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Bouteldja AA, Penichet D, Srivastava LK, Cermakian N. The circadian system: A neglected player in neurodevelopmental disorders. Eur J Neurosci 2024; 60:3858-3890. [PMID: 38816965 DOI: 10.1111/ejn.16423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/18/2024] [Accepted: 05/07/2024] [Indexed: 06/01/2024]
Abstract
Patients with neurodevelopmental disorders, such as autism spectrum disorder, often display abnormal circadian rhythms. The role of the circadian system in these disorders has gained considerable attention over the last decades. Yet, it remains largely unknown how these disruptions occur and to what extent they contribute to the disorders' development. In this review, we examine circadian system dysregulation as observed in patients and animal models of neurodevelopmental disorders. Second, we explore whether circadian rhythm disruptions constitute a risk factor for neurodevelopmental disorders from studies in humans and model organisms. Lastly, we focus on the impact of psychiatric medications on circadian rhythms and the potential benefits of chronotherapy. The literature reveals that patients with neurodevelopmental disorders display altered sleep-wake cycles and melatonin rhythms/levels in a heterogeneous manner, and model organisms used to study these disorders appear to support that circadian dysfunction may be an inherent characteristic of neurodevelopmental disorders. Furthermore, the pre-clinical and clinical evidence indicates that circadian disruption at the environmental and genetic levels may contribute to the behavioural changes observed in these disorders. Finally, studies suggest that psychiatric medications, particularly those prescribed for attention-deficit/hyperactivity disorder and schizophrenia, can have direct effects on the circadian system and that chronotherapy may be leveraged to offset some of these side effects. This review highlights that circadian system dysfunction is likely a core pathological feature of neurodevelopmental disorders and that further research is required to elucidate this relationship.
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Affiliation(s)
- Ahmed A Bouteldja
- Douglas Mental Health University Institute, Montréal, Québec, Canada
- Integrated Program in Neuroscience, McGill University, Montréal, Québec, Canada
| | - Danae Penichet
- Douglas Mental Health University Institute, Montréal, Québec, Canada
- Integrated Program in Neuroscience, McGill University, Montréal, Québec, Canada
| | - Lalit K Srivastava
- Douglas Mental Health University Institute, Montréal, Québec, Canada
- Department of Psychiatry, McGill University, Montréal, Québec, Canada
| | - Nicolas Cermakian
- Douglas Mental Health University Institute, Montréal, Québec, Canada
- Department of Psychiatry, McGill University, Montréal, Québec, Canada
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2
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Bruni O, Biggio G, Malorgio E, Nobili L. Insomnia in children affected by autism spectrum disorder: The role of melatonin in treatment. Sleep Med 2024; 119:511-517. [PMID: 38805858 DOI: 10.1016/j.sleep.2024.05.046] [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: 03/13/2024] [Revised: 05/08/2024] [Accepted: 05/23/2024] [Indexed: 05/30/2024]
Abstract
The present article explores the connection between insomnia and Autism Spectrum Disorder (ASD), focusing on the efficacy and safety of melatonin treatments as supported by existing research and current guidelines. In this narrative review a group of Italian experts provide an analysis of the various aspects of managing insomnia in children with ASD, highlighting key points that could enhance the quality of life for both patients and their caregivers. This includes the significance of comprehensively understanding the root causes of a child's sleep difficulties for more effective, long-term management. Insomnia, a condition frequently documented in neurodevelopmental disorders such as ASD, greatly affects the lives of patients and caregivers. Recent data show that melatonin-based formulations are effective and safe for treating ASD-related insomnia both short and long term. In particular, prolonged-release melatonin is poised to be the optimal choice for this patient population. This formulation is approved for the treatment of insomnia in children and adolescents aged 2-18 years suffering from ASD and/or Smith-Magenis syndrome, where sleep hygiene measures and behavioral treatments have not been sufficient. In support, emerging research in pediatric settings indicates long-term efficacy and safety, although further research efforts are still needed. Current guidelines recommend managing insomnia and sleep disturbances in ASD using a combination of behavioral and pharmacological methods, primarily melatonin. Recent concerns about accidental melatonin ingestion highlight the need for high purity standards, such as pharmaceutical-grade prolonged-release formulations. The article also summarizes emerging molecular mechanisms from preclinical research, suggesting future therapeutic approaches.
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Affiliation(s)
- Oliviero Bruni
- Dept of Developmental and Social Psychology, Sapienza University, Via dei Marsi 78, 00185, Rome, Italy.
| | - Giovanni Biggio
- Department of Life and Environmental Sciences, Institute of Neuroscience, CNR, University of Cagliari, 09042, Cagliari, Italy; Institute of Neuroscience, National Research Council (C.N.R.), University Campus, 09042, Cagliari, Italy.
| | - Emanuela Malorgio
- Italian Federation of Primary Care Pediatricians (Federazione Italiana Medici Pediatri, FIMP), Expert on Sleep Disorders AIMS, Torino, Italy.
| | - Lino Nobili
- IRCCS G. Gaslini Institute. Department of Neuroscience - Rehabilitation - Ophthalmology - Genetics - Child and Maternal Health (DINOGMI) - University of Genova, Italy.
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Estes A, Hillman A, Chen ML. Sleep and Autism: Current Research, Clinical Assessment, and Treatment Strategies. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2024; 22:162-169. [PMID: 38680972 PMCID: PMC11046719 DOI: 10.1176/appi.focus.20230028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
Autism spectrum disorder is associated with a high rate of sleep problems, affecting over 80% of autistic individuals. Sleep problems have pervasive negative effects on health, behavior, mood, and cognition but are underrecognized in autistic children. Problems initiating and maintaining sleep-hallmarks of insomnia-are common. Sleep-disordered breathing and restless legs syndrome have also been described in autism at a higher prevalence than in community populations. The authors describe current research on sleep in autistic children and potential pathophysiologic mechanisms. They describe practical approaches to sleep assessment and synthesize approaches to addressing sleep problems in autistic children.
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Affiliation(s)
- Annette Estes
- Department of Speech and Hearing Sciences (Estes) and Department of Pediatrics, Division of Pulmonary and Sleep Medicine (Chen), University of Washington, Seattle; University of Washington Autism Center (Estes, Hillman); Pediatric Sleep Disorders Center and Pulmonary and Sleep Medicine Division, Seattle Children's Hospital (Chen)
| | - Arianna Hillman
- Department of Speech and Hearing Sciences (Estes) and Department of Pediatrics, Division of Pulmonary and Sleep Medicine (Chen), University of Washington, Seattle; University of Washington Autism Center (Estes, Hillman); Pediatric Sleep Disorders Center and Pulmonary and Sleep Medicine Division, Seattle Children's Hospital (Chen)
| | - Maida Lynn Chen
- Department of Speech and Hearing Sciences (Estes) and Department of Pediatrics, Division of Pulmonary and Sleep Medicine (Chen), University of Washington, Seattle; University of Washington Autism Center (Estes, Hillman); Pediatric Sleep Disorders Center and Pulmonary and Sleep Medicine Division, Seattle Children's Hospital (Chen)
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4
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Johnson KP, Zarrinnegar P. Autism Spectrum Disorder and Sleep. Psychiatr Clin North Am 2024; 47:199-212. [PMID: 38302207 DOI: 10.1016/j.psc.2023.06.013] [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: 02/03/2024]
Abstract
Children and adolescents with autism spectrum disorder (ASD) experience sleep disturbances, particularly insomnia, at rates much higher than the general population. Daytime behavioral problems and parental stress are associated with the resultant sleep deprivation. Behavioral interventions, parental education, and melatonin are effective treatments. The epidemiology of sleep disturbances in youth with ASD is reviewed in this article as well as the latest in treatments.
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Affiliation(s)
- Kyle P Johnson
- Division of Child & Adolescent Psychiatry, Oregon Health & Science University, Mailcode: DC-7P, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA.
| | - Paria Zarrinnegar
- Division of Child & Adolescent Psychiatry, Oregon Health & Science University, Mailcode: DC-7P, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
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López-Zamora M, Cano-Villagrasa A, Cortés-Ramos A, Porcar-Gozalbo N. The Influence of Sleep Disorders on Neurobiological Structures and Cognitive Processes in Pediatric Population with ASD and Epilepsy: A Systematic Review. Eur J Investig Health Psychol Educ 2023; 13:2358-2372. [PMID: 37998056 PMCID: PMC10670909 DOI: 10.3390/ejihpe13110166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/18/2023] [Accepted: 10/23/2023] [Indexed: 11/25/2023] Open
Abstract
Autism Spectrum Disorder (ASD) and epilepsy are increasingly prevalent comorbidities in our society. These two disorders are often accompanied by other comorbidities, such as sleep disorders, significantly impacting the quality of life of individuals with ASD and epilepsy. To date, clinical approaches have primarily been descriptive in nature. Therefore, this study aimed to analyze the relationship between ASD, epilepsy, and sleep disorders, exploring neurobiological dysfunctions and cognitive alterations. A total of 22 scientific articles were selected using a systematic literature review following the criteria established using the PRISMA model. The selected articles were gathered from major databases: Medline, PubMed, PsycINFO, Google Scholar, and Web of Science. Inclusion criteria specified that study participants had an official diagnosis of ASD, the article precisely described the evaluation parameters used in the study participants, and individual characteristics of the sleep disorders of the study participants were specified. The results indicate, firstly, that the primary cause of sleep disorders in this population is directly linked to abnormal serotonin behaviors. Secondly, significant alterations in memory, attention, and hyperactivity were observed. In conclusion, sleep disorders negatively impact the quality of life and neurocognitive development of the pediatric population with ASD and epilepsy.
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Affiliation(s)
- Miguel López-Zamora
- Department of Developmental and Educational Psychology, University of Malaga, 29010 Malaga, Spain;
| | - Alejandro Cano-Villagrasa
- Faculty of Health Sciences, Universidad Internacional de Valencia, 46002 Valencia, Spain;
- Health Sciences PhD Program, Universidad Católica de Murcia UCAM, Campus de los Jerónimos n°135, Guadalupe, 30107 Murcia, Spain
| | - Antonio Cortés-Ramos
- Department of Developmental and Educational Psychology, Faculty of Educational and Sports Sciences of Melilla, University of Granada, 18071 Granada, Spain;
| | - Nadia Porcar-Gozalbo
- Faculty of Health Sciences, Universidad Internacional de Valencia, 46002 Valencia, Spain;
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Mammarella V, Orecchio S, Cameli N, Occhipinti S, Marcucci L, De Meo G, Innocenti A, Ferri R, Bruni O. Using pharmacotherapy to address sleep disturbances in autism spectrum disorders. Expert Rev Neurother 2023; 23:1261-1276. [PMID: 37811652 DOI: 10.1080/14737175.2023.2267761] [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: 06/02/2023] [Accepted: 10/03/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION Sleep disorders are the second most common medical comorbidity in autism spectrum disorder (ASD), with effects on daytime behavior and functioning, mood and anxiety, and autism core features. In children with ASD, insomnia also has a negative impact on the whole family's quality of life. Therefore, treatment of sleep disturbances should be considered as a primary goal in the management of ASD patients, and it is important to clarify the scientific evidence to inappropriate treatments. AREAS COVERED The authors review the current literature concerning the pharmacological treatment options for the management of sleep-related disorders in patients with ASD (aged 0-18 years) using the PubMed and Cochrane Library databases with the search terms: autism, autistic, autism spectrum disorder, ASD, drug, drug therapy, drug intervention, drug treatment, pharmacotherapy, pharmacological treatment, pharmacological therapy, pharmacological intervention, sleep, sleep disturbance, and sleep disorder. EXPERT OPINION Currently, clinicians tend to select medications for the treatment of sleep disorders in ASD based on the first-hand experience of psychiatrists and pediatricians as well as expert opinion. Nevertheless, at the present time, the only compound for which there is sufficient evidence is melatonin, although antihistamines, trazodone, clonidine, ramelteon, gabapentin, or suvorexant can also be considered for selection.
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Affiliation(s)
- Valeria Mammarella
- Child Neuropsychiatry Unit, Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Silvia Orecchio
- Child Neuropsychiatry Unit, Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Noemi Cameli
- Child Neuropsychiatry Unit, Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Sara Occhipinti
- Child Neuropsychiatry Unit, Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Lavinia Marcucci
- Child Neuropsychiatry Unit, Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Giuliano De Meo
- Child Neuropsychiatry Unit, Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Alice Innocenti
- Child Neuropsychiatry Unit, Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Raffaele Ferri
- Sleep Research Centre, Oasi Research Institute - IRCCS, Troina, Italy
| | - Oliviero Bruni
- Department of Social and Developmental Psychology, Sapienza University, Rome, Italy
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Maurer JJ, Choi A, An I, Sathi N, Chung S. Sleep disturbances in autism spectrum disorder: Animal models, neural mechanisms, and therapeutics. Neurobiol Sleep Circadian Rhythms 2023; 14:100095. [PMID: 37188242 PMCID: PMC10176270 DOI: 10.1016/j.nbscr.2023.100095] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/16/2023] [Accepted: 04/08/2023] [Indexed: 05/17/2023] Open
Abstract
Sleep is crucial for brain development. Sleep disturbances are prevalent in children with autism spectrum disorder (ASD). Strikingly, these sleep problems are positively correlated with the severity of ASD core symptoms such as deficits in social skills and stereotypic behavior, indicating that sleep problems and the behavioral characteristics of ASD may be related. In this review, we will discuss sleep disturbances in children with ASD and highlight mouse models to study sleep disturbances and behavioral phenotypes in ASD. In addition, we will review neuromodulators controlling sleep and wakefulness and how these neuromodulatory systems are disrupted in animal models and patients with ASD. Lastly, we will address how the therapeutic interventions for patients with ASD improve various aspects of sleep. Together, gaining mechanistic insights into the neural mechanisms underlying sleep disturbances in children with ASD will help us to develop better therapeutic interventions.
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Xiong M, Li F, Liu Z, Xie X, Shen H, Li W, Wei L, He R. Efficacy of Melatonin for Insomnia in Children with Autism Spectrum Disorder: A Meta-analysis. Neuropediatrics 2023; 54:167-173. [PMID: 36827993 PMCID: PMC10166641 DOI: 10.1055/s-0043-1761437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
AIM This study aimed to evaluate the effectiveness of melatonin in treating insomnia in children with autism spectrum disorder (ASD). METHODS Comprehensive searches were conducted in the PubMed, EMBASE, and Web of Science databases from their inception to April 20, 2022. Data were extracted and assessed for quality by two researchers. Statistical analysis was performed using the Stata 15.0 software. RESULTS Four studies including 238 patients were included. The results showed that compared with the control group, melatonin could shorten the sleep-onset latency (standardized mean difference [SMD] = - 1.34, 95% CI: -2.19 to -0.48), reduce the number of awakenings (SMD = -2.35, 95% CI: -4.62 to -0.08), and prolong the total sleep time (SMD = 1.42, 95% CI: 0.5-2.33) in children with ASD. CONCLUSION Melatonin has a certain effect on relieving sleep disturbances in children with ASD, which can shorten sleep latency, reduce the number of awakenings, and prolong total sleep time. Larger studies are required to verify this hypothesis.
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Affiliation(s)
- Mei Xiong
- Department of Nursing, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Department of Pediatric Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Fang Li
- Department of Cardiology, People's Hospital of Jianyang City, Jianyang, China
| | - Zhaohua Liu
- Department of Nursing, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Department of Cardiothoracic Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xin Xie
- Department of Nursing, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Department of Nephrology, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Sichuan Clinical Research Center for Nephropathy, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Hongli Shen
- Department of Nursing, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Department of Pediatric Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Weiteng Li
- Department of Nursing, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Department of Pediatric Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Liping Wei
- Department of Nursing, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Department of Pediatric Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Rongfang He
- Department of Nursing, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Department of Psychiatry, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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9
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Ji Q, Li SJ, Zhao JB, Xiong Y, Du XH, Wang CX, Lu LM, Tan JY, Zhu ZR. Genetic and neural mechanisms of sleep disorders in children with autism spectrum disorder: a review. Front Psychiatry 2023; 14:1079683. [PMID: 37200906 PMCID: PMC10185750 DOI: 10.3389/fpsyt.2023.1079683] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 04/13/2023] [Indexed: 05/20/2023] Open
Abstract
Background The incidence of sleep disorders in children with autism spectrum disorder (ASD) is very high. Sleep disorders can exacerbate the development of ASD and impose a heavy burden on families and society. The pathological mechanism of sleep disorders in autism is complex, but gene mutations and neural abnormalities may be involved. Methods In this review, we examined literature addressing the genetic and neural mechanisms of sleep disorders in children with ASD. The databases PubMed and Scopus were searched for eligible studies published between 2013 and 2023. Results Prolonged awakenings of children with ASD may be caused by the following processes. Mutations in the MECP2, VGAT and SLC6A1 genes can decrease GABA inhibition on neurons in the locus coeruleus, leading to hyperactivity of noradrenergic neurons and prolonged awakenings in children with ASD. Mutations in the HRH1, HRH2, and HRH3 genes heighten the expression of histamine receptors in the posterior hypothalamus, potentially intensifying histamine's ability to promote arousal. Mutations in the KCNQ3 and PCDH10 genes cause atypical modulation of amygdala impact on orexinergic neurons, potentially causing hyperexcitability of the hypothalamic orexin system. Mutations in the AHI1, ARHGEF10, UBE3A, and SLC6A3 genes affect dopamine synthesis, catabolism, and reuptake processes, which can elevate dopamine concentrations in the midbrain. Secondly, non-rapid eye movement sleep disorder is closely related to the lack of butyric acid, iron deficiency and dysfunction of the thalamic reticular nucleus induced by PTCHD1 gene alterations. Thirdly, mutations in the HTR2A, SLC6A4, MAOA, MAOB, TPH2, VMATs, SHANK3, and CADPS2 genes induce structural and functional abnormalities of the dorsal raphe nucleus (DRN) and amygdala, which may disturb REM sleep. In addition, the decrease in melatonin levels caused by ASMT, MTNR1A, and MTNR1B gene mutations, along with functional abnormalities of basal forebrain cholinergic neurons, may lead to abnormal sleep-wake rhythm transitions. Conclusion Our review revealed that the functional and structural abnormalities of sleep-wake related neural circuits induced by gene mutations are strongly correlated with sleep disorders in children with ASD. Exploring the neural mechanisms of sleep disorders and the underlying genetic pathology in children with ASD is significant for further studies of therapy.
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Affiliation(s)
- Qi Ji
- Department of Psychology, Army Medical University, Chongqing, China
- College of Basic Medicine, Army Medical University, Chongqing, China
| | - Si-Jia Li
- Department of Psychology, Army Medical University, Chongqing, China
- College of Basic Medicine, Army Medical University, Chongqing, China
| | - Jun-Bo Zhao
- Department of Psychology, Army Medical University, Chongqing, China
- College of Basic Medicine, Army Medical University, Chongqing, China
| | - Yun Xiong
- Department of Psychology, Army Medical University, Chongqing, China
- College of Basic Medicine, Army Medical University, Chongqing, China
| | - Xiao-Hui Du
- Department of Psychology, Army Medical University, Chongqing, China
| | - Chun-Xiang Wang
- Department of Psychology, Army Medical University, Chongqing, China
| | - Li-Ming Lu
- College of Educational Sciences, Chongqing Normal University, Chongqing, China
| | - Jing-Yao Tan
- College of Educational Sciences, Chongqing Normal University, Chongqing, China
| | - Zhi-Ru Zhu
- Department of Psychology, Army Medical University, Chongqing, China
- *Correspondence: Zhi-Ru Zhu,
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Niarchou M, Singer EV, Straub P, Malow BA, Davis LK. Investigating the genetic pathways of insomnia in Autism Spectrum Disorder. RESEARCH IN DEVELOPMENTAL DISABILITIES 2022; 128:104299. [PMID: 35820265 PMCID: PMC10068748 DOI: 10.1016/j.ridd.2022.104299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/11/2022] [Accepted: 06/28/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Sleep problems are common in children with autism spectrum disorder (autism). There is sparse research to date to examine whether insomnia in people with autism is related to autism genetics or insomnia genetics. Moreover, there is a lack of research examining whether circadian-rhythm related genes share potential pathways with autism. AIMS To address this research gap, we tested whether polygenic scores of insomnia or autism are related to risk of insomnia in people with autism, and whether the circadian genes are associated with insomnia in people with autism. METHODS AND PROCEDURES We tested these questions using the phenotypically and genotypically rich MSSNG dataset (N = 1049) as well as incorporating in the analyses data from the Vanderbilt University Biobank (BioVU) (N = 349). OUTCOMES AND RESULTS In our meta-analyzed sample, there was no evidence of associations between the polygenic scores (PGS) for insomnia and a clinical diagnosis of insomnia, or between the PGS of autism and insomnia. We also did not find evidence of a greater burden of rare and disruptive variation in the melatonin and circadian genes in individuals with autism and insomnia compared to individuals with autism without insomnia. CONCLUSIONS AND IMPLICATIONS Overall, we did not find evidence for strong effects of genetic scores influencing sleep in people with autism, however, we cannot rule out the possibility that smaller genetic effects may play a role in sleep problems. Our study indicated the need for a larger collection of data on sleep problems and sleep quality among people with autism.
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Affiliation(s)
- Maria Niarchou
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN, USA; Division of Genetic Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Emily V Singer
- Sleep Disorders Division, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Peter Straub
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN, USA; Division of Genetic Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Beth A Malow
- Sleep Disorders Division, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lea K Davis
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN, USA; Division of Genetic Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, TN, USA.
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11
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Belli A, Breda M, Di Maggio C, Esposito D, Marcucci L, Bruni O. Children with neurodevelopmental disorders: how do they sleep? Curr Opin Psychiatry 2022; 35:345-351. [PMID: 35165244 DOI: 10.1097/yco.0000000000000790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW In this review we summarized the available evidence on sleep disorders in children with neurodevelopmental disorders (NDDs) in particular: intellectual disability (including some genetic conditions such as Prader-Willi Syndrome, Smith-Magenis Syndrome), Autism spectrum disorder, attention-deficit/hyperactivity disorder (ADHD), Developmental Coordination Disorder, language disorders, and specific learning disorders. RECENT FINDINGS Children with NDDs frequently suffer from sleep disturbances, with a higher prevalence than that of the general pediatric population. SUMMARY These problems tend to be chronic and may cause additional cognitive and behavioral difficulties, often affecting the whole family's well-being. Sleep behaviors are also related to other important developmental skills, such as attention and listening. Investigating sleep disorders in children with NDDs is therefore crucial in clinical practice. For a systematic approach in clinical practice, we propose the use of a short and easy to remember sleep screening tool.
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Affiliation(s)
- Arianna Belli
- Child Neurology and Psychiatry Unit, Department of Human Neurosciences
| | - Maria Breda
- Child Neurology and Psychiatry Unit, Department of Human Neurosciences
| | - Chiara Di Maggio
- Child Neurology and Psychiatry Unit, Department of Human Neurosciences
- PhD Program in Behavioral Neuroscience, Department of Psychology
| | - Dario Esposito
- Child Neurology and Psychiatry Unit, Department of Human Neurosciences
| | - Lavinia Marcucci
- Child Neurology and Psychiatry Unit, Department of Human Neurosciences
| | - Oliviero Bruni
- Department of Social and Developmental Psychology, Sapienza University of Rome, Rome, Italy
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Rol de la terapia farmacológica en los trastornos del espectro autista. REVISTA MÉDICA CLÍNICA LAS CONDES 2022. [DOI: 10.1016/j.rmclc.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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13
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Veatch OJ, Mazzotti DR, Schultz RT, Abel T, Michaelson JJ, Brodkin ES, Tunc B, Assouline SG, Nickl-Jockschat T, Malow BA, Sutcliffe JS, Pack AI. Calculating genetic risk for dysfunction in pleiotropic biological processes using whole exome sequencing data. J Neurodev Disord 2022; 14:39. [PMID: 35751013 PMCID: PMC9233372 DOI: 10.1186/s11689-022-09448-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 06/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Numerous genes are implicated in autism spectrum disorder (ASD). ASD encompasses a wide-range and severity of symptoms and co-occurring conditions; however, the details of how genetic variation contributes to phenotypic differences are unclear. This creates a challenge for translating genetic evidence into clinically useful knowledge. Sleep disturbances are particularly prevalent co-occurring conditions in ASD, and genetics may inform treatment. Identifying convergent mechanisms with evidence for dysfunction that connect ASD and sleep biology could help identify better treatments for sleep disturbances in these individuals. METHODS To identify mechanisms that influence risk for ASD and co-occurring sleep disturbances, we analyzed whole exome sequence data from individuals in the Simons Simplex Collection (n = 2380). We predicted protein damaging variants (PDVs) in genes currently implicated in either ASD or sleep duration in typically developing children. We predicted a network of ASD-related proteins with direct evidence for interaction with sleep duration-related proteins encoded by genes with PDVs. Overrepresentation analyses of Gene Ontology-defined biological processes were conducted on the resulting gene set. We calculated the likelihood of dysfunction in the top overrepresented biological process. We then tested if scores reflecting genetic dysfunction in the process were associated with parent-reported sleep duration. RESULTS There were 29 genes with PDVs in the ASD dataset where variation was reported in the literature to be associated with both ASD and sleep duration. A network of 108 proteins encoded by ASD and sleep duration candidate genes with PDVs was identified. The mechanism overrepresented in PDV-containing genes that encode proteins in the interaction network with the most evidence for dysfunction was cerebral cortex development (GO:0,021,987). Scores reflecting dysfunction in this process were associated with sleep durations; the largest effects were observed in adolescents (p = 4.65 × 10-3). CONCLUSIONS Our bioinformatic-driven approach detected a biological process enriched for genes encoding a protein-protein interaction network linking ASD gene products with sleep duration gene products where accumulation of potentially damaging variants in individuals with ASD was associated with sleep duration as reported by the parents. Specifically, genetic dysfunction impacting development of the cerebral cortex may affect sleep by disrupting sleep homeostasis which is evidenced to be regulated by this brain region. Future functional assessments and objective measurements of sleep in adolescents with ASD could provide the basis for more informed treatment of sleep problems in these individuals.
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Affiliation(s)
- Olivia J Veatch
- Department of Psychiatry and Behavioral Sciences, Medical Center, University of Kansas, Kansas City, KS, USA.
| | - Diego R Mazzotti
- Division of Medical Informatics, Department of Internal Medicine, Medical Center, University of Kansas, Kansas City, KS, USA
| | - Robert T Schultz
- Center for Autism Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ted Abel
- Department of Neuroscience and Pharmacology, Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa, USA
| | | | - Edward S Brodkin
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Birkan Tunc
- Center for Autism Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Susan G Assouline
- Belin-Blank Center for Gifted Education and Talent Development, University of Iowa, Iowa City, Iowa, USA
| | | | - Beth A Malow
- Division of Sleep Medicine, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James S Sutcliffe
- Department of Molecular Physiology and Biophysics, Vanderbilt Genetics Institute, Vanderbilt University, Nashville, TN, USA
| | - Allan I Pack
- Division of Sleep Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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14
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Dell'Osso L, Massoni L, Battaglini S, Cremone IM, Carmassi C, Carpita B. Biological correlates of altered circadian rhythms, autonomic functions and sleep problems in autism spectrum disorder. Ann Gen Psychiatry 2022; 21:13. [PMID: 35534878 PMCID: PMC9082467 DOI: 10.1186/s12991-022-00390-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 04/15/2022] [Indexed: 02/05/2023] Open
Abstract
Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by a complex and multifaceted neurobehavioral syndrome. In the last decades, several studies highlighted an increased prevalence of sleep problems in ASD, which would be associated with autonomic system and circadian rhythm disruption. The present review aimed to summarize the available literature about sleep problems in ASD subjects and about the possible biological factors implicated in circadian rhythm and autonomic system deregulation in this population, as well as possible therapeutic approaches. Shared biological underpinnings between ASD symptoms and altered circadian rhythms/autonomic functions are also discussed. Studies on sleep showed how ASD subjects typically report more problems regarding insufficient sleep time, bedtime resistance and reduced sleep pressure. A link between sleep difficulties and irritability, deficits in social skills and behavioral problems was also highlighted. Among the mechanisms implicated, alteration in genes related to circadian rhythms, such as CLOCK genes, and in melatonin levels were reported. ASD subjects also showed altered hypothalamic pituitary adrenal (HPA) axis and autonomic functions, generally with a tendency towards hyperarousal and hyper sympathetic state. Intriguingly, some of these biological alterations in ASD individuals were not associated only with sleep problems but also with more autism-specific clusters of symptoms, such as communication impairment or repetitive behaviors Although among the available treatments melatonin showed promising results, pharmacological studies for sleep problems in ASD need to follow more standardized protocols to reach more repeatable and reliable results. Further research should investigate the issue of sleep problems in ASD in a broader perspective, taking into account shared pathophysiological mechanisms for core and associated symptoms of ASD.
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Affiliation(s)
- Liliana Dell'Osso
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, Pisa, Italy
| | - Leonardo Massoni
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, Pisa, Italy
| | - Simone Battaglini
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, Pisa, Italy
| | - Ivan Mirko Cremone
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, Pisa, Italy
| | - Claudia Carmassi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, Pisa, Italy
| | - Barbara Carpita
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, Pisa, Italy.
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15
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Lin PI, Masi A, Moni MA, Kummerfeld S, Eapen V. Genetic Pathways Associated With Sleep Problems in Children With Autism Spectrum Disorder. Front Psychiatry 2022; 13:904091. [PMID: 35873241 PMCID: PMC9305657 DOI: 10.3389/fpsyt.2022.904091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS Children on the autism spectrum are more likely to have sleep problems than non-autistic children. Sleep disturbance may exacerbate emotional and behavioral problems of children on the autism spectrum. A better understanding of the biological mechanisms underlying sleep disturbance provide clues to better management for this co-morbid condition in autism. The goal of the current study is to identify genetic variants associated with sleep disturbance and melatonin levels in autistic children. METHODS A total of 969 children on the autism spectrum were genotyped using the Global Screening Array v1 or Global Screening Array v2. Sleep problems were assessed using the Children's Sleep Habits Questionnaire (CSHQ). Melatonin levels were measured using the urine samples of 219 probands. The relationship between the melatonin level and CSHQ score was examined using the general linear model. The genetic variants associated with the CSHQ score and melatonin level as two separate quantitative traits were determined using genomewide association studies. RESULTS The data indicates that urine melatonin levels were positively associated with CSHQ scores, suggesting that autistic children with a poorer sleep qualiy could has higher melatonin level. Furthermore, genetic assocication studies suggest that genetic pathways involved in pro-inflammatory responses might be involved in sleep disturbance, while genetic pathways involved in catecholamine-secreting PC12 cells and Schwann cells could be associated with melatonin levels. CONCLUSIONS Taken together, our findings indicate that sleep disturbance and melatonin metabolism could be attributable to distinct biological mechanisms in autistic children since they might not share genetic contributors.
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Affiliation(s)
- Ping-I Lin
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Mental Health Research Unit, South Western Sydney Local Health District and Ingham Institute, Sydney, NSW, Australia.,Academic Unit of Psychiatry, Infant Child and Adolescent Mental Health Services, South Western Sydney Local Health District and Ingham Institute, Sydney, NSW, Australia
| | - Anne Masi
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Mohammad Ali Moni
- Artificial Intelligence and Digital Health Data Science, School of Health and Rehabilitation Sciences, Faculty of Health and Behavioural Sciences, The University of Queensland, St. Lucia, QLD, Australia
| | - Sarah Kummerfeld
- Kinghorn Centre for Clinical Genomics, Garvan Institute of Medical Research, Sydney, NSW, Australia.,St. Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Valsamma Eapen
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Mental Health Research Unit, South Western Sydney Local Health District and Ingham Institute, Sydney, NSW, Australia.,Academic Unit of Psychiatry, Infant Child and Adolescent Mental Health Services, South Western Sydney Local Health District and Ingham Institute, Sydney, NSW, Australia.,Cooperative Research Centre for Living With Autism (Autism CRC), The University of Queensland, Indooroopilly, QLD, Australia
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16
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Tan DX, Hardeland R. The Reserve/Maximum Capacity of Melatonin's Synthetic Function for the Potential Dimorphism of Melatonin Production and Its Biological Significance in Mammals. Molecules 2021; 26:7302. [PMID: 34885890 PMCID: PMC8659113 DOI: 10.3390/molecules26237302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 11/27/2021] [Accepted: 11/29/2021] [Indexed: 01/13/2023] Open
Abstract
In this article, we attempt to classify a potential dimorphism of melatonin production. Thus, a new concept of "reserve or maximum capacity of melatonin synthetic function" is introduced to explain the subtle dimorphism of melatonin production in mammals. Considering ASMT/ASMTL genes in the pseudoautosomal region of sex chromosomes with high prevalence of mutation in males, as well as the sex bias of the mitochondria in which melatonin is synthesized, we hypothesize the existence of a dimorphism in melatonin production to favor females, which are assumed to possess a higher reserve capacity for melatonin synthesis than males. Under physiological conditions, this subtle dimorphism is masked by the fact that cells or tissues only need baseline melatonin production, which can be accomplished without exploiting the full potential of melatonin's synthetic capacity. This capacity is believed to exceed the already remarkable nocturnal increase as observed within the circadian cycle. However, during aging or under stressful conditions, the reserve capacity of melatonin's synthetic function is required to be activated to produce sufficiently high levels of melatonin for protective purposes. Females seem to possess a higher reserve/maximum capacity for producing more melatonin than males. Thus, this dimorphism of melatonin production becomes manifest and detectable under these conditions. The biological significance of the reserve/maximum capacity of melatonin's synthetic function is to improve the recovery rate of organisms from injury, to increase resistance to pathogen infection, and even to enhance their chances of survival by maximizing melatonin production under stressful conditions. The higher reserve/maximum capacity of melatonin synthesis in females may also contribute to the dimorphism in longevity, favoring females in mammals.
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Affiliation(s)
- Dun-Xian Tan
- Department of Cell Systems and Anatomy, UT Health San Antonio, San Antonio, TX 78229, USA
| | - Rüdiger Hardeland
- Johann Friedrich Blumenbach Institute of Zoology and Anthropology, University of Göttingen, 37073 Göttingen, Germany;
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17
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Matura JM, Shea LA, Bankes VA. Dietary supplements, cytochrome metabolism, and pharmacogenetic considerations. Ir J Med Sci 2021; 191:2357-2365. [PMID: 34734388 DOI: 10.1007/s11845-021-02828-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 10/21/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Dietary supplement use has continued to rise. In addition to supplement-drug interactions, it is prudent to consider how dietary supplements may interact with a patient's specific pharmacogenetics. Variations in genes associated with CYP 450 enzymes have evidence of impacting drug metabolism and adverse effects. AIMS This research was performed to evaluate CYP P450 enzyme activity of the top 15 dietary supplements used in the USA in order to initiate pharmacogenetic considerations specific to commonly used dietary supplements. METHODS The most common dietary supplements used in the USA were obtained from the National Health and Nutrition Examination Survey (NHANES). Primary literature detailing supplement CYP P450 activity was compiled from PubMed using MeSH search terms: supplement name(s), cytochrome P450 enzymes, metabolism, and pharmacokinetics. Additional resources utilized for documented CYP enzyme genotypes were the pharmacogenetic databases from Clinical Pharmacogenetics Implementation Consortium and The Pharmacogenomic Variation Consortium. RESULTS Of the 15 most common dietary supplements used in the USA, 53% (cranberry, echinacea, garlic, ginkgo biloba, ginseng, melatonin, milk thistle, and valerian) exhibit CYP P450 metabolism, with some having possible induction activity as well. Melatonin and garlic are substrates of CYP1A2 and CYP2C19, respectively. Additionally, there is evidence of echinacea having possible CYP3A4 induction activity. CONCLUSION CYP P450 activity is an important consideration for any patient but becomes increasingly critical if patients have certain CYP P450 phenotypes that impact metabolism. These popular supplements have the potential for changes in supplement exposure, and adverse effects based on pharmacogenetic profiles. Furthermore, these sites of metabolism are shared with many medications, setting the stage for possibly more profound interactions between medications and supplements. This paper highlights the mechanisms in which dietary supplements may constitute a risk for patients with certain CYP P450 phenotypes. Further research is needed in the area of dietary supplements and their pharmacogenomic implications.
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Affiliation(s)
- Janelle M Matura
- School of Pharmacy, Regis University, 3333 Regis Blvd, Denver, CO, H-28, USA
| | - Leticia A Shea
- School of Pharmacy, Regis University, 3333 Regis Blvd, Denver, CO, H-28, USA.
| | - Victoria A Bankes
- School of Pharmacy, Regis University, 3333 Regis Blvd, Denver, CO, H-28, USA
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18
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Shui AM, Richdale AL, Katz T. Evaluating sleep quality using the CSHQ-Autism. Sleep Med 2021; 87:69-76. [PMID: 34534745 DOI: 10.1016/j.sleep.2021.08.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/16/2021] [Accepted: 08/22/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Sleep problems are common in autistic children and adversely impact daytime functioning. The Children's Sleep Habits Questionnaire (CSHQ) [39] was developed from a community-based sample of children and has validated a cut-off score of 41. Katz et al. [50] developed an abbreviated 23-item four-factor version of the CSHQ, which may be useful when assessing sleep in autistic children. However, a cut-off value has not yet been developed. OBJECTIVE Our objective was to develop and validate a cut-off for the CSHQ-autism total score in order to identify sleep problems among autistic children. We hypothesized that the derived cut-off value for the CSHQ-autism would perform better than the original CSHQ cut at 41 on validation in a sample of autistic children. METHODS Age-specific cut-off values were developed and validated using receiver operating characteristic analysis. RESULTS The derived cut-off values for the CSHQ-autism total score were 34, 35, 33, and 35 for the 2-3, 4-10, 11-17, and 2-17 years age groups, respectively. On validation, all cut-off values performed with moderate to high sensitivity (76.6-82.4%) and moderate specificity (69.1-75.5%), while the original CSHQ cut at 41 had high sensitivity (89.9-93.0%) but low specificity (42.6-57.7%). Using McNemar's tests, the CSHQ-autism had significantly higher specificity but lower sensitivity than the original CSHQ cut at 41 in all age groups. CONCLUSIONS The CSHQ-autism cut-off values performed better overall than the original CSHQ cut at 41 in a sample of autistic children. The CSHQ-autism cut-off can help identify sleep problems among autistic children.
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Affiliation(s)
- Amy M Shui
- Biostatistics Center, Massachusetts General Hospital, 50 Staniford Street, Suite 560, Boston, MA, 02114, USA; Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th Street, 2(nd)Floor, San Francisco, CA, 94158, USA.
| | - Amanda L Richdale
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Kingsbury Drive, Bundoora, VIC, 3086, Australia.
| | - Terry Katz
- Department of Pediatrics, University of Colorado School of Medicine, 13123 E, 16(th)Avenue, Aurora, CO, 80045, USA.
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19
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Seo WS. An update on the cause and treatment of sleep disturbance in children and adolescents with autism spectrum disorder. Yeungnam Univ J Med 2021; 38:275-281. [PMID: 34510867 PMCID: PMC8688794 DOI: 10.12701/yujm.2021.01410] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/25/2021] [Indexed: 11/30/2022] Open
Abstract
Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by abnormalities in social communication/interaction and restrictive, repetitive patterns of behavior. ASD is a relatively common psychiatric disorder, with a prevalence of approximately 1.7% in children. Although many children and adolescents with ASD visit the hospital for medical help for emotional and behavioral problems such as mood instability and self-harming behavior, there are also many visits for sleep disturbances such as insomnia and sleep resistance. Sleep disturbances are likely to increase fatigue and daytime sleepiness, impaired concentration, negatively impact on daytime functioning, and pose challenges in controlling anger and aggressive behavior. Sleep disturbance in children and adolescents with ASD negatively affects the quality of life, nothing to say the quality of life of their families and school members. In this review, sleep disturbances that are common in children and adolescents with ASD and adolescents are presented. The developmental and behavioral impacts of sleep disturbances in ASD were also considered. Finally, non-pharmacological and pharmacological treatments for sleep disturbances in children and adolescents with ASD and adolescents are reviewed.
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Affiliation(s)
- Wan Seok Seo
- Department of Psychiatry, Yeungnam University College of Medicine, Daegu, Korea
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20
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Choi G, Keil AP, Richardson DB, Daniels JL, Hoffman K, Villanger GD, Sakhi AK, Thomsen C, Reichborn-Kjennerud T, Aase H, Engel SM. Pregnancy exposure to organophosphate esters and the risk of attention-deficit hyperactivity disorder in the Norwegian mother, father and child cohort study. ENVIRONMENT INTERNATIONAL 2021; 154:106549. [PMID: 33910116 PMCID: PMC8217330 DOI: 10.1016/j.envint.2021.106549] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/26/2021] [Accepted: 03/29/2021] [Indexed: 05/31/2023]
Abstract
BACKGROUND Organophosphate esters (OPEs) are a class of flame retardants in common use. OPEs can easily leach from materials, resulting in human exposure. Increasing concentrations have been reported in human populations over the past decade. Recent studies have linked prenatal OPE exposure to hyperactivity and attention problems in children. Such behaviors are often found among children with attention-deficit hyperactivity disorder (ADHD), however, no study has investigated OPEs in relation to clinically assessed ADHD. OBJECTIVE To evaluate prenatal exposure to OPEs as risk factors for clinically assessed ADHD using a case-cohort study nested within the Norwegian Mother, Father, and Child Cohort Study (MoBa). METHODS We included in the case group 295 ADHD cases obtained via linkage with the Norwegian Patient Registry, and the sub-cohort group 555 children sampled at baseline, irrespective of their ADHD case status. Prenatal concentrations of OPE metabolites were measured in maternal urine collected at 17 weeks of gestation, and included diphenyl phosphate (DPHP), di-n-butyl phosphate (DNBP), bis(2-butoxyethyl) hydrogen phosphate (BBOEP), and bis(1,3-dichloro-2-propyl) phosphate (BDCIPP). We estimated risk ratios and the corresponding 95% confidence intervals [95% CI] using logistic regression, adjusting for season of urine collection, child sex, birth year, and maternal depression, education, and sum of urinary di(2-ethylhexyl) phthalate metabolites (∑DEHP) concentration during pregnancy. To assess the overall impact of simultaneously decreasing exposure to all chemical constituents of an OPE-phthalate mixture, quantile based g-computation was implemented. The mixture constituents included OPE and phthalate metabolites commonly detected in our study. In all models, we considered effect measure modification by child sex and polymorphisms in genes encoding paraoxonase 1 (PON1) and cytochrome P450 (P450) enzymes. Mediation analysis was conducted using thyroid function biomarkers estimated from maternal blood collected at 17 weeks of gestation. RESULTS DPHP was detected in nearly all samples (97.2%), with a higher geometric mean among the case group (0.70 µg/L) as compared to the sub-cohort (0.52 µg/L). DNBP was commonly detected as well (93.8%), while BBOEP (52.9%) and BDCIPP (22.9%) were detected less frequently. A higher risk of ADHD was observed in children with greater than median exposure to DPHP during pregnancy (risk ratio: 1.38 [95% CI: 0.96, 1.99]), which was slightly higher among girls (2.04 [1.03, 4.02]) and children of mothers with PON1 Q192R genotype QR (1.69 [0.89, 3.19]) or PON1 Q192R genotype RR (4.59 [1.38, 15.29]). The relationship between DPHP and ADHD (total risk ratio: 1.34 [0.90, 2.02]) was partially mediated through total triiodothyronine to total thyroxine ratio (natural direct effect: 1.29 [0.87, 1.94]; natural indirect effect: 1.04 [1.00, 1.10]; 12.48% mediated). We also observed an elevated risk of ADHD in relation to BDCIPP detection during pregnancy (1.50 [0.98, 2.28]). We did not observe notable differences in ADHD by DNBP (0.88 [0.62, 1.26]) or BBOEP (1.03 [0.73, 1.46]) during pregnancy. Simultaneously decreasing all constituents of common-detect OPE-phthalate mixture, specifically DPHP, DNBP, and 6 phthalate metabolites, by a quartile resulted in an ADHD risk ratio of 0.68 [0.64, 0.72]. CONCLUSION Prenatal exposure to DPHP and BDCIPP may increase the risk of ADHD. For DPHP, we observed potential modification by child sex and maternal PON1 Q192R genotype and partial mediation through maternal thyroid hormone imbalance at 17 weeks gestation.
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Affiliation(s)
- Giehae Choi
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Alexander P Keil
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - David B Richardson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Julie L Daniels
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kate Hoffman
- Nicholas School of the Environment, Duke University, Durham, NC, USA
| | | | | | | | - Ted Reichborn-Kjennerud
- Norwegian Institute of Public Health, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Heidi Aase
- Norwegian Institute of Public Health, Oslo, Norway
| | - Stephanie M Engel
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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21
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Influence of the Aryl Hydrocarbon Receptor Activating Environmental Pollutants on Autism Spectrum Disorder. Int J Mol Sci 2021; 22:ijms22179258. [PMID: 34502168 PMCID: PMC8431328 DOI: 10.3390/ijms22179258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/22/2021] [Accepted: 06/28/2021] [Indexed: 02/07/2023] Open
Abstract
Autism spectrum disorder (ASD) is an umbrella term that includes many different disorders that affect the development, communication, and behavior of an individual. Prevalence of ASD has risen exponentially in the past couple of decades. ASD has a complex etiology and traditionally recognized risk factors only account for a small percentage of incidence of the disorder. Recent studies have examined factors beyond the conventional risk factors (e.g., environmental pollution). There has been an increase in air pollution since the beginning of industrialization. Most environmental pollutants cause toxicities through activation of several cellular receptors, such as the aryl hydrocarbon receptor (AhR)/cytochrome P450 (CYPs) pathway. There is little research on the involvement of AhR in contributing to ASD. Although a few reviews have discussed and addressed the link between increased prevalence of ASD and exposure to environmental pollutants, the mechanism governing this effect, specifically the role of AhR in ASD development and the molecular mechanisms involved, have not been discussed or reviewed before. This article reviews the state of knowledge regarding the impact of the AhR/CYP pathway modulation upon exposure to environmental pollutants on ASD risk, incidence, and development. It also explores the molecular mechanisms involved, such as epigenesis and polymorphism. In addition, the review explores possible new AhR-mediated mechanisms of several drugs used for treatment of ASD, such as sulforaphane, resveratrol, haloperidol, and metformin.
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22
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Schroder CM, Banaschewski T, Fuentes J, Hill CM, Hvolby A, Posserud MB, Bruni O. Pediatric prolonged-release melatonin for insomnia in children and adolescents with autism spectrum disorders. Expert Opin Pharmacother 2021; 22:2445-2454. [PMID: 34314281 DOI: 10.1080/14656566.2021.1959549] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: Insomnia is common among children and adolescents with Autism spectrum disorder (ASD). The first drug licensed for insomnia in this population, a pediatric-appropriate prolonged-release melatonin (PedPRM) formulation is described.Areas covered: Literature search on PedPRM efficacy and safety profile in clinical trials, and a proposed decision-making algorithm to optimize outcome in the treatment of insomnia in children and adolescents with ASD.Expert opinion: PedPRM treatment effectively improves sleep onset, duration and consolidation, and daytime externalizing behaviors in children and adolescents with ASD and subsequently caregivers' quality of life and satisfaction with their children's sleep. The coated, odorless and taste-free mini-tablets are well-accepted in this population who often have sensory hypersensitivity and problems swallowing standard tablet preparations. The most frequent long-term treatment-related adverse events were fatigue (6.3%), somnolence (6.3%), and mood swings (4.2%) with no evidence of delay in height, BMI, or pubertal development, or withdrawal effects. The starting dose is 2 mg once daily independent of age or weight, escalated to 5-10 mg/day if predefined treatment success criteria are unmet. Slow melatonin metabolizers (~10% of children), may require lower doses. Given its long-term efficacy, safety and acceptance, PedPRM may ameliorate long-term consequences of insomnia in this population.
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Affiliation(s)
- Carmen M Schroder
- Department of Child and Adolescent Psychiatry & Excellence Centre for Autism and Neurodevelopmental Disorders STRAS&ND, Strasbourg University Hospitals & University of Strasbourg Medical School, 67000 Strasbourg, France; CNRS UPR 3212, Institute for Cellular and Integrative Neurosciences; Sleep Disorders Center& International Research Center for ChronoSomnology, Strasbourg, France
| | - Tobias Banaschewski
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Joaquin Fuentes
- Child and Adolescent Psychiatry Unit, Service of Child and Adolescent Psychiatry, Policlínica Gipuzkoa and GAUTENA Autism Society, San Sebastián, Spain
| | - Catherine Mary Hill
- School of Clinical Experimental Sciences, Faculty of Medicine, University of Southampton, and Southampton Children's Hospital Department of Sleep Medicine, Southampton, UK
| | - Allan Hvolby
- Department of Child and Adolescent Psychiatry, Psychiatry in Region of South Denmark, Esbjerg, and Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Maj-Britt Posserud
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Oliviero Bruni
- Department of Developmental and Social Psychology, Sapienza University, Rome, Italy
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23
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Abdul F, Sreenivas N, Kommu JVS, Banerjee M, Berk M, Maes M, Leboyer M, Debnath M. Disruption of circadian rhythm and risk of autism spectrum disorder: role of immune-inflammatory, oxidative stress, metabolic and neurotransmitter pathways. Rev Neurosci 2021; 33:93-109. [PMID: 34047147 DOI: 10.1515/revneuro-2021-0022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/01/2021] [Indexed: 12/27/2022]
Abstract
Circadian rhythms in most living organisms are regulated by light and synchronized to an endogenous biological clock. The circadian clock machinery is also critically involved in regulating and fine-tuning neurodevelopmental processes. Circadian disruption during embryonic development can impair crucial phases of neurodevelopment. This can contribute to neurodevelopmental disorders like autism spectrum disorder (ASD) in the offspring. Increasing evidence from studies showing abnormalities in sleep and melatonin as well as genetic and epigenetic changes in the core elements of the circadian pathway indicate a pivotal role of circadian disruption in ASD. However, the underlying mechanistic basis through which the circadian pathways influence the risk and progression of ASD are yet to be fully discerned. Well-recognized mechanistic pathways in ASD include altered immune-inflammatory, nitro oxidative stress, neurotransmission and synaptic plasticity, and metabolic pathways. Notably, all these pathways are under the control of the circadian clock. It is thus likely that a disrupted circadian clock will affect the functioning of these pathways. Herein, we highlight the possible mechanisms through which aberrations in the circadian clock might affect immune-inflammatory, nitro-oxidative, metabolic pathways, and neurotransmission, thereby driving the neurobiological sequelae leading to ASD.
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Affiliation(s)
- Fazal Abdul
- Department of Human Genetics, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore, 560029, Karnataka, India
| | - Nikhitha Sreenivas
- Department of Human Genetics, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore, 560029, Karnataka, India
| | - John Vijay Sagar Kommu
- Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore, 560029, Karnataka, India
| | - Moinak Banerjee
- Human Molecular Genetics Division, Rajiv Gandhi Centre for Biotechnology, Thycaud Post, Poojappura, Trivandrum, 695014, Kerala, India
| | - Michael Berk
- School of Medicine, IMPACT Strategic Research Centre, Deakin University, Barwon Health, PO Box 281, Geelong, Victoria, 3220, Australia.,Orygen, The Centre of Excellence in Youth Mental Health, The Department of Psychiatry, The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, 30 Royal Parade, Parkville, Victoria, 3052, Australia
| | - Michael Maes
- School of Medicine, IMPACT Strategic Research Centre, Deakin University, Barwon Health, PO Box 281, Geelong, Victoria, 3220, Australia.,Department of Psychiatry, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Pathum Wan, Pathum Wan District, Bangkok, 10330, Thailand.,Department of Psychiatry, Medical University of Plovdiv, bul. "Vasil Aprilov" 15A, 4002 Tsetar, Plovdiv, Bulgaria
| | - Marion Leboyer
- Université Paris Est Creteil (UPEC), AP-HP, Hôpitaux Universitaires "H. Mondor", DMU IMPACT, INSERM, IMRB, Translational Neuropsychiatry, Fondation FondaMental, 8, rue du Général Sarrail, 94010, Creteil, France
| | - Monojit Debnath
- Department of Human Genetics, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore, 560029, Karnataka, India
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24
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Earl RK, Ward T, Gerdts J, Eichler EE, Bernier RA, Hudac CM. Sleep Problems in Children with ASD and Gene Disrupting Mutations. The Journal of Genetic Psychology 2021; 182:317-334. [PMID: 33998396 DOI: 10.1080/00221325.2021.1922869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Sleep difficulties are pervasive in autism spectrum disorder (ASD), yet how sleep problems relate to underlying biological mechanisms such as genetic etiology is unclear, despite recent reports of profound sleep problems in children with ASD-associated de novo likely gene disrupting (dnLGD) mutations, CHD8, DYRK1A, and ADNP. We aimed to inform etiological contributions to ASD and sleep by characterizing sleep problems in individuals with dnLGD mutations. Participants (N = 2886) were families who completed dichotomous questions about sleep problems within a medical history interview for their child with ASD (age 3-28 years). Confirmatory factor analyses compared between those with ASD and a dnLGD mutation and those with idiopathic ASD (i.e., no known genetic event, NON) highlighted four domains (sleep onset, breathing issues, nighttime awakenings, and daytime tiredness) with sleep onset as a strong factor for both groups. Overall, participant predictors indicated that internalizing behavioral problems and lower cognitive scores were related to increased sleep problems. Internalizing problems were also related to increase nighttime awakenings in the dnLGD group. As an exploratory aim, patterns of sleep issues are described for genetic subgroups with unique patterns including more overall sleep issues in ADNP (n = 19), problems falling asleep in CHD8 (n = 22), and increased daytime naps in DYRK1A (n = 23). Implications for considering genetically defined subgroups when approaching sleep problems in children with ASD are discussed.
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Affiliation(s)
- Rachel K Earl
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Tracey Ward
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Jennifer Gerdts
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Evan E Eichler
- Department of Genome Sciences, University of Washington, Seattle, Washington, USA.,Howard Hughes Medical Institute, Seattle, Washington, USA
| | - Raphael A Bernier
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Caitlin M Hudac
- Center for Youth Development and Intervention and Department of Psychology, University of Alabama, Tuscaloosa, Alabama, USA
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25
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Eno CC, Graakjaer J, Svaneby D, Nizon M, Kianmahd J, Signer R, Martinez-Agosto JA, Quintero-Rivera F. 14q32.11 microdeletion including CALM1, TTC7B, PSMC1, and RPS6KA5: A new potential cause of developmental and language delay in three unrelated patients. Am J Med Genet A 2021; 185:1519-1524. [PMID: 33634591 DOI: 10.1002/ajmg.a.62117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 12/14/2020] [Accepted: 01/23/2021] [Indexed: 12/18/2022]
Abstract
Three unrelated patients with similar microdeletions of chromosome 14q32.11 with shared phenotypes including language and developmental delay, and four overlapping genes -CALM1, TTC7B, PSMC1, and RPS6KA5 have been presented. All four genes are expressed in the brain and have haploinsufficiency scores, which reflect low tolerance to loss of function variation. An insight on the genes in the overlapping region, which may influence the resulting phenotype has been provided. Given the three patients' similar phenotypes and lack of normal variation in this region, it was suggested that this microdeletion may be associated with developmental and language delay.
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Affiliation(s)
- Celeste C Eno
- Department of Academic Pathology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jesper Graakjaer
- Department of Clinical Genetics, Lillebaelt Hospital, Vejle, Denmark
| | - Dea Svaneby
- Department of Clinical Genetics, Lillebaelt Hospital, Vejle, Denmark
| | - Mathilde Nizon
- Department of Medical Genetics, CHU Nantes, Nantes, France
| | - Jessica Kianmahd
- Departments of Human Genetics and Pediatrics, Division of Medical Genetics, UCLA, Los Angeles, California, USA
| | - Rebecca Signer
- Departments of Human Genetics and Pediatrics, Division of Medical Genetics, UCLA, Los Angeles, California, USA
| | - Julian A Martinez-Agosto
- Departments of Human Genetics and Pediatrics, Division of Medical Genetics, UCLA, Los Angeles, California, USA
| | - Fabiola Quintero-Rivera
- Department of Pathology and Laboratory Medicine, University of California Irvine, Irvine, California, USA
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26
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Brown GM, Karthikeyan R, Pandi-Perumal SR, Cardinali DP. Autism Spectrum Disorder patients may be susceptible to COVID-19 disease due to deficiency in melatonin. Med Hypotheses 2021; 149:110544. [PMID: 33657458 PMCID: PMC7890352 DOI: 10.1016/j.mehy.2021.110544] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/14/2021] [Indexed: 02/08/2023]
Abstract
Patients with Autism Spectrum Disorder (ASD) may be particularly prone to develop COVID-19. An unusual extended course of COVID-19 disease illness has been reported in one ASD patient and a group of patients have COVID-19 disease in a neurodevelopmental facility. It has been widely reported that many of those with ASD have substantial sleep disorders with low levels of melatonin and various genetic alterations related to melatonin production have been found. Several lines of evidence point to a substantial role of melatonin in the body's innate defense system including acting as a scavenger, an antioxidant and modulating the immune system. We therefore hypothesize that melatonin deficiency may predispose those ASD patients who have low melatonin output to COVID-19 disease. Potential implications for treatment are discussed.
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Affiliation(s)
- Gregory M Brown
- Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, ON M5T 1R8, Canada.
| | | | | | - Daniel P Cardinali
- Faculty of Medical Sciences, Pontificia Universidad Católica Argentina, Buenos Aires, Argentina
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27
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Abstract
Children and adolescents with autism spectrum disorder (ASD) experience sleep disturbances, particularly insomnia, at rates much higher than the general population. Daytime behavioral problems and parental stress are associated with the resultant sleep deprivation. Behavioral interventions, parental education, and melatonin are effective treatments. The epidemiology of sleep disturbances in youth with ASD is reviewed in this article as well as the latest in treatments.
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Affiliation(s)
- Kyle P Johnson
- Division of Child & Adolescent Psychiatry, Oregon Health & Science University, Mailcode: DC-7P, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA.
| | - Paria Zarrinnegar
- Division of Child & Adolescent Psychiatry, Oregon Health & Science University, Mailcode: DC-7P, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
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28
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Shelton AR, Malow B. Neurodevelopmental Disorders Commonly Presenting with Sleep Disturbances. Neurotherapeutics 2021; 18:156-169. [PMID: 33403472 PMCID: PMC8116361 DOI: 10.1007/s13311-020-00982-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2020] [Indexed: 02/04/2023] Open
Abstract
There are multiple disorders of neurodevelopment that present with co-occurring sleep disturbances. Many of these neurodevelopmental disorders (NDD) include sleep disturbances in their diagnostic criteria. Neurobiological, genetic, and environmental factors overlap to cause different sleep disorders in individuals with NDD. Caregivers often present reporting either insomnia or hypersomnia, and based on the clinical history and findings from diagnostic tests, an appropriate diagnosis can be made. It is crucial that clinicians understand the different presentations of sleep disturbances in individuals with NDD.
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Affiliation(s)
- Althea Robinson Shelton
- Department of Neurology, Vanderbilt University Medical Center, 1161 21st Ave South, Medical Center North A-0118, Nashville, TN, 37232, USA.
| | - Beth Malow
- Department of Neurology, Vanderbilt University Medical Center, 1161 21st Ave South, Medical Center North A-0118, Nashville, TN, 37232, USA
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29
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Hu VW, Bi C. Phenotypic Subtyping and Re-analyses of Existing Transcriptomic Data from Autistic Probands in Simplex Families Reveal Differentially Expressed and ASD Trait-Associated Genes. Front Neurol 2020; 11:578972. [PMID: 33281715 PMCID: PMC7689346 DOI: 10.3389/fneur.2020.578972] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/21/2020] [Indexed: 12/25/2022] Open
Abstract
Autism spectrum disorder (ASD) describes a collection of neurodevelopmental disorders characterized by core symptoms that include social communication deficits and repetitive, stereotyped behaviors often coupled with restricted interests. Primary challenges to understanding and treating ASD are the genetic and phenotypic heterogeneity of cases that complicates all omics analyses as well as a lack of information on relationships among genes, pathways, and autistic traits. In this study, we re-analyze existing transcriptomic data from simplex families by subtyping individuals with ASD according to multivariate cluster analyses of clinical ADI-R scores that encompass a broad range of behavioral symptoms. We also correlate multiple ASD traits, such as deficits in verbal and non-verbal communication, play and social skills, ritualistic behaviors, and savant skills, with expression profiles using Weighted Gene Correlation Network Analyses (WGCNA). Our results show that subtyping greatly enhances the ability to identify differentially expressed genes involved in specific canonical pathways and biological functions associated with ASD within each phenotypic subgroup. Moreover, using WGCNA, we identify gene modules that correlate significantly with specific ASD traits. Network prediction analyses of the genes in these modules reveal canonical pathways as well as neurological functions and disorders relevant to the pathobiology of ASD. Finally, we compare the WGCNA-derived data on autistic traits in simplex families with analogous data from multiplex families using transcriptomic data from our previous studies. The comparison reveals overlapping trait-associated pathways as well as upstream regulators of the module-associated genes that may serve as useful targets for a precision medicine approach to ASD.
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Affiliation(s)
- Valerie W Hu
- Department of Biochemistry and Molecular Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Chongfeng Bi
- Department of Biochemistry and Molecular Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States
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30
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Kamara D, Beauchaine TP. A Review of Sleep Disturbances among Infants and Children with Neurodevelopmental Disorders. REVIEW JOURNAL OF AUTISM AND DEVELOPMENTAL DISORDERS 2020; 7:278-294. [PMID: 33344102 PMCID: PMC7747783 DOI: 10.1007/s40489-019-00193-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 12/04/2019] [Indexed: 02/06/2023]
Abstract
Sleep problems are common among children with neurodevelopmental disorders (NDDs). We review sleep disturbance in three major NDDs: autism spectrum disorder, Down syndrome, and fetal alcohol spectrum disorder (FASD). We review associations with functional impairment, discuss how patterns of sleep disturbance inform understanding of etiology, and theorize about mechanisms of impairment. Sleep disturbance is a transdiagnostic feature of NDDs. Caregivers report high rates of sleep problems, including difficulty falling or staying asleep. Polysomnography data reveal differences in sleep architecture and increased rates of sleep disorders. Sleep disturbance is associated with functional impairment and stress among families. Further research is needed to elucidate mechanisms of impairment and develop more effective interventions. Despite significant sleep disturbance in FASD, limited research is available.
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Affiliation(s)
- Dana Kamara
- The Ohio State University, Department of Psychology, 1835 Neil Ave., Columbus, OH 43210
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31
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Esposito D, Belli A, Ferri R, Bruni O. Sleeping without Prescription: Management of Sleep Disorders in Children with Autism with Non-Pharmacological Interventions and Over-the-Counter Treatments. Brain Sci 2020; 10:brainsci10070441. [PMID: 32664572 PMCID: PMC7407189 DOI: 10.3390/brainsci10070441] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 12/18/2022] Open
Abstract
Autism Spectrum Disorders (ASD) are lifelong neurodevelopmental conditions characterized by abnormal social interaction, communication, and behavior. Sleep disturbances represent a common comorbidity in children and adolescents with ASD, with prevalence ranging from 50 to 80%. It has been proved that sleep disruption worsens the symptoms of autism and results in challenging behaviors. Improving sleep should therefore be a primary therapeutic goal. Treatment options range from lifestyle modifications to pharmacological therapy. Several reviews have been written on pharmacological treatments, but very few on the beneficial effects of non-pharmacological interventions, over-the-counter drugs, and nutritional supplements. This study consists of a narrative review of the literature, presenting the available evidence on the following treatments: sleep education, behavioral interventions, complementary and alternative medicine (special mattresses and blankets, massage, aromatherapy, yoga, physical activity), and commonly used over-the-counter medications and supplements (antihistamines, melatonin, tryptophan, carnosine, iron, vitamins, and herbal remedies). For some treatments—such as melatonin and behavioral interventions—effectiveness in ASD is well established in the literature, while other interventions appear of benefit in clinical practice, even if specific studies in children and adolescents with ASD are lacking. Conversely, other treatments only seem to show anecdotal evidence supporting their use.
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Affiliation(s)
- Dario Esposito
- Child Neurology and Psychiatry Unit, Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy; (D.E.); (A.B.)
| | - Arianna Belli
- Child Neurology and Psychiatry Unit, Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy; (D.E.); (A.B.)
| | - Raffaele Ferri
- Sleep Research Centre, Oasi Research Institute–IRCCS, 94018 Troina, Italy;
| | - Oliviero Bruni
- Department of Developmental and Social Psychology, Sapienza University of Rome, 00185 Rome, Italy
- Correspondence:
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32
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Ballester P, Richdale AL, Baker EK, Peiró AM. Sleep in autism: A biomolecular approach to aetiology and treatment. Sleep Med Rev 2020; 54:101357. [PMID: 32759030 DOI: 10.1016/j.smrv.2020.101357] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 01/24/2023]
Abstract
People with autism spectrum disorder (ASD) commonly experience other comorbidities. Studies indicate that between 50% and 83% of individuals with ASD have sleep problems or disorders. The most commonly reported sleep problems are: (a) insomnia symptoms including the inability to get to sleep or stay asleep; and (b) circadian rhythm sleep-wake disorders, defined as a misalignment between the timing of endogenous circadian rhythms and the external environment. The circadian system provides timing information for the sleep-wake cycle that is regulated by the interaction of an endogenous processes (circadian - Process C, and homeostatic - Process S) and synchronizing agents (neurohormones and neurotransmitters), which produce somnogenic activity. A clinical priority in ASD is understanding the cause of these sleep problems in order to improve treatment outcomes. This review approaches sleep in autism from several perspectives: Sleep-wake mechanisms and problems, and brain areas and molecules controlling sleep (e.g., GABA and melatonin) and wake maintenance (e.g., serotonin, acetylcholine and glutamate). Specifically, this review examines how altered sleep structure could be related to neurobiological alterations or genetic mutations and the implications this may have for potential pharmacological treatments in individuals with ASD.
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Affiliation(s)
- P Ballester
- Neuropharmacology on Pain and Functional Diversity (NED) Research Group, Alicante Institute of Sanitary and Biomedical Research (ISABIAL), Alicante, Spain; Department of Clinical Pharmacology, Organic Chemistry and Pediatrics, Miguel Hernández University of Elche, Elche, Spain.
| | - A L Richdale
- Olga Tennison Autism Research Centre, School of Psychology & Public Health, La Trobe University, Melbourne, Australia
| | - E K Baker
- Diagnosis and Development, Murdoch Children's Research Institute, Parkville, Australia; Department of Paediatrics, University of Melbourne, Parkville, Australia; School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - A M Peiró
- Neuropharmacology on Pain and Functional Diversity (NED) Research Group, Alicante Institute of Sanitary and Biomedical Research (ISABIAL), Alicante, Spain; Department of Clinical Pharmacology, Organic Chemistry and Pediatrics, Miguel Hernández University of Elche, Elche, Spain
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33
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Abel EA, Schwichtenberg AJ, Mannin OR, Marceau K. Brief Report: A Gene Enrichment Approach Applied to Sleep and Autism. J Autism Dev Disord 2020; 50:1834-1840. [PMID: 30790196 DOI: 10.1007/s10803-019-03921-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Sleep disorders (SD) are common in autism spectrum disorder (ASD), yet relatively little is known about the potential genetic mechanisms involved in SD and ASD comorbidity. The current study begins to fill this gap with a gene enrichment study that (1) identifies risk genes that contribute to both SD and ASD which implicate circadian entrainment, melatonin synthesis, and several genetic syndromes. An over-representation analysis identified several enriched pathways that suggest dopamine and serotonin synapses as potential shared SD and ASD mechanisms. This overlapping gene set and the highlighted biological pathways may serve as a preliminary stepping-stone for new genetic investigations of SD and ASD comorbidity.
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Affiliation(s)
- Emily A Abel
- Department of Human Development and Family Studies, Purdue University, 1202 West State Street, West Lafayette, IN, USA.
- Yale Child Study Center, Yale University, New Haven, CT, USA.
| | - A J Schwichtenberg
- Department of Human Development and Family Studies, Purdue University, 1202 West State Street, West Lafayette, IN, USA
| | - Olivia R Mannin
- Department of Human Development and Family Studies, Purdue University, 1202 West State Street, West Lafayette, IN, USA
| | - Kristine Marceau
- Department of Human Development and Family Studies, Purdue University, 1202 West State Street, West Lafayette, IN, USA
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34
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Waddington H, McLay L, Woods L, Whitehouse AJO. Child and Family Characteristics Associated with Sleep Disturbance in Children with Autism Spectrum Disorder. J Autism Dev Disord 2020; 50:4121-4132. [DOI: 10.1007/s10803-020-04475-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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35
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Karthikeyan R, Cardinali DP, Shakunthala V, Spence DW, Brown GM, Pandi-Perumal SR. Understanding the role of sleep and its disturbances in Autism spectrum disorder. Int J Neurosci 2020; 130:1033-1046. [PMID: 31903819 DOI: 10.1080/00207454.2019.1711377] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Several studies have established a positive relationship between sleep difficulties and symptomatology in ASD children. The rationale for this review is to describe and discuss the sleep difficulties, which are one of the significant complications associated with autism spectrum disorder (ASD). PURPOSE Many types of sleep disorders have been reported in ASD individuals, but still lack a comprehensive study and in-depth analysis. Despite the contribution of sleep problems to the overall symptoms of ASD, the symptoms of disturbed sleep experienced by many affected patients have only recently started to receive attention from clinicians and family members. MATERIALS AND METHODS This narrative overview has been prepared based on searching standard research databases with specific keywords; b. Additional search was made using the bibliographies of the retrieved articles; and c. author's collection of relevant peer-reviewed articles. Once selected, manuscripts are then compared and summarized based on the author's perspective. Results are based on a qualitative rather than a quantitative level. RESULTS This article highlights the role of sleep in the brain and neural development of children and emphasizes that the intensity of sleep problems is associated with an increased occurrence of ASD symptoms. It also suggests the significance of treating sleep problems in ASD individuals. CONCLUSIONS The review provides broader perspectives and a better understanding of sleep problems in pathophysiology, mechanism, and management with respect to ASD individuals. Finally, the implications for clinical practice and future agendas have also been discussed.
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Affiliation(s)
- Ramanujam Karthikeyan
- Department of Animal Behavior & Physiology, School of Biological Sciences, Madurai Kamaraj University, Madurai, Tamil Nadu, India
| | - Daniel P Cardinali
- Faculty of Medical Sciences, Pontificia Universidad Católica Argentina, Buenos Aires, Argentina
| | - Venkat Shakunthala
- Department of Zoology, University of Mysuru, Manasagangotri, Karnataka, India
| | - David Warren Spence
- Independent Researcher, Department of Sleep Medicine, Toronto, Ontario, Canada
| | - Gregory M Brown
- Molecular Brain Science, Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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36
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Hyman SL, Levy SE, Myers SM. Identification, Evaluation, and Management of Children With Autism Spectrum Disorder. Pediatrics 2020; 145:peds.2019-3447. [PMID: 31843864 DOI: 10.1542/peds.2019-3447] [Citation(s) in RCA: 474] [Impact Index Per Article: 118.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Autism spectrum disorder (ASD) is a common neurodevelopmental disorder with reported prevalence in the United States of 1 in 59 children (approximately 1.7%). Core deficits are identified in 2 domains: social communication/interaction and restrictive, repetitive patterns of behavior. Children and youth with ASD have service needs in behavioral, educational, health, leisure, family support, and other areas. Standardized screening for ASD at 18 and 24 months of age with ongoing developmental surveillance continues to be recommended in primary care (although it may be performed in other settings), because ASD is common, can be diagnosed as young as 18 months of age, and has evidenced-based interventions that may improve function. More accurate and culturally sensitive screening approaches are needed. Primary care providers should be familiar with the diagnostic criteria for ASD, appropriate etiologic evaluation, and co-occurring medical and behavioral conditions (such as disorders of sleep and feeding, gastrointestinal tract symptoms, obesity, seizures, attention-deficit/hyperactivity disorder, anxiety, and wandering) that affect the child's function and quality of life. There is an increasing evidence base to support behavioral and other interventions to address specific skills and symptoms. Shared decision making calls for collaboration with families in evaluation and choice of interventions. This single clinical report updates the 2007 American Academy of Pediatrics clinical reports on the evaluation and treatment of ASD in one publication with an online table of contents and section view available through the American Academy of Pediatrics Gateway to help the reader identify topic areas within the report.
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Affiliation(s)
- Susan L Hyman
- Golisano Children's Hospital, University of Rochester, Rochester, New York;
| | - Susan E Levy
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Scott M Myers
- Geisinger Autism & Developmental Medicine Institute, Danville, Pennsylvania
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37
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Schreck KA, Richdale AL. Sleep problems, behavior, and psychopathology in autism: inter-relationships across the lifespan. Curr Opin Psychol 2019; 34:105-111. [PMID: 31918238 DOI: 10.1016/j.copsyc.2019.12.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 11/22/2019] [Accepted: 12/09/2019] [Indexed: 12/25/2022]
Abstract
Across the lifespan, autistic individuals experience symptomatology concomitant with their diagnosis including increased rates of daytime behavior (e.g. stereotypy, self-injurious behavior, and aggression) and psychopathology (e.g. attention deficit hyperactivity disorder, anxiety, and depression). In addition to this inter-related behavior and psychopathology, autistic children, adolescents, and adults consistently exhibit a wide variety of sleep problems (e.g. insomnia, reduced total sleep time, increased sleep onset latency, night waking, etc.). Early research and current research continue to describe the inter-relatedness among these daytime behaviors, psychopathology, and sleep problems for autistic individuals. Although descriptions of these issues appear in research, only preliminary suggestions exist for the causes and contributors toward the sleep problems or the interactions of sleep problems with psychopathology, although current research suggests a possible biopsychosocial interaction.
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Affiliation(s)
- Kimberly A Schreck
- Penn State Harrisburg, 777 W. Harrisburg Pike, W311 Olmsted Building, Middletown, PA 17057, United States.
| | - Amanda L Richdale
- Olga Tennison Autism Research Centre, La Trobe University, Melbourne, Victoria 3086, Australia
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38
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Deliens G, Peigneux P. Sleep-behaviour relationship in children with autism spectrum disorder: methodological pitfalls and insights from cognition and sensory processing. Dev Med Child Neurol 2019; 61:1368-1376. [PMID: 30968406 DOI: 10.1111/dmcn.14235] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2019] [Indexed: 11/30/2022]
Abstract
Sleep disturbances are frequent and varied in autism spectrum disorder (ASD). Growing evidence suggests that sleep problems in children with ASD are driven by their clinical characteristics and psychiatric comorbidities. Therefore, the wide range of reported sleep disturbances reflects the marked heterogeneity of clinical pictures in ASD. Whether sleep disturbances and their various forms may, in turn, account for at least part of the phenotypical variability of ASD is a crucial question discussed in this review. We first outline studies both validating and challenging a bidirectional theoretical framework for sleep disorders in children with ASD. We then propose to extend this model by including cognition and sensory processing as key factors in the vicious circle linking sleep disorders and autistic symptoms. WHAT THIS PAPER ADDS: There is a bidirectional interplay between autism symptoms and sleep disturbances. Sleep influence on daytime cognitive and sensory skills should be further investigated.
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Affiliation(s)
- Gaétane Deliens
- Autism in Context: Theory and Experiment (ACTE), Center for Research in Linguistics (LaDisco), Université Libre de Bruxelles, Brussels, Belgium.,Neuroscience Institute, Université Libre de Bruxelles, Brussels, Belgium
| | - Philippe Peigneux
- Neuroscience Institute, Université Libre de Bruxelles, Brussels, Belgium.,Neuropsychology and Functional Neuroimaging Research Group, Center for Research in Cognition and Neurosciences, Université Libre de Bruxelles, Brussels, Belgium
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39
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Hu VW, Devlin CA, Debski JJ. ASD Phenotype-Genotype Associations in Concordant and Discordant Monozygotic and Dizygotic Twins Stratified by Severity of Autistic Traits. Int J Mol Sci 2019; 20:ijms20153804. [PMID: 31382655 PMCID: PMC6696087 DOI: 10.3390/ijms20153804] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 07/30/2019] [Accepted: 07/31/2019] [Indexed: 12/19/2022] Open
Abstract
Autism spectrum disorder (ASD) is a highly heterogeneous neurodevelopmental disorder characterized by impaired social communication coupled with stereotyped behaviors and restricted interests. Despite the high concordance rate for diagnosis, there is little information on the magnitude of genetic contributions to specific ASD behaviors. Using behavioral/trait severity scores from the Autism Diagnostic Interview-Revised (ADI-R) diagnostic instrument, we compared the phenotypic profiles of mono- and dizygotic twins where both co-twins were diagnosed with ASD or only one twin had a diagnosis. The trait distribution profiles across the respective twin populations were first used for quantitative trait association analyses using publicly available genome-wide genotyping data. Trait-associated single nucleotide polymorphisms (SNPs) were then used for case-control association analyses, in which cases were defined as individuals in the lowest (Q1) and highest (Q4) quartiles of the severity distribution curves for each trait. While all of the ASD-diagnosed twins exhibited similar trait severity profiles, the non-autistic dizygotic twins exhibited significantly lower ADI-R item scores than the non-autistic monozygotic twins. Case-control association analyses of twins stratified by trait severity revealed statistically significant SNPs with odds ratios that clearly distinguished individuals in Q4 from those in Q1. While the level of shared genomic variation is a strong determinant of the severity of autistic traits in the discordant non-autistic twins, the similarity of trait profiles in the concordantly autistic dizygotic twins also suggests a role for environmental influences. Stratification of cases by trait severity resulted in the identification of statistically significant SNPs located near genes over-represented within autism gene datasets.
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Affiliation(s)
- Valerie W Hu
- Department of Biochemistry and Molecular Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC 20037, USA.
| | - Christine A Devlin
- Department of Biochemistry and Molecular Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC 20037, USA
| | - Jessica J Debski
- Department of Biochemistry and Molecular Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC 20037, USA
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40
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Bridgemohan C, Cochran DM, Howe YJ, Pawlowski K, Zimmerman AW, Anderson GM, Choueiri R, Sices L, Miller KJ, Ultmann M, Helt J, Forbes PW, Farfel L, Brewster SJ, Frazier JA, Neumeyer AM. Investigating Potential Biomarkers in Autism Spectrum Disorder. Front Integr Neurosci 2019; 13:31. [PMID: 31427932 PMCID: PMC6687766 DOI: 10.3389/fnint.2019.00031] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 07/03/2019] [Indexed: 01/20/2023] Open
Abstract
Background Early identification and treatment of individuals with autism spectrum disorder (ASD) improves outcomes, but specific evidence needed to individualize treatment recommendations is lacking. Biomarkers that could be routinely measured within the clinical setting could potentially transform clinical care for patients with ASD. This demonstration project employed collection of biomarker data during regular autism specialty clinical visits and explored the relationship of biomarkers with clinical ASD symptoms. Methods Eighty-three children with ASD, aged 5–10 years, completed a multi-site feasibility study integrating the collection of biochemical (blood serotonin, urine melatonin sulfate excretion) and clinical (head circumference, dysmorphology exam, digit ratio, cognitive and behavioral function) biomarkers during routine ASD clinic visits. Parents completed a demographic survey and the Aberrant Behavior Checklist-Community. Cognitive function was determined by record review. Data analysis utilized Wilcoxon two-sample tests and Spearman correlations. Results Participants were 82% male, 63% White, 19% Hispanic, with a broad range of functioning. Group means indicated hyperserotonemia. In a single regression analysis adjusting for race and median household income, higher income was associated with higher levels of blood serotonin and urine melatonin sulfate excretion levels (p = 0.004 and p = 0.04, respectively). Melatonin correlated negatively with age (p = 0.048) and reported neurologic problems (p = 0.02). Dysmorphic status correlated with higher reported stereotyped behavior (p = 0.02) and inappropriate speech (p = 0.04). Conclusion This demonstration project employed collection of multiple biomarkers, allowed for examination of associations between biochemical and clinical measures, and identified several findings that suggest direction for future studies. This clinical research model has promise for integrative biomarker research in individuals with complex, heterogeneous neurodevelopmental disorders such as ASD.
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Affiliation(s)
- Carolyn Bridgemohan
- Boston Children's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - David M Cochran
- University of Massachusetts Memorial Medical Center, Worcester, MA, United States.,University of Massachusetts Medical School, Worcester, MA, United States
| | - Yamini J Howe
- Harvard Medical School, Boston, MA, United States.,Lurie Center for Autism, Massachusetts General Hospital for Children, Lexington, MA, United States
| | | | - Andrew W Zimmerman
- University of Massachusetts Memorial Medical Center, Worcester, MA, United States.,University of Massachusetts Medical School, Worcester, MA, United States
| | - George M Anderson
- Child Study Center, Yale University School of Medicine, New Haven, CT, United States
| | - Roula Choueiri
- University of Massachusetts Memorial Medical Center, Worcester, MA, United States.,University of Massachusetts Medical School, Worcester, MA, United States
| | - Laura Sices
- Boston University Medical Center, Boston, MA, United States.,Boston University School of Medicine, Boston, MA, United States
| | - Karen J Miller
- Center for Children with Special Needs, Floating Children's Hospital at Tufts Medical Center, Boston, MA, United States.,Tufts University School of Medicine, Boston, MA, United States
| | - Monica Ultmann
- Center for Children with Special Needs, Floating Children's Hospital at Tufts Medical Center, Boston, MA, United States.,Tufts University School of Medicine, Boston, MA, United States
| | - Jessica Helt
- Lurie Center for Autism, Massachusetts General Hospital for Children, Lexington, MA, United States
| | | | - Laura Farfel
- Boston University Medical Center, Boston, MA, United States.,Center for Children with Special Needs, Floating Children's Hospital at Tufts Medical Center, Boston, MA, United States.,Autism Consortium at Harvard Medical School, Boston, MA, United States
| | | | - Jean A Frazier
- University of Massachusetts Memorial Medical Center, Worcester, MA, United States.,University of Massachusetts Medical School, Worcester, MA, United States.,Eunice Kennedy Shriver Center, University of Massachusetts Medical School, Worcester, MA, United States
| | - Ann M Neumeyer
- Harvard Medical School, Boston, MA, United States.,Lurie Center for Autism, Massachusetts General Hospital for Children, Lexington, MA, United States
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41
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Modification of the Children's Sleep Habits Questionnaire for Children with Autism Spectrum Disorder. J Autism Dev Disord 2019; 48:2629-2641. [PMID: 29500758 DOI: 10.1007/s10803-018-3520-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Sleep problems are common in children with autism spectrum disorder (ASD) and adversely impact daytime functioning. Although no questionnaires have been developed to assess sleep in children with ASD, the 33-item Children's Sleep Habits Questionnaire (CSHQ) is widely used in this population. We examined the factor structure of the CSHQ in 2872 children (age 4-10 years) enrolled in the Autism Treatment Network. A four-factor solution (Sleep Initiation and Duration, Sleep Anxiety/Co-Sleeping, Night Waking/Parasomnias, and Daytime Alertness) with 5-6 items per factor explained 75% of the total variation. Ten items failed to load on any factor. This abbreviated 23-item four-factor version of this measure may be useful when assessing sleep in children with ASD.
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42
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Johansson AEE, Dorman JS, Chasens ER, Feeley CA, Devlin B. Variations in Genes Related to Sleep Patterns in Children With Autism Spectrum Disorder. Biol Res Nurs 2019; 21:335-342. [DOI: 10.1177/1099800419843604] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background: Sleep disturbance is a frequent comorbidity in children with autism spectrum disorder (ASD), affecting an estimated 40–80% of cases. Previous reports have shown relationships between several circadian rhythm–related genes and sleep problems in ASD. The purpose of the present study was to relate variation in and around melatonin synthesis and suprachiasmatic nucleus genes to sleep problems in a large sample of children with ASD. Method: This secondary analysis used existing genotypic and phenotypic data for 2,065 children, aged 4–18 years, from the Simons Simplex Collection (SSC). Sleep problems were measured with the SSC Sleep Interview. Expression quantitative trait loci and single nucleotide polymorphisms in 25 circadian genes were chosen primarily for their impact on expression levels of target genes in the brain. Associations between variants and composite sleep problems, nighttime problems, daytime problems, and sleep duration problems were calculated using logistic regression analysis. Age, sex, nonverbal IQ, ASD severity, gastrointestinal distress, seizures, and ancestry were included as covariates. Transmission disequilibrium tests were performed to test for overtransmission of alleles in the same variants. Results: No significant associations or transmission disequilibrium were found between gene variants and sleep problems in this sample of children with ASD. Conclusion: Variation in expression of investigated genes in the melatonin synthesis and suprachiasmatic nucleus pathways did not have notable impacts on sleep problems in this large sample of children with ASD. Future research could explore translational and posttranslational effects of these genes or the effects of genes in other sleep-homeostasis pathways on sleep patterns.
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Affiliation(s)
| | - Janice S. Dorman
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Bernie Devlin
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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43
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Smith AM, Donley ELR, Burrier RE, King JJ, Amaral DG. Reply to: Lack of Diagnostic Utility of "Amino Acid Dysregulation Metabotypes". Biol Psychiatry 2019; 85:e43-e44. [PMID: 30595230 DOI: 10.1016/j.biopsych.2018.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 11/16/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Alan M Smith
- Stemina Biomarker Discovery, Inc., Madison, Wisconsin
| | | | | | - Joseph J King
- Stemina Biomarker Discovery, Inc., Madison, Wisconsin
| | - David G Amaral
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, University of California, Davis, Davis, California; Department of Psychiatry and Behavioral Sciences, University of California, Davis, Davis, California.
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44
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Carmassi C, Palagini L, Caruso D, Masci I, Nobili L, Vita A, Dell'Osso L. Systematic Review of Sleep Disturbances and Circadian Sleep Desynchronization in Autism Spectrum Disorder: Toward an Integrative Model of a Self-Reinforcing Loop. Front Psychiatry 2019; 10:366. [PMID: 31244687 PMCID: PMC6581070 DOI: 10.3389/fpsyt.2019.00366] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/13/2019] [Indexed: 12/13/2022] Open
Abstract
Background: A compelling number of studies, conducted in both children and adults, have reported an association between sleep disturbances/circadian sleep alterations and autism spectrum disorder (ASD); however, the data are sparse and the nature of this link is still unclear. The present review aimed to systematically collect the literature data relevant on sleep disturbances and circadian sleep dysrhythmicity related to ASD across all ages and to provide an integrative theoretical framework of their association. Methods: A systematic review of the MEDLINE, PubMed, and Cochrane databases was conducted from November 2018 to February 2019. The search strategies used were MeSH headings and keywords for "sleep-wake circadian rhythms" OR "circadian sleep disorders" OR "sleep-wake pattern" OR "sleep disorders" OR "melatonin" AND "autism spectrum disorder" OR "autism". Results: One hundred and three studies were identified, 15 regarded circadian sleep dysrhythmicity, 74 regarded sleep disturbances, and 17 regarded melatonin alterations in children and adults with ASD. Our findings suggested that autistic subjects frequently present sleep disturbances in particular short sleep duration, low sleep quality/efficiency, and circadian sleep desynchronization such as delayed phases and/or eveningness. Sleep disturbances and circadian sleep alterations have been related to the severity of autistic symptoms. Genetic studies have shown polymorphisms in circadian CLOCK genes and in genes involved in melatonin pathways in subjects with ASD. Conclusions: Sleep disturbances and circadian sleep alterations are frequent in subjects with autistic symptoms. These subjects have shown polymorphisms in clock genes expression and in genes involved in melatonin production. The impairment of circadian sleep regulation may increase the individual's vulnerability to develop symptoms of ASD by altering the sleep regulation in toto, which plays a key role in normal brain development. Even though controversies and "research gaps" are present in literature at this point, we may hypothesize a bidirectional relation between circadian sleep dysfunction and ASD. In particular, circadian sleep dysrhythmicity may predispose to develop ASD symptoms and vice versa within a self-reinforcing feedback loop. By targeting sleep disturbances and circadian sleep dysrhythmicity, we may improve treatment strategies for both children and adults with ASD.
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Affiliation(s)
- Claudia Carmassi
- Department of Clinical and Experimental Medicine, Psychiatry Division, University of Pisa, Pisa, Italy
| | - Laura Palagini
- Department of Clinical and Experimental Medicine, Psychiatry Division, University of Pisa, Pisa, Italy
| | - Danila Caruso
- Department of Clinical and Experimental Medicine, Psychiatry Division, University of Pisa, Pisa, Italy
| | - Isabella Masci
- Department of Clinical and Experimental Medicine, Psychiatry Division, University of Pisa, Pisa, Italy
| | - Lino Nobili
- Child Neuropsychiatry Unit, IRCCS G. Gaslini Institute, Genova, Italy.,Department of Neuroscience-Rehabilitation-Ophthalmology-Genetics-Child and Maternal Health (DINOGMI), University of Genova, Genova, Italy
| | - Antonio Vita
- Psychiatry Division, Department of Clinical and Experimental Medicine, University of Brescia, Brescia, Italy
| | - Liliana Dell'Osso
- Department of Clinical and Experimental Medicine, Psychiatry Division, University of Pisa, Pisa, Italy
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45
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Amaral FGD, Cipolla-Neto J. A brief review about melatonin, a pineal hormone. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2018; 62:472-479. [PMID: 30304113 PMCID: PMC10118741 DOI: 10.20945/2359-3997000000066] [Citation(s) in RCA: 190] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 08/31/2018] [Indexed: 11/23/2022]
Abstract
Melatonin is a ubiquitous molecule in nature, being locally synthesized in several cells and tissues, besides being a hormone that is centrally produced in the pineal gland of vertebrates, particularly in mammals. Its pineal synthesis is timed by the suprachiasmatic nucleus, that is synchronized to the light-dark cycle via the retinohypothalamic tract, placing melatonin synthesis at night, provided its dark. This unique trait turns melatonin into an internal synchronizer that adequately times the organism's physiology to the daily and seasonal demands. Besides being amphiphilic, melatonin presents specific mechanisms and ways of action devoted to its role as a time-giving agent, being widely spread in the organism. The present review aims to focus on melatonin as a pineal hormone with specific mechanisms and ways of action, besides presenting the clinical syndromes related to its synthesis and/or function disruptions.
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Affiliation(s)
| | - José Cipolla-Neto
- Departamento de Fisiologia e Biofísica, Instituto de Ciências Biomédicas, Universidade de São Paulo (USP), São Paulo, SP, Brasil
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46
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Cipolla-Neto J, Amaral FGD. Melatonin as a Hormone: New Physiological and Clinical Insights. Endocr Rev 2018; 39:990-1028. [PMID: 30215696 DOI: 10.1210/er.2018-00084] [Citation(s) in RCA: 315] [Impact Index Per Article: 52.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 06/21/2018] [Indexed: 02/07/2023]
Abstract
Melatonin is a ubiquitous molecule present in almost every live being from bacteria to humans. In vertebrates, besides being produced in peripheral tissues and acting as an autocrine and paracrine signal, melatonin is centrally synthetized by a neuroendocrine organ, the pineal gland. Independently of the considered species, pineal hormone melatonin is always produced during the night and its production and secretory episode duration are directly dependent on the length of the night. As its production is tightly linked to the light/dark cycle, melatonin main hormonal systemic integrative action is to coordinate behavioral and physiological adaptations to the environmental geophysical day and season. The circadian signal is dependent on its daily production regularity, on the contrast between day and night concentrations, and on specially developed ways of action. During its daily secretory episode, melatonin coordinates the night adaptive physiology through immediate effects and primes the day adaptive responses through prospective effects that will only appear at daytime, when melatonin is absent. Similarly, the annual history of the daily melatonin secretory episode duration primes the central nervous/endocrine system to the seasons to come. Remarkably, maternal melatonin programs the fetuses' behavior and physiology to cope with the environmental light/dark cycle and season after birth. These unique ways of action turn melatonin into a biological time-domain-acting molecule. The present review focuses on the above considerations, proposes a putative classification of clinical melatonin dysfunctions, and discusses general guidelines to the therapeutic use of melatonin.
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Affiliation(s)
- José Cipolla-Neto
- Department of Physiology and Biophysics, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
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47
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Ruppert E, Kilic-Huck U. [Diagnosis and comorbidities of Circadian Rhythm Sleep Disorders]. Presse Med 2018; 47:969-976. [PMID: 30391268 DOI: 10.1016/j.lpm.2018.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 10/08/2018] [Indexed: 10/28/2022] Open
Abstract
Circadian rhythm sleep disorders (CRSD) result from a disturbed endogenous clock (intrinsic CRSD) or from a misalignment between the biological clock and an imposed environment (extrinsic CRSD). Among intrinsic CRSD, one distinguishes the delayed sleep-wake phase disorder, the advanced sleep-wake phase disorder, the irregular sleep-wake rhythm disorder and the non-24-hour sleep-wake rhythm disorder. Shift work disorder, jet lag disorder and circadian sleep-wake disorder not otherwise specified are extrinsic CRSD. Prevalences of the different CRSD remain largely unknown. Some CRSD are particularly frequent such as sleep delayed phase syndrome in adolescents. Overall, CRSD are probably under-diagnosed. CRSD generate insomnia and excessive daytime somnolence. A biological clock dysfunction has to be evoked in case of insomnia or sleepiness. Furthermore, as CRSD can overlap with other sleep disorders, their diagnosis and treatment are essential. CRSD cause significant mental, physical or socio-professional sufferings. They are frequently associated with comorbidities, mainly neurodevelopmental, psychiatric and neurodegenerative disorders. Regarding neurodevelopmental comorbidities, therapy using a chronobiological approach is complementary to the usual clinical care. It helps to limit the significant impact of CRSD on quality of live, daytime functioning, social interactions and neurocognitive difficulties in the children. In psychiatry, sleep disorders and circadian rhythms sleep-wake disorders are a factor of vulnerability, of suicidal risk, of relapse and pharmacoresistance. Thus, diagnosis of CRSD associated with a psychiatric disorder is of major importance. Treatment using a chronobiological approach reinforcing the entrainment of the sleep-wake cycle is complementary to usual treatments. Sleep disorders and circadian sleep-wake rhythm disorders can be a preclinical sign of Alzheimer's and Parkinson's disease. In the elderly, a beginning neurodegenerative disorder can be associated with a CRSD and complaints of sleepiness, nocturnal awakenings and/or irregular sleep-wake cycles. Patients affected by neurogenerative disorders are particularly vulnerable for having CRSD. Data from different studies suggest that CRSD participate in pathophysiology of Alzheimer's disease. Even though treatment of CRSD associated with neurodegenerative disorders is entirely part of the treatment strategy, it remains uncertain to which extend this treatment may impact disease progression.
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Affiliation(s)
- Elisabeth Ruppert
- Hôpital Civil, centre des troubles du sommeil-CIRCSom, département neurologique, 1, place de l'Hôpital, 67091 Strasbourg, France; Université de Strasbourg, institut des neurosciences cellulaires et intégratives, CNRS - UPR 3212, 5, rue Blaise-Pascal, 67000 Strasbourg, France.
| | - Ulker Kilic-Huck
- Hôpital Civil, centre des troubles du sommeil-CIRCSom, département neurologique, 1, place de l'Hôpital, 67091 Strasbourg, France; Université de Strasbourg, institut des neurosciences cellulaires et intégratives, CNRS - UPR 3212, 5, rue Blaise-Pascal, 67000 Strasbourg, France
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48
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Braam W, Ehrhart F, Maas APHM, Smits MG, Curfs L. Low maternal melatonin level increases autism spectrum disorder risk in children. RESEARCH IN DEVELOPMENTAL DISABILITIES 2018; 82:79-89. [PMID: 29501372 DOI: 10.1016/j.ridd.2018.02.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 02/05/2018] [Accepted: 02/17/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND It is assumed that autism spectrum disorder (ASD) is caused by a combination of de novo inherited variation and common variation as well as environmental factors. It often co-occurs with intellectual disability (ID). Almost eight hundred potential causative genetic variations have been found in ASD patients. However, not one of them is responsible for more than 1% of ASD cases. Low melatonin levels are a frequent finding in ASD patients. Melatonin levels are negatively correlated with severity of autistic impairments, it is important for normal neurodevelopment and is highly effective in protecting DNA from oxidative damage. Melatonin deficiency could be a major factor, and well a common heritable variation, that increases the susceptibility to environmental risk factors for ASD. ASD is already present at birth. As the fetus does not produce melatonin, low maternal melatonin levels may be involved. METHODS We measured 6-sulfatoxymelatonin in urine of 60 mothers of a child with ASD and controls. RESULTS 6-sulfatoxymelatonin levels were significantly lower in mothers with an ASD child than in controls (p = 0.012). CONCLUSIONS Low parental melatonin levels could be one of the contributors to ASD and possibly ID etiology. Our findings need to be duplicated on a larger scale. If our hypothesis is correct, this could lead to policies to detect future parents who are at risk and to treatment strategies to ASD and intellectual disability risk.
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Affiliation(s)
- Wiebe Braam
- 's Heeren Loo, Department Advisium, Wekerom, The Netherlands; Governor Kremers Centre, Maastricht University Medical Centre, The Netherlands.
| | - Friederike Ehrhart
- Governor Kremers Centre, Maastricht University Medical Centre, The Netherlands; Department of Bioinformatics - BiGCaT, Maastricht University, Maastricht, The Netherlands
| | - Anneke P H M Maas
- Governor Kremers Centre, Maastricht University Medical Centre, The Netherlands; Department of Special Education, Radboud University, Nijmegen, The Netherlands
| | - Marcel G Smits
- Governor Kremers Centre, Maastricht University Medical Centre, The Netherlands; Multidisciplinary expert centre for sleep-wake disturbances and chronobiology, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Leopold Curfs
- Governor Kremers Centre, Maastricht University Medical Centre, The Netherlands
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49
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Disruption of melatonin synthesis is associated with impaired 14-3-3 and miR-451 levels in patients with autism spectrum disorders. Sci Rep 2017; 7:2096. [PMID: 28522826 PMCID: PMC5437096 DOI: 10.1038/s41598-017-02152-x] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 04/06/2017] [Indexed: 12/12/2022] Open
Abstract
Autism spectrum disorders (ASD) are characterized by a wide genetic and clinical heterogeneity. However, some biochemical impairments, including decreased melatonin (crucial for circadian regulation) and elevated platelet N-acetylserotonin (the precursor of melatonin) have been reported as very frequent features in individuals with ASD. To address the mechanisms of these dysfunctions, we investigated melatonin synthesis in post-mortem pineal glands - the main source of melatonin (9 patients and 22 controls) - and gut samples - the main source of serotonin (11 patients and 13 controls), and in blood platelets from 239 individuals with ASD, their first-degree relatives and 278 controls. Our results elucidate the enzymatic mechanism for melatonin deficit in ASD, involving a reduction of both enzyme activities contributing to melatonin synthesis (AANAT and ASMT), observed in the pineal gland as well as in gut and platelets of patients. Further investigations suggest new, post-translational (reduced levels of 14-3-3 proteins which regulate AANAT and ASMT activities) and post-transcriptional (increased levels of miR-451, targeting 14-3-3ζ) mechanisms to these impairments. This study thus gives insights into the pathophysiological pathways involved in ASD.
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50
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Lyall K, Croen LA, Sjödin A, Yoshida CK, Zerbo O, Kharrazi M, Windham GC. Polychlorinated Biphenyl and Organochlorine Pesticide Concentrations in Maternal Mid-Pregnancy Serum Samples: Association with Autism Spectrum Disorder and Intellectual Disability. ENVIRONMENTAL HEALTH PERSPECTIVES 2017; 125:474-480. [PMID: 27548254 PMCID: PMC5332182 DOI: 10.1289/ehp277] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 06/27/2016] [Accepted: 07/20/2016] [Indexed: 05/18/2023]
Abstract
BACKGROUND Polychlorinated biphenyls (PCBs) and organochlorine pesticides (OCPs) are neurodevelopmental toxicants, but few studies have examined associations with autism spectrum disorder (ASD). OBJECTIVES We aimed to determine whether prenatal exposure to PCBs and OCPs influences offspring risk of ASD and intellectual disability without autism (ID). METHODS We conducted a population-based case-control study among Southern California births, including children with ASD (n = 545) meeting Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV-TR) criteria and ID (n = 181), as well as general population (GP) controls (n = 418). Concentrations of 11 PCB congeners and 2 OCPs measured in banked second-trimester serum samples were compared between the diagnostic groups. Logistic regression was used to calculate crude and adjusted odds ratios (AOR) for associations with ASD, and separately for ID, compared with GP controls, by quartiles of analyte concentrations in primary analyses. RESULTS Geometric mean levels of several PCB congeners were higher in the ASD group than in the ID and GP groups. ASD risk was elevated for a number of PCB congeners, particularly for the highest vs. lowest quartile of PCB138/158 (AOR = 1.79; 95% CI: 1.10, 2.71) and PCB153 (AOR = 1.82; 95% CI: 1.10, 3.02), and for highest deciles of other congeners in secondary analyses. PCB138/158 was also associated with increased ID (AOR = 2.41; 95% CI: 1.18, 4.91), though no trend was suggested. OCPs were not associated with increased risk of ASD in primary analyses, whereas nonmonotonic increases in risk of ID were found with p,p´-DDE. CONCLUSIONS Our results suggest higher levels of some organochlorine compounds during pregnancy are associated with ASD and ID. Citation: Lyall K, Croen LA, Sjödin A, Yoshida CK, Zerbo O, Kharrazi M, Windham GC. 2017. Polychlorinated biphenyl and organochlorine pesticide concentrations in maternal mid-pregnancy serum samples: association with autism spectrum disorder and intellectual disability. Environ Health Perspect 125:474-480; http://dx.doi.org/10.1289/EHP277.
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Affiliation(s)
- Kristen Lyall
- Environmental Health Investigations Branch, California Department of Public Health, Richmond, California, USA
- Address correspondence to K. Lyall, AJ Drexel Autism Institute, Suite 560, 3200 Market St., Philadelphia, PA 19104 USA. Telephone: (215) 571-3215. E-mail:
| | - Lisa. A. Croen
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | - Andreas Sjödin
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Ousseny Zerbo
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | - Martin Kharrazi
- Environmental Health Investigations Branch, California Department of Public Health, Richmond, California, USA
| | - Gayle C. Windham
- Environmental Health Investigations Branch, California Department of Public Health, Richmond, California, USA
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