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Bulonza R, Watkins K, Parsons R, Sunderland B, Whitehouse A, Caccetta R. The use of psychotropic medications in autistic individuals (21 years and younger) in Western Australia: A preliminary investigation. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2024; 28:2002-2013. [PMID: 38385262 PMCID: PMC11301957 DOI: 10.1177/13623613231226099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
LAY ABSTRACT Prescriptions and use of medications to treat mental health conditions in young autistic populations are inconsistent worldwide. This makes it hard to compare findings from international studies to the Australian autistic population, where there are limited relevant studies. Apart from risperidone, there are no other medications specified for direct use in autistic persons. This study aims to gain initial broad understanding of the use of medications, commonly prescribed for mental health conditions, specifically by autistics under the age of 21 years. We analysed data that were previously collected as part of the Western Australian Autism Biological Registry between 2011 and 2015 which amounted to 239 surveys completed on young persons with diagnosed autism. The questionnaires included information on co-occurring conditions, current or previous use of medications and reasons for use of the medications. Only one-quarter of the participants in this study reported using at least one mental health-related medication in their lifetime. The most reported medications were stimulants, antidepressants and antiepileptics. The reasons for using medication included managing attention deficit hyperactivity disorder, challenging behaviours, seizures, sleep difficulties and symptoms of anxiety and depression. The number of individuals reporting medication use in this study was lower compared to other developed countries. Nevertheless, these medications should be monitored due to limited understanding of their use to manage co-occurring symptoms in young autistic persons. The findings highlight the importance of ongoing research to better understand mental health-related medications and inform best practice.
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Affiliation(s)
| | | | | | | | - Andrew Whitehouse
- Perth Children’s Hospital, Australia
- The University of Western Australia, Australia
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Baldes A, May T, Brignell A, Williams K. Patterns of Psychotropic Prescribing Practices in Autistic Children and Adolescents: An Australian Perspective of Two Cohorts Five Years Apart. Child Psychiatry Hum Dev 2024:10.1007/s10578-024-01710-5. [PMID: 38824199 DOI: 10.1007/s10578-024-01710-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2024] [Indexed: 06/03/2024]
Abstract
This study aims to describe the utilisation of psychotropic medications in Australian autistic children and adolescents. All children and adolescents with available Pharmaceutical Benefits Scheme data who endorsed an autism diagnosis in The Longitudinal Study of Australian Children, including both B (n = 233, age 0-1 years in wave 1) and K cohorts (n = 157, age 4-5 years in wave 1), were included to describe psychotropic prescribing patterns. 212 (54.4%) autistic children and adolescents received at least one psychotropic prescription and 99 (25.4%) had polypharmacy. The most common psychotropic class prescribed was antidepressants (31.3%). Children in the B cohort were more likely to have a parent-reported diagnosis of anxiety or depression (χ2 = 12.18, p < 0.001) and tended to be more likely to have received a psychotropic prescription (χ2 = 3.54, p = 0.06). Psychotropic prescribing in Australian autistic children is common despite limited evidence for efficacy and tolerability of psychotropics in this group.
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Affiliation(s)
- Anna Baldes
- Department of Paediatrics, Monash University, Clayton, VIC, Australia.
- Mental Health, Drugs and Alcohol Services, Barwon Health, Geelong, VIC, Australia.
| | - Tamara May
- Department of Paediatrics, Monash University, Clayton, VIC, Australia
- Murdoch Children's Research Institute Parkville, Parkville, VIC, Australia
| | - Amanda Brignell
- Department of Paediatrics, Monash University, Clayton, VIC, Australia
- Murdoch Children's Research Institute Parkville, Parkville, VIC, Australia
- Developmental Paediatrics, Monash Children's Hospital, Clayton, VIC, Australia
| | - Katrina Williams
- Department of Paediatrics, Monash University, Clayton, VIC, Australia
- Murdoch Children's Research Institute Parkville, Parkville, VIC, Australia
- Developmental Paediatrics, Monash Children's Hospital, Clayton, VIC, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
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Blank E, Gilbert DL, Wu SW, Larsh T, Elmaghraby R, Liu R, Smith E, Westerkamp G, Liu Y, Horn PS, Greenstein E, Sweeney JA, Erickson CA, Pedapati EV. Accelerated Theta Burst Transcranial Magnetic Stimulation for Refractory Depression in Autism Spectrum Disorder. J Autism Dev Disord 2024:10.1007/s10803-024-06244-2. [PMID: 38744742 DOI: 10.1007/s10803-024-06244-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 05/16/2024]
Abstract
PURPOSE Major depressive disorder (MDD) disproportionately affects those living with autism spectrum disorder (ASD) and is associated with significant impairment and treatment recidivism. METHODS We studied the use of accelerated theta burst stimulation (ATBS) for the treatment of refractory MDD in ASD (3 treatments daily x 10 days). This prospective open-label 12-week trial included 10 subjects with a mean age of 21.5 years, randomized to receive unilateral or bilateral stimulation of the dorsolateral prefrontal cortex. RESULTS One participant dropped out of the study due to intolerability. In both treatment arms, depressive symptoms, scored on the Hamilton Depression Rating Scale scores, diminished substantially. At 12 weeks post-treatment, full remission was sustained in 5 subjects and partial remission in 3 subjects. Treatment with ATBS, regardless of the site of stimulation, was associated with a significant, substantial, and sustained improvement in depressive symptomatology via the primary outcome measure, the Hamilton Depression Rating Scale. Additional secondary measures, including self-report depression scales, fluid cognition, and sleep quality, also showed significant improvement. No serious adverse events occurred during the study. Mild transient headaches were infrequently reported, which are expected side effects of ATBS. CONCLUSION Overall, ATBS treatment was highly effective and well-tolerated in individuals with ASD and co-occurring MDD. The findings support the need for a larger, sham-controlled randomized controlled trial to further evaluate efficacy of ATBS in this population.
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Affiliation(s)
- Elizabeth Blank
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Donald L Gilbert
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Steve W Wu
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Travis Larsh
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Rana Elmaghraby
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Rui Liu
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Elizabeth Smith
- Division of Behavioral Medicine and Child Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Grace Westerkamp
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Yanchen Liu
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Paul S Horn
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Ethan Greenstein
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - John A Sweeney
- Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Craig A Erickson
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Ernest V Pedapati
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
- Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
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Soldovieri MV, Ambrosino P, Mosca I, Servettini I, Pietrunti F, Belperio G, Syrbe S, Taglialatela M, Lemke JR. De novo variants in KCNA3 cause developmental and epileptic encephalopathy. Ann Neurol 2024; 95:365-376. [PMID: 37964487 DOI: 10.1002/ana.26826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 10/06/2023] [Accepted: 10/23/2023] [Indexed: 11/16/2023]
Abstract
OBJECTIVE Variants in several potassium channel genes, including KCNA1 and KCNA2, cause Developmental and Epileptic Encephalopathies (DEEs). We investigated whether variants in KCNA3, another mammalian homologue of the Drosophila shaker family and encoding for Kv1.3 subunits, can cause DEE. METHODS Genetic analysis of study individuals was performed by routine exome or genome sequencing, usually of parent-offspring trios. Phenotyping was performed via a standard clinical questionnaire. Currents from wild-type and/or mutant Kv1.3 subunits were investigated by whole-cell patch-clamp upon their heterologous expression. RESULTS Fourteen individuals, each carrying a de novo heterozygous missense variant in KCNA3, were identified. Most (12/14; 86%) had DEE with marked speech delay with or without motor delay, intellectual disability, epilepsy, and autism spectrum disorder. Functional analysis of Kv1.3 channels carrying each variant revealed heterogeneous functional changes, ranging from "pure" loss-of-function (LoF) effects due to faster inactivation kinetics, depolarized voltage-dependence of activation, slower activation kinetics, increased current inactivation, reduced or absent currents with or without dominant-negative effects, to "mixed" loss- and gain-of-function (GoF) effects. Compared to controls, Kv1.3 currents in lymphoblasts from 1 of the proband displayed functional changes similar to those observed upon heterologous expression of channels carrying the same variant. The antidepressant drug fluoxetine inhibited with similar potency the currents from wild-type and 1 of the Kv1.3 GoF variant. INTERPRETATION We describe a novel association of de novo missense variants in KCNA3 with a human DEE, and provide evidence that fluoxetine might represent a potential targeted treatment for individuals carrying variants with significant GoF effects. ANN NEUROL 2024;95:365-376.
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Affiliation(s)
| | - Paolo Ambrosino
- Department of Science and Technology, University of Sannio, Benevento, Italy
| | - Ilaria Mosca
- Department of Medicine and Health Science "V. Tiberio", University of Molise, Campobasso, Italy
| | - Ilenio Servettini
- Department of Medicine and Health Science "V. Tiberio", University of Molise, Campobasso, Italy
| | - Francesca Pietrunti
- Department of Medicine and Health Science "V. Tiberio", University of Molise, Campobasso, Italy
| | - Giorgio Belperio
- Department of Science and Technology, University of Sannio, Benevento, Italy
| | - Steffen Syrbe
- Center for Pediatrics and Adolescent Medicine, Division of Pediatric Epileptology, University Hospital Heidelberg, Heidelberg, Germany
| | - Maurizio Taglialatela
- Department of Neuroscience, Division of Pharmacology, University of Naples "Federico II", Naples, Italy
| | - Johannes R Lemke
- Institute of Human Genetics, University of Leipzig Medical Center, Leipzig, Germany
- Center for Rare Diseases, University of Leipzig Medical Center, Leipzig, Germany
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Rodnyy AY, Kondaurova EM, Tsybko AS, Popova NK, Kudlay DA, Naumenko VS. The brain serotonin system in autism. Rev Neurosci 2024; 35:1-20. [PMID: 37415576 DOI: 10.1515/revneuro-2023-0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 06/10/2023] [Indexed: 07/08/2023]
Abstract
Autism spectrum disorders (ASDs) are among the most common neurodevelopmental diseases. These disorders are characterized by lack of social interaction, by repetitive behavior, and often anxiety and learning disabilities. The brain serotonin (5-HT) system is known to be crucially implicated in a wide range of physiological functions and in the control of different kinds of normal and pathological behavior. A growing number of studies indicate the involvement of the brain 5-HT system in the mechanisms underlying both ASD development and ASD-related behavioral disorders. There are some review papers describing the role of separate key players of the 5-HT system in an ASD and/or autistic-like behavior. In this review, we summarize existing data on the participation of all members of the brain 5-HT system, namely, 5-HT transporter, tryptophan hydroxylase 2, MAOA, and 5-HT receptors, in autism in human and various animal models. Additionally, we describe the most recent studies involving modern techniques for in vivo regulation of gene expression that are aimed at identifying exact roles of 5-HT receptors, MAOA, and 5-HT transporter in the mechanisms underlying autistic-like behavior. Altogether, results of multiple research articles show that the brain 5-HT system intimately partakes in the control of some types of ASD-related behavior, and that specific changes in a function of a certain 5-HT receptor, transporter, and/or enzyme may normalize this aberrant behavior. These data give hope that some of clinically used 5-HT-related drugs have potential for ASD treatment.
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Affiliation(s)
- Alexander Ya Rodnyy
- Federal Research Center Institute of Cytology and Genetics, Siberian Branch of Russian Academy of Sciences, Akad. Lavrentyeva Ave. 10, Novosibirsk 630090, Russia
| | - Elena M Kondaurova
- Federal Research Center Institute of Cytology and Genetics, Siberian Branch of Russian Academy of Sciences, Akad. Lavrentyeva Ave. 10, Novosibirsk 630090, Russia
| | - Anton S Tsybko
- Federal Research Center Institute of Cytology and Genetics, Siberian Branch of Russian Academy of Sciences, Akad. Lavrentyeva Ave. 10, Novosibirsk 630090, Russia
| | - Nina K Popova
- Federal Research Center Institute of Cytology and Genetics, Siberian Branch of Russian Academy of Sciences, Akad. Lavrentyeva Ave. 10, Novosibirsk 630090, Russia
| | - Dmitry A Kudlay
- NRC Institute of Immunology FMBA of Russia, Kashirskoe Highway 24, Moscow 115522, Russia
- Sechenov's University, 8-2 Trubetskaya Str., Moscow 119991, Russia
| | - Vladimir S Naumenko
- Federal Research Center Institute of Cytology and Genetics, Siberian Branch of Russian Academy of Sciences, Akad. Lavrentyeva Ave. 10, Novosibirsk 630090, Russia
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Chung US, Kim JH. Common Comorbid Condition of Patients With Autism Spectrum Disorder and Pharmacotherapy for Patients With Autism Spectrum Disorder. Soa Chongsonyon Chongsin Uihak 2024; 35:39-43. [PMID: 38204750 PMCID: PMC10774559 DOI: 10.5765/jkacap.230006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/27/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
This article describes common comorbid condtion of the autism spectrum disorder (ASD) and recommends treatment guidelines of pharmacotherapy for patients with ASD. More than 95% of people with ASD have at least one additional disorder and guidelines how to evaluate and treat comorbid conditions in patients with ASD and 7 recommendations for treatment with medication for ASD.
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Affiliation(s)
- Un Sun Chung
- Department of Psychiatry, Kyungpook National University, School of Medicine, Daegu, Korea
| | - Ji-Hoon Kim
- Department of Psychiatry, Pusan National University, School of Medicine, Yangsan, Korea
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Argonis RA, Pedapati EV, Dominick KC, Harris K, Lamy M, Fosdick C, Schmitt L, Shaffer RC, Smith E, Will M, McDougle CJ, Erickson CA. Patterns in Medication Use for Treatment of Depression in Autistic Spectrum Disorder. J Autism Dev Disord 2023:10.1007/s10803-023-06126-z. [PMID: 37751093 DOI: 10.1007/s10803-023-06126-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION Depression impacts many individuals with autism spectrum disorder (ASD), carrying increased risk of functional impairment, hospitalization, and suicide. Prescribing medication to target depression in patients with ASD occurs despite limited available systematic data describing medication management of depression in this population. PURPOSE The purpose of this study is to discover prescribing patterns for individuals with MDD and ASD during this time period (2004-2012) to inform current and future prescribing practices with historical data. METHOD Drawing from a large clinical database describing the prescribing practices in patients with ASD, we identified 166 individuals with ASD (mean age 14.5 ± 8.3 years old) who received medication targeting symptoms of depression. We report prescribing rates for specific drugs, drug treatment duration, and reasons for drug discontinuation when applicable. RESULTS Sertraline, mirtazapine, and fluoxetine were the three most commonly prescribed medications to treat comorbid depression for this patient population. Among 241 drug starts, 123 (49%) drug treatments were continued at the final reviewed follow-up visit (average treatment duration of ± 0.72 years). The most common reason for discontinuation across all medications prescribed was loss of or lack of effectiveness. CONCLUSION This study raises concern that standard of care pharmacological treatments for depression in individuals with ASD may be less effective than in neurotypical populations. There remains a need to develop effective interventions for depression specifically tailored to the needs of individuals with ASD.
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Affiliation(s)
- Riley A Argonis
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 4002, Cincinnati, OH, 45229, USA
| | - Ernest V Pedapati
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 4002, Cincinnati, OH, 45229, USA
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kelli C Dominick
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 4002, Cincinnati, OH, 45229, USA
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Katherine Harris
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 4002, Cincinnati, OH, 45229, USA
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Martine Lamy
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 4002, Cincinnati, OH, 45229, USA
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Cara Fosdick
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 4002, Cincinnati, OH, 45229, USA
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Lauren Schmitt
- Division of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rebecca C Shaffer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Elizabeth Smith
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Meredith Will
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Christopher J McDougle
- Massachusetts General Hospital, Boston, MA, USA
- Lurie Center for Autism, Lexington, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Craig A Erickson
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 4002, Cincinnati, OH, 45229, USA.
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Hellings J. Pharmacotherapy in autism spectrum disorders, including promising older drugs warranting trials. World J Psychiatry 2023; 13:262-277. [PMID: 37383284 PMCID: PMC10294139 DOI: 10.5498/wjp.v13.i6.262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/06/2023] [Accepted: 04/18/2023] [Indexed: 06/19/2023] Open
Abstract
Available pharmacotherapies for autism spectrum disorders (ASD) are reviewed based on clinical and research experience, highlighting some older drugs with emerging evidence. Several medications show efficacy in ASD, though controlled studies in ASD are largely lacking. Only risperidone and aripiprazole have Federal Drug Administration approval in the United States. Methylphenidate (MPH) studies showed lower efficacy and tolerability for attention deficit hyperactivity disorder (ADHD) than in the typically developing (TD) population; atomoxetine demonstrated lower efficacy but comparable tolerability to TD outcomes. Guanfacine improved hyperactivity in ASD comparably to TD. Dex-troamphetamine promises greater efficacy than MPH in ASD. ADHD medications reduce impulsive aggression in youth, and may also be key for this in adults. Controlled trials of the selective serotonin reuptake inhibitors citalopram and fluoxetine demonstrated poor tolerability and lack of efficacy for repetitive behaviors. Trials of antiseizure medications in ASD remain inconclusive, however clinical trials may be warranted in severely disabled individuals showing bizarre behaviors. No identified drugs treat ASD core symptoms; oxytocin lacked efficacy. Amitriptyline and loxapine however, show promise. Loxapine at 5-10 mg daily resembled an atypical antipsychotic in positron emission tomography studies, but may be weight-sparing. Amitriptyline at approximately 1 mg/ kg/day used cautiously, shows efficacy for sleep, anxiety, impulsivity and ADHD, repetitive behaviors, and enuresis. Both drugs have promising neurotrophic properties.
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Affiliation(s)
- Jessica Hellings
- Department of Psychiatry, University of Missouri-Kansas City, Lee's Summit, MO 64063, United States
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Ure A, Cox GR, Haslam R, Williams K. Acetylcholinesterase inhibitors for autistic spectrum disorders. Cochrane Database Syst Rev 2023; 6:CD013851. [PMID: 37267443 PMCID: PMC10233795 DOI: 10.1002/14651858.cd013851.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Autism spectrum disorder (autism) is a neurodevelopmental condition characterised by impairments in social communication and interaction, plus restricted, repetitive patterns of behaviour and interests. Whilst some people embrace autism as part of their identity, others struggle with their difficulties, and some seek treatment. There are no current interventions that result in complete reduction of autism features. Acetylcholine is a neurotransmitter for the cholinergic system and has a role in attention, novelty seeking, and memory. Low levels of acetylcholine have been investigated as a potential contributor to autism symptomatology. Donepezil, galantamine, and rivastigmine (commonly referred to as acetylcholinesterase inhibitors) all inhibit acetylcholinesterase, and have slightly different modes of action and biological availability, so their effectiveness and side-effect profiles may vary. The effect of various acetylcholinesterase inhibitor on core autism features across the lifespan, and possible adverse effects, have not been thoroughly investigated. OBJECTIVES To evaluate the efficacy and harms of acetylcholinesterase inhibitors for people with the core features (social interaction, communication, and restrictive and repetitive behaviours) of autism. To assess the effects of acetylcholinesterase inhibitors on non-core features of autism. SEARCH METHODS In November 2022, we searched CENTRAL, MEDLINE, Embase, eight other databases, and two trials registers. We also searched the reference lists of included studies and relevant reviews, and contacted authors of relevant studies. SELECTION CRITERIA Randomised controlled trials (RCTs), comparing acetylcholinesterase inhibitors (e.g. galantamine, donepezil, or rivastigmine) of varying doses, delivered orally or via transdermal patch, either as monotherapy or adjunct therapy, with placebo. People of any age, with a clinical diagnosis of autism were eligible for inclusion. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Our primary outcomes were core features of autism and adverse effects. Secondary outcomes were language, irritability, hyperactivity, and general health and function. We used GRADE to assess certainty of evidence. MAIN RESULTS We included two RCTs (74 participants). One study was conducted in Iran, the second in the USA, although exact location in the USA is unclear. Galantamine plus risperidone versus placebo plus risperidone One study compared the effects of galantamine plus risperidone to placebo plus risperidone (40 participants, aged 4 years to 12 years). Primary and secondary outcomes of interest were measured postintervention, using subscales of the Aberrant Behavior Checklist (score 0 to 3; higher scores = greater impairment). Very low-certainty evidence showed there was little to no difference between the two groups postintervention for social communication (mean difference (MD) -2.75, 95% confidence interval (CI) -5.88 to 0.38), and restricted and repetitive behaviour (MD -0.55, 95% CI -3.47 to 2.37). Overall autism features were not assessed. Adverse events may be higher in the galantamine plus risperidone group (75%) compared with the placebo plus risperidone group (35%): odds ratio 5.57, 95% CI 1.42 to 21.86, low-certainty evidence. No serious adverse events were reported. Low-certainty evidence showed a small difference in irritability (MD -3.50, 95% CI -6.39 to -0.61), with the galantamine plus risperidone group showing a greater decline on the irritability subscale than the placebo group postintervention. There was no evidence of a difference between the groups in hyperactivity postintervention (MD -5.20, 95% CI -10.51 to 0.11). General health and function were not assessed. Donepezil versus placebo One study compared donepezil to placebo (34 participants aged 8 years to 17 years). Primary outcomes of interest were measured postintervention, using subscales of the Modified Version of The Real Life Rating Scale (scored 0 to 3; higher scores = greater impairment). Very low-certainty evidence showed no evidence of group differences immediately postintervention in overall autism features (MD 0.07, 95% CI -0.19 to 0.33), or in the autism symptom domains of social communication (MD -0.02, 95% CI -0.34 to 0.30), and restricted and repetitive behaviours (MD 0.04, 95% CI -0.27 to 0.35). Significant adverse events leading to study withdrawal in at least one participant was implied in the data analysis section, but not explicitly reported. The evidence is very uncertain about the effect of donepezil, compared to placebo, on the secondary outcomes of interest, including irritability (MD 1.08, 95% CI -0.41 to 2.57), hyperactivity (MD 2.60, 95% CI 0.50 to 4.70), and general health and function (MD 0.03, 95% CI -0.48 to 0.54) postintervention. Across all analyses within this comparison, we judged the evidence to be very low-certainty due to high risk of bias, and very serious imprecision (results based on one small study with wide confidence intervals). The study narratively reported adverse events for the study as a whole, rather than by treatment group. AUTHORS' CONCLUSIONS Evidence about the effectiveness of acetylcholinesterase inhibitors as a medication to improve outcomes for autistic adults is lacking, and for autistic children is very uncertain. There is a need for more evidence of improvement in outcomes of relevance to clinical care, autistic people, and their families. There are a number of ongoing studies involving acetylcholinesterase inhibitors, and future updates of this review may add to the current evidence.
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Affiliation(s)
- Alexandra Ure
- Department of Paediatrics, Monash University, Melbourne, Australia
- Developmental Paediatrics, Monash Children's Hospital, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
| | - Georgina R Cox
- Department of Paediatrics, Monash University, Melbourne, Australia
- Neurodevelopment and Disability, The Royal Children's Hospital, Melbourne, Australia
| | - Richard Haslam
- Mental Health Department, The Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Katrina Williams
- Department of Paediatrics, Monash University, Melbourne, Australia
- Developmental Paediatrics, Monash Children's Hospital, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
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Gupta N, Gupta M. Diagnostic Overshadowing in High-Functioning Autism: Mirtazapine, Buspirone, and Modified Cognitive Behavioral Therapy (CBT) as Treatment Options. Cureus 2023; 15:e39446. [PMID: 37362512 PMCID: PMC10289477 DOI: 10.7759/cureus.39446] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 06/28/2023] Open
Abstract
Diagnostic overshadowing (DO) is identified as a contributor to the missed diagnosis of individuals with an autism spectrum disorder (ASD). It has been used predominantly in the scientific literature and clinical settings to describe a phenomenon where a person's symptoms and behaviors are attributed solely to their primary diagnosis, rather than being recognized due to co-occurring conditions. DO is seen across many developmental disorders; however, females with autism may have a more difficult time getting diagnosed than males with autism because traditional diagnostic criteria for autism are often based on research that has primarily focused on males with autism. Likewise, the efficacy of approved psychopharmacological like selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy (CBT) in individuals with ASD is not well established. Amidst these challenges, it's imperative to underscore the need for screening these disorders and provide informed evidence-based treatment alternatives for shared decision-making. Mirtazapine has low but promising findings, though modified CBT has superior empirical support in the treatment of co-occurring conditions associated with ASD.
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Affiliation(s)
- Nihit Gupta
- Psychiatry, Dayton Children's Hospital, Dayton, USA
| | - Mayank Gupta
- Psychiatry and Behavioral Sciences, Southwood Psychiatric Hospital, Pittsburgh, USA
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Gupta N, Gupta M, Gandhi R. Buspirone in Autism Spectrum Disorder: A Systematic Review. Cureus 2023; 15:e39304. [PMID: 37378184 PMCID: PMC10291962 DOI: 10.7759/cureus.39304] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2023] [Indexed: 06/29/2023] Open
Abstract
The aim of this systematic review is to appraise the current evidence on the efficacy and safety of buspirone in core symptoms of autism spectrum disorder (ASD), co-occurring anxiety, and other associated symptoms. Major medical literature databases were searched for randomized controlled trials (RCTs), open-label trials, and any other relevant studies or clinical trials reporting on pediatric (age < 18 years) patients with ASD treated with buspirone for any reason. A total of 310 abstracts were screened, and six clinical trials were selected for inclusion. Out of these six clinical trials, two were RCTs (n =166 and 40), two open-label trials (n= 26 and 4), and one cross-over study (n = 1). We also included one retrospective chart review (n=31). Meta-analysis was not performed due to a lack of homogeneity in the two RCTs. Although most of the studies reported improved overall symptoms, they had different outcome measures. The quality of evidence available is low, and there is a need for higher-power studies in the future. Most studies suggested that buspirone was well tolerated and safe in pediatric patients with ASD. Based on the data, there is insufficient evidence to make conclusive recommendations on buspirone for improvement in core symptoms of ASD or cooccurring anxiety, irritability, or hyperactivity symptoms in the pediatric population. Given there are limited approved therapies for co-occurring anxiety, buspirone could be used as a safe off-label option due to the lack of behavioral activation and any serious adverse reactions.
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Affiliation(s)
- Nihit Gupta
- Psychiatry, Dayton Children's Hospital, Dayton, USA
| | - Mayank Gupta
- Psychiatry and Behavioral Sciences, Southwood Psychiatric Hospital, Pittsburgh, USA
| | - Raghu Gandhi
- Psychiatry, Abbott Northwestern Hospital, Minneapolis, USA
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12
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Secci I, Petigas L, Cuenod A, Klauser P, Kapp C, Novatti A, Armando M. Case report: Treatment-resistant depression, multiple trauma exposure and suicidality in an adolescent female with previously undiagnosed Autism Spectrum Disorder. Front Psychiatry 2023; 14:1151293. [PMID: 37181890 PMCID: PMC10169628 DOI: 10.3389/fpsyt.2023.1151293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/03/2023] [Indexed: 05/16/2023] Open
Abstract
High rates of co-occurring depression are commonly reported in youth with Autism Spectrum Disorder (ASD), especially in individuals without intellectual disability (ID). Depression in ASD undermines adaptive behavior and is associated with a higher risk of suicidality. Females with ASD may be particularly vulnerable due to their greater use of camouflaging strategies. Indeed, in comparison to males, ASD is underdiagnosed in females, despite higher rates of internalizing symptoms and suicidality. Trauma exposure may also play a role in the development of depressive symptoms in this population. Moreover, evidence for effective treatments of depression in autistic youth are lacking, with ASD individuals frequently experiencing low efficacy and side effects. We present the case of an adolescent female with previously undiagnosed ASD without ID, admitted for active suicidal plans and a treatment-resistant depression (TRD), occurred after a COVID-19 lockdown in the context of cumulative exposure to stressful life events. Comprehensive clinical assessments performed at intake confirmed severe depression with suicidality. Intensive psychotherapy and different changes in medications were carried out (SSRI, SNRI, SNRI + NaSSA, SNRI + aripiprazole), all of which were ineffective, with persistent suicidal thoughts, often requiring intensive individual monitoring. The patient was finally successfully treated with lithium augmentation of fluoxetine, with no side effects. During hospitalization she was also evaluated by an ASD specialized center, where a diagnosis of ASD was made according to the Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview-Revised (ADI-R) scores, as well as to clinical judgment of a senior psychiatrist. The present case report shows that clinicians should not overlook undiagnosed autism as a possible cause of TRD, especially in females without ID, where higher rates of under diagnosis may be in part related to their greater use of camouflage. It also suggests that ASD underdiagnosis and resulting unmet needs may be involved in vulnerability to stressful experiences, depression, and suicidality. Furthermore, it shows the complexity of providing care to TRD in youth with autism, suggesting that an augmentation therapy with lithium, a commonly recommended therapeutic strategy for refractory depression in typically developing samples, may also be effective in this population.
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Affiliation(s)
- Ilaria Secci
- Section of Child and Adolescent Neuropsychiatry, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
- Service of Child and Adolescent Psychiatry, Department of Psychiatry, Lausanne University Hospital and the University of Lausanne, Lausanne, Switzerland
| | - Lucie Petigas
- Service of Child and Adolescent Psychiatry, Department of Psychiatry, Lausanne University Hospital and the University of Lausanne, Lausanne, Switzerland
| | - Alexandra Cuenod
- Service of Child and Adolescent Psychiatry, Department of Psychiatry, Lausanne University Hospital and the University of Lausanne, Lausanne, Switzerland
- Psychiatric Liaison Service, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Paul Klauser
- Service of Child and Adolescent Psychiatry, Department of Psychiatry, Lausanne University Hospital and the University of Lausanne, Lausanne, Switzerland
- Center for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital and the University of Lausanne, Lausanne, Switzerland
| | - Carole Kapp
- Service of Child and Adolescent Psychiatry, Department of Psychiatry, Lausanne University Hospital and the University of Lausanne, Lausanne, Switzerland
| | - Audrey Novatti
- Service of Child and Adolescent Psychiatry, Department of Psychiatry, Lausanne University Hospital and the University of Lausanne, Lausanne, Switzerland
| | - Marco Armando
- Service of Child and Adolescent Psychiatry, Department of Psychiatry, Lausanne University Hospital and the University of Lausanne, Lausanne, Switzerland
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Nakamura T, Kaneko T, Sasayama D, Yoshizawa T, Kito Y, Fujinaga Y, Washizuka S. Cerebellar network changes in depressed patients with and without autism spectrum disorder: A case-control study. Psychiatry Res Neuroimaging 2023; 329:111596. [PMID: 36669239 DOI: 10.1016/j.pscychresns.2023.111596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/04/2023] [Accepted: 01/09/2023] [Indexed: 01/18/2023]
Abstract
Pathophysiological difference of depression in patients with and without autistic spectrum disorder (ASD) has not been investigated previously. Therefore, we sought to determine whether there were differences between non-ASD and ASD groups on resting-state functional magnetic resonance imaging (rs-fMRI) in patients with depression. We performed 3T MRI under resting state in 8 patients with depression and ASD and 12 patients with depression but without ASD. The ASD group showed increased functional connectivity in the cerebellar network of the left posterior inferior temporal gyrus and anterior cerebellar lobes compared to the non-ASD group in an analysis of covariance. Adding antipsychotics, antidepressants, benzodiazepines, nonbenzodiazepines, anxiolytics, hypnotics, or age as covariates showed a similar increase in functional connectivity. Thus, this study found that depressive patients with ASD had increased functional connectivity in the cerebellar network. Our findings suggest that fMRI may be able to evaluate differences in depressed patients with and without ASD.
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Affiliation(s)
- Toshinori Nakamura
- Department of Psychiatry, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Nagano, Japan.
| | - Tomoki Kaneko
- Department of Radiology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Nagano, Japan
| | - Daimei Sasayama
- Department of Psychiatry, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Nagano, Japan
| | - Tomonari Yoshizawa
- Department of Psychiatry, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Nagano, Japan
| | - Yoshihiro Kito
- Radiology Division, Shinshu University Hospital, 3-1-1 Asahi, Matsumoto, 390-8621, Nagano, Japan
| | - Yasunari Fujinaga
- Department of Radiology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Nagano, Japan
| | - Shinsuke Washizuka
- Department of Psychiatry, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Nagano, Japan
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Cortese S, Besag FM, Clark B, Hollis C, Kilgariff J, Moreno C, Nicholls D, Wilkinson P, Woodbury-Smith M, Sharma A. Common practical questions - and answers - at the British Association for Psychopharmacology child and adolescent psychopharmacology course. J Psychopharmacol 2023; 37:119-134. [PMID: 36476096 PMCID: PMC9912307 DOI: 10.1177/02698811221140005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The British Association for Psychopharmacology course on child and adolescent psychopharmacology has been run for more than 20 years and is currently a very popular course, attracting around 140 delegates/year from across the United Kingdom and abroad. As Faculty of recent sessions of the course, we have selected the most common questions we have been asked in recent years and provided evidence-based and/or expert-informed answers. We have included 27 questions and answers related to attention-deficit/hyperactivity disorder, anxiety and depressive disorders, autism spectrum disorder, bipolar disorder, eating disorders, epilepsy (in differential diagnosis or comorbid with mental health conditions), obsessive-compulsive disorder, personality disorders, psychotic spectrum disorders, and tics/Tourette syndrome in children and young people. We hope that this article will be helpful for prescribers in their daily clinical practice and we look forward to further, high-level evidence informing the answers to these and other questions in child and adolescent psychopharmacology.
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Affiliation(s)
- Samuele Cortese
- Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK.,Solent NHS Trust, Southampton, UK.,Hassenfeld Children's Hospital at NYU Langone, New York University Child Study Center, New York City, NY, USA.,Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Frank Mc Besag
- UCL School of Pharmacy, London, UK.,East London Foundation NHS Trust, Bedfordshire, UK.,Institute of Psychiatry, Psychology and Neuroscience, KCL, London, UK
| | - Bruce Clark
- National Specialist Clinic for Young People with OCD, BDD and Related Disorders, South London and Maudsley NHS Foundation Trust, London, UK
| | - Chris Hollis
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK.,Department of Child and Adolescent Psychiatry, Nottinghamshire Healthcare NHS Foundation Trust, Queen's Medical Centre, Nottingham, UK.,National Institute of Mental Health (NIHR) MindTech Medtech Co-operative, Institute of Mental Health, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre, Mental Health & Technology Theme, Institute of Mental Health, Nottingham, UK
| | - Joseph Kilgariff
- Department of Child and Adolescent Psychiatry, Nottinghamshire Healthcare NHS Foundation Trust, Queen's Medical Centre, Nottingham, UK
| | - Carmen Moreno
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, IiSGM, CIBERSAM, ISCIII, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Dasha Nicholls
- Division of Psychiatry, Imperial College London, London, UK.,NIHR ARC Northwest, London, UK
| | - Paul Wilkinson
- School of Clinical Medicine, University of Cambridge, Cambridge, Cambridgeshire, UK.,Cambridgeshire and Peterborough NHS Foundation Trust, Cambridgeshire, UK
| | | | - Aditya Sharma
- Academic Psychiatry, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Specialist Adolescent Mood Disorders Service (SAMS), Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
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15
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Acute and Repeated Administration of NLX-101, a Selective Serotonin-1A Receptor Biased Agonist, Reduces Audiogenic Seizures in Developing Fmr1 Knockout Mice. Neuroscience 2023; 509:113-124. [PMID: 36410632 DOI: 10.1016/j.neuroscience.2022.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 11/03/2022] [Accepted: 11/13/2022] [Indexed: 11/22/2022]
Abstract
Fragile XSyndrome (FXS) is a leading known genetic cause of Autism Spectrum Disorders (ASD) and intellectual disability. A consistent and debilitating phenotype of FXS is sensory hypersensitivity that manifests strongly in the auditory domain and may lead to delayed language and high anxiety. The mouse model of FXS, the Fmr1 KO mouse, also shows auditory hypersensitivity, an extreme form of which is seen as audiogenic seizures (AGS). The midbrain inferior colliculus (IC) is critically involved in generating audiogenic seizures and IC neurons are hyper-responsive to sounds in developing Fmr1 KO mice. Serotonin-1A receptor (5-HT1A) activation reduces IC activity. Therefore, we tested whether 5-HT1A activation is sufficient to reduce audiogenic seizures in Fmr1 KO mice. A selective and post-synaptic 5-HT1A receptor biased agonist, 3-Chloro-4-fluorophenyl-[4-fluoro-4-[[(5-methylpyrimidin-2-ylmethyl)amino]methyl]piperidin-1-yl] methanone (NLX-101, 0.6, 1.2, 1.8 or 2.4 mg/kg, i.p.) was administered to Fmr1 KO mice 15 min before seizure induction. Whereas the 0.6 mg/kg dose was ineffective in reducing seizures, the 1.2, 1.8 and 2.4 mg/kg doses of NLX-101 dramatically reduced seizures and increased mouse survival. Treatment with a combination of NLX-101 and 5-HT1A receptor antagonists prevented the protective effects of NLX-101, indicating that NLX-101 acts selectively through 5-HT1A receptors to reduce audiogenic seizures. NLX-101 (1.8 mg/kg) was still strongly effective in reducing seizures even after repeated administration over 5 days, suggesting an absence of tachyphylaxis to the effects of the compound. Together, these studies point to a promising treatment option targeting post-synaptic 5-HT1A receptors to reduce auditory hypersensitivity in FXS, and potentially across autism spectrum disorders.
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Pahnke J, Jansson-Fröjmark M, Andersson G, Bjureberg J, Jokinen J, Bohman B, Lundgren T. Acceptance and commitment therapy for autistic adults: A randomized controlled pilot study in a psychiatric outpatient setting. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2022:13623613221140749. [PMID: 36510817 DOI: 10.1177/13623613221140749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
LAY ABSTRACT Autistic adults are often stressed and feel depressed or anxious. However, mental health programs that are suited for autistic adults are few. Acceptance and commitment therapy is a psychotherapy method that seems to help people feel better, although not thoroughly evaluated in autistic individuals. In this study, 20 autistic adults had 14 weeks of acceptance and commitment therapy group treatment suited for autism (NeuroACT), while 19 autistic adults had ordinary care. The acceptance and commitment therapy group treatment program seemed logical and reasonable to the participants. Also, when comparing the participants in the NeuroACT group with those in the ordinary care group, the NeuroACT participants reported less stress and higher quality of life. Compared to the ordinary care group, they could also manage distressing thoughts better, perceived themselves as more flexible, and did not avoid stressful situations as much as before. However, there was no significant difference between the groups in depression, anxiety, sleep problems, social aspects of autism, everyday functioning, or executive challenges. Slightly more NeuroACT participants did not finish the treatment than ordinary care participants. In conclusion, the NeuroACT program may be a treatment for autistic adults who feel stressed and have reduced quality of life. More studies are needed to see how helpful the NeuroACT program is for autistic adults.
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Affiliation(s)
- Johan Pahnke
- Karolinska Institutet and Region Stockholm, Sweden
| | | | - Gerhard Andersson
- Karolinska Institutet and Region Stockholm, Sweden.,Linköping University, Sweden
| | - Johan Bjureberg
- Karolinska Institutet and Region Stockholm, Sweden.,Stanford University, USA
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Zaydlin M, Cara VM, Bez Y, Coffey BJ. Difficult-to-Treat Aggression in a Child with Autism Spectrum Disorder: Did We Miss Something? Bipolar Disorder As a Comorbid Psychiatric Condition in Autism Spectrum Disorder. J Child Adolesc Psychopharmacol 2022; 32:500-504. [PMID: 36383098 DOI: 10.1089/cap.2022.29228.bjc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Michelle Zaydlin
- Department of Psychiatry, University of Miami Miller School of Medicine, Miami, Florida, USA.,Department of Psychiatry, Jackson Health System, Miami, Florida, USA
| | - Valentina Metsavaht Cara
- Department of Psychiatry, University of Miami Miller School of Medicine, Miami, Florida, USA.,Department of Psychiatry, Jackson Health System, Miami, Florida, USA
| | - Yasin Bez
- Department of Psychiatry, University of Miami Miller School of Medicine, Miami, Florida, USA.,Department of Psychiatry, Jackson Health System, Miami, Florida, USA
| | - Barbara J Coffey
- Department of Psychiatry, University of Miami Miller School of Medicine, Miami, Florida, USA.,Department of Psychiatry, Jackson Health System, Miami, Florida, USA
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18
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Amadori S, Barbuti M, Perugi G. Pharmacotherapy for bipolar disorder in adults with high-functioning autism. Expert Opin Pharmacother 2022; 23:1753-1760. [PMID: 36263803 DOI: 10.1080/14656566.2022.2138332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The association between high-functioning autism (HFA) and bipolar disorder (BD) in adult subjects has been confirmed by a growing number of studies. However, identifying and treating BD in this population is a clinical challenge and requires careful assessment and adequate knowledge of both disorders. AREAS COVERED This review aims to provide a clinical presentation of mood episodes in HFA individuals, and an update on the pharmacotherapy of BD in these individuals, sharing with the reader expert opinion on the current state of the art and future perspectives. EXPERT OPINION BD has an atypical clinical presentation in HFA subjects with the possibility of diagnostic and therapeutic mistakes. Despite the absence of controlled studies, the available evidence indicates mood stabilizers, especially lithium, as the first treatment option. HFA subjects are particularly vulnerable to pharmacological side effects, such as extrapyramidal and catatonic symptoms with antipsychotics, or activation syndrome with antidepressants. Accordingly, initial titration of these drugs should be slow and their use should be limited in time. Among antipsychotics, dopamine receptor antagonists with combined serotonergic activity are preferable. Further research is needed to improve the diagnostic process and to delineate the effectiveness of different drugs for BD in HFA subjects.
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Affiliation(s)
- Salvatore Amadori
- Psychiatry Unit 2, Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56126, Pisa (PI), Italy
| | - Margherita Barbuti
- Psychiatry Unit 2, Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56126, Pisa (PI), Italy
| | - Giulio Perugi
- Psychiatry Unit 2, Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56126, Pisa (PI), Italy
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Spee BTM, Sladky R, Fingerhut J, Laciny A, Kraus C, Carls-Diamante S, Brücke C, Pelowski M, Treven M. Repeating patterns: Predictive processing suggests an aesthetic learning role of the basal ganglia in repetitive stereotyped behaviors. Front Psychol 2022; 13:930293. [PMID: 36160532 PMCID: PMC9497189 DOI: 10.3389/fpsyg.2022.930293] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
Recurrent, unvarying, and seemingly purposeless patterns of action and cognition are part of normal development, but also feature prominently in several neuropsychiatric conditions. Repetitive stereotyped behaviors (RSBs) can be viewed as exaggerated forms of learned habits and frequently correlate with alterations in motor, limbic, and associative basal ganglia circuits. However, it is still unclear how altered basal ganglia feedback signals actually relate to the phenomenological variability of RSBs. Why do behaviorally overlapping phenomena sometimes require different treatment approaches−for example, sensory shielding strategies versus exposure therapy for autism and obsessive-compulsive disorder, respectively? Certain clues may be found in recent models of basal ganglia function that extend well beyond action selection and motivational control, and have implications for sensorimotor integration, prediction, learning under uncertainty, as well as aesthetic learning. In this paper, we systematically compare three exemplary conditions with basal ganglia involvement, obsessive-compulsive disorder, Parkinson’s disease, and autism spectrum conditions, to gain a new understanding of RSBs. We integrate clinical observations and neuroanatomical and neurophysiological alterations with accounts employing the predictive processing framework. Based on this review, we suggest that basal ganglia feedback plays a central role in preconditioning cortical networks to anticipate self-generated, movement-related perception. In this way, basal ganglia feedback appears ideally situated to adjust the salience of sensory signals through precision weighting of (external) new sensory information, relative to the precision of (internal) predictions based on prior generated models. Accordingly, behavioral policies may preferentially rely on new data versus existing knowledge, in a spectrum spanning between novelty and stability. RSBs may then represent compensatory or reactive responses, respectively, at the opposite ends of this spectrum. This view places an important role of aesthetic learning on basal ganglia feedback, may account for observed changes in creativity and aesthetic experience in basal ganglia disorders, is empirically testable, and may inform creative art therapies in conditions characterized by stereotyped behaviors.
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Affiliation(s)
- Blanca T. M. Spee
- Vienna Cognitive Science Hub, University of Vienna, Vienna, Austria
- Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ronald Sladky
- Social, Cognitive and Affective Neuroscience Unit, Department of Cognition, Emotion, and Methods in Psychology, University of Vienna, Vienna, Austria
| | - Joerg Fingerhut
- Berlin School of Mind and Brain, Department of Philosophy, Humboldt-Universität zu Berlin, Berlin, Germany
- Faculty of Philosophy, Philosophy of Science and Religious Studies, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Alice Laciny
- Konrad Lorenz Institute for Evolution and Cognition Research, Klosterneuburg, Austria
| | - Christoph Kraus
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
- Medical Neuroscience Cluster, Medical University of Vienna, Vienna, Austria
| | | | - Christof Brücke
- Medical Neuroscience Cluster, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Matthew Pelowski
- Vienna Cognitive Science Hub, University of Vienna, Vienna, Austria
- Department of Cognition, Emotion, and Methods in Psychology, Faculty of Psychology, University of Vienna, Vienna, Austria
| | - Marco Treven
- Konrad Lorenz Institute for Evolution and Cognition Research, Klosterneuburg, Austria
- Medical Neuroscience Cluster, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- *Correspondence: Marco Treven,
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Abstract
BACKGROUND Autism spectrum disorder (ASD; also known as autism) is a developmental disability that begins in childhood and is typically seen in around 1% to 2% of children. It is characterised by social communication difficulties and repetitive and restricted behaviours and routines that can have a negative impact on a child's quality of life, achievement at school, and social interactions with others. It has been hypothesised that memantine, which is traditionally used to treat dementia, may be effective in reducing the core symptoms of autism as well as some co-occurring symptoms such as hyperactivity and language difficulties. If memantine is being used to treat the core symptoms of autism, it is important to review the evidence of its effectiveness. OBJECTIVES To assess the effects of memantine on the core symptoms of autism, including, but not limited to, social communication and stereotypical behaviours. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, nine other databases and three trials registers up to February 2022. We also checked reference lists of key studies and checked with experts in the field for any additional papers. We searched for retractions of the included studies in MEDLINE, Embase, and the Retraction Watch Database. No retractions or corrections were found. SELECTION CRITERIA We included randomised controlled trials (RCTs) of any dose of memantine compared with placebo in autistic people. We also included RCTs in which only one group received memantine, but both groups received the same additional therapy (e.g. a behaviour intervention). DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were core autism symptoms and adverse effects. Secondary outcomes were language, intelligence, memory, adaptive behaviour, hyperactivity, and irritability. We used GRADE to assess certainty of evidence. MAIN RESULTS We included three RCTs (two double-blind and one single-blind) with 204 participants that examined the short-term effect (immediately postintervention) of memantine in autistic people. Two studies took place in the USA and the other in Iran. All three studies focused on children and adolescents, with a mean age of 9.40 (standard deviation (SD) 2.26) years. Most participants were male (range across studies 73% to 87%). The diagnosis of ASD was based on the Diagnostic and Statistical Manual of Mental Disorders (4th edition; 4th edition, text revision; or 5th edition). To confirm the diagnosis, one study used the Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview-Revised (ADI-R); one used ADOS, ADI-R or the Autism Diagnostic Interview Screener; and one used the Gilliam Autism Rating Scale. Dosage of memantine was based on the child's weight and ranged from 3 mg to 15 mg per day. Comparisons Two studies examined memantine compared with placebo; in the other study, both groups had a behavioural intervention while only one group was given memantine. Risk of bias All studies were rated at high risk of bias overall, as they were at high or unclear risk of bias across all but four domains in one study, and all but two domains in the other two studies. One study was funded by Forest Laboratories, LLC, (Jersey City, New Jersey), Allergan. The study sponsor was involved in the study design, data collection (via contracted clinical investigator sites), analysis and interpretation of data, and the decision to present these results. The other two studies reported no financial support or sponsorship; though in one of the two, the study medication was an in-kind contribution from Forest Pharmaceuticals. Primary outcomes There was no clear evidence of a difference between memantine and placebo with respect to severity of core symptoms of autism, although we are very uncertain about the evidence. The standardised mean difference in autism symptoms score in the intervention group versus the control group was -0.74 standard deviations (95% confidence interval (CI) -2.07 to 0.58; 2 studies, 181 participants; very low-certainty evidence; medium effect size); lower scores indicate less severe autistic symptoms. Two studies (144 participants) recorded adverse effects that the authors deemed related to the study and found there may be no difference between memantine and placebo (odds ratio (OR) 0.64, 95% CI 0.17 to 2.39; low-certainty evidence). Secondary outcomes There may be no difference between memantine and placebo on language (2 studies, 144 participants; low-certainty evidence); memory or adaptive behaviour (1 study, 23 participants; both low-certainty evidence); or hyperactivity or irritability (1 study, 121 participants; both low-certainty evidence). AUTHORS' CONCLUSIONS It is unclear whether memantine is an effective treatment for autistic children. None of the three included trials reported on the effectiveness of memantine in adults. Further studies using rigorous designs, larger samples, longer follow-up and clinically meaningful outcome measures that are important to autistic people and their families will strengthen our knowledge of the effects of memantine in autism.
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Affiliation(s)
- Amanda Brignell
- Department of Paediatrics, Monash University, Melbourne, Australia
- Developmental Paediatrics, Monash Children's Hospital, Melbourne, Australia
- Department of Speech Pathology, Australian Catholic University, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
| | - Catherine Marraffa
- Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Neurodevelopment and Disability, The Royal Children's Hospital, Melbourne, Australia
| | - Katrina Williams
- Department of Paediatrics, Monash University, Melbourne, Australia
- Developmental Paediatrics, Monash Children's Hospital, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Tamara May
- Department of Paediatrics, Monash University, Melbourne, Australia
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21
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Zhao F, Zhang H, Wang P, Cui W, Xu K, Chen D, Hu M, Li Z, Geng X, Wei S. Oxytocin and serotonin in the modulation of neural function: Neurobiological underpinnings of autism-related behavior. Front Neurosci 2022; 16:919890. [PMID: 35937893 PMCID: PMC9354980 DOI: 10.3389/fnins.2022.919890] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/27/2022] [Indexed: 12/12/2022] Open
Abstract
Autism spectrum disorders (ASD) is a group of generalized neurodevelopmental disorders. Its main clinical features are social communication disorder and repetitive stereotyped behavioral interest. The abnormal structure and function of brain network is the basis of social dysfunction and stereotyped performance in patients with autism spectrum disorder. The number of patients diagnosed with ASD has increased year by year, but there is a lack of effective intervention and treatment. Oxytocin has been revealed to effectively improve social cognitive function and significantly improve the social information processing ability, empathy ability and social communication ability of ASD patients. The change of serotonin level also been reported affecting the development of brain and causes ASD-like behavioral abnormalities, such as anxiety, depression like behavior, stereotyped behavior. Present review will focus on the research progress of serotonin and oxytocin in the pathogenesis, brain circuit changes and treatment of autism. Revealing the regulatory effect and neural mechanism of serotonin and oxytocin on patients with ASD is not only conducive to a deeper comprehension of the pathogenesis of ASD, but also has vital clinical significance.
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Affiliation(s)
- Feng Zhao
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
- Key Laboratory of Traditional Chinese Medicine Classical Theory, Ministry of Education, Shandong University of Traditional Chinese Medicine, Jinan, China
- TAIYUE Postdoctoral Innovation and Practice Base, Jinan, China
- Chinese Medicine and Brain Science Core Facility, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Hao Zhang
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
- Key Laboratory of Traditional Chinese Medicine Classical Theory, Ministry of Education, Shandong University of Traditional Chinese Medicine, Jinan, China
- TAIYUE Postdoctoral Innovation and Practice Base, Jinan, China
- Chinese Medicine and Brain Science Core Facility, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Peng Wang
- School of Environmental Science and Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Wenjie Cui
- Department of Biology, Southern University of Science and Technology, Shenzhen, China
| | - Kaiyong Xu
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
- Chinese Medicine and Brain Science Core Facility, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Dan Chen
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
- Chinese Medicine and Brain Science Core Facility, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Minghui Hu
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
- TAIYUE Postdoctoral Innovation and Practice Base, Jinan, China
- Chinese Medicine and Brain Science Core Facility, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Zifa Li
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
- Key Laboratory of Traditional Chinese Medicine Classical Theory, Ministry of Education, Shandong University of Traditional Chinese Medicine, Jinan, China
- TAIYUE Postdoctoral Innovation and Practice Base, Jinan, China
- Chinese Medicine and Brain Science Core Facility, Shandong University of Traditional Chinese Medicine, Jinan, China
- Zifa Li,
| | - Xiwen Geng
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
- Key Laboratory of Traditional Chinese Medicine Classical Theory, Ministry of Education, Shandong University of Traditional Chinese Medicine, Jinan, China
- TAIYUE Postdoctoral Innovation and Practice Base, Jinan, China
- Chinese Medicine and Brain Science Core Facility, Shandong University of Traditional Chinese Medicine, Jinan, China
- Xiwen Geng,
| | - Sheng Wei
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, China
- Key Laboratory of Traditional Chinese Medicine Classical Theory, Ministry of Education, Shandong University of Traditional Chinese Medicine, Jinan, China
- TAIYUE Postdoctoral Innovation and Practice Base, Jinan, China
- Chinese Medicine and Brain Science Core Facility, Shandong University of Traditional Chinese Medicine, Jinan, China
- *Correspondence: Sheng Wei,
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22
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The Neurology and Psychopathology of Pica. Curr Neurol Neurosci Rep 2022; 22:531-536. [PMID: 35674869 DOI: 10.1007/s11910-022-01218-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Pica is defined by the American Psychiatric Association's Diagnostic and Statistical Manual, 5th edition (DSM 5) as the ongoing ingestion of materials with no nutritive or food value. More specifically such ingestions must be unremitting for at least 1 month and occur at a developmentally inconsistent age for such behavior. This article reviews the association of pica with pregnancy, micronutrient deficiencies, psychiatric disorders, dementia, and developmental disorders with emphasis on autism spectrum disorders (ASD). RECENT FINDINGS Some variants of non-nutritive consumption are prevalent behavioral norms in non-western cultures, so not all picas should be considered pathological. However, the strong association of pica with iron deficiency anemia (IDA) lends credence to the hypothesis that dopamine transmission may be disrupted in this disorder. Picas associated with ASD are resistant to medications but can be treated with applied behavioral analysis therapy (ABA). Etiological hypotheses for pica are explored with a focus on neurobiological, neuroimaging, and psychiatric correlations. Pharmacological management and behavior modification strategies are also discussed. The possibility that pica is a form of addiction analogous to food cravings is introduced and suggested as an area for further research pursuits.
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Lai AG, Chang WH, Skuse D. Autism and mental illness in children and young people require standardised approaches for assessment and treatment. THE LANCET REGIONAL HEALTH. EUROPE 2022; 16:100360. [PMID: 35368370 PMCID: PMC8968054 DOI: 10.1016/j.lanepe.2022.100360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Alvina G. Lai
- Institute of Health Informatics, University College London, London, UK
| | - Wai Hoong Chang
- Institute of Health Informatics, University College London, London, UK
| | - David Skuse
- Great Ormond Street Institute of Child Health, University College London, London, UK
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24
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A Personalized Multidisciplinary Approach to Evaluating and Treating Autism Spectrum Disorder. J Pers Med 2022; 12:jpm12030464. [PMID: 35330464 PMCID: PMC8949394 DOI: 10.3390/jpm12030464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 02/06/2023] Open
Abstract
Autism Spectrum Disorder (ASD) is a complex neurodevelopmental disorder without a known cure. Current standard-of-care treatments focus on addressing core symptoms directly but have provided limited benefits. In many cases, individuals with ASD have abnormalities in multiple organs, including the brain, immune and gastrointestinal system, and multiple physiological systems including redox and metabolic systems. Additionally, multiple aspects of the environment can adversely affect children with ASD including the sensory environment, psychosocial stress, dietary limitations and exposures to allergens and toxicants. Although it is not clear whether these medical abnormalities and environmental factors are related to the etiology of ASD, there is evidence that many of these factors can modulate ASD symptoms, making them a potential treatment target for improving core and associated ASD-related symptoms and improving functional limitation. Additionally, addressing underlying biological disturbances that drive pathophysiology has the potential to be disease modifying. This article describes a systematic approach using clinical history and biomarkers to personalize medical treatment for children with ASD. This approach is medically comprehensive, making it attractive for a multidisciplinary approach. By concentrating on treatable conditions in ASD, it is possible to improve functional ability and quality of life, thus providing optimal outcomes.
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Siafis S, Çıray O, Wu H, Schneider-Thoma J, Bighelli I, Krause M, Rodolico A, Ceraso A, Deste G, Huhn M, Fraguas D, San José Cáceres A, Mavridis D, Charman T, Murphy DG, Parellada M, Arango C, Leucht S. Pharmacological and dietary-supplement treatments for autism spectrum disorder: a systematic review and network meta-analysis. Mol Autism 2022; 13:10. [PMID: 35246237 PMCID: PMC8896153 DOI: 10.1186/s13229-022-00488-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 02/02/2022] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND There is still no approved medication for the core symptoms of autism spectrum disorder (ASD). This network meta-analysis investigated pharmacological and dietary-supplement treatments for ASD. METHODS We searched for randomized-controlled-trials (RCTs) with a minimum duration of seven days in ClinicalTrials.gov, EMBASE, MEDLINE, PsycINFO, WHO-ICTRP (from inception up to July 8, 2018), CENTRAL and PubMed (up to November 3, 2021). The co-primary outcomes were core symptoms (social-communication difficulties-SCD, repetitive behaviors-RB, overall core symptoms-OCS) measured by validated scales and standardized-mean-differences (SMDs). Associated symptoms, e.g., irritability/aggression and attention-deficit/hyperactivity disorder (ADHD) symptoms, dropouts and important side-effects, were investigated as secondary outcomes. Studies in children/adolescents and adults were analyzed separately in random-effects pairwise and network meta-analyses. RESULTS We analyzed data for 41 drugs and 17 dietary-supplements, from 125 RCTs (n = 7450 participants) in children/adolescents and 18 RCTs (n = 1104) in adults. The following medications could improve at least one core symptom domain in comparison with placebo: aripiprazole (k = 6 studies in analysis, SCD: SMD = 0.27 95% CI [0.09, 0.44], RB: 0.48 [0.26, 0.70]), atomoxetine (k = 3, RB:0.49 [0.18, 0.80]), bumetanide (k = 4, RB: 0.35 [0.09, 0.62], OCS: 0.61 [0.31, 0.91]), and risperidone (k = 4, SCM: 0.31 [0.06, 0.55], RB: 0.60 [0.29, 0.90]; k = 3, OCS: 1.18 [0.75, 1.61]) in children/adolescents; fluoxetine (k = 1, RB: 1.20 [0.45, 1.96]), fluvoxamine (k = 1, RB: 1.04 [0.27, 1.81]), oxytocin (k = 6, RB:0.41 [0.16, 0.66]) and risperidone (k = 1, RB: 0.97 [0.21,1.74]) in adults. There were some indications of improvement by carnosine, haloperidol, folinic acid, guanfacine, omega-3-fatty-acids, probiotics, sulforaphane, tideglusib and valproate, yet imprecise and not robust. Confidence in these estimates was very low or low, except moderate for oxytocin. Medications differed substantially in improving associated symptoms, and in their side-effect profiles. LIMITATIONS Most of the studies were inadequately powered (sample sizes of 20-80 participants), with short duration (8-13 weeks), and about a third focused on associated symptoms. Networks were mainly star-shaped, and there were indications of reporting bias. There was no optimal rating scale measuring change in core symptoms. CONCLUSIONS Some medications could improve core symptoms, although this could be likely secondary to the improvement of associated symptoms. Evidence on their efficacy and safety is preliminary; therefore, routine prescription of medications for the core symptoms cannot be recommended. Trial registration PROSPERO-ID CRD42019125317.
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Affiliation(s)
- Spyridon Siafis
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany.
| | - Oğulcan Çıray
- Department of Child and Adolescent Psychiatry, Mardin State Hospital, Artuklu, Mardin, Turkey
| | - Hui Wu
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Irene Bighelli
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Marc Krause
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Alessandro Rodolico
- Department of Experimental and Clinical Medicine, Psychiatric Clinic University Hospital 'Gaspare Rodolico', University of Catania, Catania, Italy
| | - Anna Ceraso
- Department of Psychiatry, Spedali Civili Hospital, Brescia, Italy
| | - Giacomo Deste
- Department of Psychiatry, Spedali Civili Hospital, Brescia, Italy
| | - Maximilian Huhn
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Social Foundation Bamberg, Teaching Hospital of the University of Erlangen, Bamberg, Germany
| | - David Fraguas
- Institute of Psychiatry and Mental Health, Hospital Clínico San Carlos, IdISSC CIBERSAM, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Antonia San José Cáceres
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Centro Investigación Biomédica en Red Salud Mental (CIBERSAM), Madrid, Spain
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece
- Faculté de Médecine, Université Paris Descartes, Paris, France
| | - Tony Charman
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Declan G Murphy
- Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Mara Parellada
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- School of Medicine, Universidad Complutense, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Centro Investigación Biomédica en Red Salud Mental (CIBERSAM), Madrid, Spain
| | - Celso Arango
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- School of Medicine, Universidad Complutense, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Centro Investigación Biomédica en Red Salud Mental (CIBERSAM), Madrid, Spain
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany
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Abstract
PURPOSE OF REVIEW To summarize recent findings regarding anxiety and trauma-related disorders in children diagnosed with autism spectrum disorder (autism), focusing on the distinct ways in which these conditions may be expressed, as well as advances in evidence-based assessment and treatment. RECENT FINDINGS Current findings suggest both anxiety and trauma-related disorders may be more prevalent, yet more complicated to address in autistic relative to non-autistic children. Overlapping symptoms and distinct manifestations of these disorders pose challenges for the accurate identification, assessment, and treatment of anxiety and trauma-related disorders in autistic children. Emerging evidence recommends adapting traditional assessment and treatment approaches to better meet the needs of autistic children. Recent research suggests autism-centered conceptualizations, which accommodate complexity in how anxiety and trauma-related disorders are experienced and expressed by autistic people, are needed to enhance the psychiatric care of this population.
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Aishworiya R, Valica T, Hagerman R, Restrepo B. An Update on Psychopharmacological Treatment of Autism Spectrum Disorder. Neurotherapeutics 2022; 19:248-262. [PMID: 35029811 PMCID: PMC9130393 DOI: 10.1007/s13311-022-01183-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2022] [Indexed: 01/05/2023] Open
Abstract
While behavioral interventions remain the mainstay of treatment of autism spectrum disorder (ASD), several potential targeted treatments addressing the underlying neurophysiology of ASD have emerged in the last few years. These are promising for the potential to, in future, become part of the mainstay treatment in addressing the core symptoms of ASD. Although it is likely that the development of future targeted treatments will be influenced by the underlying heterogeneity in etiology, associated genetic mechanisms influencing ASD are likely to be the first targets of treatments and even gene therapy in the future for ASD. In this article, we provide a review of current psychopharmacological treatment in ASD including those used to address common comorbidities of the condition and upcoming new targeted approaches in autism management. Medications including metformin, arbaclofen, cannabidiol, oxytocin, bumetanide, lovastatin, trofinetide, and dietary supplements including sulforophane and N-acetylcysteine are discussed. Commonly used medications to address the comorbidities associated with ASD including atypical antipsychotics, serotoninergic agents, alpha-2 agonists, and stimulant medications are also reviewed. Targeted treatments in Fragile X syndrome (FXS), the most common genetic disorder leading to ASD, provide a model for new treatments that may be helpful for other forms of ASD.
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Affiliation(s)
- Ramkumar Aishworiya
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, University of California Davis, 2825 50th Street, Sacramento, CA, 95817, USA
- Khoo Teck Puat-National University Children's Medical Institute, National University Health System, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Tatiana Valica
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, University of California Davis, 2825 50th Street, Sacramento, CA, 95817, USA
- Association for Children With Autism, Chisinau, Moldova
| | - Randi Hagerman
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, University of California Davis, 2825 50th Street, Sacramento, CA, 95817, USA.
- Department of Pediatrics, University of California Davis School of Medicine, 4610 X St, Sacramento, CA, 95817, USA.
| | - Bibiana Restrepo
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, University of California Davis, 2825 50th Street, Sacramento, CA, 95817, USA
- Department of Pediatrics, University of California Davis School of Medicine, 4610 X St, Sacramento, CA, 95817, USA
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28
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Straathof M, Blezer ELA, Smeele CE, van Heijningen C, van der Toorn A, Buitelaar JK, Glennon JC, Otte WM, Dijkhuizen RM. Memantine treatment does not affect compulsive behavior or frontostriatal connectivity in an adolescent rat model for quinpirole-induced compulsive checking behavior. Psychopharmacology (Berl) 2022; 239:2457-2470. [PMID: 35419637 PMCID: PMC9293859 DOI: 10.1007/s00213-022-06139-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 04/04/2022] [Indexed: 11/28/2022]
Abstract
RATIONALE Compulsivity often develops during childhood and is associated with elevated glutamate levels within the frontostriatal system. This suggests that anti-glutamatergic drugs, like memantine, may be an effective treatment. OBJECTIVE Our goal was to characterize the acute and chronic effect of memantine treatment on compulsive behavior and frontostriatal network structure and function in an adolescent rat model of compulsivity. METHODS Juvenile Sprague-Dawley rats received repeated quinpirole, resulting in compulsive checking behavior (n = 32; compulsive) or saline injections (n = 32; control). Eight compulsive and control rats received chronic memantine treatment, and eight compulsive and control rats received saline treatment for seven consecutive days between the 10th and 12th quinpirole/saline injection. Compulsive checking behavior was assessed, and structural and functional brain connectivity was measured with diffusion MRI and resting-state fMRI before and after treatment. The other rats received an acute single memantine (compulsive: n = 12; control: n = 12) or saline injection (compulsive: n = 4; control: n = 4) during pharmacological MRI after the 12th quinpirole/saline injection. An additional group of rats received a single memantine injection after a single quinpirole injection (n = 8). RESULTS Memantine treatment did not affect compulsive checking nor frontostriatal structural and functional connectivity in the quinpirole-induced adolescent rat model. While memantine activated the frontal cortex in control rats, no significant activation responses were measured after single or repeated quinpirole injections. CONCLUSIONS The lack of a memantine treatment effect in quinpirole-induced compulsive adolescent rats may be partly explained by the interaction between glutamatergic and dopaminergic receptors in the brain, which can be evaluated with functional MRI.
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Affiliation(s)
- Milou Straathof
- Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht & Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands.
| | - Erwin L. A. Blezer
- Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht & Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Christel E. Smeele
- Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht & Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Caroline van Heijningen
- Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht & Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Annette van der Toorn
- Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht & Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Jan K. Buitelaar
- Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands ,Karakter Child and Adolescent Psychiatry University Center, Nijmegen, the Netherlands
| | - Jeffrey C. Glennon
- Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands ,Conway Institute of Biomolecular and Biomedical Research, School of Medicine, University College Dublin, Dublin 4, Ireland
| | - Willem M. Otte
- Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht & Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands ,Department of Pediatric Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands
| | - Rick M. Dijkhuizen
- Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht & Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
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29
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Foldes ST, Jensen AR, Jacobson A, Vassall S, Foldes E, Guthery A, Brown D, Levine T, Tyler WJ, Frye RE. Transdermal Electrical Neuromodulation for Anxiety and Sleep Problems in High-Functioning Autism Spectrum Disorder: Feasibility and Preliminary Findings. J Pers Med 2021; 11:1307. [PMID: 34945779 PMCID: PMC8704341 DOI: 10.3390/jpm11121307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Autism spectrum disorder (ASD) is associated with anxiety and sleep problems. We investigated transdermal electrical neuromodulation (TEN) of the cervical nerves in the neck as a safe, effective, comfortable and non-pharmacological therapy for decreasing anxiety and enhancing sleep quality in ASD. METHODS In this blinded, sham-controlled study, seven adolescents and young adults with high-functioning ASD underwent five consecutive treatment days, one day of the sham followed by four days of subthreshold TEN for 20 min. Anxiety-provoking cognitive tasks were performed after the sham/TEN. Measures of autonomic nervous system activity, including saliva α-amylase and cortisol, electrodermal activity, and heart rate variability, were collected from six participants. RESULTS Self-rated and caretaker-rated measures of anxiety were significantly improved with TEN treatment as compared to the sham, with effect sizes ranging from medium to large depending on the rating scale. Sleep scores from caretaker questionnaires also improved, but not significantly. Performance on two of the three anxiety-provoking cognitive tasks and heart rate variability significantly improved with TEN stimulation as compared to the sham. Four of the seven (57%) participants were responders, defined as a ≥ 30% improvement in self-reported anxiety. Salivary α-amylase decreased with more TEN sessions and decreased from the beginning to the end of the session on TEN days for responders. TEN was well-tolerated without significant adverse events. CONCLUSIONS This study provides preliminary evidence that TEN is well-tolerated in individuals with ASD and can improve anxiety.
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Affiliation(s)
- Stephen T. Foldes
- Division of Research, Barrow Neurologic Institute at Phoenix Children’s Hospital, Phoenix, AZ 85016, USA; (S.T.F.); (A.J.); (D.B.)
- Division of Neurology, Barrow Neurologic Institute, Phoenix, AZ 85013, USA
- School of Biological and Health Sciences, Arizona State University, Tempe, AZ 85287, USA;
- Department of Child Health, University of Arizona College of Medicine Phoenix, Phoenix, AZ 85004, USA
| | - Amanda R. Jensen
- Section on Neurodevelopmental Disorders, Division of Neurology, Barrow Neurologic Institute at Phoenix Children’s Hospital, Phoenix, AZ 85016, USA;
| | - Austin Jacobson
- Division of Research, Barrow Neurologic Institute at Phoenix Children’s Hospital, Phoenix, AZ 85016, USA; (S.T.F.); (A.J.); (D.B.)
| | - Sarah Vassall
- Division of Psychology, Vanderbilt University, Nashville, TN 37240, USA;
| | - Emily Foldes
- Speech and Hearing Science, Arizona State University, Tempe, AZ 85287, USA;
| | - Ann Guthery
- Division of Psychiatry, Barrow Neurologic Institute at Phoenix Children’s Hospital, Phoenix, AZ 85016, USA; (A.G.); (T.L.)
| | - Danni Brown
- Division of Research, Barrow Neurologic Institute at Phoenix Children’s Hospital, Phoenix, AZ 85016, USA; (S.T.F.); (A.J.); (D.B.)
| | - Todd Levine
- Division of Psychiatry, Barrow Neurologic Institute at Phoenix Children’s Hospital, Phoenix, AZ 85016, USA; (A.G.); (T.L.)
| | - William James Tyler
- School of Biological and Health Sciences, Arizona State University, Tempe, AZ 85287, USA;
| | - Richard E. Frye
- Department of Child Health, University of Arizona College of Medicine Phoenix, Phoenix, AZ 85004, USA
- Section on Neurodevelopmental Disorders, Division of Neurology, Barrow Neurologic Institute at Phoenix Children’s Hospital, Phoenix, AZ 85016, USA;
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30
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Deb S, Roy M, Lee R, Majid M, Limbu B, Santambrogio J, Roy A, Bertelli MO. Randomised controlled trials of antidepressant and anti-anxiety medications for people with autism spectrum disorder: systematic review and meta-analysis. BJPsych Open 2021; 7:e179. [PMID: 34593083 PMCID: PMC8503912 DOI: 10.1192/bjo.2021.1003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Although widely used, the current evidence for the efficacy of antidepressant and anti-anxiety medications for people with autism spectrum disorder (ASD) is limited and conflicting. AIMS We carried out a systematic review and meta-analysis of randomised controlled trials that assessed the effectiveness of these medications in people with ASD. METHOD We searched the following databases: Cochrane Library, Medline, EMBASE, CINAHL, PsycINFO, ERIC, DARE and ClinicalTrials.gov. Additionally, we hand-searched 11 relevant journals. We used the Cochrane risk-of-bias tool and Jadad score to assess the quality of each included study. We carried out a meta-analysis using a random effects model. RESULTS We included 15 randomised controlled trials (13 on antidepressants and two on anti-anxiety medications) for a total of 958 people with ASD. Data showed contradictory findings among the studies, with larger studies mostly showing a non-significant difference in outcomes between the treatment and the placebo groups. Meta-analysis of pooled Yale-Brown Obsessive Compulsive Scale and Clinical Global Impression Scale data from nine studies (60%) did not show any statistically significant inter-group difference on either of the outcome measures. The adverse effects reported were mild and, in most studies, their rates did not show any significant inter-group difference. CONCLUSIONS Given the methodological flaws in the most included studies and contradictory findings, it is difficult to draw any definitive conclusion about the effectiveness of either antidepressant or anti-anxiety medications to treat either ASD core symptoms or associated behaviours. Robust, large-scale, randomised controlled trials are needed to address this issue.
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Affiliation(s)
- Shoumitro Deb
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, UK
| | - Meera Roy
- Department of Psychiatry, Hereford and Worcestershire Health and Care NHS Trust, UK
| | - Rachel Lee
- Department of Learning Disabilities, Coventry and Warwickshire Partnership NHS Foundation Trust, UK
| | - Madiha Majid
- Warwick Medical School, University of Warwick, UK
| | - Bharati Limbu
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, UK
| | - Jacopo Santambrogio
- Clinical Neuroscience PhD program, Department of Medicine and Surgery, University of Milano-Bicocca, Italy
| | - Ashok Roy
- Warwick Medical School, University of Warwick, UK
| | - Marco O Bertelli
- Research and Clinical Centre, San Sebastiano Foundation of the Misericordia of Florence, Italy
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Resting State Functional Magnetic Resonance Imaging Elucidates Neurotransmitter Deficiency in Autism Spectrum Disorder. J Pers Med 2021; 11:jpm11100969. [PMID: 34683111 PMCID: PMC8537605 DOI: 10.3390/jpm11100969] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/23/2021] [Accepted: 09/27/2021] [Indexed: 12/18/2022] Open
Abstract
Resting-state functional magnetic resonance imaging provides dynamic insight into the functional organization of the brains' intrinsic activity at rest. The emergence of resting-state functional magnetic resonance imaging in both the clinical and research settings may be attributed to recent advancements in statistical techniques, non-invasiveness and enhanced spatiotemporal resolution compared to other neuroimaging modalities, and the capability to identify and characterize deep brain structures and networks. In this report we describe a 16-year-old female patient with autism spectrum disorder who underwent resting-state functional magnetic resonance imaging due to late regression. Imaging revealed deactivated networks in deep brain structures involved in monoamine synthesis. Monoamine neurotransmitter deficits were confirmed by cerebrospinal fluid analysis. This case suggests that resting-state functional magnetic resonance imaging may have clinical utility as a non-invasive biomarker of central nervous system neurochemical alterations by measuring the function of neurotransmitter-driven networks. Use of this technology can accelerate and increase the accuracy of selecting appropriate therapeutic agents for patients with neurological and neurodevelopmental disorders.
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Prabha B, Priya M, Shanker N, Ganesh E. Aberrant behavior prediction and severity analysis for autistic child through deep transfer learning to avoid adverse drug effect. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2021.103038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Feroe AG, Uppal N, Gutiérrez-Sacristán A, Mousavi S, Greenspun P, Surati R, Kohane IS, Avillach P. Medication Use in the Management of Comorbidities Among Individuals With Autism Spectrum Disorder From a Large Nationwide Insurance Database. JAMA Pediatr 2021; 175:957-965. [PMID: 34097007 PMCID: PMC8185632 DOI: 10.1001/jamapediatrics.2021.1329] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
IMPORTANCE Although there is no pharmacological treatment for autism spectrum disorder (ASD) itself, behavioral and pharmacological therapies have been used to address its symptoms and common comorbidities. A better understanding of the medications used to manage comorbid conditions in this growing population is critical; however, most previous efforts have been limited in size, duration, and lack of broad representation. OBJECTIVE To use a nationally representative database to uncover trends in the prevalence of co-occurring conditions and medication use in the management of symptoms and comorbidities over time among US individuals with ASD. DESIGN, SETTING, AND PARTICIPANTS This retrospective, population-based cohort study mined a nationwide, managed health plan claims database containing more than 86 million unique members. Data from January 1, 2014, to December 31, 2019, were used to analyze prescription frequency and diagnoses of comorbidities. A total of 26 722 individuals with ASD who had been prescribed at least 1 of 24 medications most commonly prescribed to treat ASD symptoms or comorbidities during the 6-year study period were included in the analysis. EXPOSURES Diagnosis codes for ASD based on International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. MAIN OUTCOMES AND MEASURES Quantitative estimates of prescription frequency for the 24 most commonly prescribed medications among the study cohort and the most common comorbidities associated with each medication in this population. RESULTS Among the 26 722 individuals with ASD included in the analysis (77.7% male; mean [SD] age, 14.45 [9.40] years), polypharmacy was common, ranging from 28.6% to 31.5%. Individuals' prescription regimens changed frequently within medication classes, rather than between classes. The prescription frequency of a specific medication varied considerably, depending on the coexisting diagnosis of a given comorbidity. Of the 24 medications assessed, 15 were associated with at least a 15% prevalence of a mood disorder, and 11 were associated with at least a 15% prevalence of attention-deficit/hyperactivity disorder. For patients taking antipsychotics, the 2 most common comorbidities were combined type attention-deficit/hyperactivity disorder (11.6%-17.8%) and anxiety disorder (13.1%-30.1%). CONCLUSIONS AND RELEVANCE This study demonstrated considerable variability and transiency in the use of prescription medications by US clinicians to manage symptoms and comorbidities associated with ASD. These findings support the importance of early and ongoing surveillance of patients with ASD and co-occurring conditions and offer clinicians insight on the targeted therapies most commonly used to manage co-occurring conditions. Future research and policy efforts are critical to assess the extent to which pharmacological management of comorbidities affects quality of life and functioning in patients with ASD while continuing to optimize clinical guidelines, to ensure effective care for this growing population.
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Affiliation(s)
| | | | | | - Sajad Mousavi
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
| | - Philip Greenspun
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
| | - Rajeev Surati
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
| | - Isaac S. Kohane
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts,Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts
| | - Paul Avillach
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts,Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts
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Popow C, Ohmann S, Plener P. Practitioner's review: medication for children and adolescents with autism spectrum disorder (ASD) and comorbid conditions. NEUROPSYCHIATRIE : KLINIK, DIAGNOSTIK, THERAPIE UND REHABILITATION : ORGAN DER GESELLSCHAFT OSTERREICHISCHER NERVENARZTE UND PSYCHIATER 2021; 35:113-134. [PMID: 34160787 PMCID: PMC8429404 DOI: 10.1007/s40211-021-00395-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/15/2021] [Indexed: 11/14/2022]
Abstract
Alleviating the multiple problems of children with autism spectrum disorder (ASD) and its comorbid conditions presents major challenges for the affected children, parents, and therapists. Because of a complex psychopathology, structured therapy and parent training are not always sufficient, especially for those patients with intellectual disability (ID) and multiple comorbidities. Moreover, structured therapy is not available for a large number of patients, and pharmacological support is often needed, especially in those children with additional attention deficit/hyperactivity and oppositional defiant, conduct, and sleep disorders.
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Affiliation(s)
- Christian Popow
- Dept. Child and Adolescent Psychiatry, Medical University of Vienna, Waehringer Guertel 18–20, 1090 Vienna, Austria
| | - Susanne Ohmann
- Dept. Child and Adolescent Psychiatry, Medical University of Vienna, Waehringer Guertel 18–20, 1090 Vienna, Austria
| | - Paul Plener
- Dept. Child and Adolescent Psychiatry, Medical University of Vienna, Waehringer Guertel 18–20, 1090 Vienna, Austria
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Tkachev A, Stekolshchikova E, Bobrovskiy DM, Anikanov N, Ogurtsova P, Park DI, Horn AKE, Petrova D, Khrameeva E, Golub MS, Turck CW, Khaitovich P. Long-Term Fluoxetine Administration Causes Substantial Lipidome Alteration of the Juvenile Macaque Brain. Int J Mol Sci 2021; 22:ijms22158089. [PMID: 34360852 PMCID: PMC8348031 DOI: 10.3390/ijms22158089] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/13/2021] [Accepted: 07/16/2021] [Indexed: 12/13/2022] Open
Abstract
Fluoxetine is an antidepressant commonly prescribed not only to adults but also to children for the treatment of depression, obsessive-compulsive disorder, and neurodevelopmental disorders. The adverse effects of the long-term treatment reported in some patients, especially in younger individuals, call for a detailed investigation of molecular alterations induced by fluoxetine treatment. Two-year fluoxetine administration to juvenile macaques revealed effects on impulsivity, sleep, social interaction, and peripheral metabolites. Here, we built upon this work by assessing residual effects of fluoxetine administration on the expression of genes and abundance of lipids and polar metabolites in the prelimbic cortex of 10 treated and 11 control macaques representing two monoamine oxidase A (MAOA) genotypes. Analysis of 8871 mRNA transcripts, 3608 lipids, and 1829 polar metabolites revealed substantial alterations of the brain lipid content, including significant abundance changes of 106 lipid features, accompanied by subtle changes in gene expression. Lipid alterations in the drug-treated animals were most evident for polyunsaturated fatty acids (PUFAs). A decrease in PUFAs levels was observed in all quantified lipid classes excluding sphingolipids, which do not usually contain PUFAs, suggesting systemic changes in fatty acid metabolism. Furthermore, the residual effect of the drug on lipid abundances was more pronounced in macaques carrying the MAOA-L genotype, mirroring reported behavioral effects of the treatment. We speculate that a decrease in PUFAs may be associated with adverse effects in depressive patients and could potentially account for the variation in individual response to fluoxetine in young people.
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Affiliation(s)
- Anna Tkachev
- V. Zelman Center for Neurobiology and Brain Restoration, Skolkovo Institute of Science and Technology, 121205 Moscow, Russia; (A.T.); (E.S.); (N.A.); (P.O.); (D.P.)
| | - Elena Stekolshchikova
- V. Zelman Center for Neurobiology and Brain Restoration, Skolkovo Institute of Science and Technology, 121205 Moscow, Russia; (A.T.); (E.S.); (N.A.); (P.O.); (D.P.)
| | - Daniil M. Bobrovskiy
- Faculty of Bioengineering and Bioinformatics, Moscow State University, 119234 Moscow, Russia;
| | - Nickolay Anikanov
- V. Zelman Center for Neurobiology and Brain Restoration, Skolkovo Institute of Science and Technology, 121205 Moscow, Russia; (A.T.); (E.S.); (N.A.); (P.O.); (D.P.)
| | - Polina Ogurtsova
- V. Zelman Center for Neurobiology and Brain Restoration, Skolkovo Institute of Science and Technology, 121205 Moscow, Russia; (A.T.); (E.S.); (N.A.); (P.O.); (D.P.)
| | - Dong Ik Park
- Proteomics and Biomarkers, Max Planck Institute of Psychiatry, 80804 Munich, Germany;
| | - Anja K. E. Horn
- Institute of Anatomy and Cell Biology, Ludwig-Maximilians University, 80336 Munich, Germany;
| | - Daria Petrova
- V. Zelman Center for Neurobiology and Brain Restoration, Skolkovo Institute of Science and Technology, 121205 Moscow, Russia; (A.T.); (E.S.); (N.A.); (P.O.); (D.P.)
| | - Ekaterina Khrameeva
- Center of Life Sciences, Skolkovo Institute of Science and Technology, 121205 Moscow, Russia
- Correspondence: (E.K.); (M.S.G.); (C.W.T.); (P.K.)
| | - Mari S. Golub
- California National Primate Research Center, University of California, Davis, CA 95616, USA
- Correspondence: (E.K.); (M.S.G.); (C.W.T.); (P.K.)
| | - Christoph W. Turck
- Proteomics and Biomarkers, Max Planck Institute of Psychiatry, 80804 Munich, Germany;
- Correspondence: (E.K.); (M.S.G.); (C.W.T.); (P.K.)
| | - Philipp Khaitovich
- V. Zelman Center for Neurobiology and Brain Restoration, Skolkovo Institute of Science and Technology, 121205 Moscow, Russia; (A.T.); (E.S.); (N.A.); (P.O.); (D.P.)
- Correspondence: (E.K.); (M.S.G.); (C.W.T.); (P.K.)
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A white paper on a neurodevelopmental framework for drug discovery in autism and other neurodevelopmental disorders. Eur Neuropsychopharmacol 2021; 48:49-88. [PMID: 33781629 DOI: 10.1016/j.euroneuro.2021.02.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 02/08/2021] [Accepted: 02/15/2021] [Indexed: 12/20/2022]
Abstract
In the last decade there has been a revolution in terms of genetic findings in neurodevelopmental disorders (NDDs), with many discoveries critical for understanding their aetiology and pathophysiology. Clinical trials in single-gene disorders such as fragile X syndrome highlight the challenges of investigating new drug targets in NDDs. Incorporating a developmental perspective into the process of drug development for NDDs could help to overcome some of the current difficulties in identifying and testing new treatments. This paper provides a summary of the proceedings of the 'New Frontiers Meeting' on neurodevelopmental disorders organised by the European College of Neuropsychopharmacology in conjunction with the Innovative Medicines Initiative-sponsored AIMS-2-TRIALS consortium. It brought together experts in developmental genetics, autism, NDDs, and clinical trials from academia and industry, regulators, patient and family associations, and other stakeholders. The meeting sought to provide a platform for focused communication on scientific insights, challenges, and methodologies that might be applicable to the development of CNS treatments from a neurodevelopmental perspective. Multidisciplinary translational consortia to develop basic and clinical research in parallel could be pivotal to advance knowledge in the field. Although implementation of clinical trials for NDDs in paediatric populations is widely acknowledged as essential, safety concerns should guide each aspect of their design. Industry and academia should join forces to improve knowledge of the biology of brain development, identify the optimal timing of interventions, and translate these findings into new drugs, allowing for the needs of users and families, with support from regulatory agencies.
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Muris P, Ollendick TH. Selective Mutism and Its Relations to Social Anxiety Disorder and Autism Spectrum Disorder. Clin Child Fam Psychol Rev 2021; 24:294-325. [PMID: 33462750 PMCID: PMC8131304 DOI: 10.1007/s10567-020-00342-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 12/24/2022]
Abstract
In current classification systems, selective mutism (SM) is included in the broad anxiety disorders category. Indeed, there is abundant evidence showing that anxiety, and social anxiety in particular, is a prominent feature of SM. In this article, we point out that autism spectrum problems in addition to anxiety problems are sometimes also implicated in SM. To build our case, we summarize evidence showing that SM, social anxiety disorder (SAD), and autism spectrum disorder (ASD) are allied clinical conditions and share communalities in the realm of social difficulties. Following this, we address the role of a prototypical class of ASD symptoms, restricted and repetitive behaviors and interests (RRBIs), which are hypothesized to play a special role in the preservation and exacerbation of social difficulties. We then substantiate our point that SM is sometimes more than an anxiety disorder by addressing its special link with ASD in more detail. Finally, we close by noting that the possible involvement of ASD in SM has a number of consequences for clinical practice with regard to its classification, assessment, and treatment of children with SM and highlight a number of directions for future research.
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Affiliation(s)
- Peter Muris
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
- Stellenbosch University, Stellenbosch, South Africa.
| | - Thomas H Ollendick
- Virginia Polytechnic Institute and State University, Blacksburg, USA
- Roehampton University, London, England
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Fuentes J, Hervás A, Howlin P. ESCAP practice guidance for autism: a summary of evidence-based recommendations for diagnosis and treatment. Eur Child Adolesc Psychiatry 2021; 30:961-984. [PMID: 32666205 PMCID: PMC8140956 DOI: 10.1007/s00787-020-01587-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 06/24/2020] [Indexed: 12/11/2022]
Abstract
Across Europe, there is increased awareness of the frequency and importance of autism spectrum disorder (ASD), which is now recognised not only as a childhood disorder but as a heterogeneous, neurodevelopmental condition that persists throughout life. Services for individuals with autism and their families vary widely, but in most European countries, provision is limited. In 2018, European Society of Child and Adolescent Psychiatry (ESCAP) identified the need for a Practice Guidance document that would help to improve knowledge and practice, especially for individuals in underserviced areas. The present document, prepared by the ASD Working Party and endorsed by the ESCAP Board on October 3, 2019, summarises current information on autism and focuses on ways of detecting, diagnosing, and treating this condition.
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Affiliation(s)
- Joaquin Fuentes
- Child and Adolescent Psychiatrists, Policlínica Gipuzkoa Research Consultant, GAUTENA Autism Society, Paseo de Miramón 174, 20016, San Sebastián, Spain.
| | - Amaia Hervás
- Child and Adolescent Psychiatrists, University Hospital MutuaTerrassa, AGAUR Clinical and Genetic Research Group IGAIN, Barcelona, Spain
| | - Patricia Howlin
- Emeritus Professor of Clinical Child Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK
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Andersson M, Tangen Ä, Farde L, Bölte S, Halldin C, Borg J, Lundberg J. Serotonin transporter availability in adults with autism-a positron emission tomography study. Mol Psychiatry 2021; 26:1647-1658. [PMID: 32848204 PMCID: PMC8159737 DOI: 10.1038/s41380-020-00868-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 07/30/2020] [Accepted: 08/10/2020] [Indexed: 12/11/2022]
Abstract
Impairments in social interaction and communication, in combination with restricted, repetitive behaviors and interests, define the neurodevelopmental diagnosis of autism spectrum disorder (ASD). The biological underpinnings of ASD are not well known, but the hypothesis of serotonin (5-HT) involvement in the neurodevelopment of ASD is one of the longest standing. Reuptake through the 5-HT transporter (5-HTT) is the main pathway decreasing extracellular 5-HT in the brain and a marker for the 5-HT system, but in vivo investigations of the 5-HTT and the 5-HT system in ASD are scarce and so far inconclusive. To quantify possible alterations in the 5-HT system in ASD, we used positron emission tomography and the radioligand [11C]MADAM to measure 5-HTT availability in the brain of 15 adults with ASD and 15 controls. Moreover, we examined correlations between regional 5-HTT availability and behavioral phenotype assessments regarding ASD core symptoms. In the ASD group, we found significantly lower 5-HTT availability in total gray matter, brainstem, and 9 of 18 examined subregions of gray matter. In addition, several correlations between regional 5-HTT availability and social cognitive test performance were found. The results confirm the hypothesis that 5-HTT availability is lower in the brain of adult individuals with ASD, and are consistent with the theory of 5-HT involvement in ASD neurodevelopment. The findings endorse the central role of 5-HT in the physiology of ASD, and confirm the need for a continued investigation of the 5-HT system in order to disentangle the biology of ASD.
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Affiliation(s)
- Max Andersson
- Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Region Stockholm, Stockholm, Sweden.
| | - Ämma Tangen
- Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Region Stockholm, Stockholm, Sweden
| | - Lars Farde
- Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Region Stockholm, Stockholm, Sweden
| | - Sven Bölte
- Department of Women's and Children's Health, Karolinska Institutet, Center of Neurodevelopmental Disorders (KIND), Center for Psychiatry Research, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
- Child and Adolescent Psychiatry, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
- Curtin Autism Research Group, School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Perth, WA, Australia
| | - Christer Halldin
- Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Region Stockholm, Stockholm, Sweden
| | - Jacqueline Borg
- Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Region Stockholm, Stockholm, Sweden
| | - Johan Lundberg
- Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet and Region Stockholm, Stockholm, Sweden
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Positron emission tomography (PET) and single-photon emission computed tomography (SPECT) in autism research: literature review. Ir J Psychol Med 2021; 39:272-286. [PMID: 33818321 DOI: 10.1017/ipm.2021.15] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Autism spectrum disorder (ASD) remains a behaviourally defined condition. Its molecular basis is unknown; however, its prevalence has been increasing significantly. There have been several abnormalities in neurotransmitter systems reported in ASD. In our review, we described studies involving positron emission tomography (PET) and single-photon emission computed tomography (SPECT) that can provide useful and corroborative data. METHOD We conducted a literature review by comprehensive database searching on EMBASE, Scopus, PubMed, and PsychINFO looking for articles published since January 2009. Thirty-one studies were carefully selected - 22 PET studies and 9 SPECT studies - and reviewed by 2 independent researchers. References of the articles were also cross-checked. RESULTS Results of the studies, which mainly involve small groups of participants, are frequently inconclusive and often controversial due to the nature of ASD and its wide spectrum. Studies are conducted under different conditions and with poor control for confounding factors which creates difficulties in comparing the data. CONCLUSIONS There is ongoing need to improve methodology of the studies involving molecular imaging in ASD. Lack of consistent findings causes difficulties in evaluation, diagnosis, and treatment of the condition.
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Aye SZ, Ni H, Sein HH, Mon ST, Zheng Q, Wong YKY. The effectiveness and adverse effects of D-cycloserine compared with placebo on social and communication skills in individuals with autism spectrum disorder. Cochrane Database Syst Rev 2021; 2:CD013457. [PMID: 33583058 PMCID: PMC8094878 DOI: 10.1002/14651858.cd013457.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Symptoms of autism spectrum disorder (ASD) have been associated, in part, with the dysfunction of N-methyl-D-aspartate (NMDA) glutamate receptors at excitatory synapses and glutamate abnormalities. Medications related to glutamatergic neurotransmission, such as D-cycloserine - which is a partial agonist of the NMDA glutamate receptor - are potential treatment options for the core features of ASD. However, the potential effect of D-cycloserine on the social and communication skills deficits of individuals with ASD has not been thoroughly explored and no systematic reviews of the evidence have been conducted. OBJECTIVES To assess the efficacy and adverse effects of D-cycloserine compared with placebo for social and communication skills in individuals with ASD. SEARCH METHODS In November 2020, we searched CENTRAL, MEDLINE, Embase, six other databases and two trials registers. We also searched the reference lists of relevant publications and contacted the authors of the included study, Minshawi 2016, to identify any additional studies. In addition, we contacted pharmaceutical companies, searched manufacturers' websites and sources of reports of adverse events. SELECTION CRITERIA: All randomised controlled trials (RCTs) of any duration and dose of D-cycloserine, with or without adjunct treatment, compared to placebo in individuals with ASD. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted relevant data, assessed the risk of bias, graded the certainty of the evidence using the GRADE approach, and analysed and evaluated the data. We provide a narrative report of the findings as only one study is included in this review. MAIN RESULTS We included a single RCT (Minshawi 2016) funded by the United States Department of Defense. It was conducted at two sites in the USA: Indiana University School of Medicine and Cincinnati Children's Hospital Medical Centre. In the included study, 67 children with ASD aged between 5 and 11 years were randomised to receive either 10 weeks (10 doses) of (50 mg) D-cycloserine plus social skills training, or placebo plus social skills training. Randomisation was carried out 1:1 between D-cycloserine and placebo arms, and outcome measures were recorded at one-week post-treatment. The 'risk of bias' assessment for the included study was low for five domains and unclear for two domains. The study (67 participants) reported low certainty evidence of little to no difference between the two groups for all outcomes measured at one week post-treatment: social interaction impairment (mean difference (MD) 3.61 (assessed with the Social Responsiveness Scale), 95% confidence interval (CI) -5.60 to 12.82); social communication impairment (MD -1.08 (measured using the inappropriate speech subscale of the Aberrant Behavior Checklist (ABC)), 95% CI -2.34 to 0.18); restricted, repetitive, stereotyped patterns of behaviour (MD 0.12 (measured by the ABC stereotypy subscale), 95% CI -1.71 to 1.95); serious adverse events (risk ratio (RR) 1.11, 95% CI 0.94 to 1.31); non-core symptoms of ASD (RR 0.97 (measured by the Clinical Global Impression-Improvement scale), 95% CI 0.49 to 1.93); and tolerability of D-cycloserine (RR 0.32 (assessed by the number of dropouts), 95% CI 0.01 to 7.68). AUTHORS' CONCLUSIONS: We are unable to conclude with certainty whether D-cycloserine is effective for individuals with ASD. This review included low certainty data from only one study with methodological issues and imprecision. The added value of this review compared to the included study is we assessed the risk of bias and evaluated the certainty of evidence using the GRADE approach. Moreover, if we find new trials in future updates of this review, we could potentially pool the data, which may either strengthen or decrease the evidence for our findings.
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Affiliation(s)
- Swe Zin Aye
- Department of Paediatrics and Child Health, Quest International University Perak, Ipoh, Malaysia
| | - Han Ni
- Department of Medicine, Newcastle University Medicine Malaysia, Johor, Malaysia
| | - Htwe H Sein
- Department of Paediatrics and Child Health, Quest International University Perak, Ipoh, Malaysia
| | - San T Mon
- Department of Paediatrics, Newcastle University Medicine Malaysia, Johor, Malaysia
| | - Qishi Zheng
- Department of Epidemiology, Singapore Clinical Research Institute, Singapore, Singapore
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Granlund M, Imms C, King G, Andersson AK, Augustine L, Brooks R, Danielsson H, Gothilander J, Ivarsson M, Lundqvist LO, Lygnegård F, Almqvist L. Definitions and Operationalization of Mental Health Problems, Wellbeing and Participation Constructs in Children with NDD: Distinctions and Clarifications. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:1656. [PMID: 33572339 PMCID: PMC7916140 DOI: 10.3390/ijerph18041656] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/31/2021] [Accepted: 02/02/2021] [Indexed: 01/02/2023]
Abstract
Children with impairments are known to experience more restricted participation than other children. It also appears that low levels of participation are related to a higher prevalence of mental health problems in children with neurodevelopmental disorders (NDD). The purpose of this conceptual paper is to describe and define the constructs mental health problems, mental health, and participation to ensure that future research investigating participation as a means to mental health in children and adolescents with NDD is founded on conceptual clarity. We first discuss the difference between two aspects of mental health problems, namely mental disorder and mental illness. This discussion serves to highlight three areas of conceptual difficulty and their consequences for understanding the mental health of children with NDD that we then consider in the article: (1) how to define mental health problems, (2) how to define and assess mental health problems and mental health, i.e., wellbeing as separate constructs, and (3) how to describe the relationship between participation and wellbeing. We then discuss the implications of our propositions for measurement and the use of participation interventions as a means to enhance mental health (defined as wellbeing). Conclusions: Mental disorders include both diagnoses related to impairments in the developmental period, i.e., NDD and diagnoses related to mental illness. These two types of mental disorders must be separated. Children with NDD, just like other people, may exhibit aspects of both mental health problems and wellbeing simultaneously. Measures of wellbeing defined as a continuum from flourishing to languishing for children with NDD need to be designed and evaluated. Wellbeing can lead to further participation and act to protect from mental health problems.
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Affiliation(s)
- Mats Granlund
- CHILD, School of Health and Welfare, Jönköping University, 55110 Jönköping, Sweden; (A.K.A.); (F.L.)
- The Swedish Institute for Disability Research, 58183 Linköping, Sweden; (L.A.); (H.D.); (M.I.); (L.-O.L.)
| | - Christine Imms
- Department of Paediatrics, The University of Melbourne, Melbourne 3052, Australia;
| | - Gillian King
- Bloorview Research Institute, Torornto, ON M4G 1R8, Canada;
| | - Anna Karin Andersson
- CHILD, School of Health and Welfare, Jönköping University, 55110 Jönköping, Sweden; (A.K.A.); (F.L.)
- The Swedish Institute for Disability Research, 58183 Linköping, Sweden; (L.A.); (H.D.); (M.I.); (L.-O.L.)
| | - Lilly Augustine
- The Swedish Institute for Disability Research, 58183 Linköping, Sweden; (L.A.); (H.D.); (M.I.); (L.-O.L.)
- CHILD, School of Education and Communication, Jönköping University, 55110 Jönköping, Sweden
| | - Rob Brooks
- School of Clinical and Applied Sciences, Leeds Beckett University, Leeds LS1 3HE, UK;
| | - Henrik Danielsson
- The Swedish Institute for Disability Research, 58183 Linköping, Sweden; (L.A.); (H.D.); (M.I.); (L.-O.L.)
- Department of Behavioural Sciences and Learning, Linköping University, 58183 Linköping, Sweden
| | - Jennifer Gothilander
- School of Health, Care and Social Welfare, Mälardalen University, 72123 Vasteras, Sweden; (J.G.); (L.A.)
| | - Magnus Ivarsson
- The Swedish Institute for Disability Research, 58183 Linköping, Sweden; (L.A.); (H.D.); (M.I.); (L.-O.L.)
- Department of Behavioural Sciences and Learning, Linköping University, 58183 Linköping, Sweden
| | - Lars-Olov Lundqvist
- The Swedish Institute for Disability Research, 58183 Linköping, Sweden; (L.A.); (H.D.); (M.I.); (L.-O.L.)
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, 70185 Örebro, Sweden
| | - Frida Lygnegård
- CHILD, School of Health and Welfare, Jönköping University, 55110 Jönköping, Sweden; (A.K.A.); (F.L.)
- The Swedish Institute for Disability Research, 58183 Linköping, Sweden; (L.A.); (H.D.); (M.I.); (L.-O.L.)
| | - Lena Almqvist
- School of Health, Care and Social Welfare, Mälardalen University, 72123 Vasteras, Sweden; (J.G.); (L.A.)
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Cox GR, Williams K, Woon JM, Haslam R, Ure A. Acetylcholinesterase inhibitors for autistic spectrum disorders. Hippokratia 2021. [DOI: 10.1002/14651858.cd013851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Georgina R Cox
- Department of Paediatrics; Monash University; Melbourne Australia
- Neurodevelopment and Disability; The Royal Children's Hospital; Melbourne Australia
| | - Katrina Williams
- Department of Paediatrics; Monash University; Melbourne Australia
- Department of Paediatrics; University of Melbourne; Melbourne Australia
- Developmental Paediatrics; Monash Children's Hospital; Melbourne Australia
- Murdoch Children's Research Institute; Melbourne Australia
| | - Jade M Woon
- Neurodevelopment and Disability; The Royal Children's Hospital; Melbourne Australia
| | - Richard Haslam
- Mental Health Department; The Royal Children's Hospital; Melbourne Australia
- Department of Paediatrics; University of Melbourne; Melbourne Australia
| | - Alexandra Ure
- Department of Paediatrics; Monash University; Melbourne Australia
- Mental Health Department; The Royal Children's Hospital; Melbourne Australia
- Developmental Paediatrics; Monash Children's Hospital; Melbourne Australia
- Murdoch Children's Research Institute; Melbourne Australia
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44
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Brignell A, Prakash C, Marraffa C, Williams K, May T. Memantine for autism spectrum disorder. Hippokratia 2021. [DOI: 10.1002/14651858.cd013845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Amanda Brignell
- Murdoch Children's Research Institute; Melbourne Australia
- Department of Paediatrics; Monash University; Melbourne Australia
- Department of Speech Pathology; Australian Catholic University; Melbourne Australia
| | - Chidambaram Prakash
- RCH Mental Health Hospital Services; The Royal Children's Hospital; Melbourne Australia
| | - Catherine Marraffa
- Murdoch Children's Research Institute; Melbourne Australia
- Neurodevelopment and Disability; The Royal Children's Hospital; Melbourne Australia
- Department of Paediatrics; University of Melbourne; Melbourne Australia
| | - Katrina Williams
- Murdoch Children's Research Institute; Melbourne Australia
- Department of Paediatrics; Monash University; Melbourne Australia
- Neurodevelopment and Disability; The Royal Children's Hospital; Melbourne Australia
- Developmental Paediatrics; Monash Children's Hospital; Melbourne Australia
| | - Tamara May
- Department of Paediatrics; Monash University; Melbourne Australia
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Abstract
BACKGROUND Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by markedly impaired social interaction, impaired communication, and restricted/repetitive patterns of behavior, interests, and activities. In addition to challenges caused by core symptoms, maladaptive behaviors such as aggression can be associated with ASD and can further disrupt functioning and quality of life. For adults with ASD, these behaviors can portend adverse outcomes (e.g., harm to others or to the individual with ASD, hindering of employment opportunities, criminal justice system involvement). This article reviews the scientific literature to provide an update on evidence-based interventions for aggression in adults with ASD. METHOD A search of the electronic databases CINAHL, EMBASE, and PsycINFO was conducted using relevant search terms. After reviewing titles, abstracts, full-length articles, and reference lists, 70 articles were identified and reviewed. RESULTS The strongest (controlled trial) evidence suggests beneficial effects of risperidone, propranolol, fluvoxamine, vigorous aerobic exercise, and dextromethorphan/quinidine for treating aggression in adults with ASD, with lower levels of evidence supporting behavioral interventions, multisensory environments, yokukansan, and other treatments. CONCLUSIONS Additional randomized, controlled trials using consistent methodology that adequately addresses sources of bias are needed to determine which treatments are reliably effective in addressing aggression in adults with ASD. In the meantime, considering efficacy and adverse effect/long-term risk profiles, a practical approach could start with functional assessment-informed behavioral interventions along with encouragement of regular, vigorous aerobic exercise to target aggression in adults with ASD, with pharmacotherapy employed if these interventions are unavailable or inadequate based on symptom acuity.
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Affiliation(s)
- David S. Im
- From the University of Michigan Hospital, Department of Psychiatry, University of Michigan Medical School
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46
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Frye RE, Rossignol DA, Scahill L, McDougle CJ, Huberman H, Quadros EV. Treatment of Folate Metabolism Abnormalities in Autism Spectrum Disorder. Semin Pediatr Neurol 2020; 35:100835. [PMID: 32892962 PMCID: PMC7477301 DOI: 10.1016/j.spen.2020.100835] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Autism spectrum disorder (ASD) is a heterogeneous neurodevelopmental disorder that currently has no approved medical therapy to address core symptoms or underling pathophysiological processes. Several compounds are under development that address both underlying pathophysiological abnormalities and core ASD symptoms. This article reviews one of these treatments, d,l-leucovorin calcium (also known as folinic acid) for treatment of folate pathway abnormalities in children with ASD. Folate is a water-soluble B vitamin that is essential for normal neurodevelopment and abnormalities in the folate and related pathways have been identified in children with ASD. One of these abnormalities involves a partial blockage in the ability of folate to be transported into the brain utilizing the primary transport mechanism, the folate receptor alpha. Autoantibodies which interfere with the function of the folate receptor alpha called folate receptor alpha autoantibodies have been identified in 58%-76% of children with ASD and independent studies have demonstrated that blood titers of these autoantibodies correlate with folate levels in the cerebrospinal fluid. Most significantly, case-series, open-label, and single and double-blind placebo-controlled studies suggest that d,l-leucovorin, a reduced folate that can bypass the blockage at the folate receptor alpha by using the reduced folate carrier, an alternate pathway, can substantially improve particular symptoms in children with ASD, especially those positive for folate receptor alpha autoantibodies. This article reviews the current evidence for treating core and associated symptoms and underlying pathophysiological mechanisms in children with ASD with d,l-leucovorin.
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Affiliation(s)
- Richard E. Frye
- Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix, AZ
| | | | - Lawrence Scahill
- Department of Pediatrics, Emory University and Marcus Autism Center, Atlanta, GA
| | - Christopher J. McDougle
- Department of Psychiatry, Harvard Medical School, Boston MA and Lurie Center for Autism, Lexington, MA
| | - Harris Huberman
- Departments of Pediatrics, State University of New York – Downstate, Brooklyn, NY
| | - Edward V. Quadros
- Departments of Medicine, State University of New York – Downstate, Brooklyn, NY
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47
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Autism and Migraine: An Unexplored Association? Brain Sci 2020; 10:brainsci10090615. [PMID: 32899972 PMCID: PMC7565535 DOI: 10.3390/brainsci10090615] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 08/31/2020] [Accepted: 09/04/2020] [Indexed: 12/13/2022] Open
Abstract
Autism spectrum disorder is characterized by neurological, psychiatric and medical comorbidities—some conditions co-occur so frequently that comorbidity in autism is the rule rather than the exception. The most common autism co-occurring conditions are intellectual disability, language disorders, attention-deficit hyperactivity disorder, epilepsy, gastrointestinal problems, sleep disorders, anxiety, depression, obsessive-compulsive disorder, psychotic disorders, oppositional defiant disorder, and eating disorders. They are well known and studied. Migraine is the most common brain disease in the world, but surprisingly only a few studies investigate the comorbidity between autism and migraine. The aim of this narrative review is to explore the literature reports about the comorbidity between autism and migraine and to investigate the common neurotransmitter, immune, anatomical and genetic abnormalities at the base of these two conditions.
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Siafis S, Çıray O, Schneider-Thoma J, Bighelli I, Krause M, Rodolico A, Ceraso A, Deste G, Huhn M, Fraguas D, Mavridis D, Charman T, Murphy DG, Parellada M, Arango C, Leucht S. Placebo response in pharmacological and dietary supplement trials of autism spectrum disorder (ASD): systematic review and meta-regression analysis. Mol Autism 2020; 11:66. [PMID: 32847616 PMCID: PMC7448339 DOI: 10.1186/s13229-020-00372-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 08/14/2020] [Indexed: 12/16/2022] Open
Abstract
Background Placebo response in autism spectrum disorder (ASD) might dilute drug-placebo differences and hinder drug development. Therefore, this meta-analysis investigated placebo response in core symptoms. Methods We searched ClinicalTrials.gov, CENTRAL, EMBASE, MEDLINE, PsycINFO, WHO-ICTRP (up to July 8, 2018), and PubMed (up to July 4, 2019) for randomized pharmacological and dietary supplement placebo-controlled trials (RCTs) with a minimum of seven days of treatment. Single-group meta-analyses were conducted using a random-effects model. Standardized mean changes (SMC) of core symptoms in placebo arms were the primary outcomes and placebo positive response rates were a secondary outcome. Predictors of placebo response were investigated with meta-regression analyses. The protocol was registered with PROSPERO ID CRD42019125317. Results Eighty-six RCTs with 2360 participants on placebo were included in our analysis (87% in children/adolescents). The majority of trials were small, single-center with a duration of 8–12 weeks and published after 2009. Placebo response in social-communication difficulties was SMC = − 0.32, 95% CI [− 0.39, − 0.25], in repetitive behaviors − 0.23[− 0.32, − 0.15] and in scales measuring overall core symptoms − 0.36 [− 0.46, − 0.26]. Overall, 19%, 95% CI [16–22%] of participants were at least much improved with placebo. Caregiver (vs. clinician) ratings, lower risk of bias, flexible-dosing, larger sample sizes and number of sites, less recent publication year, baseline levels of irritability, and the use of a threshold of core symptoms at inclusion were associated with larger placebo response in at least a core symptom domain. Limitations About 40% of the trials had an apparent focus on core symptoms. Investigation of the differential impact of predictors on placebo and drug response was impeded by the use of diverse experimental interventions with essentially different mechanisms of action. An individual-participant-data meta-analysis could allow for a more fine-grained analysis and provide more informative answers. Conclusions Placebo response in ASD was substantial and predicted by design- and participant-related factors, which could inform the design of future trials in order to improve the detection of efficacy in core symptoms. Potential solutions could be the minimization and careful selection of study sites as well as rigorous participant enrollment and the use of measurements of change not solely dependent on caregivers.
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Affiliation(s)
- Spyridon Siafis
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany.
| | - Oğulcan Çıray
- Department of Child and Adolescent Psychiatry, School of Medicine, Balçova Dokuz Eylul University, İzmir, Turkey
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Irene Bighelli
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Marc Krause
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Alessandro Rodolico
- Department of Experimental and Clinical Medicine, Psychiatric Clinic University Hospital 'Gaspare Rodolico', University of Catania, Catania, Italy
| | - Anna Ceraso
- Department of Psychiatry, Spedali Civili Hospital, Brescia, Italy
| | - Giacomo Deste
- Department of Psychiatry, Spedali Civili Hospital, Brescia, Italy
| | - Maximilian Huhn
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany.,Department of Psychiatry, Psychosomatic Medicine and Psychotherapy Social Foundation Bamberg, Teaching Hospital of the University of Erlangen, Erlangen, Germany
| | - David Fraguas
- Department of Child and Adolescent Psychiatry, Hospital General Universitario Gregorio Marañón, Institute of Psychiatry and Mental Health, IiSGM, CIBERSAM, Madrid, Spain.,School of Medicine, Universidad Complutense, Madrid, Spain
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece.,Faculté de Médecine, Université Paris Descartes, Paris, France
| | - Tony Charman
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Declan G Murphy
- Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Mara Parellada
- Department of Primary Education, University of Ioannina, Ioannina, Greece.,Faculté de Médecine, Université Paris Descartes, Paris, France
| | - Celso Arango
- Department of Primary Education, University of Ioannina, Ioannina, Greece.,Faculté de Médecine, Université Paris Descartes, Paris, France
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany
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Genovese A, Butler MG. Clinical Assessment, Genetics, and Treatment Approaches in Autism Spectrum Disorder (ASD). Int J Mol Sci 2020; 21:E4726. [PMID: 32630718 PMCID: PMC7369758 DOI: 10.3390/ijms21134726] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/24/2020] [Accepted: 06/27/2020] [Indexed: 12/16/2022] Open
Abstract
Autism spectrum disorder (ASD) consists of a genetically heterogenous group of neurobehavioral disorders characterized by impairment in three behavioral domains including communication, social interaction, and stereotypic repetitive behaviors. ASD affects more than 1% of children in Western societies, with diagnoses on the rise due to improved recognition, screening, clinical assessment, and diagnostic testing. We reviewed the role of genetic and metabolic factors which contribute to the causation of ASD with the use of new genetic technology. Up to 40 percent of individuals with ASD are now diagnosed with genetic syndromes or have chromosomal abnormalities including small DNA deletions or duplications, single gene conditions, or gene variants and metabolic disturbances with mitochondrial dysfunction. Although the heritability estimate for ASD is between 70 and 90%, there is a lower molecular diagnostic yield than anticipated. A likely explanation may relate to multifactorial causation with etiological heterogeneity and hundreds of genes involved with a complex interplay between inheritance and environmental factors influenced by epigenetics and capabilities to identify causative genes and their variants for ASD. Behavioral and psychiatric correlates, diagnosis and genetic evaluation with testing are discussed along with psychiatric treatment approaches and pharmacogenetics for selection of medication to treat challenging behaviors or comorbidities commonly seen in ASD. We emphasize prioritizing treatment based on targeted symptoms for individuals with ASD, as treatment will vary from patient to patient based on diagnosis, comorbidities, causation, and symptom severity.
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Affiliation(s)
| | - Merlin G. Butler
- Department of Psychiatry & Behavioral Sciences, University of Kansas Medical Center, Kansas City, KS 66160, USA;
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50
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Jack RH, Joseph RM, Coupland C, Butler D, Hollis C, Morriss R, Knaggs RD, Cipriani A, Cortese S, Hippisley-Cox J. Secondary care specialist visits made by children and young people prescribed antidepressants in primary care: a descriptive study using the QResearch database. BMC Med 2020; 18:93. [PMID: 32349753 PMCID: PMC7191694 DOI: 10.1186/s12916-020-01560-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 03/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antidepressants may be used to manage a number of conditions in children and young people including depression, anxiety, and obsessive-compulsive disorder. UK guidelines for the treatment of depression in children and young people recommend that antidepressants should only be initiated following assessment and diagnosis by a child and adolescent psychiatrist. The aim of this study was to summarise visits to mental health specialists and indications recorded around the time of antidepressant initiation in children and young people in UK primary care. METHODS The study used linked English primary care electronic health records and Hospital Episode Statistics secondary care data. The study included 5-17-year-olds first prescribed antidepressants between January 2006 and December 2017. Records of visits to paediatric or psychiatric specialists and potential indications (from a pre-specified list) were extracted. Events were counted if recorded less than 12 months before or 6 months after the first antidepressant prescription. Results were stratified by first antidepressant type (all, selective serotonin reuptake inhibitors (SSRIs), tricyclic and related antidepressants) and by age group (5-11 years, 12-17 years). RESULTS In total, 33,031 5-17-year-olds were included. Of these, 12,149 (37%) had a record of visiting a paediatrician or a psychiatric specialist in the specified time window. The majority of recorded visits (7154, 22%) were to paediatricians. Of those prescribed SSRIs, 5463/22,130 (25%) had a record of visiting a child and adolescent psychiatrist. Overall, 17,972 (54%) patients had a record of at least one of the pre-specified indications. Depression was the most frequently recorded indication (12,501, 38%), followed by anxiety (4155, 13%). CONCLUSIONS The results suggest many children and young people are being prescribed antidepressants without the recommended involvement of a relevant specialist. These findings may justify both greater training for GPs in child and adolescent mental health and greater access to specialist care and non-pharmacological treatments. Further research is needed to explore factors that influence how and why GPs prescribe antidepressants to children and young people and the real-world practice barriers to adherence to clinical guidelines.
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Affiliation(s)
- Ruth H Jack
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK.
| | - Rebecca M Joseph
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Carol Coupland
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Debbie Butler
- National Institute of Health Research MindTech MedTech Co-operative, The Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Chris Hollis
- National Institute of Health Research MindTech MedTech Co-operative, The Institute of Mental Health, University of Nottingham, Nottingham, UK
- National Institute of Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Richard Morriss
- National Institute of Health Research MindTech MedTech Co-operative, The Institute of Mental Health, University of Nottingham, Nottingham, UK
- National Institute of Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| | | | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Samuele Cortese
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
- Center for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, UK
- Solent NHS Trust, Southampton, UK
- Department of Child and Adolescent Psychiatry, Hassenfeld Children's Hospital at NYU Langone, New York, NY, USA
| | - Julia Hippisley-Cox
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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