ABSTRACT
ImportanceHeterogeneous mental health outcomes during the COVID-19 pandemic are recognized in the general population, but it has not been systematically assessed in youth with neurodevelopmental disorders (NDD), including autism spectrum (ASD). ObjectiveIdentify subgroups of youth with ASD/NDD based on the pandemic impact on symptoms and service changes, as well as predictors of outcomes. Design, Setting, and ParticipantsThis is a naturalistic observational study conducted across 14 North American and European clinical and/or research sites. Parent responses on the Coronavirus Health and Impact Survey Initiative (CRISIS) adapted for Autism and Related Neurodevelopmental Conditions (AFAR) were cross-sectionally collected from April to October 2020. The sample included 1275, 5-21 year-old youth with ASD and/or NDD who were clinically well-characterized prior to the pandemic. Main Outcomes and MeasuresTo identify impact subgroups, hierarchical clustering analyzed eleven AFAR factors measuring pre- to pandemic changes in clinically relevant symptoms and service access. Random forest classification assessed the relative contribution in predicting subgroup membership of 20 features including socio-demographics, pre-pandemic service, and clinical severity along with indices of COVID-19 related experiences and environments empirically-derived from AFAR parent responses and global open sources. ResultsClustering analyses revealed four ASD/NDD impact subgroups. One subgroup - broad symptom worsening only (20% of the aggregate sample) - included youth with worsening symptoms that were above and beyond that of their ASD/NDD peers and with similar service disruptions as those in the aggregate average. The three other subgroups showed symptom changes similar to the aggregate average but differed in service access: primarily modified services (23%), primarily lost services (6%), and average services/symptom changes (53%). Pre-pandemic factors (e.g., number of services), pandemic environments and experiences (e.g., COVID-19 cases, related restrictions, COVID-19 Worries), and age emerged in unique combinations as distinct protective or risk factors for each subgroup. Together they highlighted the role of universal risk factors, such as risk perception, and the protective role of services before and during the pandemic, in middle childhood. Conclusions and RelevanceConcomitant assessment of changes in both symptoms and services access is critical to understand heterogeneous impact of the pandemic on ASD/NDD youth. It enabled the delineation of pathways to risk and resilience that include universal and ASD/NDD specific contributors.
ABSTRACT
The "hygiene hypothesis" describes a hypothetical scenario in which the balance between TH1 (defending host against bacterial and viral infections) and TH2 (defending against parasitic infections) immune responses is pivotal and in which the consequence of reducing the infectious stressors during infancy is increased autoimmunity (TH1-mediated) and allergy (TH2-mediated). Many epidemiological observations confirm that allergic and autoimmune diseases are significantly increased in the "developed" countries and negatively associated with childhood infections. However, it has been recently revealed that immune elements associated with allergy are extensively involved also in the pathogenesis of autoimmune demyelination and that TH2- and TH1-mediated infections ameliorate the course of the disease confirming that the allergic root is also responsible for the escalation of autoimmune disorders, and both have a common immunological denominator. In the Italian island of Sardinia, MS and type-I diabetes frequencies have sharply increased in the last decades compared to other populations living in the same Mediterranean area. Initial observation led us to believe that environmental changes favoured the MS risk rise, thus sustaining the hygiene hypothesis. However, data on MS prevalence distribution in this territory suggest that other mechanisms than environment have also to be taken into great account. Our recent epidemiological studies reveal significant differences in the MS prevalence between rural and urban areas within the same province of Sassari but, contrarily to what expected from the hygiene hypothesis, MS prevalence is significantly higher in rural, genetically "archaic", areas where the westernalization process has been less pronounced. On this basis we believe that, beside hygiene-related factors, genetics could represent a more relevant determinant of Sardinian high susceptibility to MS.
