Exploring the manifestations of anxiety in children with autism spectrum disorders

This study explores the manifestation and measurement of anxiety symptoms in 415 children with ASDs on a 20-item, parent-rated, DSM-IV referenced anxiety scale. In both high and low-functioning children (IQ above vs. below 70), commonly endorsed items assessed restlessness, tension and sleep difficulties. Items requiring verbal expression of worry by the child were rarely endorsed. Higher anxiety was associated with functional language, IQ above 70 and higher scores on several other behavioral measures. Four underlying factors emerged: Generalized Anxiety, Separation Anxiety, Social Anxiety and Over-arousal. Our findings extend our understanding of anxiety across IQ in ASD and provide guidance for improving anxiety outcome measurement.

Consensus paper: pathological role of the cerebellum in autism

There has been significant advancement in various aspects of scientific knowledge concerning the role of cerebellum in the etiopathogenesis of autism. In the current consensus paper, we will observe the diversity of opinions regarding the involvement of this important site in the pathology of autism. Recent emergent findings in literature related to cerebellar involvement in autism are discussed, including: cerebellar pathology, cerebellar imaging and symptom expression in autism, cerebellar genetics, cerebellar immune function, oxidative stress and mitochondrial dysfunction, GABAergic and glutamatergic systems, cholinergic, dopaminergic, serotonergic, and oxytocin-related changes in autism, motor control and cognitive deficits, cerebellar coordination of movements and cognition, gene-environment interactions, therapeutics in autism, and relevant animal models of autism. Points of consensus include presence of abnormal cerebellar anatomy, abnormal neurotransmitter systems, oxidative stress, cerebellar motor and cognitive deficits, and neuroinflammation in subjects with autism. Undefined areas or areas requiring further investigation include lack of treatment options for core symptoms of autism, vermal hypoplasia, and other vermal abnormalities as a consistent feature of autism, mechanisms underlying cerebellar contributions to cognition, and unknown mechanisms underlying neuroinflammation.

Is schizophrenia on the autism spectrum?

With the ongoing consideration of the diagnostic criteria for mental disorders that is active in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) and International Classification of Diseases (ICD-11) revision processes, it is timely to review the phenomenological overlap between autism and schizophrenia. These disorders have at various times been regarded alternatively as closely related and as non-overlapping and incompatible. Nevertheless, there are several reports in the literature that have described individuals with both autism and schizophrenia, and the broader phenotypes of these disorders clearly intersect. Recent studies reveal theory of mind deficits in both disorders, and mirror neuron impairments also appear to be shared. There also may be similar connectivity deficits emerging in functional imaging studies, and both disorders share several genetic signals that are being identified through detection of copy number variants. Taken together, these data suggest that it may be time to revisit the possibility that these disorders are related.

The association between short and long nocturnal sleep durations and risky behaviours and the moderating factors in Taiwanese adolescents

Sleep quantity and risky behaviours are important health issues in adolescents. This cross-sectional study aimed to examine the association between short and long nocturnal sleep durations and a variety of adolescent risky behaviours, including suicidality, violence, regular alcohol consumption, illicit drug use, truancy, unprotected sex, tattooing and criminal record of theft in a large-scale, representative population of Taiwanese adolescents, and to examine the moderating factors for the association between nocturnal sleep duration and risky behaviours. A total of 8319 adolescent students in southern Taiwan were recruited into this study and completed the questionnaires. The associations between short and long nocturnal sleep durations and adolescent risky behaviours, as well as the moderating effects of depression and socio-demographic characteristics on these associations, were examined. The results indicated that short nocturnal sleep duration was significantly associated with all risky behaviours, and long nocturnal sleep duration was significantly associated with all risky behaviours except for suicidality. Meanwhile, depression, sex, age, and maternal education level had moderating effects on the association between nocturnal sleep duration and several risky behaviours. The findings imply that professionals should investigate the concomitant risky behaviours in adolescents with short or long nocturnal sleep duration.

Lack of efficacy of citalopram in children with autism spectrum disorders and high levels of repetitive behavior: citalopram ineffective in children with autism

CONTEXT

Selective serotonin reuptake inhibitors are widely prescribed for children with autism spectrum disorders.

OBJECTIVES

To determine the efficacy and safety of citalopram hydrobromide therapy for repetitive behavior in children with autism spectrum disorders.

DESIGN

National Institutes of Health-sponsored randomized controlled trial.

SETTING

Six academic centers, including Mount Sinai School of Medicine, North Shore-Long Island Jewish Health System, University of North Carolina at Chapel Hill, University of California at Los Angeles, Yale University, and Dartmouth Medical School.

PARTICIPANTS

One hundred forty-nine volunteers 5 to 17 years old (mean [SD] age, 9.4 [3.1] years) were randomized to receive citalopram (n = 73) or placebo (n = 76). Participants had autistic spectrum disorders, Asperger disorder, or pervasive developmental disorder, not otherwise specified; had illness severity ratings of at least moderate on the Clinical Global Impressions, Severity of Illness Scale; and scored at least moderate on compulsive behaviors measured with the Children's Yale-Brown Obsessive Compulsive Scales modified for pervasive developmental disorders.

INTERVENTIONS

Twelve weeks of citalopram hydrobromide (10 mg/5 mL) or placebo. The mean (SD) maximum dosage of citalopram hydrobromide was 16.5 (6.5) mg/d by mouth (maximum, 20 mg/d).

MAIN OUTCOME MEASURES

Positive response was defined by a score of much improved or very much improved on the Clinical Global Impressions, Improvement subscale. An important secondary outcome was the score on the Children's Yale-Brown Obsessive Compulsive Scales modified for pervasive developmental disorders. Adverse events were systematically elicited using the Safety Monitoring Uniform Report Form.

RESULTS

There was no significant difference in the rate of positive response on the Clinical Global Impressions, Improvement subscale between the citalopram-treated group (32.9%) and the placebo group (34.2%) (relative risk, 0.96; 95% confidence interval, 0.61-1.51; P > .99). There was no difference in score reduction on the Children's Yale-Brown Obsessive Compulsive Scales modified for pervasive developmental disorders from baseline (mean [SD], -2.0 [3.4] points for the citalopram-treated group and -1.9 [2.5] points for the placebo group; P = .81). Citalopram use was significantly more likely to be associated with adverse events, particularly increased energy level, impulsiveness, decreased concentration, hyperactivity, stereotypy, diarrhea, insomnia, and dry skin or pruritus.

CONCLUSION

Results of this trial do not support the use of citalopram for the treatment of repetitive behavior in children and adolescents with autism spectrum disorders. Trial Registration clinicaltrials.gov Identifier: NCT00086645.

Pharmacology and genetics of autism: implications for diagnosis and treatment

Autism has the highest estimated heritability (>90%) among behaviorally defined neuropsychiatric disorders. Rapidly advancing genomic technologies and large international collaborations have increased our understanding of the molecular genetic causes of autism. Pharmacogenomic approaches are currently being applied in two single-gene disorders, fragile X syndrome and Rett syndrome, which capture many aspects of the autistic phenotype. This review describes the current state of the genetics of autism and suggests how to extend pharmacological principles pioneered in fragile X and Rett to the broader group of patients with autism.

Functional and nonfunctional female receptivity signals in the parasitoid wasp Spalangia endius (Hymenoptera: Pteromalidae)

In many taxa, females signal during courtship when they are receptive. However, just because a female signals does not mean that the male responds to the signal. This study examines female signaling of receptivity (readiness to copulate) and male response in the parasitoid wasp Spalangia endius Walker. Females folded their antennae against their heads when they were receptive, and antennal folding has been shown to be effective in eliciting male copulation attempts in a confamilial. However, male S. endius did not respond to antennal folding: males did not contact the female's antennae during courtship, and how quickly a male attempted copulation was independent of whether or not the female had antennae. Males courted from on top of the female's abdomen and appeared to detect receptivity directly from the female's abdomen rising as her genital orifice opened. On females whose abdomens did not rise, initiation of male copulation attempts were delayed but not eliminated. Based on its current lack of function as a receptivity signal and on comparisons to published reports of mating behavior in confamilials, we hypothesize that female antennal folding at receptivity is a vestigial trait in S. endius.

An update on pharmacologic treatments for autism spectrum disorders

Increasingly recognized over the past 20 years, autism spectrum disorders (ASD) are heterogeneous. Medication treatments remain fundamentally ameliorative, so prioritizing symptoms and matching medications to the patient's constellation of symptoms remains the psychopharmacologic approach to ASD. Atypical antipsychotic medications and glutamatergic agents are receiving increased attention, and antidepressants are being examined for specific symptoms and for younger patients who have autism. Large multisite networks (Research Units on Pediatric Psychopharmacology; Studies to Advance Autism Research and Treatment) have been constructed to expedite studies to elucidate effective treatments for ASD. Findings from these networks are coupled with those from recent independent trials.

Males mate guard in absentia through extended effects of postcopulatory courtship in the parasitoid wasp Spalangia endius (Hymenoptera: Pteromalidae)

The proximal mechanisms leading to monandry have been little studied in most insect orders, including Hymenoptera. In the parasitoid wasp Spalangia endius, mated females are less attractive (less often mounted) than virgins and are unreceptive (unlikely to allow copulation). Which aspects of mating are responsible was tested by observing male responses toward females whose mating had been interrupted at various stages. All females were allowed to receive precopulatory courtship and to open their genital aperture to copulate. Then some were interrupted before copulation, some after copulation but before postcopulatory courtship, and some were allowed to complete postcopulatory courtship. Females that had copulated were not less attractive than females that had not. In contrast, females that had received postcopulatory courtship were clearly both less attractive and less receptive. Thus, postcopulatory courtship functions as extended mate guarding, by making the female less attractive and less receptive to subsequent males even after the original male is no longer present. The effect of postcopulatory courtship on female attractiveness was persistent but imperfect: when males were presented sequentially to mated females, most but not all males retreated without mounting, and a female could repulse more than twenty males in succession.

Autism spectrum disorders: emerging pharmacotherapy

Autism, Asperger and other pervasive developmental disorders (PDDs) are an increasingly commonly identified group of conditions wherein patients experience significant difficulty in social interactions, communicating with others, and inflexible adherence to unusual, unhelpful and frequently stereotyped routines and behaviour. These autism spectrum disorders are now being diagnosed earlier in life (approximately 15 months), and often remain a chronic, daily burden for those afflicted. In addition to the often profound impact on an individual's quality of life, the familial, social and economic burdens of PDDs can be enormous. No treatments are curative, and most pharmacological treatments are employed to treat specific troubling symptoms rather than the core features of the disorder itself. Therefore, more effective pharmacotherapies are desperately needed. This review describes current and emerging pharmacotherapies that may advance care of people with PDDs.

Effects of constrained females on offspring sex ratios ofNasonia vitripennisin relation to local mate competition theory

Empirical studies of how constrained females affect sex ratio are few. Constrained females are those that can produce only sons (e.g., in haplodiploid species, females that have not mated or older females that have used up their sperm). In the parasitoid wasp Nasonia vitripennis (Walker, 1836), failure to mate soon after emergence increased the probability of a female being constrained and thus affected sex ratio directly. Local mate competition theory shows that whether a female is constrained can also affect sex ratio indirectly by affecting what sex ratio other females produce. However, this was not the case in N. vitripennis. A female's sex ratio was not significantly different when she was with another young mated female versus a virgin female or an old mated female depleted of sperm. These results suggest that N. vitripennis females may be unable to recognize whether another female is constrained. The increased proportion of sons in response to other females relative to when alone did not persist the day after exposure.

Outcome measures for clinical drug trials in autism

This paper identifies instruments and measures that may be appropriate for randomized clinical trials in participants with autism spectrum disorders (ASDs). The Clinical Global Impressions scale was recommended for all randomized clinical trials. At this point, however, there is no "perfect" choice of outcome measure for core features of autism, although we will discuss five measures of potential utility. Several communication instruments are recommended, based in part on suitability across the age range. In trials where the intention is to alter core features of ASDs, adaptive behavior scales are also worthy of consideration. Several "behavior complexes" common to ASDs are identified, and instruments are recommended for assessment of these. Given the prevalence of cognitive impairment in ASDs, it is important to assess any cognitive effects, although cognitive data from ASD randomized clinical trials, thus far, are minimal. Guidance from trials in related pharmacologic areas and behavioral pharmacology may be helpful. We recommend routine elicitation of side effects, height and weight, vital signs, and (in the case of antipsychotics) extrapyramidal side-effects assessment. It is often appropriate to include laboratory tests and assessments for continence and sleep pattern.

Impact of recent findings on study design of future autism clinical trials

There are specific challenges to studying the design of pharmacologic trials in child/adolescent and adult autism, such as subject stratification and parallel versus crossover designs. This article describes how optimal study design is influenced by subject selection and outcome measures chosen. Lessons learned in study design from the Research Units on Pediatric Psychopharmacology Autism Network trial with risperidone, Seaver Center trials with fluoxetine and valproate, Dartmouth trials with amantadine, and National Institutes of Health secretin trials are highlighted. The Internet System for Assessing Autistic Children system for managing multicenter clinical trials in autism and statistical issues in autism research are also described.

Asperger syndrome: to be or not to be?

PURPOSE OF REVIEW

Asperger syndrome is a pervasive developmental disorder characterized by impairments in social interactions, such as nonverbal behaviors, failure to develop peer relationships, and lack of social reciprocity with restricted, repetitive and stereotyped patterns of interest or behavior. The diagnosis of Asperger syndrome is increasingly common, and it is timely to review its phenomenology and treatment.

RECENT FINDINGS

As there is a growing public awareness and acceptance of Asperger syndrome, clinical research has produced mixed results that do not clearly discriminate Asperger syndrome from high-functioning autism. However, research does indicate that children with pervasive developmental disorder achieve better outcomes when diagnosis is made early and appropriate community supports can be marshaled.

SUMMARY

The history and phenomenology of Asperger syndrome is briefly reviewed, and recent literature relating to assessment and treatment is highlighted.

The quality of health care for adults with developmental disabilities

OBJECTIVE

The purpose of this study was to determine the health status of adults with developmental disabilities residing in community settings and the quality of the preventive, medical, dental, and psychiatric services they receive.

METHODS

Data were collected on a sample of 353 adults residing in Los Angeles, California, in 1997. Historical data were obtained from study subjects or caregivers, physical and dental examinations were performed, blood was drawn for analysis, and a psychiatrist reviewed medical records for reports of psychiatric diagnoses and consultations.

RESULTS

Health markers, such as rates of obesity, and laboratory test results of routine screening panels including blood cell counts, hemoglobin, and hematocrits; blood concentrations of liver enzymes and other enzymes, cholesterol, and tryglycerides; and urinalyses were within normal limits for an adult population. However, preventive services were notably lacking, especially for individuals living at home. Fewer than half of the study subjects had received influenza vaccine; only a third of those living alone or with family or friends had received this vaccination. Chart audits revealed that about a third received psychotropic medications, but only 24% of these individuals had psychiatric consultations noted in their record. Further, 36% of this medicated group received psychotropic drugs without any identifiable diagnosis, and simultaneous receipt of two or more antipsychotics was not uncommon.

CONCLUSIONS

Given that the U.S. health care system fails to ensure the provision of preventive services for all people, including the developmentally disabled, a systematic overhaul is necessary to establish an effective quality assurance program that will provide preventive medical, dental, and psychiatric services for people with developmental disabilities.

Maladaptive behaviour in children and adolescents with Down's syndrome

BACKGROUND

Although children with Down's syndrome (DS) are at lower risk for psychopathology than others with intellectual disability, they do show more problems than typically developing children. However, age-related trends in these problems remain unclear.

METHODS

The present authors examined age-related changes in the maladaptive behaviours of 211 children and adolescents with DS aged between 4 and 19 years (mean = 9.74 years). Most participants (n = 180) were recruited from families residing in the greater Los Angeles area, California, USA, while a minority (n = 31) were patients from a clinic specializing in the psychiatric management of people with DS. The participants were divided into four age groups: (1) 4-6 years, (2) 7-9 years, (3) 10-13 years and (4) 14-19 years.

RESULTS

Externalizing behaviours were lower across both the community and clinic samples, while internalizing behaviours were significantly higher in older adolescents aged between 14 and 19 years. Increases were found in withdrawal, seen in 63% of community-based adolescents, and 75% of clinic adolescents.

CONCLUSIONS

Older adolescents with DS may show decreased externalizing symptoms and subtle increases in withdrawal. Possible relationships are discussed between these shifts and increased risks of later-onset depression and Alzheimer's disease in adults with DS.

Treatment of pain in acutely burned children

The child with burns suffers severe pain at the time of the burn and during subsequent treatment and rehabilitation. Pain has adverse physiological and emotional effects, and research suggests that pain management is an important factor in better outcomes. There is increasing understanding of the private experience of pain, and how children benefit from honest preparation for procedures. Developmentally appropriate and culturally sensitive pain assessment, pain relief, and reevaluation have improved, becoming essential in treatment. Pharmacological treatment is primary, strengthened by new concepts from neurobiology, clinical science, and the introduction of more effective drugs with fewer adverse side effects and less toxicity. Empirical evaluation of various hypnotic, cognitive, behavioral, and sensory treatment methods is advancing. Multidisciplinary assessment helps to integrate psychological and pharmacological pain-relieving interventions to reduce emotional and mental stress, and family stress as well. Optimal care encourages burn teams to integrate pain guidelines into protocols and critical pathways for improved care.

The quality of health care for adults with developmental disabilities

OBJECTIVE

The purpose of this study was to determine the health status of adults with developmental disabilities residing in community settings and the quality of the preventive, medical, dental, and psychiatric services they receive.

METHODS

Data were collected on a sample of 353 adults residing in Los Angeles, California, in 1997. Historical data were obtained from study subjects or caregivers, physical and dental examinations were performed, blood was drawn for analysis, and a psychiatrist reviewed medical records for reports of psychiatric diagnoses and consultations.

RESULTS

Health markers, such as rates of obesity, and laboratory test results of routine screening panels including blood cell counts, hemoglobin, and hematocrits; blood concentrations of liver enzymes and other enzymes, cholesterol, and tryglycerides; and urinalyses were within normal limits for an adult population. However, preventive services were notably lacking, especially for individuals living at home. Fewer than half of the study subjects had received influenza vaccine; only a third of those living alone or with family or friends had received this vaccination. Chart audits revealed that about a third received psychotropic medications, but only 24% of these individuals had psychiatric consultations noted in their record. Further, 36% of this medicated group received psychotropic drugs without any identifiable diagnosis, and simultaneous receipt of two or more antipsychotics was not uncommon.

CONCLUSIONS

Given that the U.S. health care system fails to ensure the provision of preventive services for all people, including the developmentally disabled, a systematic overhaul is necessary to establish an effective quality assurance program that will provide preventive medical, dental, and psychiatric services for people with developmental disabilities.

Autism spectrum disorders: update of evaluation and treatment

Autistic spectrum disorders are a group of neurodevelopmental conditions that are increasingly capturing the attention of clinicians and investigators. New insights from genetics and neuropathophysiology of autism will increasingly inform treatment. Presently, individualized treatment approaches typically include a mix of behavioral and, occasionally, pharmacotherapeutic strategies. Concerning the latter, exquisite sensitivity to medication is not uncommon in some children with autism.

Self-injurious behavior: gene-brain-behavior relationships

This paper summarizes a conference held at the National Institute of Child Health and Human Development on December 6-7, 1999, on self-injurious behavior [SIB] in developmental disabilities. Twenty-six of the top researchers in the U.S. from this field representing 13 different disciplines discussed environmental mechanisms, epidemiology, behavioral and pharmacological intervention strategies, neurochemical substrates, genetic syndromes in which SIB is a prominent behavioral phenotype, neurobiological and neurodevelopmental factors affecting SIB in humans as well as a variety of animal models of SIB. Findings over the last decade, especially new discoveries since 1995, were emphasized. SIB is a rapidly growing area of scientific interest to both basic and applied researchers. In many respects it is a model for the study of gene-brain-behavior relationships in developmental disabilities.

Double-blind, placebo-controlled study of amantadine hydrochloride in the treatment of children with autistic disorder

OBJECTIVE

To test the hypothesis that amantadine hydrochloride is a safe and effective treatment for behavioral disturbances--for example, hyperactivity and irritability--in children with autism.

METHOD

Thirty-nine subjects (intent to treat; 5-19 years old; IQ > 35) had autism diagnosed according to DSM-IV and ICD-10 criteria using the Autism Diagnostic Interview-Revised and the Autism Diagnostic Observation Schedule-Generic. The Aberrant Behavior Checklist-Community Version (ABC-CV) and Clinical Global Impressions (CGI) scale were used as outcome variables. After a 1-week, single-blind placebo run-in, patients received a single daily dose of amantadine (2.5 mg/kg per day) or placebo for the next week, and then bid dosing (5.0 mg/kg per day) for the subsequent 3 weeks.

RESULTS

When assessed on the basis of parent-rated ABC-CV ratings of irritability and hyperactivity, the mean placebo response rate was 37% versus amantadine at 47% (not significant). However, in the amantadine-treated group there were statistically significant improvements in absolute changes in clinician-rated ABC-CVs for hyperactivity (amantadine -6.4 versus placebo -2.1; p = .046) and inappropriate speech (-1.9 versus 0.4; p = .008). CGI scale ratings were higher in the amantadine group: 53% improved versus 25% (p = .076). Amantadine was well tolerated.

CONCLUSIONS

Parents did not report statistically significant behavioral change with amantadine. However, clinician-rated improvements in behavioral ratings following treatment with amantadine suggest that further studies with this or other drugs acting on the glutamatergic system are warranted. The design of these and similar drug trials in children with autistic disorder must take into account the possibility of a large placebo response.

Case series: amantadine open-label treatment of impulsive and aggressive behavior in hospitalized children with developmental disabilities

OBJECTIVE

A growing body of literature implicates interactions between glutamatergic and neostriatal dopaminergic neurotransmitter systems in the development and expression of impulsivity, hyperactivity, and stereotypy. Amantadine hydrochloride, a drug used in young children for influenza prophylaxis, acts both as an indirect dopamine agonist as well as an N-methyl-D-aspartate (NMDA) receptor antagonist. Thus an open clinical trial of this medication for the treatment of symptoms of impulse control disorders in children was performed.

METHOD

A total of eight children (seven with neurodevelopmental disorders and all inpatients) with target behaviors refractory to other treatments were selected after parental informed consent. All patients were male and ranged in age from 4 to 12 years. Outcome was based on subjective consensus clinical ratings by the multidisciplinary treatment team.

RESULTS

For four of the children, amantadine was associated with marked clinical improvement. In the remainder, improvement was also observed. Amantadine was well tolerated.

CONCLUSIONS

On the basis of this experience, it appears that amantadine hydrochloride or related NMDA antagonists may warrant additional study in this and related populations.