UNIVERSIDADE FEDERAL DE MINAS GERAIS

Faculdade de Medicina
Programa de Pós-graduação em Medicina Molecular

Ana Luíza Costa Alves

FUNCIONALIDADE EM ADULTOS COM TRANSTORNO DO ESPECTRO AUTISTA:

relações entre traços autísticos, variáveis psicossociais e funcionamento cognitivo

Belo Horizonte
2019
 Ana Luíza Costa Alves

FUNCIONALIDADE EM ADULTOS COM TRANSTORNO DO ESPECTRO AUTISTA:

relações entre traços autísticos, variáveis psicossociais e funcionamento cognitivo

Versão final

Dissertação apresentada ao Programa de Pós-

Graduação em Medicina Molecular da
Universidade Federal de Minas Gerais, como
requisito parcial à obtenção do título de Mestre
em Medicina Molecular.

Orientador(a): Prof. Dr. Marco Aurélio

Romano-Silva
Co-orientador: Prof. Dr. Jonas Jardim de Paula

Belo Horizonte
2019
 Alves, Ana Luíza Costa.

AL474f Funcionalidade em adultos com transtorno do espectro autista [manuscrito]: relações

entre traços autísticos, variáveis psicossociais e funcionamento cognitivo. / Ana
Luíza Costa Alves. - - Belo Horizonte: 2019.
60f.
Orientador (a): Marco Aurélio Romano-Silva.
Coorientador (a): Jonas Jardim de Paula.
Área de concentração: Medicina Molecular.
Dissertação (mestrado): Universidade Federal de Minas Gerais, Faculdade de
Medicina.

1. Transtorno Autístico. 2. Cognição. 3. Psicologia. 4. Impacto Psicossocial. 5.

Dissertação Acadêmica. I. Romano-Silva, Marco Aurélio. II. Paula, Jonas Jardim de.
III. Universidade Federal de Minas Gerais, Faculdade de Medicina. IV. Título.

NLM: WM 203.5

Bibliotecário responsável: Fabian Rodrigo dos Santos CRB-6/2697

 AGRADECIMENTOS

Agradeço a minha família, em especial minha mãe e tia Jacira, por todo o suporte, pelos
conselhos e por sempre acreditarem que sou capaz de alcançar tudo aquilo que eu desejo,
mesmo quando eu não acredito. Aos meus irmãos, Elias e Lucas, meu padrasto, Evelen e
Rodriguinho. Obrigada por todo o amor.

Aos meus amigos queridos: Amanda, Daniel, Gabi, Lo e Thaty. Vocês sempre me
incentivaram, me impulsionaram e me acolheram. Muito obrigada pela companhia ao longo
desse caminho! Ao Gabriel, por todo amor, companheirismo e paciência. Você esteve
totalmente presente do primeiro dia até aqui. Obrigada por tanto.

À Júlia, por todas as conversas e encontros que sempre me renovavam de alguma forma.
À Eduarda, pela escuta atenta, por me ensinar o valor do autocuidado e por me ajudar a viver
uma vida cada vez mais cheia de sentido.

Agradeço às amigas de longa data: Anna, Giane, Letícia, Lívia e Nathi. Mesmo com a
distância e na correria do dia a dia, sempre tive a certeza de que vocês estavam ao meu lado. À
Bela, por todos os conselhos acadêmicos e profissionais, sigo tendo você como exemplo.

Ao meu coorientador Jonas, obrigada por desde o início disponibilizar tempo, paciência
e por acreditar no meu trabalho. Você me mostrou que fazer ciência pode ser leve, instigante e
até divertido. Nenhuma parte desse projeto teria ido adiante sem a sua orientação!
Ao meu orientador Marco Aurélio, que mesmo sem muito me conhecer no início,
acreditou no meu potencial e aceitou me orientar. Obrigada por ter aberto essa porta, por ter
possibilitado esse caminho e por ter sido disponível sempre que eu precisei. Muito obrigada!

Aos alunos de iniciação científica, Karla e Péricles, vocês podem ter aprendido, mas me
ensinaram muito mais, e eu agradeço pela paciência e confiança.

Aos voluntários dessa pesquisa: Vocês são essenciais para que estudos como esse aconteçam!

E agradeço a Deus, por ter me renovado diariamente, pelo privilégio de poder viver tudo
isso e por ter colocado pessoas tão especiais no meu caminho.

Obrigada!
 RESUMO

Pessoas com o diagnóstico de Transtorno do Espectro Autista (TEA) apresentam dificuldades

em relação a interação social e inflexibilidade comportamental, manifestos por prejuízos na
compreensão social, comunicação e presença de comportamentos que podem ser restritos,
repetitivos e/ou estereotipados. A presença desses traços varia em quantidade e intensidade,
sendo assim, atualmente entende-se o transtorno dentro de uma visão dimensional. Portanto, é
possível encontrar pessoas com autismo que apresentem sintomas severos e por isso necessitam
de muito suporte, bem como pessoas que manifestam traços mais leves e consequentemente,
menos prejuízos. Estas pessoas, consideradas pelo DSM-5 como autistas “nível 1”, foram o
foco do presente estudo. Tivemos como objetivos: 1) realizar análise descritiva da Escala
Quociente do Espectro do Autismo em uma amostra heterogênea brasileira, trata-se de uma
escala que visa auxiliar o diagnóstico de casos com sintomatologia branda e 2) verificar sua
precisão no diagnóstico de adultos; 3) caracterizar o perfil neurocognitivo de adultos com
diagnóstico de TEA e com alto funcionamento; 4) além do perfil psicossocial; 5) e funcional
desses indivíduos; 6) compreender as relações existentes entre sintomas de autismo,
funcionamento psicossocial, cognitivo e adaptativo. Para isso, dividimos o estudo em três fases.
Nas primeiras duas fases, utilizamos uma plataforma online para coleta de dados e obtivemos
1.024 voluntários. Em seguida, avaliamos via internet 157 adultos com TEA e 119 adultos com
desenvolvimento neurotípico, e posteriormente 29 adultos com TEA e 19 controles
presencialmente. Nossos resultados sugerem que traços de autismo e funcionalidade se
correlacionam com todas as variáveis psicológicas investigadas: sintomas de depressão,
ansiedade e TDAH, satisfação com a vida, falhas cognitivas, amor romântico e percepção
facial/emocional. Além disso, também se correlacionam com memória operacional verbal e
visuoespacial, e memória de longo prazo. Houve diferenças entre os grupos em todas as
variáveis psicológicas, mas não houve em relação ao desempenho cognitivo. O estudo de
autismo em adultos vem crescendo nos últimos anos e isso se faz necessário, visto que
compreender as principais dificuldades e possíveis potencialidades dessa população promove
melhor qualidade de vida, satisfação e quando necessário, possibilita a escolha de intervenções
que sejam mais adequadas.

Palavras chaves: Autismo, funcionalidade, cognição, variáveis psicológicas

 ABSTRACT

People diagnosed with Autism Spectrum Disorder (ASD) present difficulties with social
interaction and behavioral inflexibility, manifested by impairments in social understanding,
communication and behaviors that may be restricted, repetitive and/or stereotyped. The
presence of these traits varies in quantity and intensity, in this way, the disorder is now
understood within a dimensional vision. Thus, it is possible to find people with autism who
presents with severe symptoms and therefore needs more support, as well as people who
manifest milder traits and consequently fewer impairments. These individuals, considered by
DSM-5 as autistic "level 1", were the focus of the present study. We aimed to: 1) perform a
descriptive analysis of the Autism Spectrum Quotient Scale in a heterogeneous Brazilian
sample, it is a scale that aims to support the diagnosis of cases with mild symptoms, and 2)
verify their accuracy in the diagnosis of adults; 3) to characterize the neurocognitive profile of
adults diagnosed with ASD and with high functioning; 4) also the psychosocial profile; 5) and
functional of these individuals; 6) understand the relationship between autism symptoms,
psychosocial, cognitive and adaptive functioning. For this, we divided the study into three
phases. In the first two phases, we used an online platform for data collection and obtained
1,024 volunteers. Then, we evaluated 157 adults with ASD and 119 adults with neurotypical
development, and 29 adults with ASD and 19 controls personally. Our results suggest that
autism traits and functionality correlate with all the psychological variables investigated:
symptoms of depression, anxiety and ADHD, satisfaction with life, cognitive failures, romantic
love and facial/emotional perception. They also correlate with verbal and visuospatial working
memory, and long-term memory. There were differences between groups in all psychological
variables, but there was no difference in cognitive performance. The study of autism in adults
has been growing in recent years and this is necessary because understanding the main
difficulties and possible potentialities of this population promotes a better quality of life,
satisfaction and when necessary, allows the choice of interventions that are more adequate.

Keywords: Autism, functionality, cognition, psychological variables

 LISTA DE QUADROS

Quadro Página
Quadro 1: Procedimentos de avaliação adotados em diferentes fases da
pesquisa 17
 LISTA DE TABELAS

Tabela Artigo Página

Tabela 1: Análise descritiva da escala Quociente do Espectro do Autismo 1 23

Tabela 1: Descrição dos participantes e comparação entre os grupos quanto

2 40
a medidas sociodemográficas e psicossociais

Tabela 2: Descrição dos participantes e comparação entre os grupos quanto 2 41

a medidas neurocognitivas

2 44
Tabela 3: Correlações entre medidas sociodemográficas e psicossocias com
traços de autismo e funcionalidade

2 44
Tabela 4: Correlações entre medidas neurocognitivas e traços de autismo e
funcionalidade
 LISTA DE FIGURAS

Figura Artigo Pagina

Figura 1: Plataforma on-line utilizada para a coleta de dados - 13

nas fases 1 e 2

Figura 1: Delineamento do estudo e procedimentos 1 24

Figura 1: Delineamento do estudo e procedimentos realizados nas 2 34

fases 1, 2 e 3

Figura 2: Variação compartilhada entre diferentes medidas 2 42

sociodemográficas, psicológicas e neurocognitivas com traços de
autismo e funcionalidade
 SUMÁRIO

1. INTRODUÇÃO ............................................................................................................................ 11

2. OBJETIVOS ................................................................................................................................. 12

2.1 Objetivo Geral ................................................................................................................ 12

2.2 Objetivos específicos ...................................................................................................... 12

3. MÉTODO ...................................................................................................................................... 13

3.1 Considerações éticas ....................................................................................................... 13

3.2 Desenho e local do estudo .............................................................................................. 13

3.3 Participantes e procedimentos de avaliação ................................................................... 14

4. RESULTADOS ............................................................................................................................. 18

4.1 Descriptive analysis of the Autism Spectrum Quotient (AQ) in a heterogeneous sample

of Brazilian adults ..................................................................................................................................19

4.2 A psychological and neurocognitive profile of adults with Autism: predicting disability

in high functioning patients ................................................................................................................... 27

5. CONSIDERAÇÕES FINAIS ........................................................................................................ 56

6. REFERÊNCIAS ............................................................................................................................ 57

7. ANEXOS ....................................................................................................................................... 62
 11

1. INTRODUÇÃO

Os Transtornos do Espectro Autista (TEA) são transtornos do neurodesenvolvimento

que apresentam prevalência de 1:160 indivíduos, segundo a Organização Mundial da Saúde
(OMS). Os sintomas manifestam-se precocemente e seguem o curso de vida do indivíduo
gerando prejuízos funcionais importantes. O espectro autista é definido por dois grandes
conjuntos de sintomas, sendo eles: déficits na sociabilidade e padrões restritos, estereotipados
e rígidos de interesses, comportamentos ou atividades (American Psychiatric Association -
APA, 2013). Estes sintomas podem se manifestar através da presença de alterações no
desenvolvimento da linguagem, déficits na comunicação verbal e não verbal, prejuízos na
habilidade social, possível déficit intelectual, déficits cognitivos e dificuldades motoras.
As manifestações do TEA são múltiplas e a combinação dos sintomas característicos do
autismo junto a outras comorbidades, perfis cognitivos, comportamentais e funcionais, resulta
em um dos transtornos mais heterogêneos associados ao neurodesenvolvimento (Foss-Feig et
al., 2015; Doernberg & Hollander, 2016). Dessa forma, indivíduos com a mesma condição
nosológica podem apresentar sintomas que variam em termos de quantidade, intensidade e,
consequentemente, prejuízos (Tantam, 2003; Cederlund et al., 2011).
A Síndrome de Asperger e o Autismo de alto funcionamento compreendem as
manifestações mais leves dentro do espectro autista, sendo que a partir da 5ª Edição do Manual
Diagnóstico e Estatístico dos transtornos Mentais (DSM-V), a Síndrome de Asperger (SA)
passou a ser considerada um transtorno pertencente ao espectro autista. Os indivíduos com essa
síndrome apresentam os sintomas comuns aos demais indivíduos com TEA, porém não
possuem deficiência intelectual ou na linguagem, o que lhes possibilita uma adaptação
funcional consideravelmente superior aos indivíduos com autismo clássico (Barahona-Corrêa
& Filipe, 2016). Embora apresentem mais dificuldades se comparados a indivíduos com
desenvolvimento típico, muitos adultos com a Síndrome de Asperger são capazes de exercer
atividades laborais e intelectuais com bom desempenho (Hurlbutt & Chalmers, 2004). Estes
aspectos lhes conferem melhor qualidade de vida, e por consequência, melhora do quadro
clínico (Howlin et al., 2005). Apesar disso, esses indivíduos relatam prejuízos relacionados
principalmente a interação social, como dificuldades para desenvolver ou manter
relacionamentos afetivos, compartilhar interesses, compreender e descrever expressões faciais
e sentimentos próprios e de outras pessoas (Hill et al., 2004). Esses prejuízos são observados
principalmente quando é exigido deles habilidade social e flexibilidade cognitiva (Engstrom et
al., 2003).
 12

A OMS, por meio da classificação internacional da funcionalidade, recomenda que a

funcionalidade dos pacientes com diferentes condições clínicas seja avaliada considerando os
domínios cognição, mobilidade, autocuidado, interação social, atividades de vida diária e
participação em atividades comunitárias (Üstün et al., 2010). Desses, à exceção do domínio
mobilidade, é esperado que pacientes com autismo apresentem dificuldades maiores ou
menores na adaptação em múltiplos aspectos da funcionalidade. Acredita-se que diferentes
fatores podem influenciar a capacidade funcional de pessoas com autismo, como a presença e
a intensidade dos próprios traços autísticos, variáveis psicológicas e sociais, como
comorbidades psiquiátricas, comportamento hiperativo e impulsivo, satisfação com a vida, e
teoria da mente, além de funções cognitivas, como inteligência, memória, funções executivas e
fluência verbal.
Nesse sentido, buscaremos compreender a relação entre os sintomas do transtorno do
espectro autista, variáveis psicossociais e funcionalidade cognitiva. O objetivo do estudo é
analisar como esses fatores podem se associar à funcionalidade, além de definir um perfil
psicológico e cognitivo de adultos com autismo.

2. OBJETIVOS

2.1 Objetivo Geral

Investigar a relação entre traços de autismo, variáveis psicossociais e funcionamento
cognitivo em adultos com Transtorno do Espectro Autista (TEA)

2.2 Objetivos específicos

1) Realizar análise descritiva da escala Quociente do Espectro do Autismo (QA) em uma
amostra heterogênea de adultos brasileiros;
2) Investigar a precisão da QA no diagnóstico de adultos com autismo e inteligência
preservada;
3) Caracterizar o perfil de desempenho em testes neuropsicológicos de adultos com
diagnóstico de TEA e com alto funcionamento;
4) Caracterizar o perfil psicossocial desses indivíduos;
5) Caracterizar o perfil funcional desses indivíduos;
6) Analisar as relações entre sintomas de TEA, funcionamento cognitivo e aspectos
psicossociais.
 13

3. MÉTODO

3.1 Considerações éticas

O estudo que embasou essa dissertação compreende um projeto mais abrangente que
visa identificar o perfil psicológico e funcional de adultos com transtorno do espectro autista e
seus preditores. O estudo foi encaminhado e aprovado pelo Comitê de Ética em Pesquisa da
Universidade Federal de Minas Gerais (CAEE: 56534516.1.0000.5149). Os participantes
deram consentimento por meio virtual ou presencial em diferentes fases do estudo. O projeto
encontra-se de acordo com as diretrizes do Conselho Nacional de Saúde e da Declaração de
Helsinki.

3.2 Desenho e local do estudo

O estudo apresenta desenho transversal e foi feito em três fases distintas. A primeira e
segunda fases envolveram o uso de uma plataforma virtual desenvolvida no aplicativo
Googleforms (Figura 1) para a aplicação de escalas e questionários, e contou com participantes
de todas as regiões brasileiras. Posteriormente alguns dos participantes foram convidados a
realizar uma entrevista presencial, nas dependências do Centro de Tecnologia em Medicina
Molecular da UFMG. Os participantes desse último estágio eram residentes de Belo Horizonte
ou cidades vizinhas.

Figura 1: Plataforma online utilizada para a coleta de dados nas fases 1 e 2 do estudo
 14

A avaliação via internet foi selecionada de forma a reduzir o custo e viabilizar a pesquisa
dado o tempo relativamente curto para a identificação de um grupo clínico relativamente
incomum - prevalência estimada de 1% - (APA, 2013). Estudos internacionais utilizando tal
metodologia para avaliação psicológica, como sintetizado por Hoerguer e colaboradores
(2011), sugerem boa equivalência no uso de testes e escalas em ambiente virtual, desde que os
métodos de aplicação ou resposta sejam condizentes com esse contexto. Experiências anteriores
de nosso grupo, incluindo o uso de alguns dos instrumentos utilizados nesse estudo, atestam a
boa concordância entre o uso de questionários e escalas em ambiente virtual com as aplicações
tradicionais realizadas presencialmente (de Paula, 2015; de Paula et al., 2017; 2018).
As avaliações presenciais foram realizadas de forma a confirmar ou refutar o possível
diagnóstico de TEA de parte dos participantes e realizar demais procedimentos que não mantém
boa validade ou confiabilidade quando utilizados em ambiente virtual. Os últimos
procedimentos foram realizados pela autora da presente dissertação, orientado diretamente por
um médico psiquiatra e um psicólogo experientes no diagnóstico e avaliação do transtorno do
espectro autista. A aplicação dos testes neuropsicológicos a serem descritos foi realizada por
equipe de alunos de graduação capacitados no protocolo sob supervisão direta da autora.

3.3 Participantes e procedimentos de avaliação

A primeira fase do projeto contou com a participação de 1.024 voluntários de diferentes

regiões do país. O objetivo da primeira fase do estudo foi identificar participantes que
expressassem maiores traços de autismo, o que é sugestivo da presença do transtorno quando o
consideramos em uma perspectiva dimensional (APA, 2013).
Esses participantes responderam à escala Autism Quotient (Quociente Autista),
desenvolvida por Baron-Cohen e colaboradores (2011) para a detecção de quadros sutis de
autismo em adultos. A escala é uma das mais utilizadas internacionalmente para tal fim, como
revisado por Ruzich e colaboradores (2015). Um estudo de validação para a população
brasileira foi realizado por Egito e colaboradores (2018). A escala é composta por cinquenta
perguntas destinadas a mensurar diferentes comportamentos, crenças ou experiências típicas de
pessoas com autismo (Anexo). Para cada pergunta o sujeito responde em uma escala de quatro
pontos o quanto concorda ou discorda com cada uma das perguntas. No critério de correção
tradicional, adotado no presente estudo, as respostas para cada item são dicotomizadas
(sintomático x típico) e somadas em um escore total. Estudos internacionais sugerem que esse
 15

escore distingue com boa acurácia pessoas neurotípicas (que apresentam em médica 16 pontos
na escala) de pessoas com TEA (que apresentam em médica 34 pontos na escala), em diferentes
países e culturas (Ruzich et al., 2015). O ponto de corte 31/32 (controle/caso) é o mais utilizado
para a detecção de TEA, e foi adotado em nosso estudo (Lai & Baron-Cohen, 2015).
Além do Autism Quotient os participantes preencheram uma ficha de dados
sociodemográficos (incluindo idade, escolaridade, histórico de saúde, uso de medicações e
condição socioeconômica) e a um questionário de saúde mental, o Self-Reporting
Questionnaire 20 (Mari & Williams, 1985). Essa escala de vinte perguntas avalia a presença de
sintomas psiquiátricos não psicóticos, sobretudo ligados a depressão e ansiedade, sendo
sensível à detecção de diferentes transtornos mentais (Gonçalves et al., 2008).
Participantes selecionados na primeira fase foram convidados por e-mail à participação
na fase dois do estudo. Nesta, houve a participação de 276 voluntários, divididos em dois
grupos: 119 adultos neurotípicos (sem histórico de doenças neurológicas ou transtornos do
neurodesenvolvimento, sem traços significativos de autismo e com escore na SRQ-20 pouco
sugestivo de transtornos mentais) compondo o grupo controle e 157 adultos previamente
diagnosticados com autismo ou que apresentaram escore clínico (QA>31) na escala do
Quociente do Espectro do Autismo.
Os seguintes critérios de exclusão foram considerados para os propósitos desta pesquisa:
Grupo autismo: diagnóstico de transtorno do espectro autista em gravidade moderada ou severa,
presença de deficiência intelectual, doenças neurológicas ou de qualquer outra condição que
impedisse a participação no projeto. Grupo controle: presença de deficiência intelectual,
doenças neurológicas ou de qualquer outra condição que impedisse a participação no projeto.
O diagnóstico dos pacientes foi realizado considerando os critérios propostos no DSM-5.
Nessa fase foram utilizadas uma série de escalas e questionários selecionados de forma
a documentar diferentes características psicológicas dos participantes (sintomas internalizantes,
desatenção, hiperatividade, impulsividade, queixas cognitivas e teoria da mente), incluindo
medidas psicossociais (funcionalidade, relacionamento afetivo e satisfação com vida),
conforme os objetivos do estudo.
A terceira e última fase do projeto, contou com a participação de 19 adultos neurotípicos
e 29 adultos autistas com alto funcionamento. Os participantes foram adultos brasileiros, com
idade entre 18 e 60 anos, sendo que os voluntários do grupo controle foram pareados por idade,
sexo, escolaridade e condição socioeconômica, selecionados dentre os participantes da fase dois
do estudo. Essa etapa envolveu uma avaliação presencial onde foi realizada uma entrevista
 16

clínica de saúde mental com base no DSM-5 (APA, 2013; Nussbam, 2015) para confirmação
do diagnóstico de autismo e exclusão de participantes que não apresentassem o transtorno, além
da aplicação de outros testes e escalas cuja aplicação via internet seria enviesada.
Os testes em questão foram selecionados de forma a documentar grandes áreas do
funcionamento neurocognitivo: linguagem, processamento espacial, funções executivas,
velocidade de processamento, memória episódica, memória de trabalho, inteligência e tomada
de decisões. Todos os instrumentos da terceira fase foram previamente adaptados e validados
ao contexto brasileiro.
O quadro a seguir sintetiza todos os procedimentos de avaliação descritos anteriormente,
incluindo suas referências originais e adaptações brasileiras. A descrição dos participantes do
estudo será realizada posteriormente, ao detalharmos os dois estudos que compõem a
dissertação.
 17

Quadro 1: procedimentos de avaliação adotados em diferentes fases da pesquisa

Fase Aspecto Avaliado Instrumento Referência Original Adaptação Brasileira

1 Sintomas de Autismo Autism Quotient Baron-Cohen et al. (2001a) Egito et al. (2018)
Saúde Mental Self-Reporting Questionnaire 20 Mari & Williams (1985) Gonçalves et al. (2008)
Socioeconômico Critério Brasil ABEP (2008) -
2 Funcionalidade WHO Disability Assement 2.0 Üstün et al. (2010) Silveira et al. (2013)
Satisfaction with life Satisfaction with life Scale Diener et al. (1985) Hutz et al. (2014)
Impulsividade Abrv. Barrat Impulsiveness Scale Coutlee et al. (1985) De Paula & Costa (in press)
Sintomas de TDAH Adult Self-Report Scale (ADHD) Kessler et al. (2005) Leite (2011)
Queixas Cognitivas Cognitive Failures Questionnaire Broadbent et al. (1982) de Paula et al. (2018)
Amor Apaixonado Passionate Love Scale Hatfield & Sprecher (1998) Hernandez (2016)
Teoria da Mente Read the Mind in the Eyes Baron-Cohen et al. (2001b) Sanvicente-Vieira et al. (2014)
3 Diagnóstico de Autismo Clinical interview (DSM-5) Nussbam (2015) Nussbam (2015)
Saúde mental Clinical interview (DSM-5) Nussbam (2015) Nussbam (2015)
DSM-5 Transversal symptoms scale APA (2013) APA (2013)
Inteligência Vocabulary (WASI) Wechsler (1999) Trentini et al. (2014)
Matrix Reasoning (WASI) Wechsler (1999) Trentini et al. (2014)
Funções Executivas Tower of London Test Krikorian et al. (1994) de Paula et al. (2012)
Five Digit Test (Inhibiting, Sedó (2007) Sedó et al. (2015)
Flexibility)
Switching Fluency Test de Paula et al. (2015) de Paula et al. (2015)
Trail Making Test (B) Reitan (1971) Hamdan & Hamdan (2009)
Memória de Trabalho Digit Span Kessler et al. (2008) de Paula et al. (2016)
Corsi Block-Tapping Task Kessler et al. (2008) de Paula et al. (2016)
Memória Logical Memory Wechsler (1945) Nitirni (2008)
Modified Taylor Figure Test Hublay & Tremblay (2002) de Paula (2018)
Linguagem Verbal Fluency (Animals, Fruits) de Paula et al. (2015) de Paula et al. (2015)
Boston Naming Test Goodglass et al. (1983) Leite et al. (2017)
Visuoespacial Modified Taylor Figure Test Hublay & Tremblay (2002) de Paula (2018)
Thalves Visual Organization Test Alves et al. (2010) -
Velocidade de Processamento Five Digit Test (Reading, Counting) Sedó (2007) Sedó et al. (2015)
Trail Making Test (A) Reitan (1971) Hamdan & Hamdan (2009)
Tomada de Decisões Iowa Gabling Task Bechara et al. (2005) Malloy-Diniz et al. (2008)
 18

4. RESULTADOS

Nessa sessão são apresentados os artigos Descriptive analysis of the Autism Spectrum
Quotient (AQ) in a heterogeneous sample of Brazilian adults e A psychological and
neurocognitive profile of adults with Autism: predicting disability in high functioning patients
que em conjunto compõem os resultados da dissertação.
 19

4.1 Descriptive analysis of the Autism Spectrum Quotient (AQ) in a heterogeneous

sample of Brazilian adults

Ana Luíza Costa Alves1

Jonas Jardim de Paula1,2
Débora Marques de Miranda1,3
Marco Aurélio Romano-Silva1,4

1. Programa de Pós-Graduação em Medicina Molecular, Faculdade de Medicina, Universidade Federal de Minas

Gerais. Belo Horizonte-MG, Brazil
2. Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte-MG, Brazil
3. Departamento de Pediatria, Faculdade de Medicina, Universidade Federal de Minas Gerais. Belo Horizonte-
MG, Brazil
4. Departamento de Saúde Mental, Faculdade de Medicina, Universidade Federal de Minas Gerais. Belo
Horizonte- MG, Brazil
 20

ABSTRACT

The Autism Spectrum Disorder is characterized by the presence of difficulties in social

interaction, and inflexible, repetitive and/or stereotyped behaviors and interests, and there are
few tools to identify symptoms in population basis. The principal aim of the study is to present
a brief descriptive analysis of the Autism Spectrum Quotient (AQ) in a heterogeneous sample
of Brazilian adults with no autism diagnostic or other psychiatric symptoms to describe how
the autistic traits are distributed in the general population. We investigate its accuracy in a
sample with autistic adults, who presented a clinical score on the scale. The AQ is a self-report
instrument, with 50 items that are divided into five different domains: social skill, imagination,
communication, attention switching, and attention to details. Studies have found that it is a
reliable instrument to quantify autistic traits in individuals older than 18 years old and presents
an average or aboveaverage intelligence. Our findings suggest that autism traits are normally
distributed in the population, but Brazilian adults (n=385) have shown a different profile from
the original study. Further, we found that 24 adults from our sample (n=32) have a clinical score
on the AQ, which is compatible with their previous autism diagnosis.

KEYWORDS: Autism Spectrum Disorder, Asperger syndrome, psychological assessment,

psychometrics, transcultural psychology
 21

INTRODUCTION

People with Autism Spectrum Disorder (ASD) show difficulties in two main areas:
social interaction, including verbal or non-verbal communication deficits, and inflexible,
repetitive and stereotyped behaviors and interests (APA, 2013). These traits are perceived in
the early development of individual life and frequently impair their functionality in different
domains, including daily functionality, relationships, professional life, academic outputs, and
mental health. Although, besides these core symptoms, ASD is a very heterogeneous condition
and might be seen as a spectrum, where people may differ in how intense are the symptoms, m
which may range from a mild to the severe presentation. This aspect will determine the
impairments and the kind of support the person will need.
The prevalence of ASD around the world and across all ages is approximately 1%.
Besides that, some researchers consider that autism traits show a normal distribution on the
typical population. Mainly difficulties with social behavior, even it's a core symptom of autism
could be common in people with no such diagnosis (Constantino and Todd, 2003; Rutter, 2011).
The assessment of Autism in childhood is well documented in the literature, and there are many
adapted and validated clinical instruments for the assessment of those traits. However, this
scenario is different when we consider the adult with autism, especially when the clinical
condition is less severe, with average intelligence and none delay in language development.
With the proposal to quantify the autism traits in the individual older than 18 years old
with preserved intelligence, Baron-Cohen et al. (2001) developed the Autism Spectrum
Quotient (AQ), which is a self-report questionnaire with 50 items that are divided into five
different domains: social skill, imagination, communication, attention switching, and attention
to details. The cut-off score can identify the number of symptoms the individual present,
classifying for severity, and the need and kind of support necessary. Although the diagnosis of
autism should be made by a team of multidisciplinary professionals, the use of instruments and
questionnaires have the objective to give support to the diagnostic process. So, the AQ scale
allows to measure autism traits in the adult population and being helpful in the diagnostic
process. The AQ was adapted for many cultures, including for the Brazilian Portuguese by
Egito et al. (2018).
As we know the clinical importance of this instrument and the normal distribution of
those traits in the general population, we aim to briefly present a descriptive analysis of AQ
scores in a sample of Brazilian adults with no autism diagnostic or any other psychiatric
 22

condition. And then, the scale was evaluated about it is accuracy in a sample with adults with
ASD.

METHODS

The local ethics board approved our study. The research was organized in different
stages. In the first one, we use adopted an online platform for data collection. We invited by
mailing and in social media, especially in groups of researchers which work with autism and
groups of autism patients and relatives, along with other people who would like to participate
in research about autism, and received 1024 valid forms submissions in our server. We applied
a series of exclusion criteria in this initial sample: age below 18 years, self-reported history of
mental disorders or neurological diseases, use of psychotropic medication and scores above the
cut-off score for mental disorders (>7) in the Self Reporting Questionnaire-20 (SRQ-20) (Mari
& Williams, 1985). The final sample of this study involved 385 individual (294 women), with
m age of 34.3 years (SD=11.3, range=18-68).
Then we invited part of our sample who got a clinical score (>31, the international
cutoff) on the AQ or reported a previous diagnosis of ASD to a diagnostic interview following
the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders
(DSMV). We invited only participants which live in our town and were interested in the
procedure, as reported in our online form. This subsample was formed by 32 voluntaries (23
women), with a mean age was 33.6 (SD=8, range=20-50), years of schooling were 16.5
(SD=3.5).
Based on AQ responses, we computed descriptive parameters using standard scores and
percentiles following the original (Baron-Cohen et al., 2014) and Brazilian-adapted (Egito et
al., 2018) scoring systems. AQ scores showed a normal distribution according to histogram
analysis, and the mean score was 20.9 (SD=8.8).
We computed descriptive data (mean, standard deviation, minimum and maximum
values), normative values (using percentile scores) and assessed reliability by calculating the
Cronbach`s alpha based on each scoring criteria.

RESULTS

We found a good internal consistency (α=0,85 and 0.87), which means the scale
accurately measure the variable of interest in both genders. Of the total of 91 men in our first
 23

sample, voluntaries with 32 points or more (the cut-off proposed by Baron-Cohen and
colleagues) scored higher than approximately 93% of the control sample. Of 294 women, those
who obtained 32 points or more, scored higher than approximately 97% of our sample (Table
1). In the original study, 32 points represent the 98th percentile (computed from the mean and
standard deviations reported in the original paper). The study conducted by Osorio's examined
the factor structure of the Brazilian version of the scale, and they proposed a three-factor model
instead of five, a reduced version (25 items) and a different way to correct it. Besides that, they
did not indicate a different cut-off for their sample. The distribution of AQ scores according to
this method is shown in Table 1.

Table 1: Descriptive data of Autism Quotient scores stratified by scoring method and sex

Cohen et al. (2001) Egito et al. (2018)

Male Female Male Female
Mean 25 20 62 54
Std. Dev. 8 9 12 13
Min 5 3 40 28
Max 43 45 86 94
Pc.5 5 5 40 38
Pc.10 10 7 44 41
Pc.20 14 11 47 44
Pc.30 16 13 50 46
Pc.40 18 15 52 48
Pc.50 20 17 54 50
Pc.60 22 19 56 52
Pc.70 24 21 58 54
Pc.80 27 23 60 52
Pc.90 30 27 64 59
Pc.95 34 30 66 62
Alfa de Cronbach 0.87 0.85 0.76 0.82
Pc.: Percentile

The assessment of the 32 adults which scored above the international cutoff for the AQ
or had a previous diagnosis was done by the first author (ALC) and discussed with a clinical
neuropsychologist (JJdP) and a psychiatrist (MARS). Based on the 32 score cutoff two of them
did not present characteristics enough to receive an autism diagnostic, but showed symptoms
of other mental disorders (social phobia and generalized anxiety). Six voluntaries of this group
were classified as a non-clinical, and but showed borderline scores in AQ. Those results are
summarized in Figure 1.
 24

N=385
(294 women)
AQ≤31
N=1024 Without any psychiatric
Autism Quotient (AQ) diagnosis
Self-Reporting
Questionnaire 20 2 false positives
Sociodemografic N=32
(23 women) 6 false negatives
AQ>31 and/or previous
autism diagnosis
24 with clinical score
and autism diagnosis

Figure 1: Study design and procedures

DISCUSSION

The Autism Spectrum Disorder used to be considered as a diagnostic category, but the
last edition of DSM and recent researches have been proposing a dimension view for the clinical
condition. ASD varies according to symptoms, severity, and necessity for support. It is expected
that any population present from subclinical traits of ASD to a very severe condition.
As seen in other cultures AQ scores were normally distributed in our sample, and people
with autism showed very high scores in the questionnaire (above the 90th percentile). AQ also
showed good reliability, both on the original (Baron-Cohen et al., 2001) and adapted (Egito et
al., 2018) scoring systems, Our second sample, which showed scores above the cutoff score or
reported a previous diagnose of autism, we found 2 false-positive and 6 false-negative cases.
The availability of AQ as a screening instrument for autism traits in adults have huge
importance, especially in the diagnostic process of adults with fewer impairments and preserved
intelligence. These cases could be a challenge for health professionals. Besides that, knowing
the level of the autism enables the clinical to predict the impairments, to offer adequate and
quality support, also, to provide better guidance to the family. It is important to keep on mind
that the scale is not enough for the diagnostic, but still very useful in the investigation.
Finally, the results of our study suggest that our population have a different profile
comparing to the original study because the clinical score represents a smaller percentile in our
sample, which means that probably Brazilian sample report more symptoms than others
cultures. Despite this, we observe those traits distributed in the typical population. Future
 25

searches are required to adequate the use of Autism Spectrum Quotient in the Brazilian
population, as defining a cut-off score that will better consider our culture and peculiarities.

CONFLICTS OF INTEREST

The authors declare no conflict of interest

ACKNOWLEDGMENTS

Alves ALC received an scholarship from Conselho Nacional de Desenvolvimento Científico e

Tecnológico (CNPq).

REFERENCES

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (DSM-5). American Psychiatric Pub.

Constantino, J. N., & Todd, R. D. (2003). Autistic traits in the general population: a twin study.
Archives of general psychiatry, 60(5), 524-530.

Rutter, M. L. (2011). Progress in understanding autism: 2007–2010. Journal of autism and

developmental disorders, 41(4), 395-404.

Baron-Cohen, S., Wheelwright, S., Skinner, R., Martin, J., & Clubley, E. (2001). The autism-
spectrum quotient (AQ): Evidence from asperger syndrome/high-functioning autism, malesand
females, scientists and mathematicians. Journal of autism and developmental disorders, 31(1),
5-17.

Egito, J. H. T., Ferreira, G. M. R., Gonçalves, M. I., & Osório, A. A. C. (2018). Brief Report:
Factor Analysis of the Brazilian Version of the Adult Autism Spectrum Quotient. Journal of
autism and developmental disorders, 48(5), 1847-1853.
 26

Mari, J. D. J., & Williams, P. (1985). A comparison of the validity of two psychiatric screening
questionnaires (GHQ-12 and SRQ-20) in Brazil, using Relative Operating Characteristic (ROC)
analysis. Psychological medicine, 15(3), 651-659.

Baron-Cohen, S., Cassidy, S., Auyeung, B., Allison, C., Achoukhi, M., Robertson, S., ... & Lai,
M. C. (2014). Attenuation of typical sex differences in 800 adults with autism vs. 3,900
controls. PloS one, 9(7), e102251.
 27

4.2 A psychological and neurocognitive profile of adults with Autism: predicting

disability in high functioning patients

Ana Luíza Costa Alves1

Jonas Jardim de Paula1,2
Marco Aurélio Romano-Silva1,3

1. Programa de Pós-Graduação em Medicina Molecular, Faculdade de Medicina, Universidade Federal

de Minas Gerais. Belo Horizonte-MG, Brazil
2. Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte-MG, Brazil
3. Departamento de Saúde Mental, Faculdade de Medicina, universidade Federal de Minas Gerais. Belo
Horizonte-MG, Brazil.
 28

ABSTRACT

The Autism Spectrum Disorder was first mentioned around the 1940s by Leo Kanner,
and initially, researchers were focused on describing the disorder in children and this tendency
is still notable. However, nowadays some studies were been developed investigating autism
traits and their outcomes in adulthood. Considering the importance of deepening in this
knowledge and the presence of few studies with this population, our aim in this study is to
provide a psychological profile of adults with ASD and high functioning, also to understand
better their cognitive functions, highlighting the possible deficits and protective factors. The
study was organized into three phases. In the first one, we used an online platform for data
collection and we got 1.024 volunteers, then we had 157 adults with ASD and 119 adults with
neurotypical development, in the last phase there were 29 adults with ASD and 19 in the control
group. They were required to answer questionnaires assessing psychological measures and tests
evaluating cognitive function. Our results indicate a moderate correlation between autistic traits
and life satisfaction (r=-0.33), inattention (r=0.37), hyperactivity (r=0.31), functionality
(r=0.48) and cognitive failures (r=0.44). Moreover, a weak correlation between impulsivity
(r=0.18), passionate love (r=0.27) and facial/emotional perception (r=-0.21). No correlation
was found between the autism scale and executive functions, language, long-term memory,
visual abilities, and processing speed, only with visual working memory (r=0.37). Furthermore,
the results suggest a significant difference between the groups in all psychological measures,
with moderate effect size in life satisfaction (R=-0.35), inattention (R=-0.37), passionate love
(R=0.32), cognitive failures (R=-0.39) and functionality (R=-0.49). And, a small effect size in
hyperactivity (R=-0.28), impulsivity (R=-0.14) and facial/emotional perception (R=-0.16).
However, no significant difference between the groups in the tests results. These findings
suggest that adults with autism from our sample did not have differences in cognitive
functionality compared to adults with neurotypical development. Despite that, they presented
important differences regarding psychological measures.

KEYWORDS: autism spectrum disorder, function, psychological assessment,

neuropsychological assessment, Asperger syndrome
 29

INTRODUCTION

The Autism Spectrum Disorder (ASD) was first mentioned around the 1940s by the
Austrian psychiatry Leo Kanner (1943) and around the 1980s, Hans Asperger publications
(1991) also received acknowledgment for being one of the pioneers of autism study. Nowadays,
after five editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), ASD
is characterized by the presence of symptoms and difficulties in two principal areas, social
communication and behavioral flexibility. The prevalence of autism is estimated around 1% in
the population (APA, 2013).
People with autism show difficulties with social interaction, that include deficits in
verbal and non-verbal communication, difficulty to initiate and maintain a conversation or a
relationship, less eye contact, reduced interest for peers and to share emotion and interests,
inappropriate social behavior, also, deficits in emotional and facial perception. In terms of
behavioral flexibility, the patients often show a repetitive and restrictive pattern of interests,
behaviors, and activities. These can appear through stereotyped motor behavior or speech,
inflexible adherence to routine, the presence of ritualistic behaviors, hyper and restrictive focus
on one object or subject and, hyper or hypo-reactivity to sensory stimuli. Those are the basic
criteria for identifying the disorders, according to the most recent classification (APA, 2013).
Those traits emerge in the early development of individual life, and although there are
core features, ASD is best represented as a spectrum because individuals with autism can differ
into quantity and severity of the traits (Lord & Bishop, 2015). So, it's possible to exist a mild
manifestation for the disorder, but also, a very severe, as operationalized as the new level
classification of DSM-5. Therefore, the level of impairments and dysfunctionality have to be
evaluated considering the spectrum, and consequently, this will determine the kind of support
will be needed by the patient (Poon & Sidhu, 2017).
Initially, researchers were focused on describing the disorder in children and this
tendency is still notable nowadays. Considering that autism is very well documented in this
stage of life, there are more instruments to assess these symptoms in children and many tools
were translated and validated in different languages and cultures, such as Childhood Autism
Rating Scale and Screening tool for autism in two-year-old (Montecchi et al., 2004; Ousley et
al., 2000). Consequently, more interventions were developed to attend their necessities and to
improve quality of life.
 30

Despite that have wasn't a priority for a long time, some studies were been developed
investigating autism traits and their outcomes in adulthood. Gillberg and colleagues (2010), for
example, developed a long-term prospective follow-up study with 120 individuals diagnosed
with ASD in infancy and they found that in the early adulthood the majority of the group
remained dependent of their parents for education and living support. They highlight the
importance of improvements in activities and support for this population, also the necessity of
specific tools to assess some behavioral and psychosocial factors, such as quality of life.
Another follow-up study with 68 adults (mean age=29 years) with ASD, conducted by Howling
et al. (2004), found similar results. The overall conclusion is that almost all the sample in adult
age was still dependent on their families in adult age and just a few lived alone or have
permanent employment.
There are a few systematic reviews on the topic. One of the studies, carried out by
Bishop-Fitzpatrick et al. (2014), reviewed 13 studies, and found that social cognition training
and applied behavior analysis were interventions with a positive effect on the treatment of adults
with ASD. But they also pointed for the small number and poor quality of the studies in this
area. Another systematic review with 25 studies reported outcomes in adulthood (Magiati et al.,
2014) and concluded that adaptive functioning usually improved in most studies, autism
symptoms were stable along years and there is the presence of some early variables, like IQ and
language ability, that are associated with functioning outcome in adulthood.
Another topic studied in adults with autism is comorbid mental health disorders or other
psychological problems. Although this data is inconsistent, Rutter and colleagues (2015)
estimated that around 25% to over 75% of adults with autism may show have psychiatric
problems. They evaluated 58 adults with ASD (mean age=44 years) whom they followed for
forty years. In a total of 22, those adults who were able to report about their own mental state,
45% reported no mental problems, and 27% assumed to have symptoms related to depression,
anxiety and/or obsessive-compulsive disorder. Once again, the study suggests the need of a
more detailed description of the psychological function of adults with autism, using validated
measures on this purpose. In 2015, Croen and colleagues observed in their sample of adults
with autism (n=1507) that psychiatric problems were significantly more frequent in this
population comparing to the neurotypical adults. Over than 50% patients had comorbid mental
disorder and a higher rate of other medical conditions, including diabetes, seizure and
hypertension.
Beyond the high frequency of some disorders, such as depression, anxiety, and
Obsessive Compulsive Disorder (OCD), Attention-Deficit/Hyperactivity Disorder (ADHD) is
 31

another frequent comorbidity in the autism population. A review study suggests that the
prevalence of symptoms of ADHD in children with ASD was 33 to 37% and another paper
consider that 30 to 50% of individuals with ASD manifest ADHD symptoms, particularly at
preschool age (Berenguer-Forner et al., 2015; Leitner et al., 2014). These disorders present an
overlapping of phenotype features because both shows some common signals, as externalizing
symptoms, executive dysfunction and appear in the very early development. For this reason,
the differential diagnostic it's so difficult (Rommelse et al., 2010).
So, in a neurodevelopmental disorder with a high prevalence of comorbidities associated
and poor outcomes are expected important deficits in functionality and lower satisfaction with
life. Schmidt and colleagues (2015) evaluated 43 adults (mean age=31) with ASD and without
intellectual impairments and 44 controls. They observed that clinical adults reported significant
functional impairments and less life satisfaction compared with non-clinical adults. Although,
the impairments were higher in areas involving social interaction, such as communication and
participation in society, and daily living skills didn't present a difference between the groups.
Another psychological variable that may differ in this group is romantic love, the
intensity of this feeling toward another person and how this happens, considering a population
with important difficulties around social interaction, communication, sharing emotions and
facial perception. The literature is very limited in this subject. There is, however, a study that
investigated the nature and predictors of social and romantic functioning in adolescents and
adults with ASD. Twenty-five individuals with autism were assessed and they reported less
access to peers and friends comparing to the control group, and this fact impacts the learning
of social rules and romantic skills. Were concluded that social functioning is related to romantic
functioning, and impairments in the first one will cause difficulties in the second. And although
these might improve along the years, the velocity is slower compared to individuals without
ASD (Stokes et al., 2007).
Cognitive functions of adults with ASD it's another perspective that should be
considered, which can also impair in their daily functionality. Baxter et al. (2017) developed a
study combining functional and structural neuroimaging and neuropsychological tests to
investigate differences between men adults with ASD and neurotypical adults. The ASD group
(n=16) committed more mistakes on an executive function task, especially in flexibility,
working memory, and inhibition, however there weren't differences comparing to the control
group (n=17) in verbal memory and local visual search. They also found that the clinical group
presented a reduced brain activity in areas responsible for flexible thinking and the area related
to memory seemed to have a smaller volume compared to typical men.
 32

It is well established in the literature that individuals with autism in all ages have more
deficits in executive function comparing to neurotypical individuals. And, this dysfunction
seems to be relatively stable across development. However, some researchers found smaller
effect sizes in adults with ASD. They had higher scores in EF tasks than younger individuals,
perhaps due to the use of more compensatory strategies and/or neurodevelopmental maturity
(Guastella et al., 2018).
As seen, ASD is a very heterogeneous condition. Our focus in this study is the mildest
manifestation of autism, historically called of High Functioning Autism and/or Asperger
Syndrome and nowadays classified as “level 1” (mild) autism in DSM-5. These
individuals may have the same classic symptoms of autism, but less severe so they also have
fewer impairments in their daily functionality. It's no unusual that they have a good performance
at work, develop relationships or live independently. This aspect seems to be related to more
quality of life.
As there are just a few studies investigating the symptoms and impairments of ASD in
the adult population, especially with high functioning and considering the importance of
deepening in this knowledge, our aim in this study is to provide a psychological profile of adults
with ASD with high functioning and to understand better their cognitive functions, highlighting
the possible deficits and protective factors.

METHODS

Study Design

The study was organized into three phases, as detailed below. The first one we used an
online platform for data collection, and we got a total of 1.024 volunteers. They answered
questionnaires about mental health and autism traits. Our primary aim was to present a
descriptive analysis of the Autism Spectrum Quotient (AQ) in a heterogeneous sample of
Brazilian adults with no autism diagnostic, and, we also investigated the scale accuracy (showed
in topic 3.1 of this Dissertation).
The AQ scale was developed by Baron-Cohen and colleagues (2001) with the purpose
to assess autistic traits in individuals older than 18 years with preserve intelligence. It is a
selfreport questionnaire with 50 items that are divided into five different domains: social skill,
imagination, communication, attention switching, and attention to details. The score may
identify how many symptoms the individual has and the severity of them. This scale can be
 33

used as a support in the diagnostic process, consequently helping with the best intervention
choice.
In this second study, our inclusion criteria for participants with probable ASD was
volunteers in phase one which showed very high symptomatology of autism, based in the AQ
international cutoff (>31 points in the 50 items questionnaire) (Lai & Baron-Cohen, 2015)
and/or have a previous diagnosis of autism. Those volunteers compose our clinical group. For
the control group, we manually screened the Phase 1 respondents with negative scores for
autism in AQ but similar age, sex, sociodemographic status and educational level as our clinical
group, in a paired-sample design. Both clinical and control group answered psychometric
questionnaires and scales selected to assess several areas of psychosocial functioning:
satisfaction with life, cognitive complaints, inattention and hyperactivity symptoms,
impulsivity, romantic love and functionality in daily life.
In the third and final phase of this we conducted a personal interview focusing on the
clinical diagnosis of autism (according to DSM-5 criteria) and to establish a neurocognitive
profile of our participants. Those interviews and assessments were performed in the Center of
Technology in Molecular Medicine, a clinical-research facility associated with the Laboratory
of Neuroscience and Molecular Medicine of the Federal University of Minas Gerais (UFMG).
The clinical volunteers were selected from the second phase considering their residential
location (all the adults invited were from Belo Horizonte-MG or cities around) and which
showed a general pattern of high function in everyday life, as measured by specific questions
designed by our team. Meanwhile, the control group, composed of adults with neurotypical
development, again were paired with the volunteers from the clinical group. Figure 2 shows the
three phases design, sample size, psychosocial and neurocognitive measures used for
assessment.
 34

Figure 1: study design and procedures performed in phases 1, 2 and 3

 35

Participants

Firstly, 157 adults (69.4% female), mean age 32 years (SD=7.9), with autism traits
evaluated by the Autism Spectrum Quotient, all they got a clinical score (AQ>31) or have
previous autism diagnosis. And 119 adults (78.9% female), mean age 32.3 years (SD=9.2), with
no self-report of neurodevelopmental disorder and autism traits.
For the presential assessment, 29 adults (68,9% female), their mean was age 34.1 years
(SD=8) with autism previous diagnosticated following the American Psychiatric
Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria, or with
a relevant suspect that we evaluated with an interview during the process (AQ mean=36.1,
SD=6.1), their mean years of education was 16.9 years (SD=3.6). And the control group had 19
adults (84,2% female), with mean age 30.9 years (SD=10.6), means year of education was 17.2
years (SD=2.7) and mean score of AQ was 20.2 (SD=4.1).
The exclusion criteria for both groups included age below 18 years and above 60 years
old, self-reported history of neurological diseases, intellectual disability or another condition
that could impair the assessment process. For the clinical group, exclusion criteria also included
the presence of moderate or severe traits of autism that could cause important deficits in daily
functionality. And for the control group, clinical score in the AQ scale and the presence or
suspect of autism diagnose were considered exclusion criteria.

Psychological assessment

The 276 volunteers, from the second and online phase, answered a series of
questionnaires besides the AQ, which is a self-report questionnaire with 50 items that are
divided into five different domains: social skill, imagination, communication, attention
switching, and attention to details, and that proposes to assess autism traits in adults with
preserved intelligence. They also responded to:

1. The Brazilian Criteria of Economic Classification (Abep, 2016): a questionnaire

designed to assess the social and economic aspects of the population, using a proxy as
standardized score based on years of education of the family head, number of members living
in the house and quantity of household objects, and access to public services. Higher scores
indicate higher socioeconomic status. The standard score can also be divided in social classes,
labeled “A” to “D-E”, whereas class A indicates higher economic and social level.
 36

2. World Health Organization Disability Assessment Schedule - WHODAS 2.0:

proposed by the World Health Organization, which has different versions, and we choose the
reduced one with 15 items. Its evaluate functionality in six domains, like cognition, mobility,
self-care, social interaction, daily and social activities. The higher score indicates less
functionality in daily life.

To complement the assessment of functionality has been created eight questions to

investigate other aspects of it: 1) How many years in total did you spend studying?; 2) What's
your marital status?; 3) How long have you been in this marital status?; 4) Which option best
describes your main job activity?; 5) How long have you been in this job?; 6) How many jobs
did you have during your life?; 7) Do you contribute with your family income?; 8) Do you live
independently in the community or require assistance?

3. Satisfaction with Life Scale - SWLS (Diener et al., 1985): a simple scale with 5
items which evaluates life satisfaction subjectively. This measure is closely related to wellbeing
and happiness, and judged in a completely subjective manner (in which differs from quality of
life, which have objective indicators). The higher score indicates more satisfaction.
4. Adult Self-Report Scale - ASRS-18 (Leite, 2011): 18 items evaluating adult
attentiondeficit/hyperactivity disorder (ADHD). The first nine items measure symptoms of
inattention, while the other ones represent hyperactivity/impulsivity, where the participant
answers the frequency which symptom occur. A higher score in each dimensions more
symptoms of ADHD.
5. Abbreviated version of the Barratt Impulsiveness Scale 11 - ABIS (Coutlee et al.,
2014): a self-report scale which evaluates three different domains of impulsivity: motor,
decision making and lack of planning, and a summed score which represents the subject general
level of impulsivity. The short version has 13 items, derived from the original 30 questions.
Higher scores indicate higher impulsivity,
6. Passionate Love Scale: scale with 15 items (abbreviate version) designed to
measure the intensity of romantic love toward another person. The number of marked items
indicates the intensity of love, so the higher the total score higher will be the intensity of this
feeling.
7. Cognitive Failures Questionnaire (CFQ): this scale was designed to assess
quantity and frequency of routine mistakes, such as difficulties to focus on some activity, forget
names or commitments and/or problems with decision making. There are 25 questions to
 37

evaluate different cognitive aspects, like attention, memory, language, and a higher overall
score represents more errors observed by the person in his everyday life.
8. Reading The Mind in The Eyes Test - RMEt: test created to assess the capacity
of emotional and facial perception toward images of a person's eyes. Every one task of the test
(total of 37) has a photograph of a pair of eyes expressing some emotion, and the volunteer has
to choose between four options of mental state the one that better match with the facial
expression. Therefore, it's possible to evaluate the basics aspects of the theory of mind. Correct
answers indicate less difficulty with facial and emotional perception.

For the last phase, consisting in a neuropsychological assessment, the 48 volunteers

were interviewed following the DSM-V criteria for Autism Spectrum Disorder and they were
required to answer the DSM-V Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult,
which is a screening instrument for psychiatry symptoms with 23 questions and 13 domains of
mental health, such as depression, mania, anxiety, somatic symptoms, and suicide idea. And,
there was a battery of neuropsychological tests measuring different cognitive functions, like
attention, executive functions, memory, visual ability, and language. Below there are all the
abilities assessed and the respective instruments:

1. Intelligence: two subtests of Wechsler abbreviated scale of intelligence (WASI),

Vocabulary and Matrix Reasoning.
2. Executive function: Planning - Tower of London Test; Cognitive Flexibility -
Five Digit Test (flexibility), Trail Making Test (Part B) and Alternate Verbal Fluency;
Inhibitory Control - Five Digit Test (inhibition), Decision Making - Iowa Gambling Task.
3. Processing speed: Five Digit Test (reading and counting) and Trail Making Test
(Part A).
4. Memory: Verbal and visual working memory - forward and inverse order of
Digit Span and Corsi Test; Long-term memory - immediate and latter evocation of the Taylor
Complex Figure Test and Logic Memory Test.

5. Visual Abilities: Matrix Reasoning (WASI), Visuospatial Ability Test

(THALVES) and the copy of Taylor Complex Figure Test.
6. Language: Vocabulary (WASI), Alternate Verbal Fluency and Boston Naming
Test (BOSTON).
 38

The assessment frequently occurred in two sessions and at the end of all the process, the
volunteers received a report with the principal findings and suggestion of conduct when it was
needed.

Statistical analysis

Firstly, a descriptive analysis was made to characterize both samples and the level of
functionality according to the questions formulated.
Considering the non-parametric distribution of the variables, to investigate the
relationship between autistic traits and all the psychological variables we choose the Spearman
correlation test, with a p value of 0.001. And, the same statistic test was used to define the
relationship between autistic traits and cognitive functions. Moreover, the clinical and control
group were compared in all psychological and cognitive variables using the Mann-Whitney test
(p<0.001), and then we calculated the effect sizes.
All calculations were performed by SPSS Statistic software, version 25.

RESULTS

Autism group x Control group

There weren't significant differences between groups in social demographic measures,

as age, years of education and socioeconomic level. Although, the results suggest a significant
difference in all psychological measures (p<0.001), with moderate effect size in passionate love
(R=-0.33), life satisfaction (R=-0.34), inattention (R=-0.37), cognitive failures (R=-0.39) and
functionality (R=-0.50). And a small effect size in impulsivity (R=-0.14), facial/emotional
perception (R=-0.15), depression and anxiety symptoms (R=0.27) and hyperactivity (R=-0.28).
(Table 1)
However, the results seem different when we consider neurocognitive functionality. We
didn't find any significant difference between groups in the tests results. These findings suggest
that adults with autism from our sample don't have different performance on neurocognitive
tests compared to adults with neurotypical development. Despite that, autistics adults present
important differences regarding psychosocial measures. (Table 2)
 39

Autism traits and psychological/sociodemographic measures

The volunteers (n=276) presented a significant correlation (p<0.001) between autistic

traits and all psychological variables measured by the questionnaires. Correlations between
autistic traits and inattention, hyperactivity, impulsivity, passionate love, functionality,
depression, anxiety and cognitive failures were positives, so the more autistic traits the person
has probably higher will be the self-report of those variables. However, the self-report of life
satisfaction and facial/emotional perception seem to have a negative correlation. So more
autistic traits can lead to less satisfaction with life, and a smaller score on the RMET, it means
more difficulty with basics aspects of theory of mind.
The results suggest a moderate correlation between autistic traits and age (r=0.3),
hyperactivity (r=0.31) life satisfaction (r=-0.33), inattention (r=0.37), depression/anxiety
symptoms (r=0.43) cognitive failures (r=0.45) and functionality (r=0.48). And there was a weak
correlation between impulsivity (r=0.18), facial/emotional perception (r=-0.21) and passionate
love (r=0.27). Also, no correlation between years of education and socioeconomic level. (Table
3)
 40

Table 1: Participants description and group comparison on sociodemographic and psychological measures
Test Neurotypical (n=119) Autism (n=157) Group Comparison*
Pc.25 Pc.50 Pc.75 Pc.25 Pc.50 Pc.75 p r**
Symptoms of Autism Autism Quotient 16 22 27 34 37 40 - -
Age 21 29 36 32 35 38 0.123 0.09
Demographics
Education 15 17 19 15 15 18 0.310 -0.06
SES 31 38 46 29 37 45 0.156 -0.08
SRQ-20 (Depression/Anxiety) 1 4 9 5 7 12 <0.001 0.27
Mental Health
CFQ (Cognitive Complaints) 36 46 60 51 64 75 <0.001 -0.39
RMET (Theory of Mind) -0.6 -0.1 0.5 -1.2 -0.3 0.5 0.011 -0.15
ASRS Inattention 12 17 21 17 22 28 <0.001 -0.37
ADHD Symptoms
ASRS Hyperactivity 10 15 21 16 20 24 <0.001 -0.28
ABIS-11 Impulsivity 23 28 32 25 30 35 0.017 -0.14
Passionate love (PSL) 68 87 103 88 106 116 <0.001 -0.33
Psychosocial
Disability (WHODAS 2.0) 8% 18% 33% 27% 40% 50% <0.001 -0.50
Satisfaction with life (SWLS) 17 23 28 12 17 23 <0.001 -0.34
*Mann-Whitney Test. **Effect size estimated by the Z/(√n) equation
SES: Socioeconomic Status, SRQ-20: Self Reporting Questionnaire 20, CFQ: Cognitive Failures Questionnaire, RMTE: Read the Mind in the Eyes Test, ADHD: Attention
Deficit Hyperactivity Disorder, ASRS: Adult Self-Reporting Scale 18, ABIS-11: Abbreviated Barratt Impulsiveness Scale 11, PSL: Passionate Love Scale, WHODAS: World
Health Organization Disability Assessment Schedule 2.0, SWLS: Satisfaction with Life Scale
 41

Table 2: Participants description and group comparison on neurocognitive measures

Cognitive domain Test Neurotypical (n=19) Autism (n=29) Group Comparison*
Pc.25 Pc.50 Pc.75 Pc.25 Pc.50 Pc.75 p r**
IQ WASI 82 88 95 84 90 95 0.592 0.08
Verbal Fluency (animals 17 19 22 15 19 22 0.708 -0.05
Language Verbal Fluency (Fruits) 14 16 17 14 17 19 0.689 0.06
Vocabulary (WASI) 44 48 53 45 48 51 0.92 -0.01
Boston Naming test (30 items) 26 27 29 25 27 28 0.616 -0.07
Visual Organization 13 14 14 13 14 14 0.765 -0.04
Visuospatial
Modified Taylor Figure 32 34 35 31 32 34 0.090 -0.24
Matrix Reasoning (WASI) 32 38 43 36 40 46 0.259 0.16
Digit Span (Forward) 8 10 12 8 10 11 0.893 0.00
Working Memory Digit Span (Backward) 5 7 9 5 6 7 0.136 -0.21
Corsi Span (Forward) 35 45 54 40 54 70 0.220 0.18
Corsi Span (Backward) 35 54 60 48 58 77 0.070 0.26
Logical memory (Immediate recall) 11 15 18 10 11 16 0.287 -0.15
Logical memory (Delayed recall) 10 15 16 9 10 16 0.069 -0.26
Memory
Logical memory (Recognition) 13 14 15 12 14 15 0.421 -0.12
Modified Taylor Figure (Immediate recall) 16 22 25 15 18,5 24 0.177 -0.20
Modified Taylor Figure (Delayed recall) 18 22 27 16 19 23 0.134 -0.22
Trail Making A 27 38 42 27 36 53 0.614 0.07
Processing Speed
Five Digit Test Reading 20 24 28 19 23 28 0.575 -0.08
Five Digit Test Counting 24 27 31 23 26 30 0.246 -0.17
Tower of London 31 32 34 32 34 35 0.505 -0.10
Five Digit Test Inhibition 10 14 19 7 14 17 0.561 -0.08
Executive Functions
Five Digit Test Flexibility 19 24 33 17 21 29 0.342 -0.14
Trail Making B 62 68 89 52 70 81 0.974 0.00
Switching Fluency Test 8 9 10 7 9 10 0.218 -0.18
Decision Making Iowa Gambling Task -4 3 15 -11 16 35 0.456 0.11
* Mann-Whitney Test. ** Effect size estimated by the Z/(√n) equation
IQ: Intelligence Quotient, WASI: Abbreviated Wechsler Intelligence Scale
 42

Figure 2: Shared variance between different sociodemographic, psychological and

neurocognitive measures with autism traits and disability

Demorgrap 0% 5% 10% 15% 20% 25% 30%

Age
Socio

hic

Education
SES
SRQ-20 (Depression/Anxyety)
Mental
Health

CFQ (Cognitive Complaints)

RMTE (Theory of Mind)
IQ social Symptoms

ASRS Inattention
Psychos ADHD

ASRS Hyperactivity
ABIS-11 Impulsivity
Passionate love (PSL)
Satisfaction with life (SWLS)
WASI
Verbal Fluency (animals
Language

Verbal Fluency (Fruits)

Vocabulary (WASI)
Boston Naming test (30 itens)
Visuospatial

Visual Organization
Mod. Taylor Figure
Matrix Reas. (WASI)
Digti Span (Forw.)
Memory
Working

Digit Span (Back.)

Corsi Span Forw.
Corsi Span Back.
Logical memory (Imm.)
Logical memory (Del.)
Memory

Logical memory (Rec.)

Mod. Taylor Figure (Imm.)
Mod. Taylor Figure (Del.)\
Processing

Trail Making A
DM Executive Functions Speed

FDT Reading
FDT Counting
Tower of London
FDT Inhibition
FDT Flexibility
Trail Making B
Switching Fluency
Iowa Gambling Task

Autism Quotient Whodas 2.0

 43

Functionality and psychological/sociodemographic measures

We found a significant and moderate correlation between daily functionality and life
satisfaction (r=-0.33), impulsivity (r=0.33), hyperactivity (r=0.36), depression/anxiety
symptoms (r=0.38), inattention (r=0.44) and cognitive failures (r=0.53). However, a weak
correlation between facial/emotional perception (r=-0.18) and passionate love (r=0.18). And,
no correlation between functionality and all sociodemographic measures. (Table 3)
All correlations were positives, except satisfaction with life, since higher scores on
WHODAS indicate worse daily functionality, consequently less life satisfaction. The
facial/emotional perception was also negative, so more disabilities are related to more
difficulties with Theory of Mind. (Table 3)

Autism traits and neurocognitive functions

We observed a significant and moderate correlation between autistic traits and the
performance of the inverse order of Corsi test (r=0.39) and inverse order of Digit Span (-0.35),
so seems that visuospatial and verbal working memory have a relationship with autistic features.
Despite this, no correlation was found (p>0.001) between the autism scale and intelligence,
executive functions, language, long-term memory, visuospatial abilities and processing speed.
(Table 4)

Functionality and neurocognitive functions

Considering the adaptive functionality, we observed significant and moderate

correlation only between Logical Memory Test (r=0.36), so higher daily functionality is
associated to higher long-term memory. (Table 4)
 44

Table 3: Correlations between sociodemographic and psychological measures with symptoms

of autism and disability
Autism Quotient WHODAS 2.0
r p r p
Autism x Dyability Autism Quotient 1 . 0,486 <0.001
WHODAS 2.0 0,486 <0.001 1 .
Age 0,302 0,008 -0.012 0.191
Demographics Education -0,028 0,856 -0.056 0.284
SES -0,097 0,107 -0,07 0,247
SRQ-20 (Depression/Anxyety) 0,430 <0.001 0,381 <0.001
Mental Health CFQ (Cognitive Complaints) 0,450 <0.001 0,53 <0.001
RMET (Theory of Mind) -0,212 <0.001 -0,189 0,002
ADHD Symptoms ASRS Inattention 0,376 <0.001 0,449 <0.001
ASRS Hyperactivity 0,31 <0.001 0,362 <0.001
ABIS-11 Impulsivity 0,187 0,002 0,334 <0.001
Psychosocial Passionate love (PSL) 0,276 <0.001 0,186 0,002
Satisfaction with life (SWLS) -0,333 <0.001 -0,332 <0.001
*Mann-Whitney Test. **Effect size estimated by the Z/(√n) equation
SES: Socioeconomic Status, SRQ-20: Self Reporting Questionnaire 20, CFQ: Cognitive Failures Questionnaire,
RMTE: Read the Mind in the Eyes Test, ADHD: Attention Deficit Hyperactivity Disorder, ASRS: Adult Self-
Reporting Scale 18, ABIS-11: Abbreviated Barratt Impulsiveness Scale 11, PSL: Passionate Love Scale,
WHODAS: World Health Organization Disability Assessment Schedule 2.0, SWLS: Satisfaction with Life Scale

Table 4: Correlations between neurocognitive measures and symptoms of autism and disability
Autism Quotient WHODAS 2.0
r p r p
IQ WASI 0,032 0,846 0,008 0,963
Language Verbal Fluency (Animals) -0,126 0,459 0,258 0,123
Verbal Fluency (Fruits) -0,058 0,737 0,004 0,981
Vocabulary (WASI) 0,016 0,921 0,045 0,784
Boston Naming test (30 itens) 0,056 0,726 0,155 0,333
Visuospatial Visual Organization -0,054 0,735 0,034 0,833
Mod. Taylor Figure -0,006 0,973 0,13 0,417
Matrix Reas. (WASI) 0,108 0,508 -0,028 0,866
Working Memory Digti Span (Forw.) -0,136 0,398 -0,031 0,848
Digit Span (Back.) -0,355 0,023 0,279 0,077
Corsi Span Forw. 0,185 0,246 0,053 0,743
Corsi Span Back. 0,39 0,013 -0,108 0,509
Memory Logical memory (Imm.) -0,164 0,311 0,279 0,082
Logical memory (Del.) -0,243 0,13 0,366 0,02
Logical memory (Rec.) 0,002 0,993 0,138 0,396
Mod. Taylor Figure (Imm.) -0,081 0,613 0,306 0,051
Mod. Taylor Figure (Del .)\ -0,107 0,506 0,302 0,055
Processing Speed Trail Making A 0,171 0,285 -0,053 0,741
FDT Reading -0,06 0,709 0,051 0,753
FDT Counting -0,121 0,451 0,125 0,437
 45

Executive Functions Tower of London -0,031 0,847 0,158 0,324

FDT Inhibition -0,013 0,935 0,13 0,419
FDT Flexibility -0,032 0,842 0,185 0,247
Trail Making B 0,079 0,622 -0,098 0,541
Switching Fluency -0,232 0,174 0,056 0,746
Decision Making Iowa Gambling Task 0,132 0,438 0,057 0,738

DISCUSSION

This study shows us important findings of the relationship between autistic traits and
daily functionality with different psychological variables and neurocognitive functions in a
sample of adults with autism and high functionality and adults with neurotypical development.
Moreover, the differences between clinical and control group in the self-report of these
variables and in the performance of cognitive tests.
Initially, we found that autism traits are related to psychiatry symptoms, as depression,
anxiety and ADHD, life satisfaction, cognitive failures, functionality, also, but with less power,
to impulsivity, passionate love, and facial/emotional perception. These findings are in
agreement with studies in the area (Larsson et al., 2014; Dziobek et al., 2015; Roepke et al.,
2017). A review published in 2015 by Mousa and colleagues provides studies which show that
around 40% of individuals with ASD also have ADHD symptoms, 41% are clinically depressed
and 56% are more likely to be diagnosed with some anxiety disorder. They suggest that
individuals with autism are more susceptible to internalizing symptoms considering the
impairments of social stigma and difficulties with interaction and communication that usually
lead to social isolation.
The relationship that we found between autism traits and facial/emotion perception also
was already observed in previous studies and it's a frequent difficulty is this population (Wallace
et al., 2010; Geurts et al., 2016). However, the weakness of this correlation could be understood
if we consider the nature of the test. The RMET evaluate basic aspects of Theory of mind, as
our sample have high functionality, we can hypothesize that they didn't present this difficulty
or developed strategies to deal with this across life.
In related to the neurocognitive functions, the presence of more autism symptoms in the
sample was only correlated to higher scores on visuospatial working memory and lower scores
on verbal working memory. Koshino and colleagues (2005) observed in their sample of adults
with high-functioning autism that the control group might use verbal codes to perform the
memory task, while adults with autism use visual codes. Also, in another study, Geurts and
 46

colleagues (2016) evaluated 236 adults with and without ASD and they concluded that the
clinical group presents higher scores on visual memory, but similar scores on verbal memory.
Considering functionality aspects, we found that different aspects of daily functionality
are related to many psychosocial variables, as satisfaction, psychiatry symptoms and cognitive
failures. Individuals from our study with preserved mobility and cognitive capacity, with no
difficulties with self-care and daily activities, expressed more wellbeing and satisfaction with
their lives. Nevertheless, the presence and intensity of psychiatry symptoms in our sample seem
to impair functionality. It's expected that individuals with depression or anxiety disorders have
lower daily functionality.
Some researches pointed to cognitive preserve in childhood, also average or higher
intelligence, as an important predictor of functionally in adulthood, and the adequate
development of language is related to better outcomes in life (Rutter et al., 2014). It is well
established in the literature that executive functions are strongly related to the ability to adapt
to daily activities (de Paula et al., 2015), to problems resolve (Paiva et al., 2015) and to affective
regulation (Malloy-Diniz et al., 2009) in the general population.
However, some recent studies provide different findings for the autism population.
Some researches lead to the importance of the presence and severity of autism traits impacting
daily functional adaptation. In a study conducted by Tillmann and colleagues (2019), 417
individuals with ASD with different ages were evaluated and their results demonstrated high
impairments in functionality. They found that social communication problems, a core symptom
of autism, contributed to this lower adaptive functionality. While sensory, repetitive symptoms
or co‐occurring psychiatric symptoms didn't have an important contribution. Another study
found similar results. They highlighted the impact of socialization and daily living skills on
adaptive functioning, especially in higher functioning individuals. They suggested that
cognitive function does not fully explain the functionality impairments in the autism population
(Bolognani et al., 2018).
The literature also suggests the same pattern in the autism child population. Baird and
colleagues (2011), observed in 75 children with ASD that autism traits were less associated
with IQ, and they found impairments on adaptive outcome even on those children with average
intelligence. In another study, children with ASD presents adaptive function scores below IQ,
pointing to the presence of impairments in functionality despite cognitive abilities (Lord et al.,
2007). So, the impact of autism traits in daily functionality and the lower profile of adaptive
functioning in our sample were also observed in previous studies. And we also found that
 47

cognitive abilities are not really related to functionality, considering that only long-term verbal
memory correlated to the functionality scale.
The comparisons established between the clinical and control group provided some
results that we expected and are in agreement with the literature. We found significant
differences in all psychological variables. As we already described, it's more frequent in the
autism population the presence of comorbidities psychiatric, as ADHD symptoms
(BerenguerForner et al., 2015; Leitner et al., 2014) and others mental problems, such as
depression and anxiety (Rutter et al., 2015; Croen et al., 2015). And if we consider the core
symptom of ASD as deficits on social interaction and communication, impairing the way
interpersonal relationships are constructed, it's also expected a difference in this population
regarding facial/emotional perception and also romantic love, feeling toward another person
(Stokes et al., 2007). Whereas all the scenario of symptoms and impairments on functionality,
individuals with autism also present less satisfaction with life comparing to neurotypical adults.
(Schmidt et al., 2015).
Considering cognitive abilities, we didn't find differences between groups in the
neuropsychological tests results. Adults with autism and high functionality from our sample
present a preserved cognitive profile, they don't have significantly more or less cognitive
deficits comparing to adults with neurotypical development. There are many studies evaluating
neurocognition of autistic children and the literature are in agreement that this population have
more deficits in executive function, especially planning, inhibitory control, and cognitive
flexibility, also deficits in attention than the neurotypical population. (Taddei & Contena, 2015;
Hill, 2004; Kaland, Smith, & Mortensen, 2008). However, the neuropsychological profile of
adults with mild traits of autism is not really clear, considering that we don't have a large range
of studies in this are yet.
A study conducted by Murphy and colleagues (2015) found different results from ours,
they evaluated 89 males adults with ASD and 89 matched neurotypical control. They found
significant differences between groups in half of the neuropsychological tests. The clinical
group had more deficits on attention, inhibition and emotion recognition. However, they didn't
find correlations between autism symptoms and cognitive factors, and the clinical group also
have more psychological comorbidities than the control group. Those results are similar to ours,
supporting the idea that symptoms severity doesn't predict their cognitive skills.
To finish, the present study has some limitations. In all assessment process, we didn't
have access to the family report, that could give us more details about the patient functionality
and symptoms, also, about the clinical history. Considering that ASD is a neurodevelopmental
 48

disorder, knowing with details about the individual's infancy could have helped us in the
diagnostic process. Another possible limitation was the fact that part of the assessment was
online. Although studies (Hoerguer et al., 2011) provided a good equivalence between tests and
scales used in the virtual and presential environment, answer to questionnaires online can
submit us to possible misinterpretations. Another aspect that could impact our findings was that
we didn't consider the presence of mental disorder as an exclusion criterion for the control
group, only autism or another neurodevelopmental disorder.

CONCLUSION

ASD is a neurodevelopmental disorder consisted of the presence of problems with social

interaction, inflexible, repetitive or stereotyped behaviors and thoughts. Nowadays, it is seen in
a dimensional view. Our study focused on adults with the mild manifestation of the disorder
and those with high functionality. We found that the intensity of these traits is significantly
related to mental health, daily adaptive, satisfaction with life, also influence social interaction.
Functionality can also interfere in these psychosocial variables. On the other hand, autism traits
and functionality weren't related to neurocognitive function, only with working and long-term
memory.
Another important finding is that autism traits influence on deficits in daily functionality
more than cognitive abilities. We also found substantial differences between the groups in all
psychosocial variables, but not between neurocognitive functions, evidencing that the autistics
from our sample presents important impairments only in psychological and social aspects.
Studies with the adult population are necessary because the knowledge of the autism
symptoms and the principal impairments, also how this affect their lives, is essential to guide
the choice of adequate interventions. Since our findings suggest, this intervention should be
focused especially on improving social skills and giving support on basic aspects of daily
adaptive. Also, knowing the major deficits of this group could prepare adolescences for the
adulthood life, planning more effective services and giving proper support. To conclude, studies
in this area are still very necessary and it's the only way to provide adequate intervention,
considering individual difficulties. In this way, turn possible for them to have more positives
outcome and a higher quality of life.

CONFLICTS OF INTEREST
The authors declare no conflict of interest
 49

ACKNOWLEDGMENTS
Alves ALC received an scholarship from Conselho Nacional de Desenvolvimento
Científico e Tecnológico (CNPq).

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Harms, M. B., Martin, A., & Wallace, G. L. (2010). Facial emotion recognition in autism
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20(3), 290-322.

Hernandez, J. A. E. (2016). Validade de construto da Escala de Amor Apaixonado. Revista

Psicologia-Teoria e Prática, 17(3).

Hill, E. L. (2004). Evaluating the theory of executive dysfunction in autism. Developmental

review, 24(2), 189-233.

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Kanner, L. (1943). Autistic disturbances of affective contact. Nervous child, 2(3), 217-250.
 52

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Lai, M. C., & Baron-Cohen, S. (2015). Identifying the lost generation of adults with autism
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Leite, W. B. (2011). Avaliação das propriedades psicométricas da escala de autorrelato de

sintomas do transtorno do déficit de atenção e hiperatividade ASRS-18.

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 53

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 54

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Strunz, S., Schermuck, C., Ballerstein, S., Ahlers, C. J., Dziobek, I., & Roepke, S. (2017).
Romantic Relationships and Relationship Satisfaction Among Adults With Asperger Syndrome
and High‐Functioning Autism. Journal of Clinical Psychology, 73(1), 113-125.

Taddei, S., & Contena, B. (2017). Cognitive processes in ADHD and Asperger’s disorder:
Overlaps and differences in PASS profiles. Journal of attention disorders, 21(13), 1087-1093.
 55

Tarazi, F. I., Sahli, Z. T., Pleskow, J., & Mousa, S. A. (2015). Asperger’s syndrome: diagnosis,
comorbidity and therapy. Expert review of neurotherapeutics, 15(3), 281-293.

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Zanon, C., Bardagi, M. P., Layous, K., & Hutz, C. S. (2014). Validation of the Satisfaction with
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Indicators Research, 119(1), 443-453.
 56

5. CONSIDERAÇÕES FINAIS

Através dos dois artigos apresentados nessa dissertação, realizamos uma análise
descritiva da escala Quociente do Espectro do Autismo (QA) em uma amostra heterogênea de
adultos brasileiros e investigamos a sua precisão no diagnóstico de adultos com TEA e
inteligência preservada. Foi possível concluir que a nossa amostra apresenta um perfil diferente
da amostra do estudo original, mas que apesar disso, a escala apresentou-se eficaz no processo
de diagnóstico.
No segundo estudo, caracterizamos o perfil psicossocial, funcional e neurocognitivo de
indivíduos adultos com TEA e alta funcionalidade. Analisamos as possíveis relações existente
entre essas variáveis e comparamos adultos com autismo com uma amostra de adultos com
desenvolvimento típico. Observamos que a presença e a intensidade de traços autísticos se
relacionam com satisfação com a vida, ansiedade, depressão, sintomas de TDAH, amor
romântico, queixas cognitivas e percepção facial/emocional, além de funcionalidade diária.
Esta, por sua vez, também se relaciona com todas as variáveis psicossociais mencionadas.
Em relação as habilidades neurocognitivas, sintomas de autismo e funcionalidade
apenas se relacionam com memória de trabalho e de longo prazo. Além disso, encontramos
diferenças significativas entre os grupos em todas as variáveis psicossociais avaliadas, porém,
não houve diferenças em relação ao perfil neurocognitivo.
O presente estudo apresenta algumas limitações a serem consideradas, como a ausência
de participação de familiares no estudo, principalmente pais ou cuidadores, o que possibilitaria
ter acesso a mais informações acerca dos sintomas e funcionamento do paciente, bem como
sobre o seu histórico. Parte do estudo foi realizado online, o que poderia nos deixar suscetíveis
a erros de compreensão, embora, haja estudos comprovando que existe equivalência entre
estudos realizados virtual e presencialmente. Por fim, outra possível limitação diz respeito aos
critérios de exclusão do grupo controle, visto que a presença de sintomas psiquiátricos, como
depressão e ansiedade, não foi considerada um critério de exclusão.
Nossos resultados apontam para o impacto dos traços de autismo na adaptação funcional
dos indivíduos, e observamos que as habilidades cognitivas não são capazes de explicar os
prejuízos funcionais que a população de autismo apresenta. Apesar disso, enfatizamos a
importância de estudos como esse visto que possibilitam o desenvolvimento e a escolha de
intervenções que sejam cada vez mais adequadas e que possam atender efetivamente as
demandas das pessoas com autismo. E dessa forma, melhor a qualidade de vida, a satisfação e
o bem-estar dessas pessoas.
 57

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 62

7. ANEXOS

TERMO DE CONSENTIMENTO LIVRE E ESCLARECIDO – Plataforma Virtual

Título da Pesquisa: IDENTIFICAÇÃO DE PREDITORES DE ADAPTAÇÃO

FUNCIONAL EM ADULTOS COM SÍNDROME DE ASPERGER E OUTROS
TRANSTORNOS DO ESPECTRO AUTISTA. FASE 2.

Nome dos Pesquisadores Principais: Prof. Jonas Jardim de Paula, Prof. Marco Aurélio
Romano-Silva
Você sendo convidada (o) a participar desta pesquisa que tem como finalidade
identificar quais características, psicológicas, comportamentais, emocionais e sociais se
relacionam com uma boa capacidade de adaptação ao dia a dia. Nosso foco é a identificação
desses preditores em pessoas com Síndrome de Asperger ou Transtorno do Espectro Autista.
Nossa pesquisa é dividida em cinco fases. Nessa segunda fase convidamos adultos,
independente de terem esses diagnósticos ou não, a responderem uma breve entrevista e alguns
questionários e escalas em ambiente virtual, utilizando uma plataforma disponível na internet.
O foco dessa pesquisa é avaliar adultos com esses dois transtornos e adultos típicos, sem
os transtornos, mas sua prevalência é muito baixa (menos de 1% das pessoas). Seria inviável
atingir o número de participantes de nossa pesquisa, aproximadamente 110 participantes, pelos
meios de recrutamento tradicionais. Nesse sentido desenvolvemos uma plataforma virtual para
a avaliação de uma série de aspectos psicológicos e comportamentais, inclusive aqueles mais
característicos à Síndrome de Asperger e ao Autismo.
Ao participar dessa fase da pesquisa você será convidado a responder uma série de
questionários, escalas e testes sobre as principais características desses dois quadros. Você tem
plena tem liberdade de se recusar a participar e ainda se recusar a continuar participando em
qualquer fase da pesquisa, sem qualquer prejuízo. Sempre que quiser poderá pedir mais
informações sobre a pesquisa através de nossos telefones e e-mails, ou ainda, se necessário,
através do telefone do Comitê de Ética em Pesquisa.
A participação nesta pesquisa não traz complicações legais. Não prevemos maiores
riscos em sua participação, a não ser um possível descoforto durante as entrevistas ou
avaliações. Caso ocorram, você tem total liberdade para solicitar a interrupção das mesmas,
sem qualquer ônus adicional. Os procedimentos adotados nesta pesquisa obedecem aos
Critérios da Ética em Pesquisa com Seres Humanos conforme Resolução no. 196/96 do
 63

Conselho Nacional de Saúde. Nenhum dos procedimentos usados oferece riscos à sua
dignidade. Todas as informações coletadas neste estudo são estritamente confidenciais.
Somente os pesquisadores envolvidos terão conhecimento dos dados.
Ao participar desta pesquisa você não terá nenhum benefício direto. Entretanto,
esperamos que este estudo traga informações importantes sobre pacientes com Síndrome de
Aspeger ou Autismo. Nós nos comprometemos a divulgar os resultados obtidos nos principais
meos de comunicação científica. Você não terá nenhum tipo de despesa para participar desta
pesquisa, bem como nada será pago por sua participação. Contudo, receberá um breve relatório
com o resultado de alguns testes e escalas.
Após estes esclarecimentos, solicitamos o seu consentimento de forma livre para
participar desta pesquisa. Portanto marque, por favor, os itens que se seguem.
Obs: Não assine esse termo se ainda tiver dúvida a respeito. Entre em contato com os
pesquisadores nos e-mails abaixo para qualquer esclarecimento.

Prof. Dr. Jonas Jardim de Paula (Telefone: 31-98399-7175, jonasjardim@gmail.com)

Prof. Dr. Marco Aurélio Romano-Silva (Telefone: 31-3409-9135,
romanosilva@gmail.com)

COEP-UFMG - Comissão de Ética em Pesquisa da UFMG. Av. Antônio Carlos, 6627.

Unidade Administrativa II - 2º andar - Sala 2005. Campus Pampulha. Belo Horizonte, MG –
Brasil. CEP: 31270-901.