First Symposium of the Evolutionary Psychiatry Special Interest Group of the Royal College of Psychiatrists, Oct 4th 2016 in London. Lecture by Professor Simon Baron-Cohen from Cambridge University Autism Research Centre.

The three factors have different weights, and jointly build up to the diagnosis of autism. CREDIT University of Gothenburg

The development of autism may now become easier to understand, thanks to an explanatory model presented in a thesis from University of Gothenburg, Sweden. This model provides new insights into how various risk factors give rise to autism and why there is such great variability between individuals.

Autism, a neurodevelopmental condition, affects how people perceive the world around them and how they interact and communicate with others. Among individuals with autism, there are major differences in terms of personal traits and manifestations alike. The disorder is therefore usually described as a spectrum, with numerous subtle variations.

The new explanatory model is theoretical but simultaneously practical in application, since its various components are measurable through, for example, questionnaires, genetic mapping, and psychological tests. The model describes various contributing factors and how they combine to prompt an autism diagnosis and cause other neurodevelopmental conditions.

Three contributing factors

The model links three contributing factors. Together, these result in a pattern of behavior that meets the criteria for an autism diagnosis:

1. Autistic personality — hereditary common genetic variants that give rise to an autistic personality.

2. Cognitive compensation — intelligence and executive functions, such as the capacity to learn, understand others, and adapt to social interactions.

1. Exposure to risk factors — for example, harmful genetic variants, infections, and other random events during gestation and early childhood that adversely affect cognitive ability.

“The autistic personality is associated with both strengths and difficulties in cognition but does not, as such, mean that diagnostic criteria are fulfilled. Still, exposure to risk factors that inhibit people’s cognitive ability may affect their capacity to tackle difficulties, which contributes to individuals being diagnosed with autism,” says Darko Sarovic, physician and postdoctoral researcher at Sahlgrenska Academy, University of Gothenburg, who wrote the thesis.

The model makes it clear that it is the many different risk factors combined that bring about the major differences among individuals on the spectrum. The various components of the model are supported by results from previous research.

Adaptive ability

High executive functioning skills may enable people to compensate for their impairment in such a way as to mitigate the symptoms, which reduces their risk of meeting the diagnostic criteria for autism. This may explain why, at group level, researchers observe a lower degree of intelligence among people diagnosed with autism, as well as other neurodevelopmental conditions. It also affords an understanding of why intellectual disability is more common among these groups. Thus, the model indicates that low cognitive ability is not part of the autistic personality but, rather, a risk factor that leads to diagnostic criteria being met.

“The autistic personality is associated with various strengths. For example, parents of children with autism are overrepresented among engineers and mathematicians. The parents themselves have probably been able to compensate for their own autistic personality traits and thus not met the criteria for an autism diagnosis. The impact of the disorder has then become more noticeable in their children owing, for instance, to an exposure to risk factors and relatively low cognitive ability,” Sarovic says.

Difference between girls and boys

The diagnosis of autism is more common among boys than girls, and girls often get their diagnosis later in life. Some girls reach adulthood before being diagnosed, after many years of diffuse personal difficulties.

“Girls’ symptoms are often less evident to other people. It’s well known that girls generally have more advanced social skills, which probably means that they’re better at compensating for their own difficulties. Girls also tend to have fewer autistic traits and be less susceptible to the effects of risk factors. Accordingly, the model can help to answer questions about the gender gap,” Sarovic says.

Research and diagnostics

The model also proposes ways of estimating and measuring the three factors (autistic personality, cognitive compensation and exposure to risk factors). This makes it possible to use the model in the planning of research studies and interpretation of their results.

Diagnostics is another conceivable area of ​​use. In a pilot study in which 24 participants had been diagnosed with autism and 22 controls had not, measuring the three factors of the model enabled more than 93 percent to be correctly assigned to the right category. The model can also be used to explain the inception of other neurodevelopmental disorders, such as schizophrenia.

Every day across America, hundreds of children and teens with depression, anxiety, autism and other conditions end up in their local hospital’s emergency department because of a mental or behavioral health crisis.

And 12 hours later, 1 in 5 of them will still be in the ED, a study finds.

Another 12 hours after that – a full day after they arrived – 1 in 13 of them will still be in the ED. More than 60% of these patients are suicidal or have engaged in self-harm.

Meanwhile, virtually all the children who went to the same hospital for non-mental health emergencies have already received treatment and gone home, or been admitted to the hospital, within 12 hours, the study shows.

Visits of both kinds dropped dramatically in spring 2020, and even a year and a half later, non-mental health emergency visits by kids were still below pre-pandemic levels. But mental health emergency visits climbed steadily. By early 2021 they had exceeded their pre-pandemic levels and stayed there, with seasonal variation.

The study, published in the Journal of the American College of Emergency Physicians Open by a team led by an emergency physician from the University of Michigan and VA Ann Arbor Healthcare System, adds more evidence of the strain faced by the pediatric mental health system. It builds on previously reported data from large teaching hospitals and children’s hospitals.

“Insufficient access to mental health care stands out among the factors that contribute to prolonged stays in the nation’s emergency departments,” said first author Alex Janke, M.D., M.H.S., a National Clinician Scholar at VAAHS and the U-M Institute for Healthcare Policy and Innovation. “There are too few options outside of emergency care for patients in many communities.”

About 1 in 8 children who go to a community hospital for a mental health emergency end up getting admitted for at least one night or transferred to another hospital, the study finds. That number rose beyond pre-pandemic numbers by early 2021 and has stayed high ever since. Meanwhile, children’s admissions and transfers for other types of emergencies have stayed flat.

Because the hospitals in the study are not part of major academic systems, they likely do not always have child psychiatrists or other specialists in-house to work with emergency medicine teams in assessing and creating treatment plans for children in mental health crisis.

Janke and his colleagues from Yale University, the American College of Emergency Physicians and Columbia University used data from the Clinical Emergency Data Registry, with data from 107 community hospitals from January 2020 to December 2021, plus data from 2019 from 33 of those hospitals.

The majority of emergency department visits by children and teens in the United States happen in such hospitals, Janke notes. More resources that could help families get care in the local community or via telehealth could reduce the need to seek emergency care for their child, he says. Also needed are more resources to support local emergency medicine teams who find themselves caring for a child or teen in mental health crisis.

“While others are studying the epidemiology of mental health concerns among American’s youth at this point in the pandemic, our study focuses on whether the mental health system is ready for what’s coming in the door,” he said. “And the length of emergency department stays that we’re seeing here shows that it is not.”

The data source does not contain information about individual characteristics of the patients seeking care, such as what kinds of mental health care they’ve received, their demographic information, or what caused their families to seek emergency mental health care.

Janke and colleagues are working on further research on this topic. But the study does show that hospitals in the northeastern part of the country were most likely to have longer ED stays than other regions, especially the south and west.

The study does not measure “boarding” times, which is the time between an emergency care clinician’s decision to admit a patient to the time that patient actually leaves the ED for a bed in that hospital or another facility. But in a paper published earlier this year, Janke and colleagues showed that by the end of 2021, median boarding times for adult emergency patients were approaching the nationally recommended level of 3.4 hours.

If you, your child or someone you know is having a mental health crisis or considering suicide, contact the national 988 Suicide and Crisis Lifeline by calling or texting 988, or visiting 988lifeline.org for crisis chat services or for more information.