Autism Research: Lessons from the Past and Prospects for the Future

Perspectives in childhood-onset disabilities: integrating 21st-Century concepts to expand our horizons

PURPOSE

A powerful aphorism states: "If I hadn't believed it, I wouldn't have seen it!" This challenging notion reminds us how strongly we are influenced by prevailing ideas, and how we interpret things according to current fashions and teachings.

MATERIALS AND METHODS

In this paper we present and discuss contemporary perspectives concerning childhood-onset disability and the evolving nature of how people are thinking and acting. We illustrate these ideas by reminding readers of how we have all traditionally been trained and acculturated to think about many dimensions of neurodevelopmental disability ("What?"); reflect on the impact of these ways of thinking in terms of what we have conventionally "seen" and done ("So What?"); and contrast those traditions with contemporary concepts that we believe or know impact the field ("Now What?").

RESULTS

Many of the concepts discussed here will be familiar to readers. In taking this analytically critical perspective we aim to illustrate that by weaving these individual threads together we are able to create a coherent fabric that can serve children with childhood-onset NDD, their families, service providers, the community, and policy-makers. We do not purport to offer a comprehensive view of the whole field.

CONCLUSIONS

We encourage readers to consider the integration of these new ways of thinking and acting in our still-evolving field of "childhood-onset disability".

Characterizing the physical and mental health profile of children, adolescents and adults with autism spectrum disorder in Spain

Introduction

Autistic men and women are more likely to experience health issues than the general population, although the available epidemiological studies addressing co-occurrence conditions are limited. This is the first Spanish epidemiologic study addressing the health profile and poor-health exacerbating factors in individuals of all ages with autism spectrum disorder (ASD).

Methods

We analyzed 2,629 registries extracted from Autism Spain's sociodemographic registry (November 2017-May 2020). A descriptive health data analysis was conducted to assess the prevalence of other conditions associated to ASD in the Spanish population. Nervous system disorders (12.9%), mental health diagnoses (17.8%), and other comorbidities (25.4%) were reported. Men-to-women ratio was 4:1.

Results

Women, elder individuals and those with intellectual disability (ID) were at an increased risk of health comorbidities and psychopharmacological exposure. Women were also more prone to severe intellectual and functional impairment. Nearly all individuals had difficulties in their adaptative functioning, especially those with ID (50% of the population). Almost half of the sample received psychopharmacological treatments starting from infancy and early childhood, mostly antipsychotics and anticonvulsants.

Discussion

This study represents an important first approach to the health status of autistic people in Spain and can contribute to the development of public policies and innovative health strategies.

Rethinking Our Concepts and Assumptions About Autism

Autism is a clinical consensus diagnosis made based on behavioral symptoms of early developmental difficulties in domains of social-communication (SC) and restricted repetitive behaviors (RRB). Many readily assume that alongside being optimal for separating individuals based on SC and RRB behavioral domains, that the label should also be highly useful for explaining differential biology, outcomes, and treatment (BOT) responses. However, we also now take for granted the fact that the autism population is vastly heterogeneous at multiple scales, from genome to phenome. In the face of such multi-scale heterogeneity, here we argue that the concept of autism along with the assumptions that surround it require some rethinking. While we should retain the diagnosis for all the good it can do in real-world circumstances, we also call for the allowance of multiple other possible definitions that are better tailored to be highly useful for other translational end goals, such as explaining differential BOT responses.

Integrated Behavioral Health Care: Reflections of the Past

Humans have long sought to be provided with optimal health care, and the research continues in the twenty-first century. In the spirit of Galen from 19 centuries ago, empowering the patient's physician remains an important approach in health care. There is an emphasis on primary care and integration of behavioral consultation services in primary care. It remains a work in progress with help from the past and realistic hope for the future.

Relationship between absolute and relative ratios of glutamate, glutamine and GABA and severity of autism spectrum disorder

Autism spectrum disorder (ASD) is a neurodevelopmental pathology characterized by an impairment in social interaction, communication difficulties, and repetitive behaviors. Glutamate signaling abnormalities are thought to be considered as major etiological mechanisms leading to ASD. The search for amino-acidic catabolytes related to glutamate in patients with different levels of ASD might help current research to clarify the mechanisms underlying glutamate signaling and its disorders, particularly in relation to ASD. In the present study, plasma levels of the amino acids and their derivatives glutamate, glutamine, and γ-aminobutyric acid (GABA), associated with their relative ratios, were evaluated using an enzyme-linked immunosorbent assay (ELISA) technique in 40 male children with ASD and in 38 age- and gender-matched neurotypical health controls. The Social Responsiveness Scale (SRS) was used to evaluate social cognition, and the Childhood Autism Rating Scale (CARS) was used to assess subjects' behaviors. Children with ASD exhibited a significant elevation of plasma GABA and glutamate/glutamine ratio, as well as significantly lower levels of plasma glutamine and glutamate/GABA ratios compared to controls. No significant correlation was found between glutamate levels and the severity of autism, measured by CARS and SRS. In receiver operating characteristic (ROC) curve analysis, the area under the curve for GABA compared to other parameters was close to one, indicating its potential use as a biomarker. Glutamine appeared as the best predictive prognostic markers in the present study. The results of the present study indicate a disturbed balance between GABAergic and glutamatergic neurotransmission in ASD. The study also indicates that an increased plasma level of GABA can be potentially used as an early diagnostic biomarker for ASD.

A Review of Oxytocin and Arginine-Vasopressin Receptors and Their Modulation of Autism Spectrum Disorder

Oxytocin (OXT) and arginine-vasopressin (AVP) play a key regulatory part in social and affiliative behaviors; two aspects highly compromised in Autism Spectrum Disorder (ASD). Furthermore, variants in the adjacent oxytocin-vasopressin gene regions have been found to be associated with ASD diagnosis and endophenotypes. This review focuses mainly on common OXTr single nucleotide polymorphisms (SNPs), AVPR1a microsatellites and AVPR1b polymorphisms in relation to the development of autism. Although these genes did not surface in genome-wide association studies, evidence supports the hypothesis that these receptors and their polymorphisms are widely involved in the regulation of social behavior, and in modulating neural and physiological pathways contributing to the etiology of ASD. With a specific focus on variants considered to be among the most prevalent in the development of ASD, these issues will be discussed in-depth and suggestions to approach inconsistencies in the present literature will be provided. Translational implications and future directions are deliberated from a short-term and a forward-looking perspective. While the scientific community has made significant progress in enhancing our understanding of ASD, more research is required for the ontology of this disorder to be fully elucidated. By supplementing information related to genetics, highlighting the differences across male and female sexes, this review provides a wider view of the current state of knowledge of OXTr and AVPr mechanisms of functioning, eventually addressing future research in the identification of further risk factors, to build new strategies for early interventions.

Prevalence and comorbidities of autism among children referred to the outpatient clinics for neurodevelopmental disorders

INTRODUCTION

Autism spectrum disorders (ASD) is a neurodevelopmental disorder that has been rarely diagnosed in Sub-Saharan Africa. Although a proportion of children do present features of ASD in the Democratic Republic of Congo (DRC), little is known about it prevalence. Often, the co-morbidities constitute the upfront symptoms and therefore may it recognition and management difficult, aggravating as such the prognosis. The present study therefore aimed at studying the clinical profile of autism spectrum disorder (ASD) and the associated morbidities among children and adolescents in outpatient clinics in Kinshasa, the Democratic Republic of Congo.

METHODS

We conducted a cross sectional study in the three outpatients centers receiving patients referred for neurodevelopmental disorders in Kinshasa, DRC, from June 2008 to June 2010. A total of 450 subjects aged from 1-18 years old were referred and included in the study. The clinical diagnosis for ASD was made using the DSM-IV-R and the ADIR. Co-morbidities were identified using DSM-IV-R criteria together with an extensive clinical interview and observation. All patients were subject to an intellectual quotient evaluation and an electroencephalogram reporting.

RESULTS

Of the 450 subjects referred, 120 (29.3%) received the diagnosis of ASD, with boys outnumbering girls (OR 3:1. The mean age was 7.9 years (SD 3.4) (p< 0.001). Intellectual disability (75.83 %) and epilepsy (72.50%) were the main co-morbidities significantly associated with autism (p< 0.001). It was also found that co-morbidities were most frequent in subjects with an IQ<70 (p=0.05).

CONCLUSION

ASD is frequent among patients referred for neurodevelopmental disorders in the three outpatients' centers for neurodevelopmental disorders in Kinshasa. Males seem to be more affected than female. The main co-morbidities were epilepsy and intellectual disabilities. Our findings suggest that it is important to screen for ASD and co-morbidities among all subjects referred for neurodevelopmental disorders and to undertake survey on ASD in various structures of rejected children from the society in Kinshasa DRC. This will help to identify and manage ASD and associated co-morbidities at an early stage for a better prognosis.

Integrating care for neurodevelopmental disorders by unpacking control: A grounded theory study

BACKGROUND

To establish integrated healthcare pathways for patients with neurodevelopmental disorders (ND) such as autism spectrum disorder and attention-deficit hyperactivity disorder is challenging. This study sets out to investigate the main concerns for healthcare professionals when integrating ND care pathways and how they resolve these concerns.

METHODS

Using classic grounded theory (Glaser), we analysed efforts to improve and integrate an ND care pathway for children and youth in a Swedish region over a period of 6 years. Data from 42 individual interviews with a range of ND professionals, nine group interviews with healthcare teams, participant observation, a 2-day dialogue conference, focus group meetings, regional media coverage, and reports from other Swedish regional ND projects were analysed.

RESULTS

The main concern for participants was to deal with overwhelming ND complexity by unpacking control, which is control over strategies to define patients' status and needs. Unpacking control is key to the professionals' strivings to expand constructive life space for patients, to squeeze health care to reach available care goals, to promote professional ideologies, and to uphold workplace integrity. Control-seeking behaviour in relation to ND unpacking is ubiquitous and complicates integration of ND care pathways.

CONCLUSIONS

The Unpacking control theory expands central aspects of professions theory and may help to improve ND care development.

Neurotoxicants, Micronutrients, and Social Environments

SUMMARY—Systematic research evaluating the separate and interacting impacts of neurotoxicants, micronutrients, and social environments on children's cognition and behavior has only recently been initiated. Years of extensive human epidemiologic and animal experimental research document the deleterious impact of lead and other metals on the nervous system. However, discrepancies among human studies and between animal and human studies underscore the importance of variations in child nutrition as well as social and behavioral aspects of children's environments that mitigate or exacerbate the effects of neurotoxicants.

In this monograph, we review existing research on the impact of neurotoxic metals, nutrients, and social environments and interactions across the three domains. We examine the literature on lead, mercury, manganese, and cadmium in terms of dispersal, epidemiology, experimental animal studies, effects of social environments, and effects of nutrition.

Research documenting the negative impact of lead on cognition and behavior influenced reductions by the Center for Disease Control in child lead-screening guidelines from 30 micrograms per deciliter (μg/dL) in 1975 to 25 μg/dL in 1985 and to 10 μg/dL in 1991. A further reduction is currently being considered. Experimental animal research documents lead's alteration of glutamate-neurotransmitter (particularly N-methyl-D-aspartate) activity vital to learning and memory. In addition, lead induces changes in cholinergic and dopaminergic activity. Elevated lead concentrations in the blood are more common among children living in poverty and there is some evidence that socioeconomic status influences associations between lead and child outcomes. Micronutrients that influence the effects of lead include iron and zinc.

Research documenting the negative impact of mercury on children (as well as adults) has resulted in a reference dose (RfD) of 0.1 microgram per kilogram of body weight per day (μg/kg/day). In animal studies, mercury interferes with glutamatergic, cholinergic, and dopaminergic activity. Although evidence for interactions of mercury with children's social contexts is minimal, researchers are examining interactions of mercury with several nutrients.

Research on the effects of cadmium and manganese on child cognition and behavior is just beginning. Experimental animal research links cadmium to learning deficits, manganese to behaviors characteristic of Parkinson's disease, and both to altered dopaminergic functioning.

We close our review with a discussion of policy implications, and we recommend interdisciplinary research that will enable us to bridge gaps within and across domains.

Childhood antecedents and risk for adult mental disorders

Progress in treating and preventing mental disorders may follow from research that integrates development, genetics, and neuroscience. This review first delineates how longitudinal research has identified three particular groups of disorders shown to differ on the basis of symptom trajectories and risk-factor profiles. In the next section, the review describes how research on genetic contributions to psychopathology has elucidated the nature of risk for two groups of disorders, the neurodevelopmental and psychotic disorders. In the third section, the review describes how research on environmental contributions to psychopathology has targeted early temperament, its associated perturbations in information-processing functions, and its relations to a third group of disorders, the emotional disorders. For all three groups of disorders, such integrative research has generated ideas about novel interventions. The hope is that over the coming decade such ideas will lead to novel treatments that alter the trajectory of risk in developmental psychopathology.

Clinical characteristics of autism spectrum disorder in Israel: impact of ethnic and social diversities

Despite the increased global prevalence and recognition of autistic spectrum disorder (ASD), it is still scarcely reported in the Arab world. Though Israel has a higher prevalence of ASD, a previous national survey of patients diagnosed between 1972 and 2004, demonstrated that 98% of them were of Jewish ancestry. The disproportional low number of Arab children with ASD in Israel is unclear but may reflect lower awareness and cultural bias. In the present study we collected clinical and demographic characteristics of 200 children with ASD from Arab and Jewish sectors in Israel that were evaluated in two child development centers. We compared the incidence and the medical comorbidity of autism between these two ethnics groups. The medical and psychiatric comorbidity profile in these children was similar to the worldwide published studies. In the present study the prevalence of autism in the Arab sector in Israel was similar to that of the Jewish sector. The Arab patients presented with more severe autistic manifestations and higher incidence of mental retardation, familial members with autism, and consanguinity (P < 0.05), while in the Jewish sector milder forms (such as Asperger syndrome and PDD-NOS) were more frequent. This discrepancy might be explained by both genetic and cultural factors.

Evaluation of the theory of mind in autism spectrum disorders with the Strange Stories test

OBJECTIVE

To evaluate the theory of mind in autism spectrum disorders (ASD) and control individuals by applying the Strange Stories test that was translated and adapted to the Portuguese language.

METHOD

Twenty-eight children with ASD and 56 controls who were all male and aged between 6 and 12 years participated in the study.

RESULTS

There were significant differences between the median scores of the groups for each of the 12 stories of the test and for the sum total of all the median scores. The median scores for all stories were significantly greater in the control group than those in the experimental group (children with ASD). In addition, the protocol had excellent internal consistency.

CONCLUSION

The theory of mind skills assessed with the Strange Stories test indicated alterations in children with ASD compared with children in the control group.

The BTBR T+ tf/J mouse model for autism spectrum disorders-in search of biomarkers

Autism spectrum disorders (ASD) form a common group of neurodevelopmental disorders appearing to be under polygenic control, but also strongly influenced by multiple environmental factors. The brain mechanisms responsible for ASD are not understood and animal models paralleling related emotional and cognitive impairments may prove helpful in unraveling them. BTBR T+ tf/J (BTBR) mice display behaviors consistent with the three diagnostic categories for ASD. They show impaired social interaction and communication as well as increased repetitive behaviors. This review covers much of the data available to date on BTBR behavior, neuroanatomy and physiology in search for candidate biomarkers, which could both serve as diagnostic tools and help to design effective treatments for the behavioral symptoms of ASD.

Reduced sulfate plasma concentrations in the BTBR T+tf/J mouse model of autism

Clinical studies have shown that children diagnosed with autism show abnormal sulfate chemistry, which is critical for cellular and metabolic processes. To determine if the inbred BTBR T+tf/J mouse shows autism-relevant aberrations in sulfate chemistry, the present study examined plasma sulfate concentrations in BTBR T+tf/J, inbred C57BL/6J, and outbred CD-1 mice. Results showed that the BTBR T+tf/J mouse exhibits significantly lower plasma sulfate concentrations in comparison to both C57BL/6J and CD-1 mice. These results suggest that the BTBR mouse shows autism-relevant abnormalities in sulfate chemistry and may serve additional utility in examining the role of sulfate and sulfate-dependent systems in relation to autism-relevant behavioral aberrations.

Fractone-associated N-sulfated heparan sulfate shows reduced quantity in BTBR T+tf/J mice: a strong model of autism

BTBR T+tf/J (BTBR) mice show abnormal social, communicatory, and repetitive/stereotyped behaviors paralleling many of the symptoms of autism spectrum disorders. BTBR also show agenesis of the corpus callosum (CC) suggesting major perturbations of growth or guidance factors in the dorsal forebrain [1]. Heparan sulfate (HS) is a polysaccaride found in the brain and other animal tissues. It binds to a wide variety of ligands and through these ligands modulates a number of biological processes, including cell proliferation and differentiation, migration and guidance. It is aggregated on fractal-like structures (fractones) in the subventricular zone (SVZ), that may be visualized by laminin immunoreactivity (LAM-ir), as well as by HS immunoreactivity (HS-ir). We report that the lateral ventricles of BTBR mice were drastically reduced in area compared to C57BL/6J (B6) mice while the BTBR SVZ was significantly shorter than that of B6. In addition to much smaller fractones for BTBR, both HS and LAM-ir associated with fractones were significantly reduced in BTBR, and their anterior-posterior distributions were also altered. Finally, the ratio of HS to LAM in individual fractones was significantly higher in BTBR than in B6 mice. These data, in agreement with other findings linking HS to callosal development, suggest that variations in the quantity and distribution of HS in the SVZ of the lateral ventricles may be important modulators of the brain structural abnormalities of BTBR mice, and, potentially, contribute to the behavioral pathologies of these animals.

Characteristics of autism spectrum disorders in a sample of egyptian and saudi patients: transcultural cross sectional study

BACKGROUND

Autism is a biological disorder with clearly defined phenomenology. Studies from the Middle East on this topic have been particularly rare. Little is known about the influence of culture on clinical features, presentations and management of autism. The current study was done to compare characteristics of autism in two groups of Egyptian as well as Saudi children.

METHODS

The sample included 48 children with Autism Spectrum Disorder. They were recruited from the Okasha Institute of Psychiatry, Ain Shams University, Cairo, Egypt and Al-Amal Complex for Mental Health, Dammam, Kingdom of Saudi Arabia. They were grouped into an Egyptian group (n = 20) and a Saudi group (n = 28). They were assessed both clinically and psychometrically using the GARS, the Vineland adaptive behavioral scale, and the Stanford Binnet IQ test.

RESULTS

Typical autism was more prevalent than atypical autism in both groups. There were no statistically significant differences in clinical variables like regression, hyperactivity, epilepsy or mental retardation. Delayed language development was significantly higher in the Egyptian group while delay in all developmental milestones was more significant in the Saudi group. The Vineland communication subscale showed more significant severe and profound communication defects in the Saudi group while the Gilliam developmental subscale showed significantly more average scores in the Egyptian group. Both groups differed significantly such that the age of noticing abnormality was younger in the Saudi group. The age at diagnosis and at the commencement of intervention was lower in the Egyptian group. The Saudi group showed a higher percentage of missing examinations, older birth order and significantly higher preference to drug treatment, while the Egyptian group showed a high preference to behavioral and phoniatric therapies, higher paternal and maternal education, higher employment among parents and higher family concern.

CONCLUSION

Cultural context may significantly influence the age of noticing abnormality, the age of starting intervention, developmental and perinatal problems, family concerns about managing the problem as well as familial tendency for neurodevelopmental disorders, all of which have important impact on clinical symptomatology and severity of autism. Culture also influences significantly the ways of investigating and treating autism.

The speech aversion hypothesis has explanatory power in a Minimal Speech Approach to aloof, non-verbal, severe autism

In the search for 'pure autism', non-verbal children labeled aloof, Severely Autistic with Developmental Disabilities (ASA/DD), are routinely excluded from psychological research. This exclusion is predicated on the claim that they are indistinguishable from those with SLD/PMLD, which is refuted through a discussion of the extant literature. A novel, falsifiable, speech aversion hypothesis is proposed: "aloof, non-verbal young children (<7 years), with severe autism (CARS≥37), but without significant dysmorphic features, will show aversive reactions to complex speech (>2-3 words), but not to a silent interlocutor, or one imitating their vocalizations, in proximal encounters." Implications are examined by deconstructing the presenting symptoms of ASA/DD in response to the hypothesis. Supporting evidence is drawn from: Minimal Speech Approach (MSA) research showing high levels of spontaneous requests for social routines; a reinterpretation of still-face research as a still-(silent)-face paradigm; auditory processing MMN data employing EEG/MEG; and possible links to epileptiform activity and verbal auditory agnosia. Guidelines are established for future research. This hypothesis, if corroborated, would add to the auditory processing anomalies seen in severe autism and lead to synergies of existing and new areas of research, with significant theoretical, therapeutic, and educational implications.

Brief report: Prevalence of autistic spectrum disorders in the Sultanate of Oman

Prevalence of autistic spectrum disorders (ASD) in Oman is unknown. We conducted a cross-sectional study to estimate the prevalence of ASD among 0-14 year old children. Diagnoses were made as per DSM-IV-TR criteria and supplemented with information collected with the standard Childhood Autism Rating Scale (CARS) questionnaire. A total 113 cases of ASD were enumerated nationwide, indicating an overall prevalence of 1.4 (95% CI 1.2, 1.7) cases per 10,000 children aged 0-14 years. More prevalent cases were among boys (75%) and among low-income families. Ritualistic interests were more common among girls as an onset-symptom compared to boys (p = 0.03). The reported low prevalence of ASD in Oman is likely due to under-diagnosis and under-reporting.

BTBR T+tf/J mice: autism-relevant behaviors and reduced fractone-associated heparan sulfate

BTBR T+tf/J (BTBR) mice have emerged as strong candidates to serve as models of a range of autism-relevant behaviors, showing deficiencies in social behaviors; reduced or unusual ultrasonic vocalizations in conspecific situations; and enhanced, repetitive self-grooming. Recent studies have described their behaviors in a seminatural visible burrow system (VBS); a Social Proximity Test in which avoidance of a conspecific is impossible; and in an object approach and investigation test evaluating attention to specific objects and potential stereotypies in the order of approaching/investigating objects. VBS results confirmed strong BTBR avoidance of conspecifics and in the Social Proximity Test, BTBR showed dramatic differences in several close-in behaviors, including specific avoidance of a nose-to-nose contact that may potentially be related to gaze-avoidance. Diazepam normalized social avoidance by BTBRs in a Three-Chamber Test, and some additional behaviors - but not nose to nose avoidance - in the Social Proximity Test. BTBR also showed higher levels of preference for particular objects, and higher levels of sequences investigating 3- or 4-objects in the same order. Heparan sulfate (HS) associated with fractal structures in the subventricular zone of the lateral ventricles was severely reduced in BTBR. HS may modulate the functions of a range of growth and guidance factors during development, and HS abnormalities are associated with relevant brain (callosal agenesis) and behavioral (reductions in sociality) changes; suggesting the value of examination of the dynamics of the HS system in the context of autism.

A longitudinal study of epilepsy and other central nervous system diseases in individuals with and without a history of infantile autism

OBJECTIVE

To compare the prevalence and types of epilepsy and other central nervous system (CNS) diseases in a clinical sample of 118 individuals diagnosed as children with infantile autism (IA) with 336 matched controls from the general population.

METHODS

All participants were screened through the nationwide Danish National Hospital Register (DNHR). The average observation time was 30.3years (range 27-30years), and mean age at follow-up was 42.7years (range 27-57years).

RESULTS

Of the 118 individuals with IA, 29 (24.6%) were registered with at least one epilepsy diagnosis against 5 (1.5%) in the comparison group (p<0.0001; OR=21.6; 95% CI 8.1-57.3). Other CNS diseases occurred with low frequency in both groups and only cerebral palsy, unspecified (p=0.02) was significantly more frequent among participants with a history of IA.

CONCLUSIONS

Our study lends further support to the notion that epilepsy, but not other CNS diseases, is a common comorbid condition in IA. Low intelligence, but not gender, was a risk factor for epilepsy in IA.

Autism spectrum disorders in siblings of children with a developmental language disorder

Little is known about the familial characteristics of children diagnosed during childhood as having a developmental language disorder (DLD). This study aimed to investigate the prevalence of autism spectrum disorders (ASD) in siblings of probands diagnosed during childhood as having a DLD. In order to estimate the prevalence of ASD, 908 siblings of 469 probands diagnosed during childhood as having a DLD, and 3,802 siblings of 2,345 controls from the general population, without a known history of DLD, were screened for ASD through the nationwide Danish Psychiatric Central Register (DPCR). The mean length of observation was 35.2 years and 34.8 years, respectively, and the mean age at follow-up 38.4 years and 37.4 years, respectively. At follow-up one sibling (0.1%) in the DLD case group and eight siblings (0.2%) in the comparison group were known in the DPCR with a diagnosis of any ASD (P = 0.53; OR = 0.52; 95%CI 0.07-4.19). Thus our results provide no support for a familial association between DLD and ASD.

Children with attention-deficit/hyperactivity disorder and autistic features: EEG evidence for comorbid disorders

Attention-deficit/hyperactivity disorder (AD/HD) is the most common psychiatric disorder of childhood, although AD/HD is rarely the only diagnosis given to these children. Within the literature there is some debate as to whether it is valid to diagnose AD/HD with autism as a comorbid disorder, since the present diagnostic systems exclude the diagnosis of both disorders in the same child. The aim of this study was to determine whether electroencephalography (EEG) differences exist between two groups of children diagnosed with AD/HD, one scoring high (AD/HD+) and one scoring low (AD/HD-) on a measure of autism. The EEG was recorded during an eyes-closed resting condition from 19 electrodes, and Fourier transformed to provide absolute and relative power estimates in delta, theta, alpha and beta bands. Compared to age- and sex-matched controls, the AD/HD- group had increased absolute power in all frequency bands, somewhat higher relative theta activity and decreased relative delta. In comparison to the AD/HD- group, patients with autistic features (AD/HD+) had a number of qualitative differences in the beta and theta bands. These results indicate the presence of two comorbid conditions in the AD/HD+ group, which suggests that AD/HD and autism can occur in the same individual.

'Birdwatching and baby-watching': Niko and Elisabeth Tinbergen's ethological approach to autism

Biographers have largely dismissed Nikolaas 'Niko' Tinbergen's late research into the causes and treatment of autism, describing it as a deviation from his previous work, influenced by his personal desires.They have pointed to the incoherence of Tinbergen's assertions about best practices for treating autism, his lack of experience with children with autism, and his apparent embracing of psychogenic theories that the medical research community had largely abandoned. While these critiques have value, it is significant that Tinbergen himself saw his research as a logical extension of his seminal findings in the field of ethology, the science of animal behaviour. The reception of his theories, both positive and negative, was due less to their strengths or faults than to the fact that Tinbergen had inserted himself into a pre-existing and acrimonious debate in the autism research community. Debates about the relative role of environmental and hereditary factors in the aetiology of autism, and the implications of both for the efficacy of different treatments, had political and material significance for the success of parent organizations' lobbying efforts and financial support for research programmes. Tinbergen's approach was welcomed and even championed by a significant minority, who saw no problem with his ideas or methods.

A longitudinal study of gastrointestinal diseases in individuals diagnosed with infantile autism as children

BACKGROUND

A number of studies have indicated a link between gastrointestinal (GI) diseases and autism spectrum disorders.

METHOD

The objective of this study was to compare the prevalence and types of GI diseases in a clinical sample of 118 individuals diagnosed as children with infantile autism (IA) with GI diseases in 336 matched controls from the general population, based on data from the nationwide Danish National Hospital Register (DNHR). The average observation time was 30.3 years (SD 0.4) (range 27-30 years), and mean age at the end of the observation period was 42.7 years (SD 7.7) (range between 27 and 57 years of age).

RESULTS

Of the 118 individuals with IA, 97 (82.2%) had been in contact with a medical hospital (inpatient hospitalization or outpatient visits) during the observation period, compared with 312/336 (92.9%) in the control group (P= 0.001). A similar proportion of members from the case and comparison group had a diagnosis of any GI disease in the DNHR: 30.5% against 30.7%, but the nature of their diseases may be somewhat different. Only diseases of oral cavity were significantly associated with IA: 20.3% against 1.2%, P < 0.0001. Otherwise, specific GI diseases occurred with low frequency in both groups.

CONCLUSION

Overall, no evidence was found that patients with IA were more likely than control persons without IA to have defined GI diseases during the 30.3-year observation period.

Sibling sex ratio of individuals diagnosed with autism spectrum disorder as children

AIM

To study the sex ratio (proportion of males) in siblings of individuals diagnosed with autism spectrum disorders (ASDs) as children.

METHOD

In the current study, we extended previous studies dealing with the androgen theory of autism and examined sex ratios in the siblings of 326 individuals with ASD (245 males, 81 females) who had been consecutively assessed at two Danish university clinics of child psychiatry during the 25-year period from 1960 to 1985.

RESULTS

Among the 513 siblings, 300 were males and 213 females. This yields a sex ratio of 0.585, which is significantly higher than the Danish live-birth sex ratio over the same period (0.514, p=0.001). The sibling sex ratio was not associated with the IQ in the autistic probands.

INTERPRETATION

Our findings suggest a potential indirect confirmation of the androgen theory of autism.

Copy number variations associated with idiopathic autism identified by whole-genome microarray-based comparative genomic hybridization

OBJECTIVES

Autism spectrum disorder (ASD) has been thought to have strong genetic background, but major contributing genes or associated molecular-genetic pathways are yet to be identified. To explore the idiopathic ASD-associated copy number variations (CNVs), we conducted case-control study using whole-genome copy number analysis.

METHODS

Whole-genome microarray-based comparative genomic hybridization was carried out on 28 children (24 boys and four girls) diagnosed as ASD and 62 Korean adults (45 males and 17 females) without any signs of abnormalities and family history of genetic disorders as normal controls. Fluorescence in-situ hybridization and capillary electrophoresis-single-strand conformational polymorphism were used for quantitative verification of the ASD-associated CNVs.

RESULTS

Thirty-eight CNVs were identified. Among them, the distributions of copy number loss CNVs on 8p23.1 (odds ratio: 5.1, 95% confidence interval: 1.7-14.5, P=0.003) and on 17p11.2 (odds ratio: uncalculable because of zero cell, P=0.008) were found to be significantly different between ASD and control groups. DEFENSIN family occurs in a cluster at 8p23.1 region. Fluorescence in-situ hybridization and capillary electrophoresis-single-strand conformational polymorphism coherently showed reduced copy number of DEFENSIN in cases with 8p23.1 copy number loss CNV, which validated microarray-based comparative genomic hybridization results; but there are no known coding genes in the CNV on 17p11.2.

CONCLUSION

Our approach as well as results can help to elucidate the genetic mechanism of idiopathic ASD.

Defective oxytocin function: a clue to understanding the cause of autism?

The autism spectrum disorders are a group of conditions with neurobehavioral impairment affecting approximately 0.6% of children. The clinical presentation is complex and the etiology is largely unknown, although a major role of genetic factors is widely accepted. A number of genetic studies led to the identification of genes and/or copy number variants whose alterations are associated with autism, but no specific factor has been found so far to be responsible for a substantial proportion of cases. Epigenetic modifications may also play a role, as demonstrated by the occurrence of autism in genetic conditions caused by mutations in imprinted genes or regions.The article by Gregory et al. published this month in BMC Medicine, reports on genomic and epigenetic alterations of OXTR, the gene encoding the receptor for oxytocin. The involvement of this gene was suggested by its deletion in an autistic patient. The subsequent analysis of a group of unrelated autistic subjects did not show an OXTR deletion, but rather hypermethylation of the gene promoter, with a reduced mRNA expression.These findings address two major points of the current debate on the etiology and pathogenesis of autism: the role of oxytocin, known to be involved in modeling human behavior, and the possible involvement of epigenetic mechanisms. The nature of this epigenetic dysregulation is unknown but, if proved to be true, might explain the failure to identify sequence alterations in a host of candidate genes. Practical implications of these findings may be forthcoming, however not before extension and validation on a larger scale have confirmed their value.See the associated research paper by Gregory et al: http://www.biomedcentral.com/1741-7015/7/62.

Autism in Saudi Arabia: presentation, clinical correlates and comorbidity

Although autism is a global disorder, relatively little is known about its presentation and occurrence in many developing countries, such as Saudi Arabia. This article describes the reasons for referral and clinical characteristics of a sample of 49 children (37 males and 12 females) diagnosed with an autistic spectrum disorder at a tertiary referral center in Saudi Arabia. The diagnosis of autism was based on DSM-IV criteria supplemented by information obtained from parent and child interviews, rating scales, and examination of school and hospital records. Females were older than males at the time of referral. Eleven patients had a history of seizure disorder and one patient had a chromosome abnormality. Twenty-five patients were taking psychotropic medications and 14 patients were the product of consanguineous marriages. Clinical and research implications of these findings are discussed.

Caring for children with autism spectrum disorder. Part I: prevalence, etiology, and core features

Autism spectrum disorder (ASD) affects 1 in 150 children and has been gaining national attention over the past decade. Given the prevalence of this disorder, there is a high probability that pediatric nurses will care for a child with ASD, regardless of the setting in which they work. Children with ASD traverse the primary care outpatient setting, schools, subspecialty clinics, and inpatient units. A basic understanding of the current issues regarding prevalence and etiology, coupled with knowledge of the core features of ASD, will help pediatric nurses in all settings and at various practice levels better care for these children.

Trends in US autism research funding

This study shows that the number of autism research grants funded in the US from 1997 to 2006 significantly increased 15% per year. Although the majority of projects were concentrated in basic science (65%) compared to clinical (15%) and translational research (20%), there is a significant decrease in the proportion of basic research grants per year and a significant increase in the proportion of translational projects per year. The number of translational projects funded by the National Alliance for Autism Research and Cure Autism Now increased significantly, whereas the number of clinical projects significantly increased for the National Institutes of Health. In conclusion, this study demonstrates the shifting landscape of autism research from basic science to clinical and translational research.

Diagnosticando o transtorno autista: aspectos fundamentais e considerações práticas

Tendo como base modelos de prática diagnóstica implementados em outros países, o objetivo do artigo é oferecer uma revisão geral acerca do que vem a ser o transtorno autista e dos fatores críticos que devem ser considerados durante o processo diagnóstico. São discutidos aspectos dos critérios diagnósticos e também das comorbidades, incidência, etiologia e diretrizes para a prática diagnóstica. Tais diretrizes incluem formas de exploração de sintomas de risco durante exames de rotina realizados por profissionais que trabalham com a população infantil e elementos básicos necessários para a realização de uma avaliação minuciosa e criteriosa por uma equipe interdisciplinar. Isso inclui, por exemplo, o uso de instrumentos específicos auxiliares no diagnóstico, elementos importantes para a avaliação médica e psicológica e encaminhamentos para serviços adequados de intervenção e apoio.

[The use of verbal communicative abilities to increase the mean length of utterance in high-functioning autism and Asperger Syndrome]

BACKGROUND

high-functioning autism (HFA) and Asperger Syndrome (AS) are pervasive developmental disorders that present alterations in the communicative and social skills.

AIM

to use verbal communicative skill strategies (VCS) to increase the mean length of utterance (MLU) produced by individuals with HFA and AS.

METHOD

participants were three 12-year-old males with HFA or AS. Data was collected from videotape recordings of structured verbal interaction sessions with the researcher and each participant during eight months. In order to verify the effects of the intervention, a multiple baseline research design across the participants was used, being composed by two phases: baseline (BL) and intervention (I). In the BL phase, spontaneous interaction situations occurred between the researcher and each participant. In the first phase of I, the intervention sessions occurred twice a week and gradually worked their way to once a week, but only after each participant had reached the goal of increasing the MLU. The number of sessions decreased gradually to avoid any drop in performance. The strategies which were used were divided in blocks of activities: spontaneous conversation; activities involving specific language difficulties; games with rules; story/report telling; and meta-linguistic activities.

RESULTS

the application of the proposed strategies for verbal communicative abilities achieved the purpose of increasing the MLU of all three participants.

CONCLUSION

suggestions are made for further researches that investigate the maintenance of the results in other environments and during the interaction with different communication partners.

Epilepsy and other neurological diseases in the parents of children with infantile autism. A case control study

In order to study the broader phenotype of infantile autism (IA) we compared the rates and types of epilepsy and other neurological diseases in the parents of 111 consecutively admitted patients with IA with a matched control group of parents of 330 children from the general population. All participants were screened through the nationwide Danish National Hospital Register (DNHR). We inquired about epilepsy and other neurological diseases during an observation period of 27 years. A similar proportion of case- and control mothers had a diagnosis of any neurological disease, 9.9% vs 10.6%. For case fathers the proportion was 5.7% vs 9.7%. No single neurological disease was significantly more frequent among parents of persons with IA. Our study lent support to the notion that epilepsy and other neurological diseases are not part of the broader IA phenotype.

Autoimmune diseases in parents of children with infantile autism: a case-control study

This register study compared the rates and types of autoimmune disease in the parents of 111 patients (82 males, 29 females; mean age at diagnosis 5y 5mo [SD 2y 6mo]) with infantile autism (IA) with a matched control group of parents of 330 children from the general population. All parents were screened through the nationwide Danish National Hospital Register. We inquired about 35 autoimmune diseases during an observation period of 27 years. At follow-up the case and control mothers were identical in age (65y 7mo [SDs 9y 7mo and 9y respectively]). For case and control fathers the figures were 70 years 2 months (SD 10y 2mo) and 69 years 1 month (SD 10y 1mo) respectively. A similar proportion of case and control mothers had a diagnosis of any autoimmune disease: 10.8% versus 9.1%. For case fathers the proportion was 8.6% versus 4.6%. Two autoimmune conditions were associated with IA: ulcerative colitis in mothers (p=0.05) and type 1 diabetes in fathers (p=0.02). Additional studies are required to determine whether there is a true association between a parental history of autoimmune disease and pervasive developmental disorder in their offspring.

Differential diagnosis of Hispanic children referred for autism spectrum disorders: complex issues

This study examines the decision-making process used for differential diagnosis of a sample of Hispanic children referred for autism spectrum disorders (ASDs). Of the sample of 28 children, 18 were diagnosed with ASDs. Of the 10 children who were not diagnosed with ASDs, 80% were found to have multiple diagnostic labels or comorbidities. Mann-Whitney U analyses determined the differences between the children with the most severe social impairment, children with less severe social impairment and the non-autistic children on several domains commonly used to assess ASDs. These analyses indicated significant differences in some characteristics of the children in the sample. Based on these results, a decision-tree for the diagnosis of children with and without ASDs with comorbid disorders was developed.

Predictors of expressive vocabulary growth in children with autism

PURPOSE

The purpose of this exploratory study was to examine the variability and predictors of expressive vocabulary development in children with autism and very delayed language.

METHOD

This study involved 35 children with autism whose initial chronological ages were between 20 and 71 months and whose initial expressive vocabularies were less than 60 words. Their expressive vocabularies were measured at baseline and at 6, 12, and 24 months following the start of intervention using the MacArthur-Bates Communicative Developmental Inventory (L. Fenson et al., 1993).

RESULTS

A cluster analysis revealed 4 distinct patterns of expressive vocabulary development over 2 years. The number of words said, the presence of verbal imitation skills and pretend play skills with objects, and the number of gestures to initiate joint attention at baseline were all associated with the cluster of children who demonstrated the most rapid expressive vocabulary growth over time. The 2 clusters of children who demonstrated the least vocabulary growth had the most significant developmental delays and autism severity at 6 months, but not at baseline.

CONCLUSIONS

This study confirms the heterogeneity in language development in young children with autism and, consistent with other reports, confirms that specific prelinguistic skills are predictive of development.

The development of young siblings of children with autism from 4 to 54 months

Cognitive and language skills of 39 siblings of children with autism (SIBS-A) and 39 siblings of typically developing children (SIBS-TD) at ages 4, 14, 24, 36, and 54 months were compared. Twelve of the 39 SIBS-A revealed a delay in cognition and/or language (including one child diagnosed with autism) compared to only two SIBS-TD. Developmental trajectories revealed that the cognitive differences disappeared by age 54 months, but some differences in language ability remained. Thus, most SIBS-A were well-functioning, but some revealed cognitive and/or language difficulties during the preschool years. Even these siblings by and large caught up by the age of 54 months, with receptive and expressive language abilities remaining an area of difficulty for some earlier identified siblings.

Psychiatric disorders in the parents of individuals with infantile autism: a case-control study

BACKGROUND

The rates and types of psychiatric disorders were studied in the parents of individuals with infantile autism (IA).

SAMPLING AND METHODS

To estimate the prevalence and types of psychiatric disorders, the parents of 115 individuals with IA and the parents of 330 controls from the general population were screened through the nationwide Danish Psychiatric Central Register covering a period of 33 years. The IA individuals had been seen as in-patients at two university clinics of child psychiatry during a 25-year period and had been referred from the entire country of Denmark.

RESULTS

Psychiatric disorders were found in 15.7% of mothers with autistic children, which was significantly higher than the 8.2% found in the control group. The only diagnostic category in which a statistically significant overrepresentation could be found was that of personality disorder. A personality disorder diagnosis was found in 7.8% of mothers with autistic children in comparison to 2.1% of mothers in the control group.

CONCLUSION

The findings so far suggest that in future studies it is important to pay attention to issues such as relatives examined, control groups and methods of data collection.