Identification and evaluation of children with autism spectrum disorders

Childhood autism and auditory system abnormalities

Hearing disorders are common among children with autism, ranging from peripheral and sensorineural hearing deficit or loss to auditory hypersensitivity with bizarre reactions to sounds. The auditory abnormalities and consequent sensory deprivation exacerbate the communication deficit of autism, and early auditory assessment holds an important place in the planning of intervention and the overall prognosis of patients. Physiologic, pathologic, imaging, and neurochemical studies have revealed an array of aberrations in the perception and processing of the audiologic stimuli, including (among others) maturational defects, atypical lateralization, and serotonin dysfunction.

Clinical genetic testing for patients with autism spectrum disorders

BACKGROUND

Multiple lines of evidence indicate a strong genetic contribution to autism spectrum disorders (ASDs). Current guidelines for clinical genetic testing recommend a G-banded karyotype to detect chromosomal abnormalities and fragile X DNA testing, but guidelines for chromosomal microarray analysis have not been established.

PATIENTS AND METHODS

A cohort of 933 patients received clinical genetic testing for a diagnosis of ASD between January 2006 and December 2008. Clinical genetic testing included G-banded karyotype, fragile X testing, and chromosomal microarray (CMA) to test for submicroscopic genomic deletions and duplications. Diagnostic yield of clinically significant genetic changes was compared.

RESULTS

Karyotype yielded abnormal results in 19 of 852 patients (2.23% [95% confidence interval (CI): 1.73%-2.73%]), fragile X testing was abnormal in 4 of 861 (0.46% [95% CI: 0.36%-0.56%]), and CMA identified deletions or duplications in 154 of 848 patients (18.2% [95% CI: 14.76%-21.64%]). CMA results for 59 of 848 patients (7.0% [95% CI: 5.5%-8.5%]) were considered abnormal, which includes variants associated with known genomic disorders or variants of possible significance. CMA results were normal in 10 of 852 patients (1.2%) with abnormal karyotype due to balanced rearrangements or unidentified marker chromosome. CMA with whole-genome coverage and CMA with targeted genomic regions detected clinically relevant copy-number changes in 7.3% (51 of 697) and 5.3% (8 of 151) of patients, respectively, both higher than karyotype. With the exception of recurrent deletion and duplication of chromosome 16p11.2 and 15q13.2q13.3, most copy-number changes were unique or identified in only a small subset of patients.

CONCLUSIONS

CMA had the highest detection rate among clinically available genetic tests for patients with ASD. Interpretation of microarray data is complicated by the presence of both novel and recurrent copy-number variants of unknown significance. Despite these limitations, CMA should be considered as part of the initial diagnostic evaluation of patients with ASD.

It looks like autism: caution in diagnosis

CASE 1: At 3 years of age, Billy was seen by his pediatrician for a well child visit. Spontaneous speech was limited during the visit. He did not interact with the pediatrician and attempts to play with Billy resulted in oppositional behavior. About 3 months after the visit, Billy's parents requested a developmental evaluation; he was diagnosed with autism by means of an observational measure and a parent interview. Billy was born full term after an uncomplicated labor, delivery and postnatal period. Motor milestones were normal. His parents recalled that he used his finger to point to an object prior to using words. He spoke several single words by his first birthday and used phrases before age 2 years. Billy was described as often having difficulty with transitions, but he is happy and outgoing in familiar situations. At 3 years old, when he started preschool, Billy did not speak to either the teacher or other children. This pattern of refusal to speak persists. His parents report that he talks to them and one uncle using complete sentences with clear speech. Billy prefers to repeat activities and is reluctant to try activities. He frequently plays with the same toy cars placing them in a neat line and becomes upset if things are not done in the same way. An uncle has Asperger syndrome. CASE 2: Juan, a 3 year old Mexican-American boy, was referred by his preschool teacher because "he does not interact with other children or use language at an age-appropriate level." He prefers to play alone, resists participation in group activities at preschool, and does not share as well as other students according to his teacher. Expressive language with speech is rarely seen in preschool. In contrast, at home he plays interactively, shares toys with his older brother and speaks in short, clear sentences. In preschool, English is spoken exclusively. At home, Spanish is the primary language. Prenatal and birth histories were uneventful. Motor and social milestones were achieved art the expected times. He spoke his first word at 18 months and 2-word phrases at 2 years. Currently, he speaks in full sentences with pleurals and pronouns. He follows commands and recently had a normal audiogram. His parents, who speak English with ease, are concerned about the teacher's observations at school. The physical examination was normal; the developmental and behavioral assessments were conducted by an English speaking clinician. Juan played interactively with toys while demonstrating curiosity, showing and joint attention. There was no speech production during a 30 minute period although he did follow directions. When a Spanish speaking clinician assumed responsibility for the assessment, Juan's speech production increased significantly. He told a story about his drawing and talked about the family dog and his brother. He had good eye contact and appropriate pragmatic speech when the dialogue was in Spanish.

The prodrome of autism: early behavioral and biological signs, regression, peri- and post-natal development and genetics

Autism is one of the most heritable neurodevelopmental conditions and has an early onset, with symptoms being required to be present in the first 3 years of life in order to meet criteria for the 'core' disorder in the classification systems. As such, the focus on identifying a prodrome over the past 20 years has been on pre-clinical signs or indicators that will be present very early in life, certainly in infancy. A number of novel lines of investigation have been used to this end, including retrospective coding of home videos, prospective population screening and 'high risk' sibling studies; as well as the investigation of pre- and peri-natal, brain developmental and other biological factors. While no single prodromal sign is expected to be present in all cases, a picture is emerging of indicative prodromal signs in infancy and initial studies are being undertaken to attempt to ameliorate early presentation and even 'prevent' emergence of the full syndrome.

Child vocalization composition as discriminant information for automatic autism detection

Early identification is crucial for young children with autism to access early intervention. The existing screens require either a parent-report questionnaire and/or direct observation by a trained practitioner. Although an automatic tool would benefit parents, clinicians and children, there is no automatic screening tool in clinical use. This study reports a fully automatic mechanism for autism detection/screening for young children. This is a direct extension of the LENA (Language ENvironment Analysis) system, which utilizes speech signal processing technology to analyze and monitor a child's natural language environment and the vocalizations/speech of the child. It is discovered that child vocalization composition contains rich discriminant information for autism detection. By applying pattern recognition and machine learning approaches to child vocalization composition data, accuracy rates of 85% to 90% in cross-validation tests for autism detection have been achieved at the equal-error-rate (EER) point on a data set with 34 children with autism, 30 language delayed children and 76 typically developing children. Due to its easy and automatic procedure, it is believed that this new tool can serve a significant role in childhood autism screening, especially in regards to population-based or universal screening.

Mercury induces inflammatory mediator release from human mast cells

Background

Mercury is known to be neurotoxic, but its effects on the immune system are less well known. Mast cells are involved in allergic reactions, but also in innate and acquired immunity, as well as in inflammation. Many patients with Autism Spectrum Disorders (ASD) have "allergic" symptoms; moreover, the prevalence of ASD in patients with mastocytosis, characterized by numerous hyperactive mast cells in most tissues, is 10-fold higher than the general population suggesting mast cell involvement. We, therefore, investigated the effect of mercuric chloride (HgCl₂) on human mast cell activation.

Methods

Human leukemic cultured LAD2 mast cells and normal human umbilical cord blood-derived cultured mast cells (hCBMCs) were stimulated by HgCl2 (0.1-10 μM) for either 10 min for beta-hexosaminidase release or 24 hr for measuring vascular endothelial growth factor (VEGF) and IL-6 release by ELISA.

Results

HgCl₂ induced a 2-fold increase in β-hexosaminidase release, and also significant VEGF release at 0.1 and 1 μM (311 ± 32 pg/10⁶ cells and 443 ± 143 pg/10⁶ cells, respectively) from LAD2 mast cells compared to control cells (227 ± 17 pg/10⁶ cells, n = 5, p < 0.05). Addition of HgCl₂ (0.1 μM) to the proinflammatory neuropeptide substance P (SP, 0.1 μM) had synergestic action in inducing VEGF from LAD2 mast cells. HgCl₂ also stimulated significant VEGF release (360 ± 100 pg/10⁶ cells at 1 μM, n = 5, p < 0.05) from hCBMCs compared to control cells (182 ± 57 pg/10⁶ cells), and IL-6 release (466 ± 57 pg/10⁶ cells at 0.1 μM) compared to untreated cells (13 ± 25 pg/10⁶ cells, n = 5, p < 0.05). Addition of HgCl₂ (0.1 μM) to SP (5 μM) further increased IL-6 release.

Conclusions

HgCl₂ stimulates VEGF and IL-6 release from human mast cells. This phenomenon could disrupt the blood-brain-barrier and permit brain inflammation. As a result, the findings of the present study provide a biological mechanism for how low levels of mercury may contribute to ASD pathogenesis.

Motor coordination in autism spectrum disorders: a synthesis and meta-analysis

Are motor coordination deficits an underlying cardinal feature of Autism Spectrum Disorders (ASD)? Database searches identified 83 ASD studies focused on motor coordination, arm movements, gait, or postural stability deficits. Data extraction involved between-group comparisons for ASD and typically developing controls (N = 51). Rigorous meta-analysis techniques including random effects models, forest and funnel plots, I (2), publication bias, fail-safe analysis, and moderator variable analyses determined a significant standardized mean difference effect equal to 1.20 (SE = 0.144; p <0.0001; Z = 10.49). This large effect indicated substantial motor coordination deficits in the ASD groups across a wide range of behaviors. The current overall findings portray motor coordination deficits as pervasive across diagnoses, thus, a cardinal feature of ASD.

Advancing early detection of autism spectrum disorder by applying an integrated two-stage screening approach

BACKGROUND

Few field trials exist on the impact of implementing guidelines for the early detection of autism spectrum disorders (ASD). The aims of the present study were to develop and evaluate a clinically relevant integrated early detection programme based on the two-stage screening approach of Filipek et al. (1999), and to expand the evidence base for this approach.

METHODS

The integrated early detection programme encompassed: 1) training relevant professionals to recognise early signs of autism and to use the Early Screening of Autistic Traits Questionnaire (ESAT; Dietz, Swinkels et al., 2006; Swinkels, van Daalen, van Engeland, & Buitelaar, 2006), 2) using a specific referral protocol, and 3) building a multidisciplinary diagnostic team. The programme was evaluated in a controlled study involving children in two regions (N = 2793, range 0-11 years). The main outcome variables were a difference in mean age at ASD diagnosis and a difference in the proportion of children diagnosed before 36 months.

RESULTS

ASD was diagnosed 21 months (95% CI 9.6, 32.4) earlier in the experimental region than in the control region during the follow-up period, with the mean age at ASD diagnosis decreasing by 19.5 months (95% CI 10.5, 28.5) from baseline in the experimental region. Children from the experimental region were 9.4 times (95% CI 2.1, 41.3) more likely than children from the control region to be diagnosed before age 36 months after correction for baseline measurements. Most of these early diagnosed children had narrowly defined autism with mental retardation.

CONCLUSIONS

The integrated early detection programme appears to be clinically relevant and led to the earlier detection of ASD, mainly in children with a low IQ.

The genetics of autism: key issues, recent findings, and clinical implications

Autism spectrum disorders (ASDs) are highly heritable. Gene discovery promises to help illuminate the pathophysiology of these syndromes, yielding opportunities for the development of novel treatments and understanding of their natural history. Although the underlying genetic architecture of ASDs is not yet known, the literature demonstrates that it is not a monogenic disorder with mendelian inheritance, rather a group of complex genetic syndromes with risk deriving from genetic variations in multiple genes. This article reviews the origins of the common versus rare variant debate, highlights recent findings in the field, and addresses the clinical implications of common and rare variant discoveries.

Minor physical anomalies in autism: a meta-analysis

Autism is a complex neurodevelopmental disorder in which the interactions of genetic, epigenetic and environmental influences play a causal role. Despite the compelling evidence for a strong heritability, the etiology and molecular mechanisms underlying autism remain unclear. High phenotypic variability and genetic heterogeneity confounds the identification of susceptibility genes. The lack of robust indicators to tackle this complexity in autism has led researchers to seek for novel diagnostic tools to create homogenous subgroups. Several studies have indicated that patients with autism have higher rates of minor physical anomalies (MPAs) and that MPAs may serve as a diagnostic tool; however, the results have been inconsistent. Using the cumulative data from seven studies on MPAs in autism, this meta-analysis seeks to examine whether the aggregate data provide evidence of a large mean effect size and statistical significance for MPAs in autism. It covers the studies using multiple research methods till June 2007. The current results from seven studies suggested a significant association of MPAs in autism with a robust pooled effect size (d=0.84), and thereby provide the strongest evidence to date about the close association between MPAs and autism. Our results emphasize the importance of MPAs in the identification of heterogeneity in autism and suggest that the success of future autism genetics research will be exploited by the use of MPAs. Implications for the design of future studies on MPAs in autism are discussed and suggestions for further investigation of these important markers are proposed. Clarifying this relation might improve understanding of risk factors and molecular mechanisms in autism.

Assessing the impact of a combined analysis of four common low-risk genetic variants on autism risk

Background

Autism is a complex disorder characterized by deficits involving communication, social interaction, and repetitive and restrictive patterns of behavior. Twin studies have shown that autism is strongly heritable, suggesting a strong genetic component. In other disease states with a complex etiology, such as type 2 diabetes, cancer and cardiovascular disease, combined analysis of multiple genetic variants in a genetic score has helped to identify individuals at high risk of disease. Genetic scores are designed to test for association of genetic markers with disease.

Method

The accumulation of multiple risk alleles markedly increases the risk of being affected, and compared with studying polymorphisms individually, it improves the identification of subgroups of individuals at greater risk. In the present study, we show that this approach can be applied to autism by specifically looking at a high-risk population of children who have siblings with autism. A two-sample study design and the generation of a genetic score using multiple independent genes were used to assess the risk of autism in a high-risk population.

Results

In both samples, odds ratios (ORs) increased significantly as a function of the number of risk alleles, with a genetic score of 8 being associated with an OR of 5.54 (95% confidence interval [CI] 2.45 to 12.49). The sensitivities and specificities for each genetic score were similar in both analyses, and the resultant area under the receiver operating characteristic curves were identical (0.59).

Conclusions

These results suggest that the accumulation of multiple risk alleles in a genetic score is a useful strategy for assessing the risk of autism in siblings of affected individuals, and may be better than studying single polymorphisms for identifying subgroups of individuals with significantly greater risk.

The visual perception of motion by observers with autism spectrum disorders: a review and synthesis

Traditionally, psychological research on autism spectrum disorder (ASD) has focused on social and cognitive abilities. Vision provides an important input channel to both of these processes, and, increasingly, researchers are investigating whether observers with ASD differ from typical observers in their visual percepts. Recently, significant controversies have arisen over whether observers with ASD differ from typical observers in their visual analyses of movement. Initial studies suggested that observers with ASD experience significant deficits in their visual sensitivity to coherent motion in random dot displays but not to point-light displays of human motion. More recent evidence suggests exactly the opposite: that observers with ASD do not differ from typical observers in their visual sensitivity to coherent motion in random dot displays, but do differ from typical observers in their visual sensitivity to human motion. This review examines these apparently conflicting results, notes gaps in previous findings, suggests a potentially unifying hypothesis, and identifies areas ripe for future research.

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.

The contribution of rare diseases to understanding the epidemiology of neurodevelopmental disabilities

Our objective is to describe the contribution of rare diseases to our understanding of the epidemiology of neurodevelopmental disabilities (NDDs) by comparing and contrasting the epidemiologic features of NDDs classified according to key characteristics of developmental delay or deviance in such areas as behavior or cognition (the phenotypic approach; autism spectrum disorders and intellectual disability as examples) versus classification based on the identification of an etiologic diagnosis (the etiologic approach; 22q11.2 deletion syndrome and fragile X syndrome as examples). We suggest specific applications in which consideration of rare etiology-based NDDs might further our understanding of NDD epidemiology overall; what is needed to integrate the two classification approaches; and identify practical challenges in achieving that integration. Understanding commonalities and differences in the epidemiologic features of the phenotypically and etiologically defined NDD classifications provides a useful framework for furthering our understanding of the prevalence, distribution, and causes of NDDs, as well as delivering appropriate diagnostic resources, appropriate treatments, accurate prognostic information, and estimates of recurrence risk for these disorders.

Randomized, controlled trial of an intervention for toddlers with autism: the Early Start Denver Model

OBJECTIVE

To conduct a randomized, controlled trial to evaluate the efficacy of the Early Start Denver Model (ESDM), a comprehensive developmental behavioral intervention, for improving outcomes of toddlers diagnosed with autism spectrum disorder (ASD).

METHODS

Forty-eight children diagnosed with ASD between 18 and 30 months of age were randomly assigned to 1 of 2 groups: (1) ESDM intervention, which is based on developmental and applied behavioral analytic principles and delivered by trained therapists and parents for 2 years; or (2) referral to community providers for intervention commonly available in the community.

RESULTS

Compared with children who received community-intervention, children who received ESDM showed significant improvements in IQ, adaptive behavior, and autism diagnosis. Two years after entering intervention, the ESDM group on average improved 17.6 standard score points (1 SD: 15 points) compared with 7.0 points in the comparison group relative to baseline scores. The ESDM group maintained its rate of growth in adaptive behavior compared with a normative sample of typically developing children. In contrast, over the 2-year span, the comparison group showed greater delays in adaptive behavior. Children who received ESDM also were more likely to experience a change in diagnosis from autism to pervasive developmental disorder, not otherwise specified, than the comparison group.

CONCLUSIONS

This is the first randomized, controlled trial to demonstrate the efficacy of a comprehensive developmental behavioral intervention for toddlers with ASD for improving cognitive and adaptive behavior and reducing severity of ASD diagnosis. Results of this study underscore the importance of early detection of and intervention in autism.

Screening of 18-24-month-old children for autism in a semi-urban community in Sri Lanka

All children aged 18-24 months in a defined geographical area were initially screened for autism, using 'Red Flag' criteria. All the children with one or more positive 'Red Flag' signs were further screened using Modified Checklist for Autism in Toddlers (M-CHAT) translated to Sinhala, followed by a comprehensive clinical assessment. Of a sample of 374 children, 'Red Flag' signs were positive in 28 (7.4%). Four children received a diagnosis of autism on clinical assessment giving a prevalence of 1.07% or 1 per 93 in the 18-24-month age group. Sensitivity of M-CHAT was only 25%, and specificity 70%. The high prevalence detected strongly justifies early community-based screening, but a culturally sensitive screening tool needs to be developed for Sri Lanka.

Autism

Autism spectrum disorders are characterised by severe deficits in socialisation, communication, and repetitive or unusual behaviours. Increases over time in the frequency of these disorders (to present rates of about 60 cases per 10,000 children) might be attributable to factors such as new administrative classifications, policy and practice changes, and increased awareness. Surveillance and screening strategies for early identification could enable early treatment and improved outcomes. Autism spectrum disorders are highly genetic and multifactorial, with many risk factors acting together. Genes that affect synaptic maturation are implicated, resulting in neurobiological theories focusing on connectivity and neural effects of gene expression. Several treatments might address core and comorbid symptoms. However, not all treatments have been adequately studied. Improved strategies for early identification with phenotypic characteristics and biological markers (eg, electrophysiological changes) might hopefully improve effectiveness of treatment. Further knowledge about early identification, neurobiology of autism, effective treatments, and the effect of this disorder on families is needed.

The ELGAN study of the brain and related disorders in extremely low gestational age newborns

BACKGROUND

Extremely low gestational age newborns (ELGANs) are at increased risk for structural and functional brain abnormalities.

AIM

To identify factors that contribute to brain damage in ELGANs.

STUDY DESIGN

Multi-center cohort study.

SUBJECTS

We enrolled 1506 ELGANs born before 28 weeks gestation at 14 sites; 1201 (80%) survived to 2 years corrected age. Information about exposures and characteristics was collected by maternal interview, from chart review, microbiologic and histological examination of placentas, and measurement of proteins in umbilical cord and early postnatal blood spots.

OUTCOME MEASURES

Indicators of white matter damage, i.e. ventriculomegaly and echolucent lesions, on protocol cranial ultrasound scans; head circumference and developmental outcomes at 24 months adjusted age, i.e., cerebral palsy, mental and motor scales of the Bayley Scales of Infant Development, and a screen for autism spectrum disorders.

RESULTS

ELGAN Study publications thus far provide evidence that the following are associated with ultrasongraphically detected white matter damage, cerebral palsy, or both: preterm delivery attributed to preterm labor, prelabor premature rupture of membranes, or cervical insufficiency; recovery of microorganisms in the placenta parenchyma, including species categorized as human skin microflora; histological evidence of placental inflammation; lower gestational age at delivery; greater neonatal illness severity; severe chronic lung disease; neonatal bacteremia; and necrotizing enterocolitis.

CONCLUSIONS

In addition to supporting a potential role for many previously identified antecedents of brain damage in ELGANs, our study is the first to provide strong evidence that brain damage in extremely preterm infants is associated with microorganisms in placenta parenchyma.

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.

Autism: an emerging 'neuroimmune disorder' in search of therapy

BACKGROUND

Autism spectrum disorders (ASDs) are neurodevelopmental disorders characterized by difficulties in communication and by repetitive and stereotypic behaviors, as well as by social impairment, attention, cognitive, and learning defects. ASDs present in early childhood and their prevalence has increased significantly to 1/150 children. Despite a number of theories, the actual reasons for this increase are still not clear. There is no reliable screening test, and no definite pathogenesis or curative therapy. Consequently, there is a major gap hampering development of effective treatments.

OBJECTIVE

To review recent publications on ASDs pathogenesis and treatment with emphasis on neuroimmune processes and new therapeutic approaches.

METHODS

Mostly original papers (450) on epidemiology, possible pathogenesis or treatment of ASDs in Medline from 1990 to May 2009 were reviewed. All authors contributed to this review.

RESULTS/CONCLUSION

Increased oxidative stress and immune dysregulation are present in ASDs. Mast-cell activation may contribute to gut-blood-brain barrier disruption and brain inflammation. No effective treatments have emerged. Well-designed clinical trials with nonpsychotropic drugs were few and ASD characteristics varied considerably, making conclusions difficult. Psychotropic drugs are often used for stereotypic and aggressive behaviors. Unique combinations with antioxidant and anti-inflammatory flavonoids hold promise. New potential translational research areas and possible treatments are suggested.

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.

Sugar-coaters and straight talkers: communicating about developmental delays in primary care

OBJECTIVES

The goals were to investigate parents' and early intervention (EI) specialists' beliefs and experiences regarding discussing child development in primary care and to identify communication barriers and opportunities.

METHODS

Focus groups were held with (1) mothers of young children with typical development, (2) mothers of young children who received EI services, and (3) EI specialists. Seven groups (N = 46 participants) were conducted in the greater Cleveland, Ohio, area. Meetings were audio-recorded, transcribed, coded, and analyzed, to identify themes.

RESULTS

Most mothers reported a preference for a nonalarmist style of communication when developmental delays are suspected. In contrast, some mothers preferred a more direct style, including the use of labels to help them understand their child's development. The importance of preparation to accept information about developmental delays emerged as a theme in all groups. Elements contributing to preparedness included information about expected developmental skills, suggestions for promoting skills, and a specific time frame for follow-up evaluation. Mothers of children with disabilities perceived that early reassurance of normalcy by providers in response to their concerns led to self-doubt and increased difficulty accepting the diagnosis.

CONCLUSIONS

Mothers and EI specialists have clear ideas about factors that promote or impede communication regarding child development. This information can inform primary care providers' approaches to monitoring and screening the development of young children and to communicating with parents regarding suspected developmental delays.

Autism Spectrum Disorders and Mastocytosis

Autism Spectrum Disorders (ASD) are diagnosed in early childhood and include Autism, Asperger's disorder and Pervasive neurodevelopmental disorder - not otherwise specified (PDD-NOS, or atypical autism). ASD are associated with varying degrees of dysfunctional communication and social skills, repetitive and stereotypic behaviors, as well as attention and learning disabilities. Most ASD patients also have food intolerance and other allergic symptomatology indicative of mast cell activation. The number of ASD cases have increased over the last decade to 1/100, but there is no definite pathogenesis or curative therapy. We report that the apparent prevalence of ASD in patients with mastocytosis, a rare disease occuring in 1/4,000 children and characterized by an increased number of hypersensitive mast cells in many organs, is about 1/10 or 10 times higher than the general population. A child with skin mastocytosis [urticaria pigmentosa, (UP)] and regressive autism is presented to illustrate the point. Allergic, infectious, neuroimmune and environmental triggers may activate mast cells to release vasoactive, inflammatory and neurotoxic molecules. These could disrupt the gut-blood-brain-barriers (BBB), and/or activate susceptibility genes, thus contributing to brain inflammation and ASD.

How early do parent concerns predict later autism diagnosis?

OBJECTIVE

To study the relationship between parent concerns about development in the first year and a half of life and later autism diagnostic outcomes.

METHOD

Parent concerns about development were collected for infants at high and low risk for autism, using a prospective, longitudinal design. Parents were asked about developmental concerns at study intake and when their infant was 6, 12, and 18 months. Infants were then followed up until 36 months, when diagnostic status was determined.

RESULTS

By the time their child was 12 months, parents who have an older child with autism reported significantly more concerns in autism spectrum disorders-related areas than parents of children with typical outcomes. These concerns were significantly related to independent measures of developmental status and autism symptoms and helped predict which infants would later be diagnosed with autism or autism spectrum disorders. At 6 months, however, the concerns of parents who have an older child with autism do not predict outcome well.

CONCLUSION

Explicitly probing for parent concerns about development is useful for identifying children in need of closer monitoring and surveillance, as recommended by the American Academy of Pediatrics.

Communicative acts of children with autism spectrum disorders in the second year of life

PURPOSE

To examine the communicative profiles of children with autism spectrum disorders (ASD) in the second year of life.

METHOD

Communicative acts were examined in 125 children 18 to 24 months of age: 50 later diagnosed with ASD; 25 with developmental delays (DD); and 50 with typical development (TD). Precise measures of rate, functions, and means of communication were obtained through systematic observation of videotaped behavior samples from the Communication and Symbolic Behavior Scales Developmental Profile (A. Wetherby & B. Prizant, 2002).

RESULTS

Children with ASD communicated at a significantly lower rate than children with DD and TD. The ASD group used a significantly lower proportion of acts for joint attention and a significantly lower proportion of deictic gestures with a reliance on more primitive gestures compared with the DD and TD groups. Children with ASD who did communicate for joint attention were as likely as other children to coordinate vocalizations, eye gaze, and gestures. Rate of communicative acts and joint attention were the strongest predictors of verbal outcome at age 3.

CONCLUSION

By 18 to 24 months of age, children later diagnosed with ASD showed a unique profile of communication, with core deficits in communication rate, joint attention, and communicative gestures.

A prospective study of toddlers with ASD: short-term diagnostic and cognitive outcomes

BACKGROUND

Despite recent increases in the number of toddlers referred for a differential diagnosis of autism spectrum disorders (ASD), knowledge of short-term stability of the early diagnosis as well as cognitive outcomes in this cohort is still limited.

METHOD

Cognitive, social, and communication skills of 89 clinic-referred toddlers were assessed at the average age of 21.5 (SD = 4.9) months, and reassessed at 46.9 (SD = 7.7) months. Groups with stable and unstable diagnostic presentation were identified and compared on their profile of cognitive and social-communicative skills obtained at the time of initial diagnosis.

RESULTS

Stability of the ASD diagnosis was 100%; diagnosis of autism was stable in 74% of cases as compared to 83% and 81% in PDD-NOS and Non-ASD groups, respectively. Worsening of social disability symptoms resulting in autism diagnosis was noted in 17% of toddlers initially diagnosed with PDD-NOS and in 19% of toddlers with initial diagnosis of non-ASD disorder. However, marked improvement was noted in approximately 1/4 of children initially presenting with autism, warranting diagnostic reassignment to PDD-NOS at follow-up. An analysis of developmental skills profiles suggests particular relevance of the assessment of verbal and nonverbal communication skills to diagnostic differentiation between subtypes within ASD in the second year of life.

CONCLUSIONS

Stability of ASD diagnosis in toddlers is high, though marked changes in severity of symptoms is to be expected in a minority of cases. Simultaneous consideration of cognitive, social, and communication skills profiles enhances accuracy of diagnostic classification and prediction of outcome.

Autism Spectrum Disorders in Young Children

Retrospective research studies, videotape analyses of children later diagnosed with autism spectrum disorders (ASD), and recent studies on younger siblings of children diagnosed with ASD, at high-risk of ASD, provide evidence of the early signs of ASD in children as young as 12 months. This article provides a review of early identification, diagnostic assessment, and treatment for young children (0-5 years old) with ASD. Several screening tools as well as comprehensive assessment measures are described. The authors also discuss how the family context is affected by the diagnosis, in terms of adaptation to the diagnosis and to treatment. Finally, the authors present a brief review of interventions for young children with ASD.

Collaborative approach to autism: a parent's perspective

Collaborative Practice provides a forum for healthcare professionals to share expertise and enhance communication.

Helping the student with Asperger's Disorder with social and behavioral issues in the school: nursing, psychology, and educators working in unison

School Health provides a forum to discuss policy, practice, research, issues and trends, and pearls of wisdom to enhance the day-to-day care of children in the school setting, from day care to high school.

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.

Autism spectrum disorders in preschool-aged children: prevalence and comparison to a school-aged population

PURPOSE

The purpose of this study was to determine the prevalence and case characteristics of children with autism spectrum disorders (ASDs) among 4-year-olds and to compare findings to previous prevalence estimates for 8-year-olds in the same geographic area.

METHODS

South Carolina (SC) has been a participant in the Centers for Disease Control and Prevention's active, population-based, multiple-site ASD surveillance network for 8-year-olds since 2000. The 8-year-old methodology, designed to identify children both with and without prior diagnosis, was applied in SC with modification to include information sources for younger children.

RESULTS

The ASD prevalence among 4-year-olds in 2006 was 8.0 per 1000 (95% confidence interval [CI], 6.1-9.9), or 1 in 125. In comparison, ASD prevalence among 8-year-olds in the same geographic area was 7.6 (95% CI, 5.7-9.5) in 2000 and 7.0 (95% CI 5.1-8.9) in 2002. Developmental concerns were documented at earlier ages across time, and while most cases received services, only 20% to 29% received services specific to ASD.

CONCLUSIONS

Findings should provide useful information for the planning of health/education policies and early intervention strategies for ASD.

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.

Pervasive developmental disorders and psychosis

Pervasive developmental disorders (PDDs) and infantile schizophrenia were initially thought to be the same condition, but distinct differences were described in later research. However, attempts to identify psychosis in individuals with PDDs continue to be challenging and controversial. The two disorders share many similar features, including perceptual abnormalities, thought disorder, catatonia, and deficiencies in reality testing. Progress has been made in describing features of PDDs that can be confused with psychosis and in surveying the prevalence of psychotic symptoms in populations with intellectual disability, although there are fewer data on PDD populations. Further research is needed on the longitudinal course of PDDs and the relationships with adult disorders such as psychosis and mood disorders. This research would not only improve the diagnosis and treatment of these complex disorders but would help to unravel the complex brain pathways involved in the perception of the external world that is central to psychosis and PDDs.

Lowering developmental screening thresholds and raising quality improvement for preterm children

OBJECTIVES

To determine: 1) if preterm children were referred, identified and received early intervention (EI)/ early childhood special education (ECSE) services at rates equivalent to term children after implementation of a universal, periodic Ages and Stages Questionnaire (ASQ) surveillance and screening system; 2) if pediatricians sufficiently lowered their screening thresholds with preterm children;and 3) if quality improvement opportunities exist.

PATIENT AND METHODS

Secondary analysis was performed on 64 lower-risk, mostly late-preterm and 1363 term children who originally presented to their 12- or 24-month well- visits. Higher-risk preemies already involved with an EI agency/ identified with a delay were excluded. Board-certified pediatricians (N=18), and nurse practitioners (N = 2), blind to the ASQ results, were secondary participants. Differences between preterm and term developmental agency referrals were examined comparing Pediatric Developmental Impression to the ASQ under natural clinic conditions using a combined in-office or mail-back data collection protocol. Medical record and county EI/ECSE follow-up outcomes were conducted at 36 to 60 months.

RESULTS

At 12 and 24 months, preterm (versus term) referral rates were 9.5%(versus 5.6%) with Pediatric Developmental Impression and 26.2% (versus 8.1%) with the ASQ. By 36 to 60 months, 37.5% of preterm (20.8% term) children were referred to EI/ECSE; of which, 50.0% of preterm (42.4% term) children were eligible for services, 54.2%of preterm children were identified with a developmental-behavioral disorder and 29.2% of preterm (20.8% term) children did not follow-up. For ASQ-only preterm referrals,55.6% were subsequently diagnosed with a developmental delay and/or disorder.Preterm children were 2 times more likely to be eligible than term children [corrected].

CONCLUSIONS

Combined referral, quality improvement and outcome data suggests that clinicians should lower their threshold for administering a psychometrically sound developmental screen when providing surveillance for ex-preemies. Quality improvement opportunities exist with diligent developmental surveillance and a more collaborative, standardized, reliable and interpersonal referral process.

Parents' reports predict abnormal investigations in global developmental delay

AIMS

To identify symptoms reported by parents that predict abnormal laboratory investigations in preschoolers with global developmental delay (GDD).

METHODS

A cross-sectional descriptive study of 81 boys and 38 girls, with a mean age of 43.5 months (SD = 13.4), with global developmental delay. All parents/guardians completed the following: (1) a semistructured interview about their child and family; (2) the Child Development Inventory (CDI); (3) the Possible Problems Checklist (PPC); and (4) the Child Behavior Checklist 1(1/2)-5 (CBCL).

RESULTS

There were 61 abnormal results: MRI 37 (31%); high-resolution chromosomes 8 (7%); fragile X molecular testing 4 (3%); and microarray comparative genomic hybridization 12 (10%). A total of 47 children had abnormal tests (40%): none, 72 (60%); one, 36 (30%); two, 8 (7%); three, (3%). Younger children with more developmental delays are more likely to have abnormal tests. They are clumsy, more passive, and less disobedience. They had lower total, externalizing, and internalizing problems scores. The odds of finding an abnormal investigation are increasingly greater as parent's report of language comprehension and social development ratios increase, and decrease in likelihood for every increase in the expressive language and fine motor ratios.

INTERPRETATION

Parent's reports predict abnormal tests and indicate quantifiable differences requiring investigation.

Clinical assessment and management of toddlers with suspected autism spectrum disorder: insights from studies of high-risk infants

With increased public awareness of the early signs and recent American Academy of Pediatrics recommendations that all 18- and 24-month-olds be screened for autism spectrum disorders, there is an increasing need for diagnostic assessment of very young children. However, unique challenges exist in applying current diagnostic guidelines for autism spectrum disorders to children under the age of 2 years. In this article, we address challenges related to early detection, diagnosis, and treatment of autism spectrum disorders in this age group. We provide a comprehensive review of findings from recent studies on the early development of children with autism spectrum disorders, summarizing current knowledge on early signs of autism spectrum disorders, the screening properties of early detection tools, and current best practice for diagnostic assessment of autism spectrum disorders before 2 years of age. We also outline principles of effective intervention for children under the age of 2 with suspected/confirmed autism spectrum disorders. It is hoped that ongoing studies will provide an even stronger foundation for evidence-based diagnostic and intervention approaches for this critically important age group.

Timing of identification among children with an autism spectrum disorder: findings from a population-based surveillance study

OBJECTIVE

At what age are children with an autism spectrum disorder (ASD) identified by community providers? What factors influence the timing of when children are identified with ASDs? This study examined the timing of when children with ASDs are identified.

METHOD

Data came from 13 sites participating in the Centers for Disease Control and Prevention's 2002 multisite ongoing autism surveillance program, the Autism and Developmental Disabilities Monitoring Network. Survival analysis was used to examine factors that influence the timing of community-based identification and diagnosis.

RESULT

Data from health and education records reveal that the median age of identification was 5.7 years (SE 0.08 years). Parametric survival models revealed that several factors were associated with a younger age of identification: being male, having an IQ of 70 or lower, and having experienced developmental regression. Significant differences in the age of identification among the 13 sites were also discovered.

CONCLUSIONS

The large gap between the age at which children can be identified and when they actually are identified suggests a critical need for further research, innovation, and improvement in this area of clinical practice.