Management of children with autism spectrum disorders

Managing irritability and aggression in autism spectrum disorders in children and adolescents

Children with autism and autism spectrum disorders have a high rate of irritability and aggressive symptoms. In one study up to 20% of children with autism have symptoms of irritability and aggression including aggression, severe tantrums, and deliberate self injurious behavior (Lecavalier [2006] J. Autism Dev. Disord. 36:1101-1114.). These symptoms can lead to impairment and distress in both home and school settings. Medications to treat the irritability will be discussed across categories of antipsychotics, antidepressants, antihypertensive agents, and others. Emphasis will be placed on medications with the most safety and efficacy and FDA approval.

Autism spectrum disorders in the DSM-V: better or worse than the DSM-IV?

The DSM-V-committee has recently published proposed diagnostic criteria for autism spectrum disorders. We examine these criteria in some detail. We believe that the DSM-committee has overlooked a number of important issues, including social imagination, diagnosis in infancy and adulthood, and the possibility that girls and women with autism may continue to go unrecognised or misdiagnosed under the new manual. We conclude that a number of changes need to be made in order that the DSM-V-criteria might be used reliably and validly in clinical practice and research.

Cognitive Skills of Young Children with and without Autism Spectrum Disorder Using the BSID-III

Objective. The purpose of the study was to compare the cognitive skills of young children diagnosed with autism spectrum disorder (ASD) to same-aged peers referred for possible developmental delays or behavioral concerns using the Bayley Scales of Infant Development-Third Edition. Method. A retrospective chart review was conducted of 147 children ages 16 to 38 months who were referred to a diagnostic clinic for developmental evaluation. Children with ASD were compared to those without ASD with respect to cognition and language outcomes, both overall and by age. Results. While language skills in children with ASD were more significantly delayed than language skills in children without ASD, there was less discrepancy in the cognitive skills of children with and without ASD. Conclusion. Formal cognitive assessment of children with ASD can provide guidance for developmental expectations and educational programming. Cognitive skills of children with ASD may be underappreciated.

Management of symptoms in children with autism spectrum disorders: a comprehensive review of pharmacologic and complementary-alternative medicine treatments

In the care of children with autism spectrum disorders (ASD), medical treatment is typically considered an adjunct to educational and behavioral interventions. Nonetheless, large proportions of children with ASD are managed medically and receive both pharmacologic and complementary-alternative medicine (CAM) treatments. Although many medical treatments have been studied in children with ASD, studies vary widely in terms of the sample, sample size, research design, purposes of treatment, and measurements of change. Surprisingly, comprehensive reviews of the options for medical management in ASD are lacking, particularly reviews that address both pharmacologic and CAM treatments. Furthermore, reviews to date tend to emphasize general effects of medication; this perspective contradicts medical practice, which targets particular symptoms during treatment selection and monitoring. This review of 115 studies adds to the ASD treatment literature by (1) including studies of individuals 0 to 22 years of age; (2) aggregating studies of pharmacologic treatments and CAM treatments; and importantly, (3) organizing treatment response by ASD symptoms, differentiating core and associated symptoms.

Mental health implications of music: insight from neuroscientific and clinical studies

Neuroscientific and clinical studies of music over the past two decades have substantially increased our understanding of its use as a means of therapy. The authors briefly review current literature related to music's effect on people with different mental illnesses, and examine several neurobiological theories that may explain its effectiveness or lack thereof in treating psychiatric disorders. Neuroscientific studies have shown music to be an agent capable of influencing complex neurobiological processes in the brain and suggest that it can potentially play an important role in treatment. Clinical studies provide some evidence that music therapy can be used as an alternative therapy in treating depression, autism, schizophrenia, and dementia, as well as problems of agitation, anxiety, sleeplessness, and substance misuse, though whether it can actually replace other modes of treatment remains undetermined. Future research should include translational studies involving both neuroscience and clinical medicine that investigate the long-term effects of music intervention and that lead to the development of new strategies for music therapy.

Emerging role of aripiprazole for treatment of irritability associated with autistic disorder in children and adolescents

Autistic disorder is a largely misunderstood and difficult to treat neurodevelopmental disorder. Three core domains of functioning are affected by autistic disorder, ie, socialization, communication, and behavior. Signs of autistic disorder may be present early, but are frequently overlooked, resulting in a delay in its diagnosis and a subsequent delay in treatment. No one definitive therapy is available, and treatment consists of early educational and behavioral interventions, as well as drug therapy. Atypical antipsychotics have often been used in the treatment of autistic disorder to target irritability, aggression, and self-injurious behavior, all of which can interfere with other aspects of treatment. One atypical antipsychotic, aripiprazole, has recently been approved for treatment of irritability associated with autistic disorder. Based on the results from two randomized, controlled trials, with efficacy data from nearly 300 patients, treatment with aripiprazole was associated with reductions in irritability, global improvements in behavior, and improvements in quality of life from both the patient and caregiver perspectives. Dosage of aripiprazole ranged from 5 mg to 15 mg per day. Aripiprazole was well tolerated during clinical trials, with most adverse events considered mild or moderate. Clinically relevant weight gain occurred in about 30% of patients given aripiprazole, although when compared with other atypical antipsychotics, aripiprazole appears to have fewer metabolic effects and a lower risk of weight gain. However, pediatric patients taking any atypical antipsychotic should be carefully monitored for potential adverse events, because the long-term effects of antipsychotic therapy in this population are not well known. When used appropriately, aripiprazole has the potential to be an effective treatment for children with autistic disorder to improve irritability and aggressive behavior and improve quality of life.

The relation of social behaviours and challenging behaviours in infants and toddlers with Autism Spectrum Disorders

PURPOSE

Challenging behaviours are a commonly co-occuring problem in children with ASD and are often present during the toddler years. The relationship that these challenging behaviours have with core features of ASD, specifically social behaviours, was examined in this study.

METHOD

This study analysed the relationship between socialization and challenging behaviours among 153 toddlers with autism spectrum disorder. Social behaviour was evaluated using the Battelle Developmental Inventory, 2nd Edition and challenging behaviours were assessed using Baby and Infant Screen for Children with aUtIsm Traits, Part 3.

RESULT

Lower levels of adult interaction and peer interaction were associated with higher levels of stereotypic behaviour, aggressive/destructive behaviour and to a lesser extent self-injury.

CONCLUSIONS

The nature of the relationships between socialization and challenging behaviours likely interact in several ways. A better understanding of these relationships is essential to early identification and treatment of children with ASD.

Can state early intervention programs meet the increased demand of children suspected of having autism spectrum disorders?

OBJECTIVE

To determine whether Early Intervention programs have the capacity to accommodate the expected increase in referrals following the American Academy of Pediatrics' 2007 recommendation for universal screening of 18- and 24-month-old children for Autism Spectrum Disorders (ASD).

METHOD

We conducted a telephone survey of all state and territory early. Intervention coordinators about the demand for ASD evaluations, services, and program capacity. We used multivariate models to examine state-level factors associated with the capacity to serve children with ASD.

RESULTS

Fifty-two of the 57 coordinators (91%) responded to the survey. Most states reported an increase in demand for ASD-related evaluations (65%) and services (58%) since 2007. In addition, 46% reported that their current capacity poses a challenge to meeting the 45-day time limit for creating the Individualized Family Service Plan. Many states reported that they have shortages of ASD-related personnel, including behavioral therapists (89%), speech-language pathologists (82%), and occupational therapists (79%). Among states that reported the number of service hours (n = 34) 44% indicated that children with ASD receive 5 or fewer weekly service hours. Multivariate models showed that states with a higher percentage of African-American and Latino children were more likely to have provider shortages whereas states with higher population densities were more likely to offer a greater number of service hours.

CONCLUSION

Many Early Intervention programs may not have the capability to address the expected increase in demand for ASD services. Early Intervention programs will likely need enhanced resources to provide all children with suspected ASD with appropriate evaluations and services.

Caring for the child with an autism spectrum disorder in the acute care setting

PURPOSE

This article explores the challenges that patients with autistic spectrum disorders (ASDs) face when hospitalized and provides assessment strategies and plan-of-care suggestions for nursing caregivers.

CONCLUSIONS

With a high prevalence rate of medical comorbidities among this population, such as gastrointestinal complaints and seizures, nurses are likely to care for hospitalized patients with an ASD.

PRACTICE IMPLICATIONS

For a child with an ASD, hospitalization can be an overwhelming sensory and cognitive experience. Nurses equipped with an understanding of the unique needs of a child with ASD can tailor the plan of care to reduce patient and family anxiety, optimize treatment goals, and reduce the stress of hospitalization.

Complementary and alternative medicine in autism: an evidence-based approach to negotiating safe and efficacious interventions with families

This review focuses on helping clinicians identify resources and develop strategies they may use to effectively negotiate safe and effective use of complementary and alternative medicine (CAM) treatments with families of children with autism spectrum disorders (ASD), as well as other neurodevelopmental disorders. Since new types of CAM continue to be introduced into the autism community, emphasis is placed on providing clinicians with tools to help families negotiate the myriad of available treatments and make decisions based on current safety and efficacy data, while remaining mindful of the reasons families may be considering these treatments. We familiarize readers with high-quality, evidence-based resources that providers and families may use to ascertain current information about specific types of CAM, verify the content of biologically-based treatments, identify ongoing CAM research and obtain toolkits designed to help healthcare providers raise the topic of CAM usage and facilitate disclosure and discussion of CAM use with patients and their families.

Autism Spectrum Disorder: Correlation between aberrant behaviors, EEG abnormalities and seizures

The relationship between epilepsy, epileptiform discharges, cognitive, language and behavioral symptoms is not clearly understood. Since difficulties with socialization and maladaptive behaviors are found in children with Autism Spectrum Disorder (ASD), we inquired whether epileptiform activity and seizures are associated with adverse behavioral manifestations in this population. We reviewed our EEG database between 1999–2006, and identified 123 children with ASD. EEG abnormalities were found in 39 children (31%). A control group of age and gender matched ASD children with normal EEG’s was obtained. Packets of questionnaires including the Vineland Adaptive Behavior Scale II (VABS), Aberrant Behavior Checklist (ABC) and the Childhood Autism Rating Scale (CARS) were sent by mail. Out of 21 packets received, 11 had normal and 10 had abnormal EEG’s. There were no statistically significant differences in behavior between the two groups. Statistical analysis of discharge location and frequency did not reveal a significant trend. However, children with ASD and seizures had statistically significant lower scores in VABS daily living (P=0.009) and socialization (P=0.007) as compared to those without seizures. ASD children with seizures had higher ABC levels of hyperactivity and irritability. Differences in irritability scores nearly reached statistical significance (P=0.058). There was no significant difference in the degree of CARS autism rating between the groups. Our study did not reveal statistically significant differences in behaviors between ASD children with and without EEG abnormalities. However, ASD children with seizures revealed significantly worse behaviors as compared to counterparts without seizures.

Psychotropic medication use among children with autism spectrum disorders enrolled in a national registry, 2007-2008

Patterns of current psychotropic medication use among 5,181 children with autism spectrum disorders (ASD) enrolled in a Web-based registry were examined. Overall, 35% used at least one psychotropic medication, most commonly stimulants, neuroleptics, and/or antidepressants. Those who were uninsured or exclusively privately insured were less likely to use >or=3 medications than were those insured by Medicaid. Psychiatrists and neurologists prescribed the majority of psychotropic medications. In multivariate analysis, older age, presence of intellectual disability or psychiatric comorbidity, and residing in a poorer county or in the South or Midwest regions of the United States increased the odds of psychotropic medication use. Factors external to clinical presentation likely affect odds of psychotropic medication use among children with ASD.

Neuronal glucose transporter isoform 3 deficient mice demonstrate features of autism spectrum disorders

Neuronal glucose transporter (GLUT) isoform 3 deficiency in null heterozygous mice led to abnormal spatial learning and working memory but normal acquisition and retrieval during contextual conditioning, abnormal cognitive flexibility with intact gross motor ability, electroencephalographic seizures, perturbed social behavior with reduced vocalization and stereotypies at low frequency. This phenotypic expression is unique as it combines the neurobehavioral with the epileptiform characteristics of autism spectrum disorders. This clinical presentation occurred despite metabolic adaptations consisting of an increase in microvascular/glial GLUT1, neuronal GLUT8 and monocarboxylate transporter isoform 2 concentrations, with minimal to no change in brain glucose uptake but an increase in lactate uptake. Neuron-specific glucose deficiency has a negative impact on neurodevelopment interfering with functional competence. This is the first description of GLUT3 deficiency that forms a possible novel genetic mechanism for pervasive developmental disorders, such as the neuropsychiatric autism spectrum disorders, requiring further investigation in humans.

Evaluation, diagnosis, and treatment of gastrointestinal disorders in individuals with ASDs: a consensus report

Autism spectrum disorders (ASDs) are common and clinically heterogeneous neurodevelopmental disorders. Gastrointestinal disorders and associated symptoms are commonly reported in individuals with ASDs, but key issues such as the prevalence and best treatment of these conditions are incompletely understood. A central difficulty in recognizing and characterizing gastrointestinal dysfunction with ASDs is the communication difficulties experienced by many affected individuals. A multidisciplinary panel reviewed the medical literature with the aim of generating evidence-based recommendations for diagnostic evaluation and management of gastrointestinal problems in this patient population. The panel concluded that evidence-based recommendations are not yet available. The consensus expert opinion of the panel was that individuals with ASDs deserve the same thoroughness and standard of care in the diagnostic workup and treatment of gastrointestinal concerns as should occur for patients without ASDs. Care providers should be aware that problem behavior in patients with ASDs may be the primary or sole symptom of the underlying medical condition, including some gastrointestinal disorders. For these patients, integration of behavioral and medical care may be most beneficial. Priorities for future research are identified to advance our understanding and management of gastrointestinal disorders in persons with ASDs.

Celiac disease presenting as autism

Gluten-restricted diets have become increasingly popular among parents seeking treatment for children diagnosed with autism. Some of the reported response to celiac diets in children with autism may be related to amelioration of nutritional deficiency resulting from undiagnosed gluten sensitivity and consequent malabsorption. A case is presented of a 5-year-old boy diagnosed with severe autism at a specialty clinic for autistic spectrum disorders. After initial investigation suggested underlying celiac disease and varied nutrient deficiencies, a gluten-free diet was instituted along with dietary and supplemental measures to secure nutritional sufficiency. The patient's gastrointestinal symptoms rapidly resolved, and signs and symptoms suggestive of autism progressively abated. This case is an example of a common malabsorption syndrome associated with central nervous system dysfunction and suggests that in some contexts, nutritional deficiency may be a determinant of developmental delay. It is recommended that all children with neurodevelopmental problems be assessed for nutritional deficiency and malabsorption syndromes.

Begleitsymptomatik bei tief greifenden Entwicklungsstörungen

Fragestellung: Kinder und Jugendliche mit tief greifenden Entwicklungsstörungen zeigen neben der Kernsymptomatik eine Vielzahl assoziierter Erkrankungen i. S. von genetischen Syndromen oder neurologischen Erkrankungen, die für die Behandlung und den Verlauf der Störung von Bedeutung sind. In der vorliegenden Arbeit wird die Art und Häufigkeit dieser somatischen Begleiterscheinungen in Relation zur Intelligenz der Patienten analysiert. Methodik: Die Stichprobe besteht aus 601 Patienten, bei denen zwischen 1997 und 2007 in der Abteilung für Entwicklungsstörungen des Heckscher-Klinikums die Diagnose einer tief greifenden Entwicklungsstörung gestellt wurde. Neben genetischen Syndromen wurden auch neurologische Störungen erfasst. Ergebnisse: 373 (62 %) der Patienten hatten eine, 121 (20 %) zwei Diagnosen auf der Achse IV des multiaxialen Klassifikationsschemas. Genetische Störungen wurden bei insgesamt 6 % (N = 37) der Stichprobe festgestellt. Die häufigsten neurologischen Diagnosen waren Bewegungsstörungen (N = 214; 35.6 %) und Epilepsien (N = 98; 16.3 %). Patienten mit einer Intelligenzminderung zeigen häufiger somatische Begleiterscheinungen als Patienten ohne Intelligenzminderung. Schlussfolgerungen: Tief greifende Entwicklungsstörungen sind komplexe Störungsbilder, die überzufällig häufig einhergehen mit neurologischen Störungen und einem breiten Spektrum an genetischen Syndromen. Kinder mit autistischen Störungen und einer Intelligenzminderung zeigen mehr Begleiterkrankungen und sind in der psychosozialen Anpassung deutlicher beeinträchtigt als Kinder mit autistischen Störungen ohne Intelligenzminderung.

Psychotropic drug treatments for people with autism and other developmental disorders: a primer for practicing behavior analysts

Many people with developmental disabilities receive medications prescribed to improve behavior. This manuscript overviews the psychopharmacology of developmental disabilities and considers how practitioners can assist in improving the quality of the pharmacological treatments that their clients receive.

Aripiprazole in the treatment of irritability in children and adolescents with autistic disorder

OBJECTIVE

The objective of this study was to evaluate short-term efficacy and safety of aripiprazole in the treatment of irritability in children and adolescents with autistic disorder who were manifesting behaviors such as tantrums, aggression, self-injurious behavior, or a combination of these.

METHODS

This 8-week, double-blind, randomized, placebo-controlled, parallel-group study was conducted of children and adolescents (aged 6-17 years) with autistic disorder. Patients were randomly assigned (1:1) to flexibly dosed aripiprazole (target dosage: 5, 10, or 15 mg/day) or placebo. Efficacy outcome measures included the Aberrant Behavior Checklist irritability subscale and the Clinical Global Impression-Improvement score (CGI-I). Safety and tolerability were also assessed.

RESULTS

Ninety-eight patients were randomly assigned to receive placebo (n = 51) or aripiprazole (n = 47). Mean improvement in Aberrant Behavior Checklist irritability subscale score was significantly greater with aripiprazole than with placebo from week 1 through week 8. Aripiprazole demonstrated significantly greater global improvements than placebo, as assessed by the mean CGI-I score from week 1 through week 8; however, clinically significant residual symptoms may still persist for some patients. Discontinuation rates as a result of adverse events (AEs) were 10.6% for aripiprazole and 5.9% for placebo. Extrapyramidal symptom-related AE rates were 14.9% for aripiprazole and 8.0% for placebo. No serious AEs were reported. Mean weight gain was 2.0 kg on aripiprazole and 0.8 kg on placebo at week 8.

CONCLUSIONS

Aripiprazole was efficacious in children and adolescents with irritability associated with autistic disorder and was generally safe and well tolerated.

Prevalence of parent-reported diagnosis of autism spectrum disorder among children in the US, 2007

OBJECTIVES

The reported increasing prevalence of autism spectrum disorder (ASD) and attendant health and family impact make monitoring of ASD prevalence a public health priority.

METHODS

The prevalence of parent-reported diagnosis of ASD among US children aged 3 to 17 years was estimated from the 2007 National Survey of Children's Health (sample size: 78037). A child was considered to have ASD if a parent/guardian reported that a doctor or other health care provider had ever said that the child had ASD and that the child currently had the condition. The point-prevalence for ASD was calculated for those children meeting both criteria. We examined sociodemographic factors associated with current ASD and with a past (but not current) ASD diagnosis. The health care experiences for children in both ASD groups were explored.

RESULTS

The weighted current ASD point-prevalence was 110 per 10,000. We estimate that 673,000 US children have ASD. Odds of having ASD were 4 times as large for boys than girls. Non-Hispanic (NH) black and multiracial children had lower odds of ASD than NH white children. Nearly 40% of those ever diagnosed with ASD did not currently have the condition; NH black children were more likely than NH white children to not have current ASD. Children in both ASD groups were less likely than children without ASD to receive care within a medical home.

CONCLUSIONS

The observed point-prevalence is higher than previous US estimates. More inclusive survey questions, increased population awareness, and improved screening and identification by providers may partly explain this finding.

A placebo-controlled, fixed-dose study of aripiprazole in children and adolescents with irritability associated with autistic disorder

OBJECTIVE

To evaluate the short-term efficacy and safety of aripiprazole in the treatment of irritability in children and adolescents with autistic disorder.

METHOD

Two hundred eighteen children and adolescents (aged 6-17 years) with a diagnosis of autistic disorder, and with behaviors such as tantrums, aggression, self-injurious behavior, or a combination of these symptoms, were randomized 1:1:1:1 to aripiprazole (5, 10, or 15 mg/day) or placebo in this 8-week double-blind, randomized, placebo-controlled, parallel-group study. Efficacy was evaluated using the caregiver-rated Aberrant Behavior Checklist Irritability subscale (primary efficacy measure) and the clinician-rated Clinical Global Impressions-Improvement score. Safety and tolerability were also assessed.

RESULTS

At week 8, all aripiprazole doses produced significantly greater improvement than placebo in mean Aberrant Behavior Checklist Irritability subscale scores (5 mg/day, -12.4; 10 mg/day, -13.2; 15 mg/day, -14.4; versus placebo, -8.4; all p < .05). All aripiprazole doses demonstrated significantly greater improvements in mean Clinical Global Impressions-Improvement score than placebo at week 8. Discontinuation rates due to adverse events were as follows: placebo 7.7%, aripiprazole 5 mg/day 9.4%, 10 mg/day 13.6%, and 15 mg/day 7.4%. The most common adverse event leading to discontinuation was sedation. There were two serious adverse events: presyncope (5 mg/day) and aggression (10 mg/day). At week 8, mean weight change (last observation carried forward) was as follows: placebo +0.3 kg, aripiprazole 5 mg/day +1.3 kg, 10 mg/day +1.3 kg, and 15 mg/day +1.5 kg; all p < .05 versus placebo.

CONCLUSIONS

Aripiprazole was efficacious and generally safe and well tolerated in the treatment of children and adolescents with irritability associated with autistic disorder.

A training model for the diagnosis of autism in community pediatric practice

OBJECTIVE

Early diagnosis of autism spectrum disorders (ASD) currently represents a critical public health and clinical practice issue. Waits for diagnostic services are quite lengthy and hinder the start of early intervention services thought to be crucial for optimizing functional developmental outcomes for children and their families. In this study, we present data from a newly developed training program (Screening Tools and Referral Training-Evaluation and Diagnosis training) designed to help pediatricians diagnose young children with ASD in the context of traditional community practice settings.

METHODS

A small, targeted group of community pediatricians participated in an intensive training, conducted specialized ASD evaluations within their own practices, and then referred a consecutive series of children to a medical center diagnostic clinic for an independent assessment of ASD.

CONCLUSION

Results of this small pilot study indicate good agreement (71%) between pediatrician judgments and independent diagnostic ASD evaluations, but a significant trend toward overidentification when a diagnostic decision is forced. We discuss the implications of this study with regard to revisiting traditional service models of diagnostic assessment for young children with ASD.

Dexmedetomidine for procedural sedation in children with autism and other behavior disorders

Dexmedetomidine has been increasingly in use for pediatric noninvasive procedural sedation. This retrospective study examined experience in children with autism and other neurobehavioral disorders, populations often difficult to sedate. Records of children with autism or neurobehavioral disorders sedated with dexmedetomidine at Chris Evert Children's Hospital and Kosair Children's Hospital were reviewed. Demographic and sedation-related data were collected, including sedative doses, time to sedation, efficacy, and complications. Comparisons of sedative doses, efficacy between autism and neurobehavioral patients, and analysis of age-related factors were performed. In all, 315 patients were sedated, most commonly for magnetic resonance imaging. Mean induction and total dexmedetomidine doses were 1.4 +/- 0.6 and 2.6 +/- 1.6 microg/kg, respectively, with no differences between autism and neurobehavior patients. Most patients (90%) patients received concomitant midazolam. There was an age-related decrease in dexmedetomidine dose, independent of midazolam use. Seven patients required intervention for hypotension, bradycardia, or both, and only one adverse respiratory event (obstruction requiring nasopharyngeal airway placement) occurred. There were two episodes of overt recovery-related agitation. All but four procedures were successfully completed (4/315, or 98.7%). Dexmedetomidine with or without midazolam was an effective sedative in this population. The regimen appeared to be well tolerated with few adverse events, including recovery-related agitation, and appears to be an attractive option for this population.

The school nurse's role in treatment of the student with autism spectrum disorders

PURPOSE

Some healthcare concerns have been found to be commonly associated with Autism Spectrum Disorders (ASD). Identification and treatment of these medical issues can improve the functioning of the child with ASD. This article will offer practical suggestions for the school nurse.

CONCLUSIONS

As a "front-line" medical professional in the schools, the school nurse is positioned to provide guidance on implementing interventions for the student with ASD.

PRACTICE IMPLICATIONS

By being knowledgeable about current research and treatment options for the various associated medical conditions, the school nurse can help the student achieve academic success in the school setting.

Recent advances in the pathogenesis of syndromic autisms

Background. Current advances in genetic technology continue to expand the list of medical conditions associated with autism. Clinicians have to identify specific autistic-related syndromes, and to provide tailored counseling. The aim of this study is to elucidate recent advances in autism research that offer important clues into pathogenetic mechanisms of syndromic autism and relevant implications for clinical practice. Data Sources. The PubMed database was searched with the keywords “autism” and “chromosomal abnormalities,” “metabolic diseases,” “susceptibility loci.” Results. Defined mutations, genetic syndromes, and metabolic diseases account for up to 20% of autistic patients. Metabolic and mitochondrial defects may have toxic effects on the brain cells, causing neuronal loss and altered modulation of neurotransmission systems. Alterations of the neocortical excitatory/inhibitory balance and perturbations of interneurons' development represent the most probable pathogenetic mechanisms underlying the autistic phenotype in Fragile X-Syndrome and Tuberous Sclerosis Complex. Chromosomal abnormalities and potential candidate genes are strongly implicated in the disruption of neural connections, brain growth, and synaptic/dendritic morphology. Conclusion. Metabolic testing may be appropriate if specific symptoms are present. High-resolution chromosome analysis may be recommended if a specific diagnosis is suspected because of obvious dysmorphisms. Identifying cryptic chromosomal abnormalities by whole genome microarray analysis can increase the understanding of the neurobiological pathways to autism.

Complementary alternative medicine for children with autism: a physician survey

Previous studies suggest over half of children with autism are using complementary alternative medicine (CAM). In this study, physicians responded (n = 539, 19% response rate) to a survey regarding CAM use in children with autism. Physicians encouraged multi-vitamins (49%), essential fatty acids (25%), melatonin (25%) and probiotics (19%) and discouraged withholding immunizations (76%), chelation (61%), anti-infectives (57%), delaying immunizations (55%) and secretin (43%). Physicians encouraging CAM were more likely to desire CAM training, inquire about CAM use, be female, be younger, and report greater autism visits, autism education and CAM knowledge. Physicians were more likely to desire CAM training, inquire about CAM and view CAM as a challenge for children with autism compared to children with other neurodevelopmental and chronic/complex conditions.

Medical homes for children with autism: a physician survey

BACKGROUND

Primary care physicians can enhance the health and quality of life of children with autism by providing high-quality and comprehensive primary care.

OBJECTIVE

To explore physicians' perspectives on primary care for children with autism.

METHODS

National mail and e-mail surveys were sent to a random sample of 2325 general pediatricians and 775 family physicians from April 2007 to October 2007.

RESULTS

The response rate was 19%. Physicians reported significantly lower overall self-perceived competency, a greater need for primary care improvement, and a greater desire for education for children with autism compared with both children with other neurodevelopmental conditions and those with chronic/complex medical conditions. The following barriers to providing primary care were endorsed as greater for children with autism: lack of care coordination, reimbursement and physician education, family skeptical of traditional medicine and vaccines, and patients using complementary alternative medicine. Adjusting for key demographic variables, predictors of both higher perceived autism competency and encouraging an empirically supported therapy, applied behavior analysis, included having a greater number of autism patient visits, having a friend or relative with autism, and previous training about autism.

CONCLUSIONS

Primary care physicians report a lack of self-perceived competency, a desire for education, and a need for improvement in primary care for children with autism. Physician education is needed to improve primary care for children with autism. Practice parameters and models of care should address physician-reported barriers to care.

A case study in the misrepresentation of applied behavior analysis in autism: the gernsbacher lectures

I know that most men, including those at ease with problems of the greatest complexity, can seldom accept the simplest and most obvious truth if it be such as would oblige them to admit the falsity of conclusions which they have proudly taught to others, and which they have woven, thread by thread, into the fabrics of their life. (Tolstoy, 1894)This article presents a case study in the misrepresentation of applied behavior analysis for autism based on Morton Ann Gernsbacher's presentation of a lecture titled "The Science of Autism: Beyond the Myths and Misconceptions." Her misrepresentations involve the characterization of applied behavior analysis, descriptions of practice guidelines, reviews of the treatment literature, presentations of the clinical trials research, and conclusions about those trials (e.g., children's improvements are due to development, not applied behavior analysis). The article also reviews applied behavior analysis' professional endorsements and research support, and addresses issues in professional conduct. It ends by noting the deleterious effects that misrepresenting any research on autism (e.g., biological, developmental, behavioral) have on our understanding and treating it in a transdisciplinary context.

Recent advances in autism spectrum disorders

OBJECTIVE

This review article provides an overview of the most recent developments in the literature regarding autism spectrum disorders including epidemiology, etiology, assessment, and management/treatment.

METHOD

A review of the recent literature was conducted using Medline and the search term "Autism Spectrum Disorders."

RESULTS

Autism Spectrum Disorders are more common than previously believed (1 in 166), and etiology appears to be multifaceted including both heritable and non-heritable factors. State of the art treatment includes comprehensive medical monitoring as well as behavioral intervention.

CONCLUSIONS

Current and anticipated federal funding, policy changes, and large scale research projects provide promise for increasing knowledge about Autism Spectrum Disorders.

A national profile of the health care experiences and family impact of autism spectrum disorder among children in the United States, 2005-2006

OBJECTIVES

We sought to examine the health care experiences of children with autism spectrum disorder and the impact of autism spectrum disorder on the family and to assess whether having a medical home is associated with less family impact.

METHODS

We used the 2005-2006 National Survey of Children With Special Health Care Needs to compare 2088 children with special health care needs, aged 3 to 17 years, reported by their parents to have autism spectrum disorder, with children with special health care needs with "other emotional, developmental, or behavioral problems" (excluding autism spectrum disorder; n=9534) and 26751 other children with special health care needs. We used weighted logistic regression to examine unmet needs for specific health care and support services, delayed care, no usual care source or personal physician, difficulty receiving referrals, and financial, employment, or time problems because of child's care.

RESULTS

Nationally, an estimated 535000 children have special health care needs and autism spectrum disorder, a prevalence of 86 per 10000 children aged 3 to 17 years. Among children with special health care needs, 5.6% have autism spectrum disorder. Compared with other children with special health care needs without emotional, developmental, or behavioral problems, children with special health care needs with autism spectrum disorder were more likely to have unmet needs for specific health care services, family support services, delayed or foregone care, difficulty receiving referrals, and care that is not family centered. Children with special health care needs with autism spectrum disorder were more likely to live in families that report financial problems, need additional income for the child's medical care, reduce or stop work because of the child's condition, spend >or=10 hours per week providing or coordinating care, and paid more than $1000 in the previous year for the child's care. The financial impacts of autism spectrum disorder were significantly more burdensome when children with special health care needs did not have a medical home.

CONCLUSIONS

Children with special health care needs with autism spectrum disorder are significantly more likely to have problems regarding access to care and unmet needs, and their families have greater financial, employment, and time burdens compared with other children with special health care needs. Receipt of primary care in a medical home may reduce these burdens.