Behavioral correlates of epileptiform abnormalities in autism

Evaluation of the Behavioral Effect of Psychostimulants in Children with Autism Spectrum Disorder: A Cross-Sectional Study

BACKGROUND

 Autism spectrum disorder (ASD) is often accompanied by comorbid conditions such as attention deficit hyperactivity disorder and epilepsy. In this context, patients are often treated with psychostimulants in an attempt to control behavioral symptoms. This study aims to understand the behavioral effects of psychostimulants in children with ASD and investigate if interictal epileptiform discharges on electroencephalogram (EEG) can act as a modifying factor in this behavior.

METHODS

 Sixty-eight patients with ASD who were being accompanied in the Department of Child and Adolescent Psychiatry of the Centro Hospitalar Universitário de São João and had previously done an EEG assessment answered a questionnaire regarding their behavioral response to psychostimulants.

RESULTS

 In total, 47.4% of patients reported improved agitation, 56.1% enhanced concentration, and 8.8% improved sleep. Conversely, 28.1% experienced worsened agitation, 15.8% worsened concentration, and 17.5% worsened sleep. The remaining reported no alterations. The age of diagnosis correlated significantly with improved agitation, with a higher diagnosis age being associated with a higher probability of improvement. Extended-release methylphenidate and genetic variations were significantly associated with worsening of agitation. Regarding speech, 86% exhibited no changes, while 14% showed alterations, mostly, 87.5%, characterized as negative. For other behavioral alterations, 45.6% reported negative changes, 3.5% reported positive changes, and 50.9% reported no additional alterations. Female gender was significantly associated with other negative behavioral changes. A significant correlation was found between treatment duration and the probability of improvement in agitation, concentration, and other behavioral changes.

Autism and Epilepsy

Epilepsy is one of the most common comorbidities in individuals with autism spectrum disorders (ASDs). Risk factors include the presence of developmental delay/intellectual disability, female sex, age, and an underlying genetic condition. Due to higher prevalence of epilepsy in ASD, it is important to have a high index of suspicion for seizures and refer to a neurologist if there are concerns. Genetic testing is recommended for all children with ASD but it becomes more high yield in children with epilepsy and ASD.

Autism with co-occurring epilepsy care pathway in Europe

BACKGROUND

Autism and epilepsy often occur together. Epilepsy and other associated conditions have a substantial impact on the well-being of autistic people and their families, reduce quality of life, and increase premature mortality. Despite this, there is a lack of studies investigating the care pathway of autistic children with co-occurring epilepsy in Europe.

METHODS

We analyzed the care pathway for autistic children with associated epilepsy in Italy, Spain, and the United Kingdom from the perspective of caregivers (using a survey aimed at caregivers of autistic children 0-18 years old), the autistic community, and professionals, in order to identify major barriers preventing caregivers and autistic children from receiving timely screening and treatment of possible co-occurring epilepsy.

RESULTS

Across all three countries, an analysis of the current care pathway showed a lack of systematic screening of epilepsy in all autistic children, lack of treatment of co-occurring epilepsy, and inappropriate use of antiepileptic drugs. A major challenge is the lack of evidence-based harmonized guidelines for autism with co-occurring epilepsy in these countries.

CONCLUSIONS

Our findings show both heterogeneity and major gaps in the care pathway for autism with associated epilepsy and the great efforts that caregivers must make for timely screening, diagnosis, and adequate management of epilepsy in autistic children. We call for policy harmonization in Europe in order to improve the experiences and quality of life of autistic people and their families.

Relationship of epilepsy on the linguistic-cognitive profile of children with ASD: A systematic review of the literature

Introduction

The prevalence of comorbidity between epilepsy and Autism Spectrum Disorder (ASD) in the pediatric age increased significantly in recent years. The onset of epilepsy negatively influences the abilities of the user with ASD. Thus, epilepsy will be a disabling factor that will reduce the cognitive-linguistic skills of users with ASD. The main objective of this work is to review the current scientific literature and to compare the relationship of epilepsy on the development of cognitive and linguistic skills of children with ASD.

Methods

In this regard, a systematic search was carried out in the main sources (Medline, PubMed, WOS, ResearchGate and Google Scholar). 481 articles were identified, from which, after meeting the different inclusion and exclusion criteria, a total of 18 studies of relevance to the objectives of this work were selected.

Results

The results reflect that, at a global level, epilepsy significantly influences the performance of cognitive- linguistic skills in people with ASD.

Discussion

In conclusion, epilepsy in the ASD population leads to a reduction in cognitive and linguistic abilities, which respond to the different types of epilepsy and their location, significantly impacting the quality of life and basic activities of daily living of the user with ASD.

EEG abnormalities and clinical phenotypes in pre-school children with autism spectrum disorder

BACKGROUND

Abnormalities on electroencephalography (EEG) results have been reported in a high percentage of children with Autism Spectrum Disorder (ASD). The purpose of this study was to explore the prevalence of EEG abnormalities in a clinical population of pre-school children with Autism Spectrum Disorder and the differences in terms of the following phenotypic characteristics: adaptive behavior, executive functioning, severity of Autism Spectrum Disorder core symptoms, and comorbidity symptoms.

METHODS

A cross-sectional analysis of 69 children who attended the Autism Spectrum Disorder early diagnosis program with electroencephalography and clinical diagnosis was performed. A battery of questionnaires was also made to parents to evaluate emotions, behavior, and functional skills for daily living.

RESULTS

Out of 69 pre-school children with Autism Spectrum Disorder, twenty nine (42%) had abnormalities in electroencephalography results. The group with abnormal epileptiform electroencephalography exhibited more impairment in executive functioning and social-relationship coexisting symptoms.

CONCLUSIONS

The presence of an abnormal epileptiform electroencephalography in pre-school children with ASD already suggests a worse development in clinical features.

Electroencephalographic Abnormalities in Autism Spectrum Disorder: Characteristics and Therapeutic Implications

A large body of literature reports the higher prevalence of epilepsy in subjects with Autism Spectrum Disorder (ASD) compared to the general population. Similarly, several studies report an increased rate of Subclinical Electroencephalographic Abnormalities (SEAs) in seizure-free patients with ASD rather than healthy controls, although with varying percentages. SEAs include both several epileptiform discharges and different non-epileptiform electroencephalographic abnormalities. They are more frequently associated with lower intellectual functioning, more serious dysfunctional behaviors, and they are often sign of severer forms of autism. However, SEAs clinical implications remain controversial, and they could represent an epiphenomenon of the neurochemical alterations of autism etiology. This paper provides an overview of the major research findings with two main purposes: to better delineate the state-of-the-art about EEG abnormalities in ASD and to find evidence for or against appropriateness of SEAs pharmacological treatment in ASD.

Association of Autism Onset, Epilepsy, and Behavior in a Community of Adults with Autism and Severe Intellectual Disability

Autism spectrum disorders (ASDs) are hard to characterize due to their clinical heterogeneity. Whether epilepsy and other highly prevalent comorbidities may be related to specific subphenotypes such as regressive ASD (i.e., the onset of symptoms after a period of apparently typical development) is controversial and yet to be determined. Such discrepancies may be related to the fact that age, level of cognitive functioning, and environmental variables are often not taken into account. We considered a sample of 20 subjects (i) between 20 and 55 years of age, (ii) with severe/profound intellectual disability, (iii) living in the same rural context of a farm community. As a primary aim, we tested for the association between epilepsy and regressive ASD. Secondly, we explored differences in behavioral and pharmacological profiles related to the presence of each of these conditions, as worse behavioral profiles have been separately associated with both epilepsy and regressive ASD in previous studies. An initial trend was observed for associations between the presence of epilepsy and regressive ASD (odds ratio: 5.33; 95% CI: 0.62-45.41, p-value: 0.086). Secondly, subjects with either regressive ASD or epilepsy showed worse behavioral profiles (despite the higher pharmacotherapy they received). These preliminary results, which need to be further confirmed, suggest the presence of specific associations of different clinical conditions in subjects with rarely investigated phenotypes.

Measurement of excitation-inhibition ratio in autism spectrum disorder using critical brain dynamics

Balance between excitation (E) and inhibition (I) is a key principle for neuronal network organization and information processing. Consistent with this notion, excitation-inhibition imbalances are considered a pathophysiological mechanism in many brain disorders including autism spectrum disorder (ASD). However, methods to measure E/I ratios in human brain networks are lacking. Here, we present a method to quantify a functional E/I ratio (fE/I) from neuronal oscillations, and validate it in healthy subjects and children with ASD. We define structural E/I ratio in an in silico neuronal network, investigate how it relates to power and long-range temporal correlations (LRTC) of the network's activity, and use these relationships to design the fE/I algorithm. Application of this algorithm to the EEGs of healthy adults showed that fE/I is balanced at the population level and is decreased through GABAergic enforcement. In children with ASD, we observed larger fE/I variability and stronger LRTC compared to typically developing children (TDC). Interestingly, visual grading for EEG abnormalities that are thought to reflect E/I imbalances revealed elevated fE/I and LRTC in ASD children with normal EEG compared to TDC or ASD with abnormal EEG. We speculate that our approach will help understand physiological heterogeneity also in other brain disorders.

Factors Associated With Seizure Onset in Children With Autism Spectrum Disorder

BACKGROUND AND OBJECTIVES

Children with autism spectrum disorder (ASD) have a higher prevalence of epilepsy compared with general populations. In this pilot study, we prospectively identified baseline risk factors for the development of seizures in individuals with ASD and also identified characteristics sensitive to seizure onset up to 6 years after enrollment in the Autism Speaks Autism Treatment Network.

METHODS

Children with ASD and no history of seizures at baseline who either experienced onset of seizures after enrollment in the Autism Treatment Network or remained seizure free were included in the analysis.

RESULTS

Among 472 qualifying children, 22 (4.7%) experienced onset of seizures after enrollment. Individuals who developed seizures after enrollment exhibited lower scores at baseline on all domains of the Vineland Adaptive Behavior Scales, greater hyperactivity on the Aberrant Behavior Checklist (25.4 ± 11.8 vs 19.2 ± 11.1; P = .018), and lower physical quality of life scores on the Pediatric Quality of Life Inventory (60.1 ± 24.2 vs 76.0 ± 18.2; P < .001). Comparing change in scores from entry to call-back, adjusting for age, sex, length of follow-up, and baseline Vineland II composite score, individuals who developed seizures experienced declines in daily living skills (-8.38; 95% confidence interval -14.50 to -2.50; P = .005). Adjusting for baseline age, sex, and length of follow-up, baseline Vineland II composite score was predictive of seizure development (risk ratio = 0.95 per unit Vineland II composite score, 95% confidence interval 0.92 to 0.99; P = .007).

CONCLUSIONS

Individuals with ASD at risk for seizures exhibited changes in adaptive functioning and behavior.

Clinical and Therapeutic Challenges when Psychiatric Disorders Occur in Neurological Diseases: A Narrative Review

Background:

Over the course of the 20th century, neurology and psychiatry diverged and became two separate disciplines. Subsequently, the continuous progress of neurosciences confused their boundaries. However, with ‘the splitting’ and ‘the lumping’ approaches, relevant difficulties remain in targeting clinical and therapeutic goals, when psychiatric signs and symptoms co-occur with neurological diseases.

Objective:

The study summarize current evidence on psychiatric signs and symptoms comorbid with neurological diseases, with the aim to provide information on diagnostic problems and available therapeutic options.

Methods:

Finding from searches of publications on ‘PsycInfo’, ‘Medline’, and ‘Science Direct’, from January 1993 to December 2018 (25 years) is summarized in a narrative manner on six main neurological areas: congenital neurological illnesses (n=16), dementias (n=15), basal ganglia diseases (n=30), epilepsy (n=22), strokes/focal brain injuries (n=29), and neurological neoplastic/paraneoplastic diseases (n=15).

Results:

Clinical phenotypes of psychiatric syndromes are frequently described in neurological studies. Little evidence is provided on the most adequate therapeutic approaches.

Conclusion:

Psychiatric syndromes in comorbidity with neurological diseases are heterogeneous and severe; evidence-based treatments are scarce. Despite a model supporting an equal approach between psychiatric and neurological syndromes, psychiatric syndromes in neurological diseases have been described, to a relevant degree, as less important, leading to a hierarchical primate of the neurological manifestations, and thus, in our opinion, limiting the systematic studies on psychopharmacological treatments in this area.

Common psychiatric comorbidities in epilepsy: How big of a problem is it?

Psychiatric illness and epilepsy commonly co-occur in adults and in children and adolescents. Theories of comorbidity are complex, but recurring associations between the conditions suggest overlap that is more than simple co-occurrence. Common underlying pathophysiology may imply that epilepsy itself may constituently include psychiatric symptoms. Conditions such as depression or cognitive difficulties commonly occur and in some cases, are considered to be associated with specific epilepsy characteristics such as localization or seizure type. Regardless of etiologic attributions to psychiatric comorbidity, it is clear today that treatment for epilepsy needs to target psychiatric illness. In many cases, quality-of-life improvements depend more upon addressing psychiatric symptoms than seizures themselves. This article is part of the Special Issue "Obstacles of Treatment of Psychiatric Comorbidities in Epilepsy".

EEG Abnormalities as a Neurophysiological Biomarker of Severity in Autism Spectrum Disorder: A Pilot Cohort Study

To date, the phenotypic significance of EEG abnormalities in patients with ASD is unclear. In a population affected by ASD we aimed to evaluate: the phenotypic characteristics; the prevalence of EEG abnormalities; the potential correlations between EEG abnormalities and behavioral and cognitive variables. Sixty-nine patients with ASD underwent cognitive or developmental testing, language assessment, and adaptive behavior skills evaluation as well as sleep/wake EEG recording. EEG abnormalities were found in 39.13% of patients. EEG abnormalities correlated with autism severity, hyperactivity, anger outbursts, aggression, negative or destructive behavior, motor stereotypies, intellectual disability, language impairment and self-harm. Our findings confirmed that EEG abnormalities are present in the ASD population and correlate with several associated phenotypic features.

[Epilepsy and autism spectrum disorders in children]

The problem of epilepsy comorbidity with autism spectrum disorders in children is discussed. The incidence data of autism spectrum disorders in epilepsy, epileptiform discharges on the EEG in autism spectrum disorders and epilepsy in autism spectrum disorders are reviewed. The following types of epilepsy and autism co-occurrence are discussed: both conditions are independent, have different causes and may co-occur by chance; epilepsy and autism are associated, both being independent consequences of the same genetic disorder or early cerebral damage; autism is caused by the epileptic process which interferes with the function of specific brain networks involved in the development of communication and social behavior; autism is a result of the withdrawal reaction in the epileptic child. The known genetic causes of epilepsy and autism spectrum disorders comorbidity are provided. The practical issues are discussed, in particular the rational indication of antiepileptic drugs to the children suffering autism spectrum disorders.

Electroencephalogram (EEG) for children with autism spectrum disorder: evidential considerations for routine screening

Routine electroencephalograms (EEG) are not recommended as a screen for epileptic discharges (EDs) in current practice guidelines for children with autism spectrum disorder (ASD). However, a review of the research from the last three decades suggests that this practice should be reevaluated. The significant comorbidity between epilepsy and ASD, its shared biological pathways, risk for developmental regression, and cognitive challenges demand increased clinical investigation requiring a proactive approach. This review highlights and explains the need for screening EEGs for children with ASD. EEG would assist in differentiating EDs from core features of ASD and could be included in a comprehensive assessment. EEG also meets the demand for evidence-based precision medicine and focused care for the individual, especially when overlapping processes of development are present.

Epilepsy and interictal epileptiform activity in patients with autism spectrum disorders

PURPOSE

The purpose of this study was to determine the prevalence of epilepsy and subclinical epileptiform abnormalities in children with autism spectrum disorder (ASD), and to investigate its effects on core autistic symptoms and adaptive behavior skills.

METHODS

Patients with diagnosis of ASD who met full criteria on Autism Diagnostic Interview-Revised (ADI-R) were included in the study. Adaptive behavior skills were assessed by Vineland Adaptive Behavior Scale-II (VABS-II). Clinical assessment for epilepsy and video electroencephalography (EEG) (v-EEG) examinations during wakefulness and/or sleep were prospectively performed in all patients.

RESULTS

A total of 112 patients with diagnosis of ASD of mean age 6.58 ± 3.72 were included in the study. Based on clinical and v-EEG assessments, three groups of patients were defined: 1) patients with epilepsy (n = 17; 15.2%); 2) patients with epileptiform discharges in absence of clinical seizures (n = 14; 12.5%); 3) patients without epilepsy and without epileptiform discharges (n = 81; 72.3%). There were no significant differences between three groups of patients on ADI-R subscores. Speech development was also not significantly related to epilepsy. There was a slight tendency of the VABS-II motor skills score to be higher in the group of patients with autism without clinical diagnosis of epilepsy and without subclinical epileptiform discharges (p < 0.05) in comparison with the two other groups. According to this tendency, we might claim that patients with higher scores on motor skills could have 0.88 times lower odds for having epileptiform EEG activity.

CONCLUSIONS

According to our results, we were not able to detect differences in the ADI-R between the three populations with ASD, all with unknown etiology. Epilepsy, as well as subclinical epileptic discharges, showed small effects on Motor Skills in patients with autism, and had no effect on adaptive behavior Communication/Socialization/Daily Living Skills.

EEG endophenotypes in autism spectrum disorder

OBJECTIVES

The association between autism spectrum disorder (ASD) and epilepsy is well-known. Abnormalities on electroencephalography (EEG) results have been reported in patients with ASD without a history of seizures. However, little is known about the relationship between abnormalities on EEG results and the core features of ASD. The purpose of the study was to determine the relationship between the presence of epilepsy and/or abnormalities on EEG results and disease-associated impairments in young children with ASD.

METHODS

Data were collected from medical records at Cincinnati Children's Hospital Medical Center (CCHMC) of patients with well-characterized ASD. Patients were subdivided into three groups: ASD without epilepsy but with abnormal EEG results, ASD without epilepsy and normal EEG results, and ASD with epilepsy. Developmental (Mullen Scales of Early Learning (MSEL)), adaptive (Vineland Adaptive Behavior Scales (VABS)), behavioral (Child Behavior Checklist), and language (Preschool Language Scales (PLS)) assessments, along with birth and developmental histories, medications, and medical comorbidities were collected. Electroencephalography data were abstracted from reports and included presence, characterization, and location of abnormalities.

RESULTS

Analysis was performed on 443 patients with ASD. Seventy patients (15.8%) had epilepsy at the time of ASD diagnosis. Out of 372 patients with ASD and no epilepsy, 95 (25.5%) had an abnormal EEG result (67.4% epileptiform, 36.8% other abnormalities). Majority of epileptiform discharges were focal (83%) and most commonly seen in the left temporal region. The group with abnormal EEG results exhibited more impaired adaptive functioning when compared with the group with normal EEG results (p < 0.05). The group with abnormal EEG results was more similar to the group with epilepsy, differing only in expressive language (p < 0.01) and fine motor (p < 0.05) skills on the Mullen Scales. The group with epilepsy exhibited lower scores in all areas of developmental and adaptive functioning compared with the group with normal EEG results (p < 0.05). At the time of analysis, 13 patients (8 in the group with abnormal EEG results, 5 in the group with normal EEG results) developed epilepsy at a mean age of 10.5 years ± 3.3 years.

CONCLUSIONS

The presence of an abnormal EEG result or epilepsy in the setting of ASD suggests worse developmental and adaptive functioning. Further analysis will help to clarify associations and offer insight into treatment for this subpopulation without epilepsy but with abnormal EEG results.

Neuropsychiatric effects of epilepsy in developmental disorders

PURPOSE OF REVIEW

The overlap of neuropsychiatric illness and developmental disability continues to be prominently recognized in clinical practice and in the academic literature. Theoretical and practical considerations may represent a frontier for understanding brain and behavior relationships. The purpose of this review is to explore this common relationship and report on recent literature that helps advance the larger fields of psychiatry and neurology.

RECENT FINDINGS

Overlap between developmental disability, epilepsy, and neuropsychiatric illness may be more common than originally thought. Excessive excitatory neurotransmitter activity may be present in epilepsy and in autism spectrum disorder. Specific seizure types may be associated with features of developmental disabilities and neuropsychiatric conditions.

SUMMARY

Neuropsychiatric illness is common in epilepsy and more frequent in developmental disabilities than generally recognized. Seizure foci in the temporal lobe may play a significant role. Brain connectivity and specific neurotransmitter systems are active areas of investigation. Antiepileptic drugs may improve neuropsychiatric symptoms in persons with developmental disability and epilepsy.

EEG abnormalities and long term seizure outcome in high functioning autism

Electroencephalographic abnormalities may occur in autistic spectrum disorders (ASD) even in the absence of clinical seizures. These abnormalities may vary from nonspecific changes to epileptiform abnormalities and are more common compared to the overall population. The level of intelligence is a significant risk factor for epilepsy in ASD. However, the relation between the functionality of the individuals with autism and the electroencephalographic (EEG) abnormalities, and the clinical significance of these abnormalities still remain relatively unclear. In this study we investigated the presence of EEG abnormalities in sixteen children diagnosed with high-functioning ASD. EEG recording was performed for at least 2 h and included at least 90 min of sleep activity. While none of the patients had clinical seizures, 5 patients (31.3%) were detected to have EEG abnormalities. Four of these were epileptiform (25%), and one patient developed seizure during follow-up. Our results support the fact that EEG abnormalities are observed at a higher rate also in ASD with a better functionality. The potential impact of EEG abnormalities on cognition and behavior, and the risk of epilepsy should be considered during long-term follow-up of these patients.