Management of hyperactivity and other acting-out problems in patients with autism spectrum disorder

Hyperactivity/impulsivity, aggression, self injury, and irritability are disruptive behaviors that frequently accompany autism spectrum disorders (ASD). The psychostimulants and atypical antipsychotics have been used with some success to manage hyperactivity, but neither drug group is fully satisfactory and clinical response to the stimulants varies. For other disruptive symptoms (irritability, aggression, self injury), both older antipsychotics and newer atypical antipsychotics have been shown to have helpful effects. Because of potential side effects, atypical antipsychotics should ordinarily be preferred over older agents. A small group of studies suggests that selective serotonin reuptake inhibitors may be helpful in managing symptoms related to aggression, self injury, and the like. A small and largely imperfect literature suggests that beta blockers, mood stabilizers, and alpha-2 agonists may also have some role for treating such symptoms. More research is needed on the management of all of these target symptoms, both for new agents (e.g., atomoxetine) and for established psychoactive medicines.

Clozapine Withdrawal Catatonia Associated With Cholinergic and Serotonergic Rebound Hyperactivity

Catatonia as a clozapine withdrawal syndrome has not been well documented. There is only 1 case of excited catatonia described with the diagnosis made according to strict criteria. The authors report a patient who developed a catatonic stuporous state following abrupt discontinuation of clozapine, associated with features of cholinergic and serotonergic hyperactivity. The catatonic state resolved within 1 week with reinstatement of clozapine. It is suggested that serotonergic hyperactivity was involved, contributed by cholinergic rebound, in the pathogenesis of this patient's clozapine withdrawal catatonic syndrome.

An association of Ephedra use with psychosis and autonomic hyperactivity

Ephedra extract is used in a number of dietary supplements taken for a variety of purposes including weight loss. Although recent events have led to calls for Ephedra to be removed from the market and the FDA has had over 18,000 adverse event reports, newspaper reports cite only a few instances of clearly associated adverse events associated with Ephedra use. In this communication, we review the literature and present a case report of Ephedra use associated with the onset of psychosis and autonomic hyperactivity after administration of risperidone. We conclude that the behavioral effects of Ephedra are a public health concern.

The effects of a double blind, placebo controlled, artificial food colourings and benzoate preservative challenge on hyperactivity in a general population sample of preschool children

AIMS

To determine whether artificial food colourings and a preservative in the diet of 3 year old children in the general population influence hyperactive behaviour.

METHODS

A sample of 1873 children were screened in their fourth year for the presence of hyperactivity at baseline (HA), of whom 1246 had skin prick tests to identify atopy (AT). Children were selected to form the following groups: HA/AT, not-HA/AT, HA/not-AT, and not-HA/not-AT (n = 277). After baseline assessment, children were subjected to a diet eliminating artificial colourings and benzoate preservatives for one week; in the subsequent three week within subject double blind crossover study they received, in random order, periods of dietary challenge with a drink containing artificial colourings (20 mg daily) and sodium benzoate (45 mg daily) (active period), or a placebo mixture, supplementary to their diet. Behaviour was assessed by a tester blind to dietary status and by parents' ratings.

RESULTS

There were significant reductions in hyperactive behaviour during the withdrawal phase. Furthermore, there were significantly greater increases in hyperactive behaviour during the active than the placebo period based on parental reports. These effects were not influenced by the presence or absence of hyperactivity, nor by the presence or absence of atopy. There were no significant differences detected based on objective testing in the clinic.

CONCLUSIONS

There is a general adverse effect of artificial food colouring and benzoate preservatives on the behaviour of 3 year old children which is detectable by parents but not by a simple clinic assessment. Subgroups are not made more vulnerable to this effect by their prior levels of hyperactivity or by atopy.

Contractile properties, fiber types, and myosin isoforms in fast and slow muscles of hyperactive Japanese waltzing mice

This study focuses on the effects of neuromuscular hyperactivity on the contractile properties, fiber type composition, and myosin heavy chain (MHC) isoform expression of fast-twitch extensor digitorum longus (EDL) and slow-twitch soleus (SOL) muscles in Japanese waltzing mice (JWM) of the C57BL/6J-v2J strain. The same properties were studied in the homologous muscle of control CBA/J mice (CM). In comparison to CM, the JWM exhibited (i) longer activity periods, prolonged bouts of running and a higher food intake, (ii) slower twitch and tetanic contractions of both EDL and SOL muscles, decreased cold and post-tetanic potentiation of the EDL, as well as increased cold and post-tetanic depressions of the SOL. Electrophoretic analyses of MHC isoform revealed a shift toward slower isoforms in both EDL and SOL muscles of JWM as compared to the homologous muscles of CM, namely, a shift from the fastest MHCIIb to the MHCIId/x isoform in the EDL muscle and a shift from MHCIIa to MHCI in the SOL muscle. The latter also contained a higher percentage of type I fibers and displayed a higher capillary density than the SOL muscle of CM. These findings show that the inherently enhanced motor activity of the JWM leads to fiber type transitions in the direction of slower phenotypes. JWM thus represent a suitable model for studying fast-to-slow fiber transitions under the influence of spontaneous motor hyperactivity.

[Clinical heterogeneity of Alzheimer's disease. Different clinical profiles can predict the progression rate]

INTRODUCTION

Alzheimer's disease (AD) is a degenerative dementia that may disclose different cognitive, behavioral, psychiatric and functional symptoms since onset. These distinct cognitive profiles support the conception of clinical heterogeneity and account for AD's highly variable rate of progression. In spite of strict diagnostic criteria NINCS ADRDA's and DSM IV the clinical certainty is only about 85%. Mayeux define 4 subtypes: a). Benign: mild cognitive and functional impairment without focal signs and late onset behavioral signs, slow progression; b). Myoclonic: usually of presenile onset with severe cognitive deterioration, mutism and early onset myoclonus; c). Extrapyramidal: early onset akineto rigid signs with severe cognitive, behavioral and psychiatric involvement; d). Typical: gradual and progressive cognitive, behavioral and functional impairment. The differentiation of these subtypes will allow us to define discrete patterns of progression, to define prognostic subgroups, and to homogenize them for clinical research and drug trials.

DEVELOPMENT

We examined 1000 charts of probable AD patients from the Santojanni Center. We found 42% extrapyramidal, 35% typical, 15% benign and 8% myoclonic. The early onset of parkinsonism and myoclonus predict a rapidly evolving cognitive impairment and a more severe rate of progression with psychiatric disorders and dependency in activities of daily living. (DADL) Patients with low level of education, low cognitive performance at entry as well as those with rapid rate of cognitive deterioration had a faster rate of progression to DADL.

CONCLUSION

Delusions, low level of education, extrapyramidal signs and motor hyperactivity but not hallucinations, and anosognosia were the best non cognitive predictors of DADL.

Mobilized peripheral blood cells administered intravenously produce functional recovery in stroke

Filgratism (granulocyte colony stimulating factor, G-CSF)-mobilized peripheral blood progenitor cells (PBPCs) have replaced bone marrow (BM) as a preferred source of autologous stem cells, in light of the faster hematologic recovery and lesser supportive care requirement exhibited by PBPC transplants. Other hematopoietic stem cells, like the human umbilical cord blood-derived stem cells (hUCBs), and nonhematopoietic stem cells have been shown to improve motor function in rodent models of injury and degenerative disease. In the present study we transplanted either G-CSF-mobilized PBPCs or hUCBs in rats 24 h after permanent middle cerebral artery occlusion (MCAO), and assessed their behavioral abnormalities in spontaneous activity and spontaneous motor asymmetry. In both transplanted groups of rats we observed a significant reduction of the stroke-induced hyperactivity compared with nontransplanted, stroked animals. In addition, transplantation of G-CSF PBPC and hUCB cells prevented the development of extensive motor asymmetry. Our findings raise the possibility that PBPCs could provide a novel transplantation therapy to treat stroke.

Involuntary vocalisations and a complex hyperkinetic movement disorder following left side thalamic haemorrhage

A variety of involuntary speech phenomena as for example palilalia have been described as consequences of neurological disorders. Palilalia is the involuntary repetition of syllabels, words and phrases in ongoing speech. We describe a 73 year old woman who suffered from a hypertensive thalamic haemorrhage. MRI revealed that the lesion was predominantly located within the pulvinar, extending to the lateroposterior thalamic nuclei and to the pretectal area with possible involvement of the medial geniculate body. Few months after the event she developed involuntary vocalisations with whole words and meaningless syllables being rapidly reiterated. In contrast to typical palilalia these vocalisations were not meaningfully related to the ongoing speech of the patient. In addition, the patient developed a complex hyperkinetic movement disorder with right-sided painful hemidystonia and bilateral clonic jerks and a right-sided postural tremor.

Sleep-related hyperkinetic seizures of temporal lobe origin

Sleep-related hyperkinetic seizures are a common feature of nocturnal frontal lobe epilepsy. Although sleep-related seizures with a temporal lobe origin have been reported, they commonly lack hyperkinetic activity. The authors describe three patients with sleep-related seizures characterized by frenetic, agitated, hyperactive movements (bimanual/bipedal activity, rocking, axial, pelvic, and hemiballistic movements), in whom stereo-EEG investigation and surgical outcome demonstrated a temporal lobe origin of the attacks.

Cerebellar deficits and hyperactivity in mice lacking Smad4

Smad4 is a central mediator of TGF-beta signals, which are known to play essential roles in many biological processes. Using a Cre-loxP approach to overcome early embryonic lethality, we have studied functions of TGF-beta/Smad4 signals in the central nervous system (CNS). No obvious deficits were detected in mice carrying the targeted disruption of Smad4 in the CNS. The overall morphology of the hippocampus appeared normal. There was no change in the proliferation of neuronal precursor cells, nor in several forms of synaptic plasticity. In contrast, deletion of Smad4 resulted in a marked decrease in the number of cerebellar Purkinje cells and parvalbumin-positive interneurons. Accompanied by the abnormality in the cerebellum, mutant mice also exhibited significantly increased vertical activity. Thus, our study reveals an unexpected role for Smad4 in cerebellar development and in the control of motor function.

Adaptability of Japanese quail chicks to conditions of simulated weightlessness

The objective of this study was to evaluate the adaptability of young Japanese quail chicks to the simulated weightlessness, represented by hypodynamy. Unsexed hatchlings were subjected to hypodynamy on either the first, second or third day of age and reared under these conditions to 21 days of age. During this period, the control quail chicks were housed in a floor box. The effect of hypodynamy on adaptability of chicks was significant (P < 0.001). Approximately 75% of all chicks exposed to hypodynamy were not able to adapt in three experimental groups, although significant differences in adaptability were not found between these groups. Those birds were considered as non-adapted (eliminated from experiment) that manifested hyperactivity, escape attempts, turning 180 degrees in the sling, soaking in the water from the drinker, as well as the total apathy, at least three times per day. This experiment confirmed that some quail chicks are capable of adapting to conditions simulating weightlessness to 21 days of age and that the first 2-weeks after hatching may be a critical period of quail sensitivity to hypodynamy. This finding raises a key issue relevant to rearing quails in simulated weightlessness until the age of sexual maturity.

Antisocial violent offenders with attention deficit hyperactivity disorder demonstrate akathisia-like hyperactivity in three-channel actometry

Actometry enables quantitative and qualitative analysis of various hyperactivity disorders. Antisocial violent offenders have demonstrated diurnal increases in motor activity that may be related to attention deficit hyperactivity disorder (ADHD) that often precedes antisocial development. Motor restlessness in ADHD has common features with neuroleptic-induced akathisia. In this study, three-channel actometry was used to compare 15 antisocial violent offenders who had a history of ADHD with 15 healthy control subjects and 10 akathisia patients. The Barnes Akathisia Rating Scale (BARS) was used for clinical evaluation of akathisia symptoms. Ankle movement indices and the ankle-waist ratio differentiated the antisocial patients from the healthy controls significantly, with no overlap, and the same parameters expectedly differentiated the akathisia patients from the healthy controls. The repetitive, rhythmic pattern of akathisia was found in 13 of the 15 antisocial patients. Nine of the antisocial patients scored 2 or 3 (mild to moderate akathisia) on the BARS. Thus, the motor hyperactivity of antisocial ADHD patients has common features with mild akathisia. This may be due to a common hypodopaminergic etiology of ADHD and akathisia.

Pharmacological evidence for a correlation between hippocampal CA1 cell damage and hyperlocomotion following global cerebral ischemia in gerbils

Global ischemia, induced in Mongolian gerbils by bilateral occlusion of the carotid arteries for 5 min, produced a significant increase in locomotor activity at 1 day post-occlusion and a severe loss of hippocampal CA1 neurons at 4 days post-occlusion. To explore the pharmacological relationship between ischemia-induced hypermotility and CA1 cell death in the hippocampus, we evaluated the efficacy of diverse classes of putative neuroprotective agents for preventing hypermotility and delayed neuronal death. Administration of any drug 30 min before global ischemia dose-dependently, and with similar potency, ameliorated both hippocampal delayed neuronal death and locomotor hyperactivity, with a rank order: tacrolimus (FK506)>nizofenone>clonindine>dizocilpine (MK-801)>6-(1H-imidazol-1-yl)-7-nitro-2,3(1H,4H)-quinoxalinedione hydrochloride (YM90K)>phencyclidine>pentobarbital>2-(4-(p-fluorobenzoyl)-piperidin-1-yl)-2'-acetonaphthone hydrochloride (E-2001)>cis-(+/-)-4-phosphonomethyl-2-piperidine carboxylic acid (CGS19755)>3,4-dichloro-N-methyl-N-[2-(1-pyrrolidinyl)-cyclohexyl]benzeneacetamide (U-50,488H)>piroxicam>eliprodil>vinpocetine. Furthermore, potencies of the protective effect on delayed neuronal death and inhibitory effects on hypermotility were closely correlated (r=0.98). These results suggest that post-ischemic CA1 injury and hypermotility share common mechanisms, and further imply that it is possible to predict the neuroprotective efficacy of drugs more easily by examining the inhibitory effects on post-ischemic hypermotility in global ischemia model in gerbils.

[Neurobiology of hyperactivity disorder]

AIMS

Hyperactivity disorder (HAD) is chiefly characterised by excessive motor activity that is maintained throughout the whole day. Despite the fact that the first clinical descriptions of HAD date from the early 20th century, we still do not know much about the exact nature of this neurobiological disorder.

METHOD

The different denominations used to refer to this alteration have not exactly helped to shed light on the disorder. Two terms are currently employed for it, attention deficit hyperactivity disorder (ADHD), which is characterised by inattention, impulsiveness and hyperactivity, and HAD. In either case, it would be the hyperactive behaviour that would lead parents to seek specialised help. Since there are no biological markers, children with hyperactivity are diagnosed through interviews and questionnaires administered to the children, the parents and teachers. This has sometimes led to children with different behavioural manifestations being grouped under a same heading, as regards the aetiology of their disorder or how they respond to treatment.

CONCLUSIONS

It is therefore obvious that there is a need to establish subgroups that enable the neurobiological features of HAD to be clearly defined. An approach to the study of this disorder from different perspectives and methodologies (genetics, neuroanatomy, neurochemistry or neurophysiology) that allow long term efficient therapeutic alternatives to be developed would undoubtedly make an important contribution in this direction.

Successful use of ECT as the sole modality of treatment in a case of motility psychosis

Episodic psychoses characterized by predominant abnormalities of movement are called motility psychoses in Leonhard's classification of endogenous psychoses. They have been treated with a variety of methods, including ECT and lithium. Here we describe a case of motility psychosis that was successfully managed with ECT as the only modality of treatment.

Levetiracetam in autistic children: an open-label study

The objectives of this study were to determine whether autistic children taking levetiracetam (1) showed improvement in the areas of aggression, impulsivity, hyperkinesis, and mood instability, and (2) showed a nootropic response. Ten white autistic boys ranging from 4 to 10 years were compared pretreatment and while taking levetiracetam for an average of 4.1 weeks. Inattention, hyperkinesis, and impulsivity were evaluated using the Achenbach Attention Problems scale, Conners DSM-IV Total scale, and the Conners Attention-Deficit Hyperactivity Disorder Index scale, all of which showed statistically significant improvements. Mood instability was measured with the Conners Global Index (CGI) Emotional Lability and CGI Total scales, both of which showed statistically significant improvements. Aggressive behavior, as measured with the Achenbach Aggression scale, showed statistically significant improvement only for subjects who were not recently weaned from medications that reduce aggression (e.g., risperidone, carbamazepine, desipramine). Levetiracetam may reduce hyperactivity, impulsivity, mood instability, and aggression in autistic children with these problems. No nootropic effect was observed.

Dyskinesias following neural transplantation in Parkinson's disease

Severe dyskinesias during the 'off' phases (periods of increased Parkinson's disease (PD) disability) have been observed following intrastriatal transplantation of human embryonic mesencephalic tissue. Here we retrospectively analyzed 14 patients who were followed for up to 11 years after grafting, and found that dyskinesias (abnormal involuntary movements and postures) increased during postoperative off phases, but were generally of mild to moderate severity. Dyskinesia severity was not related to the magnitude of graft-derived dopaminergic re-innervation, as judged by (18)F-labeled 6-L-fluorodopa (FD) positron emission tomography (PET), indicating that off-phase dyskinesias probably did not result from excessive growth of grafted dopaminergic neurons.

Dopamine re-uptake inhibitor GBR-12909 induction of aberrant behaviors in animal models of dopamine dysfunction

Many individuals with mental retardation exhibit chronic aberrant behaviors (CABs) that includes hyperactive, stereotyped, aggressive, and self-injurious behaviors. Brain imaging studies have found that several of these individuals have abnormalities in their dopaminergic neurotransmitter systems that are thought to be responsible in part, for the development of these behaviors. The present study evaluated the effects of a selective dopamine re-uptake blocker, GBR-12909 in three animal models of varying striatal dopamine concentrations. The three animal models included the neonatal 6-hydroxydopamine (6-OHDA)-lesioned rat, a model of dopamine neuronal depletion, the prenatal methylazoxymethanol (MAM)-exposed rat, a model of hyper-dopaminergic innervation and control rats, a model of normal dopaminergic function. The animals were given five daily injections of GBR-12909 and videotaped observations were conducted immediately following the injections and 6h later. The results of the study indicate that the MAM-treated rats exhibited more hyperactive behaviors than either the 6-OHDA or the control animals in response to the GBR-12909 injections. However, the 6-OHDA and control rats exhibited more self-injurious behaviors than the MAM rats. Interestingly, the topography of the self-injurious behavior exhibited differed from that we have previously observed in 6-OHDA lesioned rats following dopamine agonists and resembles the mouthing behaviors seen in some individuals with mental retardation, in particular those with Rett syndrome. These findings indicate the models of varying dopaminergic function interact differently with a dopamine re-uptake blocker than dopamine agonists and that the partially dopamine depleted model may model the behaviors seen in individuals with Rett syndrome.

Melanin-concentrating hormone 1 receptor-deficient mice are lean, hyperactive, and hyperphagic and have altered metabolism

Melanin-concentrating hormone (MCH) is a cyclic 19-aa hypothalamic neuropeptide derived from a larger prohormone precursor of MCH (Pmch), which also encodes neuropeptide EI (NEI) and neuropeptide GE (NGE). Pmch-deficient (Pmch-/-) mice are lean, hypophagic, and have an increased metabolic rate. Transgenic mice overexpressing Pmch are hyperphagic and develop mild obesity. Consequently, MCH has been implicated in the regulation of energy homeostasis. The MCH 1 receptor (MCH1R) is one of two recently identified G protein-coupled receptors believed to be responsible for the actions of MCH. We evaluated the physiological role of MCH1R by generating MCH1R-deficient (Mch1r-/-) mice. Mch1r-/- mice have normal body weights, yet are lean and have reduced fat mass. Surprisingly, Mch1r-/- mice are hyperphagic when maintained on regular chow, and their leanness is a consequence of hyperactivity and altered metabolism. Consistent with the hyperactivity, Mch1r-/- mice are less susceptible to diet-induced obesity. Importantly, chronic central infusions of MCH induce hyperphagia and mild obesity in wild-type mice, but not in Mch1r-/- mice. We conclude that MCH1R is a physiologically relevant MCH receptor in mice that plays a role in energy homeostasis through multiple actions on locomotor activity, metabolism, appetite, and neuroendocrine function.

[Laboratory diagnosis of hyperkinetic movement disorders in adulthood]

Hyperkinetic movement disorders such as dystonia, chorea, ballism, myoclonus, tics, and tremor may be idiopathic or symptomatic in origin. Symptomatic movement disorders need further diagnostic testing in order to identify their etiology. In addition to clinical findings, imaging techniques, and electrophysiological testing, laboratory studies are required. Here, we review the prevalence of diseases presenting with symptomatic hyperkinetic movement disorders and discuss the diagnostic relevance of laboratory studies.

Zuclopenthixol treatment of behavioral disturbances in mentally retarded children and adolescents: an open-label study

The present open-label study assessed the efficacy of zuclopenthixol, an thioxanthene neuroleptic with combined dopamine receptors (D1/D2) antagonist activity, in the treatment of severe behavioral disturbances in mentally retarded children and adolescents. A sample of 15 (11 males, 4 females) mentally retarded children and adolescents, ages 5-18 years (12.2 +/- 2.3 [mean +/- SD] years), all exhibiting severe behavioral disturbances, was evaluated. The 12-week zuclopenthixol treatment (up to 26 mg/day) was initiated after a week's washout from previous antipsychotic agents. An assessment of the behavioral disturbances was performed using the 14-item Checklist for Behavior Problems Involving Limited or No Social Awareness (CBP-NSA). The Udvalg for kliniske undersøgelser (UKU) Side Effect Rating Scale was used to assess the pharmacologic side effects. Results show a significant reduction in total CBP-NSA scores and in individual items such as hyperactivity, aggressive behavior, and temper tantrums (p < 0.001 for each). It seems that zuclopenthixol monotherapy is effective and well tolerated in the treatment of severe behavioral disturbances in mentally retarded children and adolescents. Double-blind, placebo-controlled studies are needed before definitive conclusions can be drawn regarding the efficacy and safety of zuclopenthixol for this population.

Cumulative trauma disorder risk for children using computer products: results of a pilot investigation with a student convenience sample

OBJECTIVES

Cumulative trauma disorder is a major health problem for adults. Despite a growing understanding of adult cumulative trauma disorder, however, little is known about the risks for younger populations. This investigation examined issues related to child/adolescent computer product use and upper body physical discomfort.

METHODS

A convenience sample of 212 students, grades 1-12, was interviewed at their homes by a college-age sibling or relative. One of the child's parents was also interviewed. A 22-item questionnaire was used for data-gathering. Questionnaire items included frequency and duration of use, type of computer products/games and input devices used, presence of physical discomfort, and parental concerns related to the child's computer use.

RESULTS

Many students experienced physical discomfort attributed to computer use, such as wrist pain (30%) and back pain (15%). Specific computer activities-such as using a joystick or playing noneducational games-were significantly predictive of physical discomfort using logistic multiple regression. Many parents reported difficulty getting their children off the computer (46%) and that their children spent less time outdoors (35%).

CONCLUSIONS

Computer product use within this cohort was associated with self-reported physical discomfort. Results suggest a need for more extensive study, including multiyear longitudinal surveys.