Persons with and without autism process sensory information differently. Differences in sensory processing are directly relevant to social functioning and communicative abilities, which are known to be hampered in persons with autism. We collected functional magnetic resonance imaging data from 25 autistic individuals and 25 neurotypical individuals while they performed a silent gesture recognition task. We exploited brain network topology, a holistic quantification of how networks within the brain are organized to provide new insights into how visual communicative signals are processed in autistic and neurotypical individuals. Performing graph theoretical analysis, we calculated two network properties of the action observation network: ‘local efficiency’, as a measure of network segregation, and ‘global efficiency’, as a measure of network integration. We found that persons with autism and neurotypical persons differ in how the action observation network is organized. Persons with autism utilize a more clustered, local-processing-oriented network configuration (i.e. higher local efficiency) rather than the more integrative network organization seen in neurotypicals (i.e. higher global efficiency). These results shed new light on the complex interplay between social and sensory processing in autism.

The actions and feelings questionnaire (AFQ) provides a short, self-report measure of how well someone uses and understands visual communicative signals such as gestures. The objective of this study was to translate and cross-culturally adapt the AFQ into Dutch (AFQ-NL) and validate this new version in neurotypical and autistic populations. Translation and adaptation of the AFQ consisted of forward translation, synthesis, back translation, and expert review. In order to validate the AFQ-NL, we assessed convergent and divergent validity. We additionally assessed internal consistency using Cronbach's alpha. Validation and reliability outcomes were all satisfactory. The AFQ-NL is a valid adaptation that can be used for both autistic and neurotypical populations in the Netherlands.

Heightened attention towards negative information is characteristic of depression. Evidence is emerging for a negative attentional bias in Autism spectrum disorder (ASD), perhaps driven by the high comorbidity between ASD and depression. We investigated whether ASD is characterised by a negative attentional bias and whether this can be explained by comorbid (sub) clinical depression. Participants ( n = 116) with current (CD) or remitted depression (RD) and/or ASD, and 64 controls viewed positively and negatively valenced (non-)social pictures. Groups were compared on three components of visual attention using linear mixed models. Both CD individuals with and without ASD, but not remitted depressed and never-depressed ASD individuals showed a negative bias, suggesting that negative attentional bias might be a depressive state-specific marker for depression in ASD.

In human communication, social intentions and meaning are often revealed in the way we move. In this study, we investigate the flexibility of human communication in terms of kinematic modulation in a clinical population, namely, autistic individuals. The aim of this study was twofold: to assess (a) whether communicatively relevant kinematic features of gestures differ between autistic and neurotypical individuals, and (b) if autistic individuals use communicative kinematic modulation to support gesture recognition. We tested autistic and neurotypical individuals on a silent gesture production task and a gesture comprehension task. We measured movement during the gesture production task using a Kinect motion tracking device in order to determine if autistic individuals differed from neurotypical individuals in their gesture kinematics. For the gesture comprehension task, we assessed whether autistic individuals used communicatively relevant kinematic cues to support recognition. This was done by using stick-light figures as stimuli and testing for a correlation between the kinematics of these videos and recognition performance. We found that (a) silent gestures produced by autistic and neurotypical individuals differ in communicatively relevant kinematic features, such as the number of meaningful holds between movements, and (b) while autistic individuals are overall unimpaired at recognizing gestures, they processed repetition and complexity, measured as the amount of submovements perceived, differently than neurotypicals do. These findings highlight how subtle aspects of neurotypical behavior can be experienced differently by autistic individuals. They further demonstrate the relationship between movement kinematics and social interaction in high-functioning autistic individuals. LAY SUMMARY: Hand gestures are an important part of how we communicate, and the way that we move when gesturing can influence how easy a gesture is to understand. We studied how autistic and typical individuals produce and recognize hand gestures, and how this relates to movement characteristics. We found that autistic individuals moved differently when gesturing compared to typical individuals. In addition, while autistic individuals were not worse at recognizing gestures, they differed from typical individuals in how they interpreted certain movement characteristics.

Background: Cognitive theories of major depressive disorder (MDD) assume that cognitive biases engender and maintain depressive symptoms. Given the higher prevalence of MDD in autism spectrum disorders (ASD) than in the general population, we performed a structured review of the empirical literature on cognitive biases in ASD to examine the possible role of biases in the increased cognitive vulnerability for MDD. Method: We reviewed the recent literature on cognitive biases in individuals with ASD. Literature searches were conducted by using the databases PubMed and PsycInfo consistent with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. The 31 identified studies meeting our inclusion criteria were evaluated for quality using a modified version of the Systematic Assessment of Quality in Observational Research (SAQOR) rating system. Results: The results show that half of the studies included did not find differences in cognitive biases in individuals with ASD compared to controls. In the studies that did establish differences in cognitive bias, individuals with ASD were reported to show less pronounced negative biases. A closer inspection reveals that Theory of Mind demands of the task and developmental age might partially have influenced these results. Importantly, most of the studies included did not control for symptoms of depression and/or anxiety. Conclusions: Although, based on the current literature, differential cognitive biases may not be a marker for MDD in ASD, more research is needed taking specific potential confounders, and distorting influences into account.

Objective: Symptoms of ADHD are expected to be more difficult to treat in patients with a combination of ADHD and autism spectrum disorder (ASD) as opposed to only ADHD. Little evidence is available on the influence of ASD on the effects of pharmacotherapy in adults with ADHD. This study addresses this gap. Method: 60 adults with ADHD and comorbid ASD were selected from an outpatient clinic and compared with 226 adults from the same clinic with only ADHD. Similar treatment regimens were received. Results: Significant decreases in symptoms of ADHD were found in both groups. A diagnosis of ASD did not affect the reduction in symptoms of ADHD. No significant group differences in side effects or vital signs were found. Conclusion: Results show that medication for ADHD can effectively and safely be prescribed to patients with ADHD and comorbid ASD. Suggestions for future research are discussed.

ADHD has a considerable economic impact. The aim of this study is to conduct a trial-based economic evaluation of mindfulness-based cognitive therapy (MBCT) added to treatment as usual (TAU) versus TAU in adults with ADHD.

Background. There is a high need for evidence-based psychosocial treatments for adult attention-deficit hyperactivity disorder (ADHD) to offer alongside treatment as usual (TAU). Mindfulness-based cognitive therapy (MBCT) is a promising psychosocial treatment. This trial investigated the efficacy of MBCT + TAU v. TAU in reducing core symptoms in adults with ADHD. Methods. A multicentre, single-blind, randomised controlled trial (ClinicalTrials.gov: NCT02463396). Participants were randomly assigned to MBCT + TAU (n = 60), an 8-weekly group therapy including meditation exercises, psychoeducation and group discussions, or TAU only (n = 60), which reflected usual treatment in the Netherlands and included pharmacotherapy and/or psychoeducation. Primary outcome was ADHD symptoms rated by blinded clinicians. Secondary outcomes included self-reported ADHD symptoms, executive functioning, mindfulness skills, self-compassion, positive mental health and general functioning. Outcomes were assessed at baseline, post-treatment, 3and 6-month follow-up. Post-treatment effects at group and individual level, and follow-up effects were examined. Results. In MBCT + TAU patients, a significant reduction of clinician-rated ADHD symptoms was found at post-treatment [M difference =−3.44 (−5.75, −1.11), p = 0.004, d = 0.41]. This effect was maintained until 6-month follow-up. More MBCT + TAU (27%) than TAU participants (4%) showed a ⩽30% reduction of ADHD symptoms ( p = 0.001). MBCT + TAU patients compared with TAU patients also reported significant improvements in ADHD symptoms, mindfulness skills, self-compassion and positive mental health at post-treatment, which were maintained until 6-month follow-up. Although patients in MBCT + TAU compared with TAU reported no improvement in executive functioning at post-treatment, they did report improvement at 6-month follow-up. Conclusions. MBCT might be a valuable treatment option alongside TAU for adult ADHD aimed at alleviating symptoms. Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that can persist into adulthood and has an estimated prevalence of 2.5% at adult age (Simon et al. 2009). In several European countries and the United States, pharmacotherapy with stimulant medication is suggested as first-line treatment for adult ADHD (NICE, 2009; Kooij et al. 2010; UMHS, 2013). In the Netherlands, stimulant medication is often combined with psychoeducation and skills training after or parallel to pharmacotherapy (NVvP, 2015). Despite the demonstrated efficacy of stimulants in the short term (Faraone & Glatt, 2010; Moriyama et al. 2013), there is a call for evidence-based psychosocial treatments to offer in addition or as an alternative to pharmacotherapy (Matheson et al. 2013). Several patients experience adverse effects that can result in discontinuation (Gajria et al. 2014), some patients are reluctant to take medication (Matheson et al. 2013), or respond insufficiently to stimulants and experience residual symptoms (Wigal, 2009) and long-term beneficial effects have not been convincingly established (Moriyama et al. 2013). Consequently, the NICE guidelines (NICE, 2009) and the European consensus statement (Kooij et al. 2010) emphasise that pharmacotherapy should be part of a multimodal treatment approach. A growing amount of evidence is showing that psychosocial treatments, like cognitive–behavioural therapy (CBT), can have an additional effect to pharmacotherapy in alleviating residual symptoms in adults with ADHD (Young et al. 2016), although a recent study did not find a difference between a group psychotherapy programme, including cognitive–behavioural elements and clinical management (Philipsen et al. 2015). Upcoming psychosocial treatments for ADHD are mindfulness-based interventions (MBIs). Mindfulness is defined as intentionally paying attention to present moment experiences in a non-judgemental way (Kabat-Zinn, 1990). Neuroscientific studies showed that in healthy subjects, MBIs can result in improved attention regulation, enhanced brain activity and altered attention-related brain areas such as greater cortical thickness and enhanced white-matter integrity in the anterior cingulated cortex (Fox et al. 2014; Tang et al. 2015). Bachmann et al. (2016) suggested that mindfulness meditation can strengthen functioning in brain regions that underlie neuropsychological deficits in ADHD, positioning MBI as a promising treatment for ADHD. Currently, the evidence for MBIs for ADHD is growing and a first meta-analysis including three studies in adults demonstrated preliminary evidence for the efficacy of MBIs in reducing core symptoms, especially inattentiveness, with moderate-to-large effect sizes (Cairncross & Miller, 2016). However, these findings should be interpreted with caution, as the included studies either lacked randomisation (Edel et al. 2017), were underpowered (Schoenberg et al. 2014; Mitchell et al. 2017), used different MBIs (Schoenberg et al. 2014; Edel et al. 2017; Mitchell et al. 2017) and/or lacked a follow-up period (Schoenberg et al. 2014; Edel et al. 2017; Mitchell et al. 2017). Mindfulness-based cognitive therapy (MBCT) combines mindfulness practice with elements of CBT (Segal et al. 2012). We previously reported moderate-to-large efficacy of a 12-weekly adapted version of MBCT in reducing ADHD symptoms and improving executive functioning in comparison to a waitlist control group (Hepark et al. 2015). These results were in line with a recent randomised controlled trial (RCT) in college students with ADHD that found a reduction of ADHD symptoms after an adapted 6 weeks version of MBCT. However, both studies had methodological limitations, such as a small sample size (Gu et al. 2018), the lack of a follow-up period, no outcome data for drop-outs and single-centre enrolment (Hepark et al. 2015). Therefore, the current RCT took account of these limitations. Themain aim of our RCTwas to examine the efficacy of MBCT added to treatment as usual (TAU) compared with TAU alone in reducing core symptoms as rated by a clinician in adults with ADHD. Secondary outcomes included selfreported ADHD symptoms, executive functioning, mindfulness skills, self-compassion, positive mental health and general functioning.

Primary caregivers experience consequences from being in close contact to a person with autism spectrum disorder (ASD). This study used the Involvement Evaluation Questionnaire to explore the level of consequences of 104 caregivers involved with adults with High Functioning ASD (HF-ASD) and compared these with the consequences reported by caregivers of patients suffering from depression and schizophrenia. Caregivers involved with adults with an HF-ASD experience overall consequences comparable to those involved with patients with depression or schizophrenia. Worrying was the most reported consequence. More tension was experienced by the caregivers of ASD patients, especially by spouses. More care and attention for spouses of adults with an HF-ASD appears to be needed.

Abstract Background There is a high need for evidence-based psychosocial treatments for adult attention-deficit hyperactivity disorder (ADHD) to offer alongside treatment as usual (TAU). Mindfulness-based cognitive therapy (MBCT) is a promising psychosocial treatment. This trial investigated the efficacy of MBCT + TAU v. TAU in reducing core symptoms in adults with ADHD. Methods A multicentre, single-blind, randomised controlled trial (ClinicalTrials.gov: NCT02463396). Participants were randomly assigned to MBCT + TAU (n = 60), an 8-weekly group therapy including meditation exercises, psychoeducation and group discussions, or TAU only (n = 60), which reflected usual treatment in the Netherlands and included pharmacotherapy and/or psychoeducation. Primary outcome was ADHD symptoms rated by blinded clinicians. Secondary outcomes included self-reported ADHD symptoms, executive functioning, mindfulness skills, self-compassion, positive mental health and general functioning. Outcomes were assessed at baseline, post-treatment, 3- and 6-month follow-up. Post-treatment effects at group and individual level, and follow-up effects were examined. Results In MBCT + TAU patients, a significant reduction of clinician-rated ADHD symptoms was found at post-treatment [M difference = −3.44 (−5.75, −1.11), p = 0.004, d = 0.41]. This effect was maintained until 6-month follow-up. More MBCT + TAU (27%) than TAU participants (4%) showed a ⩽30% reduction of ADHD symptoms (p = 0.001). MBCT + TAU patients compared with TAU patients also reported significant improvements in ADHD symptoms, mindfulness skills, self-compassion and positive mental health at post-treatment, which were maintained until 6-month follow-up. Although patients in MBCT + TAU compared with TAU reported no improvement in executive functioning at post-treatment, they did report improvement at 6-month follow-up. Conclusions MBCT might be a valuable treatment option alongside TAU for adult ADHD aimed at alleviating symptoms.

Attention Deficit Hyperactivity Disorder (ADHD) is characterized by poor cognitive control/attention and hypofunctioning of the dorsal anterior cingulate cortex (dACC). In the current study, we investigated for the first time whether real-time fMRI neurofeedback (rt-fMRI) training targeted at increasing activation levels within dACC in adults with ADHD leads to a reduction of clinical symptoms and improved cognitive functioning. An exploratory randomized controlled treatment study with blinding of the participants was conducted. Participants with ADHD (n = 7 in the neurofeedback group, and n = 6 in the control group) attended four weekly MRI training sessions (60-min training time/session), during which they performed a mental calculation task at varying levels of difficulty, in order to learn how to up-regulate dACC activation. Only neurofeedback participants received continuous feedback information on actual brain activation levels within dACC. Before and after the training, ADHD symptoms and relevant cognitive functioning was assessed. Results showed that both groups achieved a significant increase in dACC activation levels over sessions. While there was no significant difference between the neurofeedback and control group in clinical outcome, neurofeedback participants showed stronger improvement on cognitive functioning. The current study demonstrates the general feasibility of the suggested rt-fMRI neurofeedback training approach as a potential novel treatment option for ADHD patients. Due to the study's small sample size, potential clinical benefits need to be further investigated in future studies.TRIAL REGISTRATION:ISRCTN12390961.

Deficits in multiple neuropsychological domains and specific personality profiles have been observed in attention-deficit/hyperactivity disorder (ADHD). In this study we investigated whether personality traits are related to neurocognitive profiles in adults with ADHD. Neuropsychological performance and Five Factor Model (FFM) personality traits were measured in adults with ADHD (n = 133) and healthy controls (n = 132). Three neuropsychological profiles, derived from previous community detection analyses, were investigated for personality trait differences. Irrespective of cognitive profile, participants with ADHD showed significantly higher Neuroticism and lower Extraversion, Agreeableness, and Conscientiousness than healthy controls. Only the FFM personality factor Openness differed significantly between the three profiles. Higher Openness was more common in those with aberrant attention and inhibition than those with increased delay discounting and atypical working memory / verbal fluency. The results suggest that the personality trait Openness, but not any other FFM factor, is linked to neurocognitive profiles in ADHD. ADHD symptoms rather than profiles of cognitive impairment have associations with personality traits.

Atomoxetine treatment is associated with improvements in functional outcomes in patients with attention-deficit/hyperactivity disorder (ADHD), although relationships between improvements in these outcomes and reductions in ADHD symptoms have not been comprehensively investigated in adults.

The aim of this study was to develop and validate the Adult Social Behavior Questionnaire (ASBQ), a multidimensional Autism Spectrum Disorder (ASD) questionnaire that contains both a self report version and a version to be completed by someone close. Psychometric qualities, convergence between self report and other report ratings, and scores in a group diagnosed with ASD and multiple comparison groups were examined.Principal Component Analyses yielded a structure with six dimensions (reduced contact, reduced empathy, reduced interpersonal insight, violation of social conventions, insistence on sameness, and sensory stimulation/motor stereotypies) for both self- and other-report versions. Reliability estimates and correlations between self- and other-ratings were good and the score profile on the 44-item ASBQ differentiated a group with ASD from a non-clinical group and patients with depression, schizophrenia and ADHD.We conclude that the ASBQ is a short and easy to apply questionnaire that captures the heterogeneous nature of ASD. It yields a score profile among six ASD problem domains both from the perspective of the patient and from a significant other.

Attention-deficit/hyperactivity disorder (ADHD) is a common childhood psychiatric disorder that often persists into adulthood. While several studies have identified altered functional connectivity in brain networks during rest in children with ADHD, few studies have been performed on adults with ADHD. Existing studies have generally investigated small samples. We therefore investigated aberrant functional connectivity in a large sample of adult patients with childhood-onset ADHD, using a data-driven, whole-brain approach. Adults with a clinical ADHD diagnosis (N = 99) and healthy, adult comparison subjects (N = 113) underwent a 9-minute resting-state fMRI session in a 1.5 T MRI scanner. After elaborate preprocessing including a thorough head-motion correction procedure, group independent component analysis (ICA) was applied from which we identified six networks of interest: cerebellum, executive control, left and right frontoparietal and two default-mode networks. Participant-level network maps were obtained using dual-regression and tested for differences between patients with ADHD and controls using permutation testing. Patients showed significantly stronger connectivity in the anterior cingulate gyrus of the executive control network. Trends were also observed for stronger connectivity in the cerebellum network in ADHD patients compared to controls. However, there was considerable overlap in connectivity values between patients and controls, leading to relatively low effect sizes despite the large sample size. These effect sizes were slightly larger when testing for correlations between hyperactivity/impulsivity symptoms and connectivity strength in the executive control and cerebellum networks. This study provides important insights for studies on the neurobiology of adult ADHD; it shows that resting-state functional connectivity differences between adult patients and controls exist, but have smaller effect sizes than existing literature suggested.

The dopamine transporter gene, DAT1 (SLC6A3), has been studied extensively as a candidate gene for attention-deficit/hyperactivity disorder (ADHD). Different alleles of variable number of tandem repeats (VNTRs) in this gene have been associated with childhood ADHD (10/10 genotype and haplotype 10-6) and adult ADHD (haplotype 9-6). This suggests a differential association depending on age, and a role of DAT1 in modulating the ADHD phenotype over the lifespan. The DAT1 gene may mediate susceptibility to ADHD through effects on striatal volumes, where it is most highly expressed. In an attempt to clarify its mode of action, we examined the effect of three DAT1 alleles (10/10 genotype, and the haplotypes 10-6 and 9-6) on bilateral striatal volumes (nucleus accumbens, caudate nucleus, and putamen) derived from structural magnetic resonance imaging scans using automated tissue segmentation. Analyses were performed separately in three cohorts with cross-sectional MRI data, a childhood/adolescent sample (NeuroIMAGE, 301 patients with ADHD and 186 healthy participants) and two adult samples (IMpACT, 118 patients with ADHD and 111 healthy participants; BIG, 1718 healthy participants). Regression analyses revealed that in the IMpACT cohort, and not in the other cohorts, carriers of the DAT1 adult ADHD risk haplotype 9-6 had 5.9 % larger striatum volume relative to participants not carrying this haplotype. This effect varied by diagnostic status, with the risk haplotype affecting striatal volumes only in patients with ADHD. An explorative analysis in the cohorts combined (N = 2434) showed a significant gene-by-diagnosis-by-age interaction suggesting that carriership of the 9-6 haplotype predisposes to a slower age-related decay of striatal volume specific to the patient group. This study emphasizes the need of a lifespan approach in genetic studies of ADHD.

Objective: To assess the burden of illness and health care resource utilization of adult nonpsychotic psychiatric outpatients with attention-deficit/hyperactivity disorder (ADHD) in Europe.Methods: This was a multicountry, cross-sectional, observational study where unselected routine patients from clinical psychiatric outpatient settings were screened and assessed for ADHD. Patients were evaluated using the Clinical Global Impressions of Severity (CGI-S) scale, the Sheehan Disability Scale (SDS), and the EuroQol-5 Dimensions questionnaire. Data on comorbidities, functional impairment, and health care resource utilization were captured.Results: The study enrolled 2284 patients, of whom 1986 completed the study. The prevalence of ADHD was 17.4%, of whom 46.0% had a previous ADHD diagnosis. Patients with ADHD had a high clinical burden with psychiatric comorbidities, especially depression (43.0%) and anxiety disorders (36.4%). Substance abuse (9.2% vs. 3.4%) and alcohol abuse (10.3% vs. 5.2%) were more common in the ADHD cohort vs. the non-ADHD cohort. Only 11.5% of the patients with ADHD had no other psychiatric disorder. Various measures indicated a significantly poorer level of functioning for patients with ADHD than without ADHD, as indicated by higher scores for CGI-S (3.8 vs. 3.3) and SDS (18.9 vs. 11.6) and higher percentages of debt (35.5% vs. 243%) and criminality (13.8% vs. 6.1%). Lastly, the health care resource utilization was considerable and similar between adult psychiatric outpatients diagnosed and not diagnosed with ADHD.Conclusions: Although care was taken when choosing the sites for this study, to make it representative of the general outpatient adult psychiatric population, caution should be advised in generalizing the findings of our study to the general ADHD or psychiatric outpatient population. This was an observational study, thus no inference on causality can be drawn. Having ADHD imposes a considerable health and social burden on patient and health care resource utilization comparable to other chronic psychiatric disorders.