Children born preterm are at increased risk of deviation from the typical developmental trajectory. The probability of adverse developmental sequelae is increased in those with history of major perinatal complications. Retinopathy of prematurity (ROP) is a pathological disordered growth of retinal blood vessels occurring in very preterm neonates who require supplemental oxygen. ROP has been linked to intermittent hypoxemic events and blood gas derangements occurring in the Neonatal Intensive Care Unit (NICU), particularly in ventilated infants. Though presence and severity of ROP have been linked to neurodevelopmental impairment, little is known about the relationship between ROP severity and motor development in the preschool age. Because the same hypoxemic events and blood gas changes that lead to severe ROP may also lead to greater developmental deficits in motor control, we hypothesized that ROP severity will be inversely linked to the quality of motor functioning even in NICU graduates without neurological impairments.

We included 95 preterm (23.6 - 33.6 weeks gestation) preschoolers (49 females, 44 members of twin pairs or triplets). The participants' age ranged from 3.3 - 4.1 years (adjusted for prematurity). ROP screening was conducted during NICU stay and rated from immature retina (0) to grade 4. Motor abilities were assessed with the Peabody Developmental Motor Scales (PDMS-2). Cases with diagnosed perinatal brain pathology (moderate to severe) or cerebral palsy were excluded from analyses.

We used linear mixed regression analyses with multiple gestation as a random factor. Severity of ROP was our predictor of interest, whereas socioeconomic status, sex, gestational age, and birth-weight SD served as covariates. Separate analyses were conducted using the PDMS-2 Total Motor, Fine Motor, and Gross Motor Quotients as dependent variables. ROP severity explained a unique portion of the variance in the Total Motor Quotient (F[1, 89] = 5.59, p = .02). Examination of the relationship between ROP severity and motor skill domains yielded a significant association for the Fine Motor Quotient (F[1, 89] = 6.19, p = .015) and a trend for the Gross Motor Quotient (F[1, 89] = 3.64, p = .06).

The results of this study reveal that increase in ROP severity is linked to poorer motor skills in preterm-born preschoolers without major disabilities or perinatal diagnosis of moderate to severe brain pathology. This association was evident for both fine and gross motor skills, though only the relationship between ROP severity and the former motor index reached conventional statistical significance. Importantly, ROP severity accounted for a unique portion of the variance in motor performance, over and above the variance explained by other perinatal risk factors. This result is consistent with previous research findings indicating that ROP is linked to the occurrence of multiple, subtle hypoxemic events and 'exposure' to blood gas derangements during NICU stay in very preterm neonates who require respiratory support.

Infant motor development is a robust predictor of long-term developmental outcomes, especially in infants at high risk for neurodevelopmental impairments, such as those born preterm (PT, gestational age [GA] <37 weeks). Although direct assessments of motor development are available, they are infrequently applied by pediatricians in routine screening of the broader population of infants born preterm. Parent ratings, such as the Ages and Stages Questionnaire, 3rd Ed., can be used to screen for motor delays. However, this and other existing screening measures focus on whether children have reached milestones based on pre-established cutoffs, rather than on assessing development along a continuum of ability. The present study examined the validity of the Motor domain of the recently developed caregiver report screening tool, PediaTracTM, in distinguishing infants born PT from infants born full term (FT, GA ^37 weeks) across the first 6 months of life. The reliability and factor structure of this motor scale were also evaluated.

PediaTracTM is a web-based caregiver report assessing infant development across multiple domains, including motor functioning. This study reports on results from the PediaTracTM Motor domain for the study sample of 571 caregiver-infant dyads (240 PT, 331 FT). Caregivers rated their infants on age-targeted motor skills during the newborn period (NB, defined as term equivalent for the PT group) and at 2-, 4-, and 6-months after the NB period. Item Response Theory (IRT) methods were applied to assess the reliability (i.e., information) of caregiver-reported motor skills at each age. Using the IRT item parameters of discrimination and difficulty, items were selected for inclusion and to estimate theta, an index of the latent trait, motor ability, for each infant. Analyses conducted at each age assessed the effects of group, sex, and group x sex on the motor trait. Scale reliabilities and factor structure were also examined.

The PT group had significantly higher scores than the FT group on the motor trait at the NB period but significantly lower scores by 4 and 6 months, suggesting slower development of motor skills in the PT group. Means (SD) theta scores (similar to z scores) for the PT and FT groups, respectively, were .14 (.88) and -.05 (.91) for the NB period, -.01 (.90) and .01 (.91) for 2 months, .20 (.90) and .36 (88) for 4 months, and .46 (78) and .66 (.89) for 6 months. Effects for sex and group x sex interactions were not significant. Reliabilities, estimated at a point close to mean theta, were .94, .93, .96, and .98 at the NB, 2-, 4-, and 6-month periods, respectively. Exploratory factor analyses revealed evidence for a single primary motor factor and multiple second-order factors at each age.

Findings provide strong support for applications of the caregiver reported PediaTracTM motor scales in screening infants born PT and other at-risk populations for early delays or abnormalities in motor development. Advantages of this method include its ease of administration, sensitivity to developmental change, and promise in assessing subdomains of motor skill.

Motor weaknesses are frequently observed in very preterm children (VPT; gestational age [GA] < 30 weeks) prior to school entry and may serve as markers of risk for school-age cognitive and behavioral deficits. The aims of the present study were to: (1) determine if weaknesses in preschool motor skills in children born VPT and a full-term comparison group (FT; GA > 37 weeks) are associated with lower scores on tests of cognition and caregiver ratings of behavior in early elementary school; (2) explore the possibility that weaknesses in preschool motor abilities predict less positive changes in cognition and behavior across follow-up; and (3) determine if associations between preschool motor skills and later cognitive and behavioral functioning differed for the two groups.

Thirty-eight children born VPT and thirty born FT completed measures of motor skills, global cognitive ability, and executive function and caregivers completed questionnaires assessing children's behavior at age 4 (T1; M = 4.71 years) and at ages 7 or 8 (T2; M = 7.87 years). ANCOVAs were used to examine group differences in cognitive and behavioral outcomes. Hierarchical regressions were conducted to examine the Movement Assessment Battery for Children, 2nd Ed. (MABC-2) total score at T1 as a predictor of T2 scores on cognitive tests and behavior ratings (step 1). Covariates included sex and socioeconomic status (step 1). Outcomes included the Differential Ability Scales-II (DAS-II), NIH Toolbox Dimensional Change Card Sort (DCCS), Behavior Rating Inventory of Executive Function Global Executive Composite (BRIEF GEC), Emotion Regulation Checklist, and Social Communications Questionnaire at T2. T1 status on the T2 cognitive and behavioral outcomes was included as a predictor to determine if T1 MABC-2 predicted change in these outcomes from T1 to T2 (step 2). In separate analyses, T1 MABC-2 x group interactions were included to determine if associations of the T1 MABC-2 with T2 outcomes differed by group.

The VPT group had significantly lower scores than the FT group on the DAS-II at T2. Lower scores on the T1 MABC-2 were significantly associated (p < .05) with lower scores on the DAS-II and DCCS and more executive dysfunction on the BRIEF-GEC. These associations were stronger for the VPT group than for the FT group for the T2 DAS-II Global Cognitive Ability and Verbal composites but not for the other outcomes. Lower scores on the T1 MABC-2 were associated with less positive change on the DAS-II Nonverbal composite and the DCCS and increased executive dysfunction on the BRIEF-GEC.

Weaknesses in motor abilities at 4 years of age were associated with cognitive and behavioral difficulties at early school age, both for children born VPT and those born FT. These weaknesses were also associated with less favorable changes in cognition and behavior across the transition from preschool to early school age. Findings suggest that early motor abilities provide a marker of generalized developmental impairment or that early motor impairments have cascading effects on development. These results support the need for early screening and intervention for motor deficits in preschoolers born either VPT or FT.

To examine associations between executive function (EF) domains (attentional control, information processing, cognitive flexibility, and goal setting) and math computation performance at 7 and 13 years in children born very preterm (VP; <30 weeks' gestation), and secondly, to investigate the associations of 7-year EF with change in math performance from 7 to 13 years.

In the prospective, longitudinal Victorian Infant Brain Studies (VIBeS) cohort of children born VP, assessment of EF and math performance was undertaken at 7 (n = 187) and 13 years (n = 174). Univariable and multivariable regression models (including all domains of EF) were used to examine associations between EF domains at both timepoints with math performance, as well as associations between EF at 7 years with change in math from 7 to 13 years.

At 7 and 13 years, all EF domains were positively associated with concurrent math performance, with multivariable models finding information processing, cognitive flexibility and goal setting independently contributed to math performance at both ages. All EF domains were positively associated with improvement in math performance from 7 to 13 years, with multivariable models finding that goal setting contributed unique variance to improvement in math over this period.

This study provides evidence for a strong, consistent association between EF and math performance in children born VP and emphasizes the importance of goal setting capacity for later improvement in math performance.

Preterm children with very low birthweight (VLBW) / extremely low birthweight (ELBW) with normal early development had been found poorer executive functions (EFs) at preschool-age (Ni, Huang & Guo, 2011). The previous study found that the risks of deficits in EFs at preschool-age of preterm children can be attenuated by more supportive home environment (Taylor & Clark, 2016). However, former studies didn't investigate the effect of birthweight and home environment on cognitive EFs of preterm children simultaneously, especially those with normal early development. The present study aims to investigate the predictive effect of birthweight and home environment on the cognitive EFs of VLBW / ELBW preterm children.

The preterm children were recruited from the Premature Baby Foundation of Taiwan. Inclusion criteria were their scores of Bayley Scales of Infant and Toddler Development, second or third edition at 12 and 24 months, and Wechsler Preschool and Primary Scale of Intelligence, Revised Edition at 5 years old were higher than 70. Exclusion criteria were visual impairment, hearing impairment, and cerebral palsy. There was a total of 287 preterm children with age 6 recruited in the present study. Preterm children were then divided into VLBW group (n=202, birthweight between 1001-1500g) and ELBW group (n=85, birthweight less than 1000g). The typical children included 89 term-born healthy and typically developing children with age 6, who were recruited from comparable social status families in the community. Four types of cognitive EFs including 22 indicators were assessed. Inhibition ability including 8 indicators was assessed through Comprehensive Nonverbal Attention Test Battery (CNAT), cognitive flexibility including 6 indicators was assessed through Wisconsin Card Sorting Test (WCST), working memory including 2 indicators was assessed through Digit Span Subtest of Wechsler Intelligence Scale for Children-IV (WISC-IV) and Knox's Cube Test (KCT), planning ability including 6 indicators was assessed through Tower of London (ToL). The home environment was assessed through Home Observation for Measurement of the Environment (HOME), Revised edition. Data were analyzed with Stepwise Regression.

Results showed that the regression model with birthweight significantly predicted 83.3% of planning ability indicators, 83.3% of cognitive flexibility indicators, and 50% of working memory indicators. Among indicators mentioned above, birthweight has been found the greatest predictive effect on summation-of score of ToL (R2=.04, p<.001). The regression model with HOME significantly predicted 66.7% of planning ability indicators, 16.7% of cognitive flexibility indicators, and 12.5% of inhibition ability indicators. Among the indicators mentioned above, HOME has been found the greatest predictive effect on rule-1 of ToL (R2=.027, p=.001). The regression model with birthweight and HOME significantly predicted 50% of planning ability indicators. Among indicators mentioned above, the regression model has been found the greatest predictive effect on summation-of-score of ToL (R2=.061, p<.001).

Both birthweight and home environment have been found significantly predicted different types of cognitive EFs at preschool-age of VLBW / ELBW preterm children with normal early development. Though the home environment doesn't have such a great predictive effect as birthweight is, both birthweight and home environment are significant predictors of planning ability.

Previous studies had shown that even with normal early development, preterm children at age six still have executive function deficits, including planning, cognitive flexibility, and nonverbal working memory. The present study aims to discuss further the correlation between IQ and EF of preterm children with different birthweight in order to clarify the potential influence of birthweight.

The preterm children were recruited from the Regional Cohort Network for premature infants who were admitted to neonatal intensive care units. Inclusion criteria were their scores of Bayley Scales of Infant and Toddler Development, second or third edition at 12 and 24 months, and Wechsler Preschool and Primary Scale of Intelligence, Revised Edition at 5 years old were higher than 70. Meanwhile, their FSIQ of Wechsler Intelligence Scale for Children, Fourth Edition were higher than 85 at age 6. Exclusion criteria were visual impairment, hearing impairment, and cerebral palsy. There was a total of 251 preterm children recruited in the present study. Preterm children were then divided into very low birthweight (VLBW) and extremely low birth weight (ELBW) groups. The VLBW group included 183 preterm children, whose birthweight is between 1000-1500g, and gestational age is less than 37 weeks. The ELBW group included 68 preterm children, whose birthweight is less than 1000g and gestational age is less than 37 weeks. Four types of executive function were assessed. Inhibition was assessed through Comprehensive Nonverbal Attention Test Battery (CNAT), cognitive flexibility was assessed through Wisconsin Card Sorting Test (WCST), verbal working memory was assessed through the Longest Digit Span Forward (LDSB) index of Digit Span Subtest of Wechsler Intelligence Scale for Children-IV (WISC-IV), and nonverbal working memory was assessed through Knox's Cube Test (KCT), and planning ability was assessed through Tower of London (ToL). Data were analyzed with independent T-test and Pearson Correlation.

In VLBW preterm group, results showed that there were significant correlations (p<.05) between FSIQ and EF indexes in five out of six indexes of WCST, LDSB of Digit Span of WISC-IV, Backward score of Knox's Cube Test, and three out of six indexes of ToL. As to the CNAT, there was no index of CNAT that was significantly correlated with FSIQ in the VLBW preterm group. In ELBW preterm group, results showed that there were significant correlations (p<.05) between FSIQ and EF indexes in one out of five indexes of CNAT, one out of six indexes of WCST, Backward score of Knox's Cube Test, and two out of six indexes of ToL. And the LDSB of Digit Span of WISC-IV was not significantly correlated with FSIQ in ELBW preterm group.

There were fewer EF indexes significantly correlated with FSIQ in ELBW preterm children with normal early development than VLBW preterm children with normal early development, suggesting that even with an IQ higher than 85, lower the birthweight, especially lower than 1000g, higher the EF performance should be concerned. Therefore, in the clinical setting, it is very important to assess the EF independently. And birthweight may be a crucial factor in preterm children's prefrontal cortex maturity.

Previous studies had shown that very low birth weight(VLBW) preterm children with normal early development had poorer cognitive executive functions(CEFs) and emotional executive functions(EEFs) at preschool-aged. There were still about 73% of children with deficits of CEFs and 74% of them with deficits of EEFs at school-aged. (Ni et al., 2011; Chiang et al., 2019; Lee et al., 2022). Besides, former studies less discuss the core neuropsychological ability related to the EFs development. In this study, meta-attention was chosen as the core ability. This study applied longitudinal design aimed to discuss the predictive power of meta-attention at preschool-aged on the CEFs and EEFs at school-aged for VLBW preterm and typically developing children.

The VLBW group was referred by Premature Baby Foundation of Taiwan. These children have been followed up with Bayley Scales of Infant Development(BSID) II or III administered at the age of 12 months and 24 months and Wechsler Preschool and Primary Scale of Intelligence-Revised(WPPSI-R) at the age of 5-year-old. Children with visual impairment, auditory impairment, cerebral palsy developmental indices of BSID-II or III less than 70, or full-scale IQ of WPPSI-R less than 70 were excluded.

The typical group was recruited from the community and included 30 children whose development was typical. Both preterm and typically developing children completed the CEFs and EEFs test at 6 and 8. Four types of CEFs including 33 indicators were assessed: Meta-attention including 18 indicators through Comprehensive Nonverbal Attention Test Battery(CNAT), working memory including 2 indicators through Digit Span Subtest of Wechsler Intelligence Scale for Children-IV(WISC-IV) and Knox’s Cube Test(KCT), planning ability including 6 indicators through Tower of London(ToL), and cognitive flexibility including 7 indicators through Wisconsin Card Sorting Test(WCST).

Two types of EEFs including 5 indicators were assessed. We designed Emotional EF Ecological Assessment Battery for Children in Taiwan to assess EEFs, including 3 indicators of theory of mind and 2 indicators of emotion regulation. Data were analyzed with correlation analysis and independent sample t-test.

Meta-attention at 6 among the VLBW group significantly correlated with 73.3% of CEFs and 80% of EEFs indicators at 8 and had significant predictive power on working memory, planning ability, cognitive flexibility, emotion regulation, and theory of mind. (p<.05) When the significance level was 0.01, meta-attention still correlated with 33% of CEFs and 80% of EEFs indicators and can predict those CEFs and EEFs among the VLBW group. Meta-attention at 6 among the typical group significantly correlated with 26.7% of CEFs and 80% of EEFs indicators at 8 and had significant predictive power on working memory, planning ability, emotion regulation, and theory of mind. (p<.05)

When the significance level was 0.01, meta-attention only correlated with 80% of EEFs indicators and can’t predict any CEFs and EEFs among the typical group.

Meta-attention at 6 can predict CEFs and EEFs among VLBW preterm children at 8, while the effect didn’t be found among typically developing children. Thus, meta-attention can be served as a clinical cut-point for VLBW preterm children to find the deficits and intervene early.

Many studies supported that children with autism spectrum disorder (ASD) have worse executive functions (EFs) when compared to typically developmental (TD) children in many domains, such as planning, flexibility, inhibition, and self-monitoring. The current study aims to use an adapted version of the computerized tower test to investigate the EFs of children with ASD. Furthermore, the researcher also assessed children's EFs-related behaviors in their schools using a teacher-filled behavior rating inventory of executive function, 2nd edition (BRIEF-2).

61 Children aged 7 to 12 years old (M = 9.23) were included in the current study. 29 of them were in the ASD group, and 31 of them were in the TD group. All participants conducted an adapted computerized tower test. All participants' teachers completed BRIEF-2 to investigate their EFs-related behaviors in their schools.

The results indicated that there were no significant differences in the tower test between the ASD group and TD group in all indexes. Therefore, it implied that the current indexes might not be sensitive enough to distinguish whether a child has ASD or not. In addition, we further investigate the correlations between the tower test and the teacher-filled BRIEF-2. We found the different patterns in the two groups. In the ASD group, we found that the task-monitor index was positively correlated with total-number-of-rule-violations, total-complete-time, and total-rule-violations-per-item-ratio. The task-monitor index was negatively correlated with total-achievement-score, implying that poorer ability to monitor tasks leads to a longer completion time, more rule violations, and a lower total achievement score. Moreover, we also found a high correlation between the organization-of-materials in BRIEF-2 and total-complete-time in the tower test, suggesting the long problem-solving time in ASD groups is highly related to the disability of keeping working space ordered. In addition, we found that the shift index is positively correlated with total-complete-time and total-rule-violations-per-item-ratio. Hence, it indicates that those with poor flexibility in solving problems tend to need more time to complete tasks and violate more rules in ASD groups. In the TD group, we only found the correlation effects were significant between inhibition and self-monitor in the BRIEF-2 and the total-rule-violations-per-item-ratio in the tower test. It suggested that individuals with behavioral regulation problems, such as impulse control and monitoring problems are more likely to make rule violations. The result indicated that behavioral regulations play a more significant role in the TD group. In contrast, cognitive and emotional regulations are more critical in ASD children.

Our findings found no significant difference in the computerized tower test between children with and without ASD, suggesting that the current indexed might not be sensitive enough to differentiate children with or without ASD. However, the results of the correlation between the tower test and teacher-filled BRIEF-2 showed that different patterns might be the cause of the EF performances between the two groups, indicating that there might be a different domain of EFs the children used in the tower test between two groups.

Therefore, further research could focus on developing new indexes in the Tower test and finding the EF mechanism of ASD children with different approaches.

Executive functioning (EF) is impaired in autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD), and EF challenges are exacerbated in youth with ASD and ADHD (ASD+ADHD), which may impact diagnostic timing. We hypothesized youth with ASD+ADHD would be more impaired in EF (as opposed to other functional domains) compared to autistic youth without ADHD (ASD-only), with particular deficits in metacognition and inhibition. We also predicted youth with ASD+ADHD would be at significant risk for delayed ASD diagnosis and that greater EF challenges would predict earlier age of ASD diagnosis across groups.

Data from a clinical database was extracted for 400 youth who received a new diagnosis of ASD after age 5, either with a co-occurring diagnosis of ADHD (ASD+ADHD group: n=297; Mage of ASD diagnosis=10.49; 25.9% female; 48.1% white) or without a co-occurring ADHD diagnosis (ASD-only group: n=100; Mage of ASD diagnosis=12.02; 34.0% female; 44.7% white). EF was measured with the BRIEF-2 parent-report, and ASD symptom strength was measured with the SRS-2 School Age form. Independent samples t-tests investigated whether a) the ASD+ADHD group was uniquely impaired in EF compared to the ASD-only group, b) parents of ASD+ADHD report elevated EF problems, and c) the ASD+ADHD group was at significant risk for delayed ASD diagnosis. Pearson correlations examined the association between age of ASD diagnosis and EF for each diagnostic group. Hierarchical linear regressions further analyzed whether specific EF domains concurrently predicted age of ASD diagnosis, after controlling for the known predictors of assigned sex at birth, FSIQ, and ASD symptom strength.

The ASD+ADHD group had greater challenges in overall EF (t=-6.42, p<.001), metacognitive skills (t=-6.47, p <.001), and inhibition skills (t=-7.06, p<.001). There was no significant difference in parent-reported autism symptoms between the ASD and ASD+ADHD groups (t=0.973, p=.331). The ASD+ADHD group received ASD diagnoses earlier than the ASD-only group (t=4.194, p<.001). In the ASD-only group, age of ASD diagnosis was not significantly correlated to overall EF, metacognitive skills, nor inhibition skills (ps>.05). In the ASD+ADHD group, ASD diagnosis was significantly related to overall EF (r(297)=.128, p=.027) and metacognitive skills (r(297)=.329, p<.001) but not inhibition skills (r(297)=.078, p=.180). Hierarchical linear regressions controlling for assigned sex at birth, FSIQ, and SRS-2 T-scores were used to determine whether these EF components significantly predicted age of ASD diagnosis. Overall EF did not predict age of ASD diagnosis in the ASD+ADHD group (ß=.034, t=1.417, p=.157), but metacognitive skills did (ß=.123, t=5.582, p<.001).

Our findings suggest youth with ASD+ADHD have greater impairment in overall EF, metacognition, and inhibition compared to ASD-only youth, despite similar levels of ASD traits, consistent with hypotheses. Contrary to our hypothesis, youth with ASD+ADHD in this sample were diagnosed with ASD earlier. However, results also suggest EF problems, specifically metacognitive deficits, predict later age of ASD diagnosis. Future research is needed to replicate findings and better understand how EF and other functional domains predict ASD diagnostic timing.

The present study aims to better understand learning strategies and difficulties in autistic youth. Previous studies have found that autistic youth have difficulties with executive function skills and poorer performance in memory and learning tasks, especially those that require spontaneous retrieval of information compared to memory tasks that provide external retrieval cues. Additionally, it has been theorized that autistic youth employ a serial approach rather than a semantic approach to learning. The current study hypothesized that the autistic sample will have (a) significant difficulties in learning and memory, (b) employ a serial approach more frequently and a semantic approach less frequently than the CVLT normative sample, and (c) will benefit significantly when provided with external retrieval cues.

Archival data from a mixed clinical and research database were examined for this study. Participants include 740 autistic individuals between the ages of 5.50 and 24.3 (M = 10.90, SD = 2.98). The sample consisted of 22.2% girls and 34.0% Black, Indigenous, and people of color (BIPOC). All individuals had a FSIQ > 70 (M = 99.91, SD = 16.09) and were clinically diagnosed with autism using DSM-IV-TR or DSM-V criteria by a clinician at an autism diagnostic center. Participants completed the age-appropriate California Verbal Learning Test (CVLT, Delis et al. 1987) which is a neuropsychological measure that examines verbal memory and learning. One-sample t-tests were used to examine the sample's verbal memory abilities and their learning strategies. A paired sample t-test was used to evaluate the sample's performance before and after an external retrieval cue was given.

Results from the one-sample t-tests indicate that the autistic sample performed worse than the CVLT normative data with a large effect size (t(739)= -9.440, p <.001, Cohen's d = 1.292). Secondly, the autistic sample was less likely to use a semantic learning approach (t(739) = -1.841, p = .033, Cohen's d = 1.234), but not more likely to use a serial approach (t(739)=-.040, p=.484) compared to the normative sample. Lastly, the paired sample t-test results show that the sample performed significantly better after receiving the external retrieval cue (t(739)=-2.570, p=.005, Cohen's d = .770).

The data supported the first hypothesis; autistic individuals have increased difficulties with learning and verbal memory. However, the data only partially support the second hypothesis. The sample was less likely to use a semantic approach to learning but was not more likely to use serial learning. This finding is opposed to the Weak Central Coherence (WCC) theory, which suggests that autistic individuals are more likely to have detail-oriented, bottom-up cognitive thinking styles, consistent with a serial learning strategy. Lastly, data showed improvement when autistic individuals received a retrieval cue. This result supports the Task Support Hypothesis (TSH) and indicates that autistic individuals benefit from cues for memory recall, particularly those that capitalize on their areas of strength. This study did not use a control group and is limited in ethno-racial diversity; therefore, these are preliminarily findings that require further replication.

With the onset of the COVID-19 pandemic, many families face barriers in accessing critical services for their children. However, there is a disproportionate impact on families of children with Neurodevelopmental Disorders (NDDs), particularly those who are dependant on receiving regular services. The current study investigated how service delivery has changed for children and families with NDDs during the COVID-19 pandemic, to identify which groups are most at risk for service disruption and negative outcomes, and to provide actionable recommendations for community agencies that provide early interventions for future pandemics.

Data was collected in the fall and winter of 2020/2021 during the Covid-19 pandemic. Families were recruited from a local service provider in British Columbia whose Early Years Support services delivery model was changed to online delivery during the pandemic. Children had a diagnosis of NDD or were on the waitlist for an assessment. Overall, 26 families participated in a semi-structured interview that asked about their experiences of receiving services for their children during the pandemic. Of these families, 20 subsequently completed online questionnaires that asked about their parenting stress levels and their children’s behaviour throughout the pandemic. Families of a range of compositions were drawn from different ethnicities (30% white, 25% South Asian, 20% Filipino, and the remaining 5% identified as Indigenous, African or East Asian). The mean age of children was 3.80 years (SD =0.72).

From the survey, we found that 58% of parents reported higher than average levels of mental health and behavioural challenges in their children during the Covid-19 pandemic. In addition, 45% of parents reported higher than average parenting stress levels. Qualitative interview data indicated that most parents reported positive experiences with receiving services during the Covid-19 pandemic and reported feeling supported even with social distancing measures. However, families also reported increased stress levels and isolation, particularly those who have children with Autism Spectrum Disorder, who rely on early funding (06 years) and early services. One of the themes that emerged from parents who were on the waitlist to receive an assessment was that wait times around assessments were very long, which contributed to parent stress levels. Parents also reported concerns around wait times to access services and difficulty of accessing online services due to internet and connection issues.

The current study identified central themes of stressors and barriers experienced by families and children with NDDs in service delivery. Overall, parents reported satisfaction in changes in service delivery in most ways; however, they also reported stresses and barriers that included wait times, increased isolation, and accessing online services. Actionable steps to reduce family stress include better communication between service providers and families for wait times, and more variability in appointment times. Specific recommendations for current and future pandemics will be expanded on in the poster.

This study seeks to describe the context and contents of YouTube videos featuring non-evidence-based practices (NEBPs) for autism spectrum disorder, including recent fad usage of transcranial magnetic stimulation.

A sample search of autism intervention-related YouTube videos was conducted to reflect the experience of caregivers researching autism intervention information on the internet. Exclusion criteria was applied to create a preliminary dataset. The videos were categorized into general evidence-based practice (EBP), non-evidence-based practice (NEBP), and both EBP and NEBP. The NEBP-related videos were then qualitatively described using a priori codes based on the literature regarding signs of pseudoscience, as well as an iteratively developed codebook through a constant comparative method between two independent coders.

Total videos from the YouTube search using the query "Autism Treatment" were capped at 150 videos. Total videos in English were 138. Total discrete videos (non-repeated) were 134. Total NEBP-related discrete videos were 62 (46% of final dataset); Total EBP-related videos were 38 (28.3% of final dataset); and total videos containing both EBP and NEBP as subject matter were 25 (18.6% of final dataset). Of the NEBP-related in the final dataset, the most frequent NEBP which occurred was stem cell therapy (n=26), followed by the Son-Rise program (n=13), Cannabis/marijuana (n=5), transcranial magnetic stimulation/magnetic e-resonance therapy (n=5), neurofeedback (n=1), brain rehabilitation (n=1), suramin (n=2), fecal transplants (n=2), Hyperbaric Oxygen therapy (n=1), Ayurvedic medicine (n=1), virtual reality (n=1), and others. The constant comparative method of coding yielded results specific to videos about NEBPs in autism, including: statements declaring a treatment will be effective, a banner on the YouTube page indicating if the channel is from a reputable source, a parent testimonial, a parent or caregiver display of emotion with respect to treatment efficacy, statements regarding pre-intervention repetitive or challenging behaviors, statements regarding demonstrated effects of the treatment, statements of a definitive cause of autism, statements regarding the severity of the autism in the treatment subject, specific words in reference to autism, including "disease", "toxin", or "inflammation", discussion of the financial aspect of the treatment, and videos with both high and low production values.

The likelihood of a caregiver encountering and watching videos containing NEBP-related material when using a general query to search the internet for information on autism intervention is high. Additionally, videos regarding NEBPs have more engagements (e.g., likes, comments, shares) than videos regarding EBPs, oftentimes by multitudes. The information contained within videos in which an NEBP is the subject aligns with pre-established warning signs for pseudoscience for autism interventions, however this study also contributes new warning signs through the construction of the iterative codebook. Specifically, statements about treatment efficacy in the absence of cited research, an emotional parent testimony about the individual with autism's experience with the NEBP therapy, statements regarding behavioral improvements linked to participation in the therapy oftentimes in the context of inflated claims, and clear and confident statements regarding the cause of autism with no cited research.

Relative to their typically developing peers, autistic individuals experience greater difficulties in domains of functioning that are relevant to learning and adult outcomes, such as sensory sensitivities, anxiety, and social. However, little is known about how difficulties in these domains relate to the receipt of special education services as well as adult outcomes, such as vocational achievement. The current study sought to fill this gap by examining if difficulties in various learning-related domains as ascertained via the Learning Needs Screening Tool (LNST) were associated with historical special education receipt and vocational status.

400 autistic adults, recruited via the Simons Powering Autism Research (SPARK) participant registry Research Match service, participated in this study (40.5% male, mean age=28.9 years). All participants completed the LNST, which collects responses to 13 core questions about learning (such as challenges with memorization, note taking, spelling and identifying arithmetic signs), as well as 7 additional questions with checkbox and free response options, and yields a total score from 0-30. LNST item 14 and its response options (1-9) capture suspected causes of learning difficulties (e.g., 'too much noise or activity bothers me,' 'I get nervous taking tests'). These individual questions as well as the total of endorsed learning related challenges were then evaluated in relation to historical special education receipt (“yes” vs. “no”) and vocational outcomes (“yes” vs. “no” engaging in 10+ hours of postsecondary education or employment without supports), as assessed via the Taylor Vocational Index.

Logistic regression was utilized to predict the dependent variables of interest. Models included sex assigned at birth and age in the first step as covariates. Then either the total of learning related challenges endorsed or the 9 individual learning-related challenges from the LNST were included as independent variables of interest. For historical special education receipt, two items - “It’s hard for me to work by myself” (B = .78, p<.05) and “I get nervous taking tests” (B = .49, p<.05) were positively associated with a history of special education services. For vocational outcomes, the total learning related challenges (B = -.25, p<.001) as well as endorsement of one item -“It’s hard for me to work by myself” (B = -.88, p=<.05) were associated with poorer vocational outcomes.

These findings shed light on the possible learning-related challenges that are experienced by autistic adults. Further examination of the role these learning related challenges play in the receipt of special education and on vocational outcomes is warranted. In particular, difficulties with independence in work was related to both special education receipt and poorer vocational outcomes, indicating that it may be a fruitful area of focus for vocational training programs.

Employment is crucial in the lives of adults with Autism Spectrum Disorder (ASD) as gainful occupational activity creates opportunities to form meaningful social relationships, participate in community life, and become financially independent. Impairments in pragmatic language skills (i.e., use of language to achieve social goals) negatively impact the ability to make and maintain cooperative work relationships with employers and coworkers, which are critical aspects of employment. A specific pragmatic skill key to workplace communication includes using a suitable degree of politeness, loosely defined as demonstrating the appreciation of the thoughts and feelings of your listener. Politeness can be measured with politeness markers (PMs). Appropriate PM use promotes positive, cooperative relationships. There are two main categories of PMs: positive and negative PMs. Positive PMs express appreciation or praise to the listener. Negative PMs avoid conflict and marks consideration of the thoughts and feelings of the listener. Crucially, negative PMs require more monitoring of social boundaries as they require consideration of the conversational partner’s potential reactions to statements and their emotional states. This makes PMs a novel new approach to evaluating speech in persons with ASD. Because PMs serve a purely social function in language, they include non-tangible words, such as would, could, may, or might. The current study explores the utility of an employment-specific social communication assessment tool, the Voicemail Elicitation Task (VET), in persons with ASD. The VET has proven sensitive to identifying social communication deficits in persons with traumatic brain injury.

The current cohort comparative study included a sample of young adults with ASD (n=22) and neurotypical controls (NTC; n=10). All participants were given the VET, which utilizes a standardized computerized language sampling procedure that assesses politeness markers (PMs) in work-related role-play scenarios. The outcome measure of the VET is PMs per minute (PMpM) which is obtained by dividing the sum of PMs by the speaking time (in minutes). Higher PMpM indicates higher PM use (more politeness), while lower PMpM indicates lower PM use (less politeness).

The preliminary results indicated a significantly lower total PMpM in ASD participants (mean: 13.68 SD: 6.28) compared to NTCs (mean 18.72, SD: 3.65), p = 0.026. Post hoc analysis indicated that the differences in groups were driven by significantly lower negative PMs rates used by the ASD group (mean 9.18, SD: 5.77) compared to NTCs (mean: 16.30, SD: 7.78), p = 0.002, while both groups were similar in their mean level of positive PMs use, p = 0.442.

This study represents an important step toward validating the VET for use in ASD, which will improve the capacity of the field to address unemployment in this population. The results of the current study indicate that individuals with ASD show deficits in PM use which could impact their interpersonal relationships within the workplace environment. Designing interventions to target these deficits could help provide better employment outcomes for this population.

Nearly 85% of adults on the autism spectrum are unemployed, although nearly 70% of those who are unemployed express a desire and willingness to work. The job interview has been identified as a significant obstacle to obtaining employment by young adults on the spectrum. A growing field of research has been focused on evaluating innovative training tools to improve interview skills. Our previous work shows that a virtual reality job interview training (VR-JIT) tool improves certain job interview skills (such as sounding professional, establishing rapport), but does not improve the ability to speak about personal strengths and abilities. The current study combined VR-JIT with a new training tool: Kessler Foundation Strength Identification and Expression (KF-STRIDE), an intervention grounded in principles of positive psychology. KF-STRIDE targets identification of personal character strengths and expressing those strengths to employers in a socially appropriate way.

The current study evaluated data from 20 autistic youth, randomized to an experimental group (n=10) and a services-as-usual (SAU) control group (n=10). Those in the experimental group participated in a 12 session intervention (9 sessions using VR-JIT and 3 sessions in KF-STRIDE). Each session was roughly one hour. Job interview performance was assessed by video-recorded mock job interviews rated by blinded assessors pre- and post- the intervention. Paired samples t-tests were conducted to examine differences in job interview skills from baseline to follow up in both groups.

The intervention group showed a significant improvement from baseline to follow-up in job interview skills in general (p = .004), and specifically sharing strengths about themselves to a future employer (p = .004). No significant differences were seen from baseline to follow-up in the SAU group. Conclusions: Individuals on the autism spectrum are significantly underemployed, which negatively impacts one’s ability to lead an independent life. Two innovative tools: VR-JIT and KF-STRIDE successfully improved job interview skills, including the ability to identify and express personal strengths. These findings indicate that these combined tools may help to improve employment skills for individuals on the autism spectrum.

Participation in sports likely confers multiple benefits for children and adolescents with autism spectrum disorder (ASD). Adolescent student athletes often undergo preseason testing as part of a broader concussion management program for schools. This study compares preseason neurocognitive functioning and symptom reporting between high school athletes with and without ASD.

Participants were derived from a database of 60,751 adolescent student athletes from Maine (aged 13-18) who completed preseason testing between 2009 and 2019 and did not have missing data on the history question relating to ASD. There were 425 students (0.7%) who self-reported having been diagnosed with ASD in their health history. Cognitive functioning was measured by ImPACT, and the Post-Concussion Symptom Scale (PCSS) was used to obtain symptom ratings. Group differences between the ASD and the population control group on the five ImPACT cognitive test composite raw scores and the total symptom score from the PCSS were examined using Mann-Whitney U tests.

Compared to the population control sample, those with ASD reported much greater rates of comorbid conditions: attention deficit/hyperactivity disorder (50.1% vs. 10.3%), special education (39.2% vs. 4.4%), learning disabilities (43.8% vs. 4.4%), and prior treatment for a psychiatric condition (23.4% vs. 7.5%). Groups differed significantly across all neurocognitive composites (p values <.002). However, all differences were negligible in terms of the magnitude of the effects (r values range from 0.01-0.03). The groups also differed significantly on the PCSS total symptom score (p<.001), but the magnitude of the difference was negligible (r=.031). Among boys, the ASD group endorsed 21 of the 22 symptoms at a greater rate. Among girls, the ASD group endorsed 11 of the 22 individual baseline symptoms at a greater rate than the control group. Examples of symptoms that were endorsed at a higher rate among both boys and girls with ASD: sensitivity to noise (girls: odds ratio, OR=4.38; boys: OR=4.99), numbness or tingling (girls: OR=3.67; boys: OR=3.25), difficulty remembering (girls: OR=2.01; boys: OR=2.49), difficulty concentrating (girls: OR=1.82; boys: OR=2.40), sleeping more than usual (girls: OR=1.94; boys: OR=1.97), sensitivity to light (girls: OR=1.82; boys: OR=1.76), sadness (girls: OR=1.72; boys: OR=2.56), nervousness (girls: OR=1.80; boys: OR=2.27), and feeling more emotional (girls: OR=1.79; boys: OR=2.84).

Students with ASD participating in organized sports are likely high functioning, on average. There were small differences in their cognitive test scores compared to the population control sample. They endorsed more symptoms, however, during baseline preseason testing. If they sustain a concussion, their clinical management should be more intensive to maximize the likelihood of swift and favorable recovery.

Individuals diagnosed with autism spectrum disorder (ASD) experience negative self-evaluation, indicated by low levels of self-esteem and describing themselves more negatively to others. Variations in reading comprehension, difficulty identifying emotions, and masking (camouflaging of autistic traits) make it difficult to accurately measure self-evaluation of individuals with ASD using subjective self-report scales such as the Rosenburg Self-Esteem Scale. Therefore, it is important to explore more objective methods of measuring self-evaluation in ASD. Sentiment analysis is a popular Natural Language Processing (NLP) technique used to quantify the emotional content of language programmatically by automatically transforming text into a data frame of words represented as individual values or tokens. Each token can then be categorized as positive or negative with a sentiment dictionary. The current study aims to investigate an automated sentiment analysis approach to evaluate self-evaluation by quantifying implicit linguistic affective valence of ASD participants' verbal self-describing statements in a naturalistic setting. Specifically, we evaluated the frequency of positive or negative words used during a mock job interview in which individuals with ASD were asked to describe themselves. We then examined the relationship between positive and negative word usage and standard self-report measures of self-evaluation.

Twenty-four young adults with ASD were included in this study with an age range of 15-24 and a mean age of 19.2 years. Participants completed a battery of assessments including a mock job interview in which they were asked to describe themselves as a measure of implicit self-esteem. Self-esteem and knowledge of personal strengths was assessed using the Rosenberg Self-Esteem Scale and Strengths Knowledge Scale, respectively. Interview transcripts were automatically transformed into word token data frames using the tidytext package in Rstudio. Frequencies of positive and negative words were calculated and their ratio to total word count was used to measure the implicit positivity and negativity of transcripts.

There was a significant negative correlation between the frequency of negative sentiment in transcripts and measure on the Rosenburg Self-Esteem Scale (r = -.376, p = .035) and the Strengths Knowledge Scale (r = -.387, p = .031) indicating that individuals with higher self-esteem and knowledge of their strengths used fewer negative words when talking during a mock interview.

While our results are preliminary, this pilot study represents the first to use automated sentiment analysis to study self-evaluation in individuals with ASD. The use of this technique on natural linguistic data collected through a mock job interview allows researchers to quantitatively analyze the emotionality of transcriptions and create insights that would otherwise be unavailable using more subjective qualitative techniques. Limited research into self-evaluation in this population has yielded inconsistent results, relying too heavily upon qualitative or self-report measures. The ability to programmatically quantify affective valence in transcripts is a time and cost-effective technique for improving validity of future measures of self-evaluation.

Children with Down syndrome (DS) show marked differences in their early development when compared to typically developing (TD) peers. Major domains of challenge include intellectual abilities, executive functioning, and structural language. Children with DS have a unique profile of strengths and weaknesses that must be considered when comparing them to TD children, especially in terms of Theory of Mind (ToM). ToM encompasses the developmental milestones reached early in childhood when children develop the ability to conceptualize and understand others' thoughts, emotions, perspectives, and intentions. In TD children, these abilities typically begin to mature around 4-6 years of age, while in children with DS, delays are observed relative to chronological age expectations. Evidence shows that children with DS have impaired ToM abilities; however, these deficits might be more related to underlying delays in structural language, rather than a fundamental misunderstanding of social cues. The present study seeks to fill gaps in the literature by using a nonverbal assessment (The Penny Hiding Game; PHG) to evaluate a) ToM abilities in children with DS relative to younger TD peers of a similar mental ability level and b) relationships between ToM performance and structural language skills.

25 children with DS (60% F, M=11.39 years) and 25 TD children (40% F, M = 5.37, range = 3 to 7) participated. Participants' structural language abilities were briefly assessed using the Wechsler Individual Achievement Test- III Listening Comprehension Test (Oral Discourse Comprehension subcomponent). ToM was assessed using the PHG.

Univariate analysis of covariance was used to explore differences in ToM performance between groups while controlling for mental ability level. Children with DS (M= 2.79, SD= 2.23) performed significantly worse than TD peers (M= 4.28, SD= 1.87) on the ToM task (F(1, 60)= 4.5, p= .038). Linear regression was used to assess associations between ToM and structural language abilities. When both groups were lumped together, there was a modest association between ToM and Listening Comprehension scores (R2 = .12, F (1, 55) = 7.29, p= .009). However, when groups were considered separately, significant associations were not observed (p>.1).

The DS group showed markedly diminished ToM performance compared to TD controls, as expected based on the literature. However, data did not suggest a clear association between ToM and structural language skills. While an association was observed when groups were lumped, this relationship was likely driven by group differences in both ToM and structural language skills. Future research should examine the relationship between ToM performance, different aspects of language functioning, and the cooccurrence of autistic traits among children with DS in order to augment our understanding of linguistic and social correlates of ToM performance in young children with DS.

22q11.2 Deletion Syndrome (22q11DS) is a multi-systemic disorder with great clinical heterogeneity. It is the most common microdeletion syndrome and one of the most common genetic causes of developmental delays (e.g., motor/speech). 22q11DS is estimated to occur between 1/2,000-4,000 live births. However, the diverse clinical presentation of 22q11DS and health inequities that impact ethnically, racially, linguistically, and economically marginalized groups, make early identification, diagnosis, and access to beneficial early interventions (e.g., speech/behavioral therapy) even more challenging. Therefore, 22q11DS’ true prevalence may be larger than documented. Challenges associated with diagnosis, as well as neurocognitive, psychiatric, and medical co-morbidities associated with 22q11DS have been reported to affect the quality of life and well-being of people living with 22q11DS and their families. Yet, there is limited longitudinal data on lifelong functional outcomes of this population and the social factors that may shape them. This study aimed to 1) review the extant literature on adaptive functioning across the lifespan in 22q11DS and 2) report on relevant social and structural variables considered in the literature to contextualize adaptive functioning.

A scoping review was conducted between January-June 2022 across six electronic databases: PubMed, Scopus, PsycINFO, Ovid MEDLINE, EBSCO, and Embase. The 'building block’ method was used to identify and design a comprehensive search strategy used to scan publications’ titles, keywords, and abstracts. Citation mining strategy was utilized to identify additional relevant studies. The following inclusion criteria was met: 1) empirical studies conducted in humans, 2) participants with confirmed diagnosis of 22q11DS, 3) evaluation of adaptive functioning, 4) use of at least one standardized measure of adaptive functioning and 5) written or translated into English or Spanish.

Eighty-four records were initially identified. After deduplication, abstract screening, and full record reviews, a total of twenty-two studies met inclusion criteria for this review. Only eight publications explored adaptive skills as one of their primary outcomes. Clinically significant symptoms of anxiety, withdrawal, anhedonia, and flat affect were associated with worse functional outcomes. Fifteen studies reported between one and three demographic variables (e.g., race/ethnicity, years of education), and only two studies documented mental health treatment status/history. Most studies reported lower adaptive abilities in participants with 22q11DS independent from their cognitive abilities, but the majority of participants scored between the below average range and exceptionally low range on measures of intellectual functioning. Nonetheless, information on contextual variables (e.g., educational/occupational opportunities) that may help to interpret these findings was lacking.

Methodological differences (e.g., definition and measurement of adaptive functioning), recruitment bias (small, clinic-based identified samples) and lack of information regarding contextual level factors, may be limiting our understanding of the neurocognitive and neuropsychiatric trajectories of people with 22q11DS. It is vital to increase representative samples in epidemiological/clinical studies, as well as research examining the social and structural factors (e.g., access to healthcare, socioeconomic position) that impact functional outcomes in this population to promote public health policies that can improve brain health across the lifespan.

Autism is a neurodevelopmental disorder characterized by impairments in social communication and the presence of restricted and repetitive behaviors (RRBs). Clinical diagnosis of autism is often complicated by heterogeneity in core autism traits and other individual characteristics (e.g., cognition). Previous literature suggests that degree of autism characteristics, cognitive ability, and age contribute to identifying homogenous subgroups of autism, which facilitates prognosis and treatment planning. The present study extends these findings by examining profiles of cognition, age, and autism characteristics (measured by the Autism Diagnostic Observation Schedule, Second Edition [ADOS-2]) in a clinical sample of school-aged children presenting with concern for possible autism. Profiles are also described according to whether children received an autism diagnosis and clinician ratings of emotional/behavioral problems, which have been shown to influence diagnostic clarity when assessing for autism.

We conducted a retrospective chart review of 188 children (68% male) ages 4-17 years (M=8.9) who were referred for an autism evaluation. Latent profile analysis was conducted using age, ADOS-2 Social Affect (SA) and RRB scores, and verbal and non-verbal intelligence quotients (VIQ/NVIQ). Model fit comparing 2, 3, 4, and 5-class models was assessed using log-likelihood, AIC, BIC, SABIC, entropy, and Lo, Mendell, and Rubin (LMR) and bootstrap likelihood ratio (BLRT) tests. The frequency of clinical autism diagnosis and ADOS-2 emotional/behavioral problems were calculated across profiles in the best-fitting model.

The 5-class model demonstrated the best fit. The following characteristics were observed across five profiles: 1) mean age = 9.5 years, Low Average VIQ/NVIQ, and low SA (M=5.2) and RRB (M=0.7) scores; 2) mean age = 7.3 years, Average VIQ/NVIQ, and low SA (M=3.1) and RRB (M=0.8) scores; 3) mean age = 10.1 years, Low Average VIQ/NVIQ, and high SA (M=11.3) and RRB (M=4.2) scores; 4) mean age = 8.8 years, Average VIQ/NVIQ, and moderately high SA (M=9.6) and RRB (M=3.4) scores; and 5) Exceptionally High VIQ, Above Average NVIQ, and comparatively mid-level SA (M=6.6) and RRB (M=3.6) scores. Autism diagnosis and emotional/behavioral problems varied across profiles. Profiles 1 and 2 contained lower diagnosis rates (33% and 10%, respectively). Profiles 3 and 4 contained the highest diagnosis rates (97% in both), followed by profile 5 (75%). In terms of emotional/behavioral problems, Profile 2 exhibited the highest overactivity (56%). Profile 3 demonstrated the highest rate of tantrums/disruptive behaviors (20%).

Findings revealed distinct profiles of IQ and autism characteristics within a clinical sample of school-aged children referred for possible autism. Children with the highest scoring ADOS profile were older compared to other profiles. Higher and lower scoring ADOS profiles exhibited both lower and higher IQ scores. Descriptive analyses suggested that the frequency of autism diagnosis was notably higher in moderate and high-scoring ADOS profiles; however, emotional/behavioral problems were salient in only one low and one high-scoring ADOS profile. The findings suggest that higher-scoring ADOS profiles consistently demonstrated high autism diagnosis rates but varied across IQ and behavioral problems. These results have implications for interpreting these characteristics during clinical autism diagnosis.