaphragmatic breathing relaxation technique over three visits. On the fourth visit, participants were randomized to either receive feedback of their anxiety level or no feedback from the Anxiety Meter while completing a stress-eliciting task (public speaking) and asked to engage in deep breathing if anxious. RESULTS: Feedback from the Anxiety Meter was associated with increased likelihood of initiating deep breathing in response to anxiety. LIMITATIONS: Limitations include the small sample size, imbalanced group matching for IQ and sex, and the controlled-laboratory settings which limit the statistical power and generalizability of the results to real-world settings. CONCLUSIONS: Although these results are limited by the relatively small sample size, they support the feasibility of using a wearable device and real-time feedback to improve anxiety symptom awareness. Trial Registration ClinicalTrials.gov Identifier: NCT02160691, registration date: 06/05/2014.

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22. Plummer T, Bryan M, Dullaghan K, Harris A, Isenberg M, Marquez J, Rolling L, Triggs A. Parent Experiences and Perceptions of Safety When Transporting Children With Autism Spectrum Disorder. The American journal of occupational therapy : official publication of the American Occupational Therapy Association. 2021; 75(5).

IMPORTANCE: Motor vehicle accidents are the leading cause of unintentional deaths of children ages 1 and older, particularly children with health care needs. OBJECTIVE: To explore family caregivers’ experiences and current practices while transporting children diagnosed with autism spectrum disorder (ASD). DESIGN: A concurrent nested mixed-methods approach was used to gain insight into caregiver experiences. SETTING: Participants completed an online Qualtrics survey. PARTICIPANTS: A convenience sample of 54 caregivers of children with ASD from 17 U.S. states. RESULTS: Themes that emerged include sensory behaviors of children, education related to child passenger safety, and participation in the community. Statistically significant findings suggest a correlation between caregivers (n = 39) being less likely to participate in activities away from home if the child had attempted to elope (p = .013), displayed aggressive behaviors (p = .005), or demonstrated self-injurious behaviors (p = .001). CONCLUSIONS AND RELEVANCE: The findings suggest a correlation between caregivers limiting the distance traveled during vehicular transportation and behavioral safety concerns. If caregivers must limit travel, they may refrain from accessing the community and engaging in leisure pursuits. What This Article Adds: The findings suggest that therapists who treat children with ASD should be familiar with child passenger safety restraints, particularly for elopement.

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23. Qi Y, Han JX. Rehabilitation Educational Design for Children with Autism Based on the Radial Basis Function Neural Network. Journal of healthcare engineering. 2021; 2021: 2961546.

Children with autism need appropriate educational toys to assist rehabilitation training, so as to inhibit the development of autism. Toys and related treatments for children with autism can alleviate some of the deficits of children with autism. By using toys as stimuli and various sensations obtained by children with autism or toys as a result of reinforcement, the improvement of certain capabilities expected by related therapies can be achieved through the process of stimulation and reinforcement. However, in the process of pediatrics toy development, it is difficult for toy designers to assess whether the purpose of stimulation and reinforcement can be achieved. There are many factors that affect the design of rehabilitation toys. The industry has not formed a unified design evaluation standard, and the effects of product rehabilitation training are uneven. A method based on the radial basis function (RBF) neural network was proposed in this research to study the rehabilitation design and evaluation of rehabilitation toys for children with autism. Firstly, according to the three demand indicators for the evaluation of rehabilitation training for children with autism, that is, « useful, educational, and entertaining, » the analytic network process (ANP) method was chosen as the weighting method for determining each indicator in the overall evaluation. The RBF neural network rehabilitation model for children with autism was designed and evaluated. The maximum error of the model was less than 10%. The evaluation method was objective and reasonable, so as to provide a reference for the more accurate design evaluation, purchase, and development of rehabilitation toys for children with autism.

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24. Schmidt EK, Hand BN, Havercamp S, Sommerich C, Weaver L, Darragh A. Sex Education Practices for People With Intellectual and Developmental Disabilities: A Qualitative Study. The American journal of occupational therapy : official publication of the American Occupational Therapy Association. 2021; 75(3).

IMPORTANCE: People with intellectual and developmental disabilities (IDD) express a clear interest in intimate relationships but face many barriers to receiving sex education (SE) that would support their engagement in these relationships. OBJECTIVE: To understand barriers to, the context of, and recommendations for SE for people with IDD. DESIGN: Qualitative study design with interviews and focus groups with four key stakeholder groups. Data were analyzed using a constant comparative approach. PARTICIPANTS: Participants were 8 youths with IDD, 9 parents, 12 health care providers, and 8 educators. RESULTS: Four barriers to SE were identified: (1) values and cultural issues, (2) parental attitudes toward their child’s sexuality, (3) a lack of organizational policies and standards, and (4) limited professional education or societal biases. These barriers contribute to a SE context primarily initiated by people with IDD or provided reactively. The participants recommended proactive, formal SE provided by multiple stakeholders throughout adulthood. CONCLUSIONS AND RELEVANCE: Stakeholders should advocate for policies, standards, and additional training for parents, educators, and health care providers to support SE for people with IDD throughout adulthood. What This Article Adds: Barriers to SE contribute to the current context in which SE is shared with people with IDD. Stakeholders can advocate for policies, standards, and training to overcome these barriers and support recommendations for proactive, formal SE provided by multiple stakeholders through adulthood.

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25. Siller M, Morgan L, Wedderburn Q, Fuhrmeister S, Rudrabhatla A. Inclusive Early Childhood Education for Children With and Without Autism: Progress, Barriers, and Future Directions. Frontiers in psychiatry. 2021; 12: 754648.

University-affiliated lab and model schools play an important role in creating educational innovations in inclusive early childhood education (ECE) for young children with Autism Spectrum Disorder (ASD). In the United States, access to inclusive high-quality ECE programs for young children with disabilities has been required by law for over 40 years, has been recommended by leading professional organizations, and has been emphasized in federal public policy initiatives. Yet, improvement in the rates of young children with disabilities experiencing inclusion has been limited. This review article consists of three parts. First, we identify and describe four barriers to wide-scale implementation of inclusive ECE programs for children with ASD in the US. These barriers include (1) the fragmented nature of the ECE system in the United States, (2) the age at which ASD is typically first diagnosed in the community, (3) the diverse presentation/support needs of children with ASD, and (4) the thoughts and feelings of parents of children without disability about inclusion. Second, we used a snowball sampling approach to identify nine leading university-affiliated, inclusive lab and model schools for young children with ASD. By describing these programs, we highlight similarities and differences between programs, and capture the unique ways in which these programs adapt to local conditions, resources, and barriers (e.g., federal and state regulations, funding sources, community resources, institutional structures and priorities, professional orientation and training, access to families and staff). Finally, we propose a roadmap for researchers focused on the development, evaluation, and implementation of community-viable inclusive ECE programs in ASD. This roadmap leverages synergies between inclusive university-affiliated lab and model preschools in ASD, and proposes the formation of a research network that creates an infrastructure for cross-program collaboration.

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26. Skaletski EC, Bradley L, Taylor D, Travers BG, Bishop L. Quality-of-Life Discrepancies Among Autistic Adolescents and Adults: A Rapid Review. The American journal of occupational therapy : official publication of the American Occupational Therapy Association. 2021; 75(3): 7503180090p1-p22.

IMPORTANCE: Quality of life (QoL) is a core outcome of occupational therapy, but it is decreased among autistic adolescents and adults. This is the first review of QoL from an occupational therapy standpoint. OBJECTIVE: To identify self-reported QoL differences between autistic and nonautistic samples; investigate sex differences in QoL among autistic people; examine consistency in QoL among autistic people across age, intellectual disability (ID), and self- versus proxy-report method; and appraise occupational therapy-related interventions addressing QoL among autistic people. DATA SOURCES: Articles published in peer-reviewed journals between 2010 and 2020, located through Academic Search Ultimate, PubMed, and OTseeker, along with the American Journal of Occupational Therapy, British Journal of Occupational Therapy, Canadian Journal of Occupational Therapy, and Australian Occupational Therapy Journal. Study Selection and Data Collection: Article samples consisted of at least 20% autistic females and used self-reported QoL measures. Qualitative research was excluded, as well as studies with participants younger than age 13 yr. Twenty-seven articles qualified (3 Level 1B, 13 Level 3B, and 11 Level 4). FINDINGS: Autistic adolescents and adults demonstrated decreased self-reported QoL compared with nonautistic peers across age and ID presence. One article compared sex differences in QoL among autistic people. Interventions improved QoL among autistic people. CONCLUSIONS AND RELEVANCE: Autistic adolescents and adults demonstrate decreased QoL in comparison with nonautistic peers. Questions remain related to sex differences in QoL among autistic people, an area for future research. Multiple evidence-based approaches to improve QoL in the autistic population are relevant to occupational therapy practice. What This Article Adds: Self-reported QoL among autistic adolescents and adults is clearly lower than among their nonautistic counterparts. This article provides information on multiple interventions related to occupational therapy to improve QoL among autistic people.

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27. Varela I, Fernández-Feijoo J, García E, Diniz-Freitas M, Martínez I, Roca J, Diz P, Limeres J. Development of a new tool for predicting the behavior of individuals with intellectual disability in the dental office: A pilot study. Disability and health journal. 2022; 15(2): 101229.

BACKGROUND: The dental treatment of individuals with intellectual disability can represent a considerable professional challenge. OBJECTIVE: To develop a model for predicting the behavior of patients with intellectual disability in the dental office. METHODS: The study group comprised 250 patients with Down syndrome (DS), autism spectrum disorder (ASD), cerebral palsy (CP), idiopathic cognitive impairment or rare disorders. We collected their demographic, medical, social and behavioral information and identified potential predictors (chi-squared test). We developed stratified models (Akaike information criterion) to anticipate the patients’behavior during intraoral examinations and to discern whether the dental treatment should be performed under general anesthesia. These models were validated in a new study group consisting of 80 patients. Goodness of fit was quantified with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under the receiver operating characteristic curve (AUC). We developed a mathematical algorithm for executing the models and developed software for its practical implementation (PREdictors of BEhavior in Dentistry, « PREBED »). RESULTS: For patients with DS, ASD and CP, the model predicting the need for physical restraint during examination achieved a PPV of 0.90, 0.85 and 1.00, respectively, and an NPV of 0.66, 0.76 and 1.00, respectively. The model predicting the need for performing treatment under general anesthesia achieved a PPV of 0.63, 1.00 and 1.00, respectively, and an NPV of 1.00, 1.00 and 0.73, respectively. However, when validating the stratified models, the percentage of poorly classified individuals (false negatives + false positives) ranged from 24% to 46.6%. CONCLUSIONS: The results of the PREBED tool open the door to establishing new models implementing other potentially predictive variables.

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28. Victor AK, Donaldson M, Johnson D, Miller W, Reiter LT. Molecular Changes in Prader-Willi Syndrome Neurons Reveals Clues About Increased Autism Susceptibility. Frontiers in molecular neuroscience. 2021; 14: 747855.

Background: Prader-Willi syndrome (PWS) is a neurodevelopmental disorder characterized by hormonal dysregulation, obesity, intellectual disability, and behavioral problems. Most PWS cases are caused by paternal interstitial deletions of 15q11.2-q13.1, while a smaller number of cases are caused by chromosome 15 maternal uniparental disomy (PW-UPD). Children with PW-UPD are at higher risk for developing autism spectrum disorder (ASD) than the neurotypical population. In this study, we used expression analysis of PW-UPD neurons to try to identify the molecular cause for increased autism risk. Methods: Dental pulp stem cells (DPSC) from neurotypical control and PWS subjects were differentiated to neurons for mRNA sequencing. Significantly differentially expressed transcripts among all groups were identified. Downstream protein analysis including immunocytochemistry and immunoblots were performed to confirm the transcript level data and pathway enrichment findings. Results: We identified 9 transcripts outside of the PWS critical region (15q11.2-q13.1) that may contribute to core PWS phenotypes. Moreover, we discovered a global reduction in mitochondrial transcripts in the PW-UPD + ASD group. We also found decreased mitochondrial abundance along with mitochondrial aggregates in the cell body and neural projections of +ASD neurons. Conclusion: The 9 transcripts we identified common to all PWS subtypes may reveal PWS specific defects during neurodevelopment. Importantly, we found a global reduction in mitochondrial transcripts in PW-UPD + ASD neurons versus control and other PWS subtypes. We then confirmed mitochondrial defects in neurons from individuals with PWS at the cellular level. Quantification of this phenotype supports our hypothesis that the increased incidence of ASD in PW-UPD subjects may arise from mitochondrial defects in developing neurons.

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29. Washington SE, Johnson KR, Hollenbeck JM. Environmental Modifications and Supports for Participation Among Adults Aging With Intellectual and Developmental Disabilities: A Scoping Review. The American journal of occupational therapy : official publication of the American Occupational Therapy Association. 2021; 75(4).

IMPORTANCE: Adults aging with intellectual and developmental disabilities (IDD) continue to face barriers to participation in meaningful occupation; moreover, the increased life expectancy of adults with IDD intensifies the need for age- and environment-specific support. OBJECTIVE: To map and categorize transdisciplinary literature on environmental modifications and supports for adults aging with IDD. DATA SOURCES: Studies published between January 1, 2000, and January 1, 2019, identified through PubMed and Scopus. Study Selection and Data Collection: Eleven articles met the inclusion criteria and contained information specific to occupational participation based on environmental modification (e.g., physical space, technology, universal design, type of living setting), social supports (e.g., family members, caretakers, peer groups, health care professionals, policies, organizational infrastructure), or both and adults age ≥35 yr with IDD. FINDINGS: Eleven studies met the criteria for this scoping review. Thematic coding was used to examine the articles within one or more themes: definition of need, environmental risk and assessment, environmental setting, intervention and program planning, use of technology, and bureaucracy. CONCLUSIONS AND RELEVANCE: This review highlights collective and individual outcomes in the areas of assessment, intervention, and advocacy. Further research is needed within the scope of occupational therapy and disability studies that examines environmental factors and participation outcomes in this population. What This Article Adds: The authors define the interconnectedness of adults aging with IDD and environmental factors, identify barriers to participation, and guide occupational therapy practitioners’ logic on how to positively affect environmental change and supports through intervention.

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30. Zhang H, Sun Y, Zhu Y, Hong J, Zheng M. Case Report: Prenatal Diagnosis for a Rett Syndrome Family Caused by a Novel MECP2 Deletion With Heteroduplexes of PCR Product. Frontiers in pediatrics. 2021; 9: 748641.

Rett syndrome is an X-linked dominant, postnatal neurological disorder. Approximately 80-90% of classic Rett syndrome patients harbor mutations in the coding region of MECP2. Somatic or germline MECP2 mosaicism is not rare, and paternal germline MECP2 mosaicism occurs in especially high proportions. Here, we report the case of a Chinese girl with Rett syndrome in whom a heterozygous deletion was found in exon 4 of MECP2 using multiplex ligation-dependent probe amplification. To obtain an accurate region of deletion, we narrowed down the deletion region using real-time quantitative PCR, and subsequent long-range PCR was performed to detect the deletion breakpoints. Surprisingly, three DNA bands from long-range PCR products were observed after gel electrophoresis. To exclude somatic mosaicism, we performed T-A cloning and DNA sequencing, the middle DNA band was proved to be a heteroduplex of the PCR product in vitro. Meanwhile, a prenatal diagnosis was performed for the pregnant mother of the patient. Our study showed that the patient was heterozygous for the deletion of 713-base pairs in exon 4 of MECP2 (MECP2: c.441_1153del713), resulting in a frameshift and premature termination of the 487 amino acid protein at the 154th codon. In summary, we reported a novel heterozygous deletion in the MECP2 gene with heteroduplexes of the PCR product in vitro, which can help in the genetic counseling and prenatal diagnosis of disorders of MECP2 defects.

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31. Zhang X, Huang J, Zheng G, Liang J, Hu B, Lou Z, Li A, Ding Y. Prenatal exposure to di (2-ethylhexyl) phthalate causes autism-like behavior through inducing Nischarin expression in the mouse offspring. Biochemical and biophysical research communications. 2021; 585: 29-35.

Epidemiologic evidence has suggested a relationship between di (2-ethylhexyl) phthalate (DEHP) prenatal exposure and autism spectrum disorders (ASD), but the underlying mechanisms are still at large unknown. In this study, pregnant mice were intragastrically administered with DEHP once a day from GD 3 to GD 17 and the neurobehavioral changes of offspring were evaluated. In addition to the repetitive stereotyped behaviors, DEHP at the concentration of 50 mg/kg/day and above significantly impaired the sociability of the offspring (P < 0.05) and decreased the density of dendritic spines of pyramidal neurons in the prefrontal cortex (P < 0.05). At the same time, the expression of Nischarin protein in prefrontal lobe increased (P < 0.05). Similarly, after 12-h incubation of DEHP at the concentration of 100 nM, the total spine density, especially the mushroom and stubby spine populations, significantly decreased in the primary cultured prefrontal cortical neurons (P < 0.05). However, the inhibitory effect of DEHP were reversed by knockdown of Nischarin expression. Collectively, these results suggest that prenatal DEHP exposure induces Nischarin expression, causes dendritic spine loss, and finally leads to autism-like behavior in mouse offspring.

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