The autistic spectrum: subgroups, boundaries, and treatment

Does adolescent drug use belong on the antisocial spectrum? Mediating the drug-crime connection with cognitive impulsivity

The purpose of this study was to determine whether adolescent drug use can be considered part of the antisocial spectrum. This was done by testing two pathways from adolescent drug use to early adult offending, one of which was mediated by cognitive insensitivity and the other of which was mediated by cognitive impulsivity. It was hypothesized that the impulsivity-mediated pathway would achieve significance, the insensitivity-mediated pathway would not achieve significance, and the impulsivity-mediated indirect effect would significantly outperform the insensitivity-mediated indirect effect. Participants for this study were the 4576 youth from the National Longitudinal Study of Adolescent to Adult Health (Add Health). All participants in the current investigation were between the ages of 11 and 18 at the start of the study (Time 1 or Wave II of Add Health). The research hypothesis received partial support in that while the impulsivity-mediated pathway achieved significance and the insensitivity-mediated pathway did not, the difference between the two pathways was non-significant. These results suggest that early drug use may play a role in the antisocial spectrum as an antecedent to delinquency/crime by way of cognitive impulsivity.

Brain mapping across 16 autism mouse models reveals a spectrum of functional connectivity subtypes

Autism Spectrum Disorder (ASD) is characterized by substantial, yet highly heterogeneous abnormalities in functional brain connectivity. However, the origin and significance of this phenomenon remain unclear. To unravel ASD connectopathy and relate it to underlying etiological heterogeneity, we carried out a bi-center cross-etiological investigation of fMRI-based connectivity in the mouse, in which specific ASD-relevant mutations can be isolated and modeled minimizing environmental contributions. By performing brain-wide connectivity mapping across 16 mouse mutants, we show that different ASD-associated etiologies cause a broad spectrum of connectional abnormalities in which diverse, often diverging, connectivity signatures are recognizable. Despite this heterogeneity, the identified connectivity alterations could be classified into four subtypes characterized by discrete signatures of network dysfunction. Our findings show that etiological variability is a key determinant of connectivity heterogeneity in ASD, hence reconciling conflicting findings in clinical populations. The identification of etiologically-relevant connectivity subtypes could improve diagnostic label accuracy in the non-syndromic ASD population and paves the way for personalized treatment approaches.

Asperger syndrome from childhood into adulthood

Asperger syndrome, a form of autism with normal ability and normal syntactical speech, is associated with a variety of comorbid psychiatric disorders. The disorder is well known to child psychiatry, and we are beginning to recognise the extent of its impact in adulthood. The article reviews the diagnosis and assessment of Asperger syndrome and its links with a wide range of psychiatric issues, including mental disorder, offending and mental capacity. It also describes the broader, non-psychiatric management of Asperger syndrome itself, which includes social and occupational support and education, before touching on the implications the disorder has for our services.

Changes in the frequency and characteristics of children diagnosed with autistic disorder in two Norwegian cohorts: 1992 and 2009

Background:

Is the increasing prevalence of autistic disorder (AD) a well-documented trend or merely a reflection of the wider recognition of AD among both the public at large and health care professionals? Data from relevant studies are frequently compromised by comparisons of different sites and different diagnostic methods.

Objectives:

To explore changes over time, we reviewed the following: 1) the frequency of AD diagnoses; 2) the characteristics of the diagnosed children; and 3) the ages of the children when initial concerns were addressed and AD diagnoses made.

Method:

We compared the case records of children between the ages of 1 and 17 years who were residing in Nordland County, Norway, and who were diagnosed with AD during two different data collection periods: 1992 (Cohort 1) and 2009 (Cohort 2).

Results:

In Cohort 1, 28 children were diagnosed with AD; 71 children in Cohort 2 received AD diagnoses. The increase was greatest among children with intelligence quotient (IQ) values of at least 70. The proportion of children with genetic syndromes was around 20% in both cohorts. Median age at AD diagnosis did not differ between the two cohorts (4.5 vs. 5.0 years, respectively). When the two cohorts were combined, children with IQ values of 70 or more without a genetic syndrome and those with IQ values of less than 50 with genetic syndromes were diagnosed at approximately the same age (5.5 and 5.3 years, respectively). Both groups were significantly older at diagnosis as compared with children with IQ values of less than 50 without genetic syndromes (3.5 years).

Conclusions:

The increase in the number of children diagnosed with AD is consistent with findings from international studies. Contrary to predictions, the age at diagnosis was not reduced over time. A higher proportion of children with IQ values in the average range in the latter cohort may have contributed to this. A delayed diagnosis of AD among children with genetic syndromes may indicate that early autism symptoms are attributed to the genetic condition. Clinical implications are discussed.

Re-conceptualizing ASD Within a Dimensional Framework: Positive, Negative, and Cognitive Feature Clusters

Introduction of the National Institute of Mental Health's Research Domain Criteria and revision of diagnostic classification for Autism Spectrum Disorder in the latest diagnostic manual call for a new way of conceptualizing heterogeneous ASD features. We propose a novel conceptualization of ASD, borrowing from the schizophrenia literature in clustering ASD features along positive, negative, and cognitive dimensions. We argue that this dimensional conceptualization can offer improved ability to classify, diagnose, and treat, to apply and predict response to treatment, and to explore underlying neural and genetic alterations that may contribute to particular feature clusters. We suggest the proposed conceptualization can advance the field in a manner that may prove clinically and biologically useful for understanding and addressing heterogeneity within ASD.

Autism and nutrition: the role of the gut-brain axis

Autism spectrum disorder (ASD) is characterised by deficits in the ability to socialise, communicate and use imagination, and displays of stereotypical behaviour. It is widely accepted that ASD involves a disorder in brain development. However, the real causes of the neurodevelopmental disorders associated with ASD are not clear. In this respect, it has been found that a majority of children with ASD display gastrointestinal symptoms, and an increased intestinal permeability. Moreover, large differences in microbiotic composition between ASD patients and controls have been reported. Therefore, nutrition-related factors have been hypothesised to play a causal role in the aetiology of ASD and its symptoms. Through a review of the literature, it was found that abnormalities in carbohydrate digestion and absorption could explain some of the gastrointestinal problems observed in a subset of ASD patients, although their role in the neurological and behavioural problems remains uncertain. In addition, the relationship between an improved gut health and a reduction of symptoms in some patients was evaluated. Recent trials involving gluten-free diets, casein-free diets, and pre- and probiotic, and multivitamin supplementation show contradictive but promising results. It can be concluded that nutrition and other environmental influences might trigger an unstable base of genetic predisposition, which may lead to the development of autism, at least in a subset of ASD patients. Clear directions for further research to improve diagnosis and treatment for the different subsets of the disorder are provided.

[Psychotherapy of Asperger syndrome in adults]

There is an increase in awareness in professionals that the Asperger syndrome (AS) in adulthood is associated with specific problems and burdens which may well differ from those in childhood and adolescence. The core symptoms of AS generally persist into adulthood, however in contrast to childhood and adolescence there is no specific support system for adults in Germany. Also the environment of the afflicted patient changes thus producing different challenges and problems. In addition a subgroup of patients with high functioning AS primarily presents in adulthood generally due to secondary psychosocial problems, depression or anxiety. Difficulties in social interaction, problems with modified daily routines and unforeseen situations cause severe frustration for the majority of the patients. While several therapy programs have been developed and implemented for children and adolescents, for adults there are none. Also there is a lack of comprehensive concepts addressing the specific needs of adult patients with AS. From an economic perspective this is particularly unfortunate since affected people often have good or excellent partial abilities and might be very valuable employees. In this article existing therapeutic concepts for AS are summarized and a newly designed group therapy program for adult patients with Asperger syndrome in Freiburg is introduced (Freiburg Asperger-spezifische Therapie für Erwachsene, FASTER) which specifically addresses the needs and problems of adult patients with AS.

Recognizing and treating Rett syndrome in schools

A review of the literature on Rett syndrome (RS) for school-based professionals is presented from a behavioral perspective. A description of RS is provided, including distinctive physical, behavioral, and emotional features, diagnostic criteria for classic and formes frustes forms of RS, and stages of the disorder. The similarities and differences between RS and autism are reviewed. Controversies regarding the classification of RS are presented, including whether RS should be classified as a neurological or psychiatric condition and whether RS should remain classified as a pervasive developmental disorder. Last, a variety of options for the treatment of RS are discussed.

Searching for autism symptomatology in children with epilepsy--a new approach to an established comorbidity

The Prevalence of Autistic Spectrum Disorder in Children Surveyed in a Tertiary Care Epilepsy Clinic

Clarke DF, Roberts W, Daraksan M, Dupuis A, McCabe J, Wood H, Snead OC 3rd, Weiss SK

Epilepsia 2005;46:1970–1977.

It is well documented that children with autistic spectrum disorder (ASD) have an increased prevalence of seizures; however, studies have not been done to evaluate the prevalence of ASD in children with epilepsy. This comorbidity is important to define as early diagnosis and intervention in some children with ASD has been shown to improve outcome.

Method

Children with epilepsy seen in a tertiary care epilepsy clinic were evaluated using validated autism screening questionnaires (ASQ). In addition, questions about sleep-related disorders, behavior, seizure characteristics, antiepileptic agents, and body mass index (BMI) were requested. An attempt was then made to determine if there was a correlation between the factors identified and ASD.

Results

Of the 107 questionnaires returned, 97 ASQs were properly completed and used in this study. Approximately 32% of children fit the ASQ criteria for having ASD. Most children had not been previously diagnosed. Worst behavior and daytime sleepiness was seen in those at greater risk ( p < 0.01). Seizures also occurred earlier (approximately 2 years) in children at risk of having ASD.

Conclusion

Though confirmatory diagnostic evaluations are needed, this questionnaire-based study suggests that children with epilepsy are at greater risk of having ASD, and illustrates the need for more clinical vigilance. Behavioral difficulties and daytime sleepiness identified in these children could potentially affect their ability to learn. It is of interest that the age of seizure onset identified in those at greater risk corresponds with the approximate age of regression identified in some children with ASD.

[Does the Fragmented Images Test measure locally oriented visual processing in autism spectrum disorders?]

OBJECTIVE

The cognitive phenotype of autism spectrum disorders (ASD) is characterized among other things by local processing (weak central coherence). It was examined whether a test that measures identification of fragmented pictures (FBT) is able to seize this preference for local processing.

METHOD

The FBT performance of 15 patients with ASD, 16 with depression, 16 with schizophrenia and of 16 control subjects was compared. In addition, two tests well known to be sensitive to local processing were assessed, namely the Embedded Figures Test (EFT) and the Block Design Test (BDT).

RESULTS

ASD patients demonstrated a preference for local processing. Difficulties in global processing, or more specifically in gestalt perception (FBT), were accompanied by good performance on the EFT and BDT as expected. Controlling for age and nonverbal intelligence (ANCOVA) reduced differences to trends. However, the calculation of difference scores (i.e., subtraction of FBT from EFT performance) resulted in significant differences between ASD and control groups even after controlling for of age and intelligence.

CONCLUSIONS

The FBT is a suitable exploratory test of local visual processing in ASD. In particular, a difference criterion can be generated (FBT vs. EFT) that discriminates between ASD and clinical as well as healthy control groups.

Predictive value of subclinical autistic traits at age 14-15 months for behavioural and cognitive problems at age 3-5 years

It is unclear whether subclinical autistic traits at very young age are transient or stable, and have clinical relevance. This study investigated the relationship between early subclinical autistic traits and the occurrence of later developmental and behavioural problems as well as problems in cognitive and language functioning. Parents of infants aged 14-15 months from the general population completed the Early Screening of Autistic Traits Questionnaire (ESAT). Three groups of children with high, moderate, and low ESAT-scores (total n = 103) were selected. Follow-up assessments included the CBCL 1(1/2)-5 at age 3 years, and the SCQ, the ADI-R, the ADOS-G, an on-verbal intelligence test, and language tests for comprehension and production at age 4-5 years. None of the children met criteria for autism spectrum disorder at follow-up. Children with high ESAT-scores at 14-15 months showed significantly more internalizing and externalizing problems at age 3 years and scored significantly lower on language tests at age 4-5 years than children with moderate or low ESAT-scores. Further, significantly more children with high ESAT-scores (14/26, 53.8%) than with moderate and low ESAT-scores (5/36, 13.9% and 1/41, 2.4%, respectively) were in the high-risk/clinical range on one or more outcome domains (autistic symptoms, behavioural problems, cognitive and language abilities). Subclinical autistic traits at 14-15 months predict later behavioural problems and delays in cognitive and language functioning rather than later ASD-diagnoses. The theoretical implications of the findings lie in the pivotal role of early social and communication skills for the development of self-regulation of emotions and impulses. The practical implications bear on the early recognition of children at risk for behavioural problems and for language and cognitive problems.

Brain-derived neurotrophic factor and autism: maternal and infant peripheral blood levels in the Early Markers for Autism (EMA) Study

To investigate levels of brain-derived neurotrophic factor (BDNF) in mid-pregnancy and neonatal blood specimens as early biologic markers for autism, we conducted a population-based case-control study nested within the cohort of infants born from July 2000 to September 2001 to women who participated in the prenatal screening program in Orange County, CA. Cases (n=84) were all children receiving services for autism at the Regional Center of Orange County. Two comparison groups from the same study population were included: children with mental retardation or developmental delay (n=49) receiving services at the same regional center, and children not receiving services for developmental disabilities, randomly sampled from the California birth certificate files (n=159), and frequency matched to autism cases on sex, birth year, and birth month. BDNF concentrations were measured in archived mid-pregnancy and neonatal blood specimens drawn during routine prenatal and newborn screening using a highly sensitive bead-based assay (Luminex, Biosource Human BDNF Antibody Bead Kit, Invitrogen-Biosource, Carlsbad, CA). The concentration of BDNF in maternal mid-pregnancy and neonatal specimens was similar across all three study groups. These data do not support previous findings of an association between BDNF and autism and suggest that the concentration of BDNF during critical periods of early neurodevelopment is not likely to be a useful biomarker for autism susceptibility.

Stereotypies and repetitive/restrictive behaviours in infants with autism and pervasive developmental disorder

PURPOSE

Autism Spectrum Disorders (ASD) are characterized by severe and debilitating symptoms including stereotyped and repetitive behaviours. Stereotypies and repetitive behaviours constitute core features of ASD and markedly impede attempts to remediate the disorder. Little previous research has examined characteristics of the core features of ASD in infants.

METHOD

In the present study, 760 infants with autism, PDD-NOS or no diagnosis of ASD but at risk for other developmental delays or physical disabilities were evaluated with respect to the nature and extent of their stereotyped and ritualistic behaviour using the Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT). A Kruskal-Wallis test with follow-up Mann-Whitney tests were employed to test for significant differences.

RESULTS

Infants with autism evinced the highest amount of stereotypic behaviour, followed by those with PDD-NOS and atypical development. A sub-set of BISCUIT items could accurately predict diagnostic group membership.

CONCLUSIONS

These data suggest that many core features of ASD are distinct and can be reliably identified early in life. The potential early identification of these behavioural challenges could lead to earlier intervention practices and symptom alleviation for children in this population.

Epilepsy in patients with pervasive developmental disorder not otherwise specified

Data on epilepsy in pervasive developmental disorder not otherwise specified are few and scanty. Seventy-seven patients with pervasive developmental disorder not otherwise specified were compared with 77 with autistic disorder, matched for age and sex. The 2 groups were divided into 3 subgroups each: A, without electroencephalography (EEG) paroxysmal abnormalities or epilepsy; B, with EEG paroxysmal abnormalities without epilepsy; and C, with epilepsy. Mild mental retardation (P < .01), pathological neurological examination (P < .05), cerebral lesions (P < .01), abnormal EEG background activity (P < .001), and associated genetic pathologies (P < .01) were more common in pervasive developmental disorder not otherwise specified. Familial antecedents for epilepsy prevailed in subgroup C (P < .01). Epilepsy occurred in 35.1% of patients with pervasive developmental disorder not otherwise specified, with no statistically significant difference compared with autistic disorder. The mean age of seizure onset was earlier (2 years 8 months) in pervasive developmental disorder not otherwise specified (P < .000). Seizure outcome was better in autistic disorder. Genetic diseases and cerebral lesions should be investigated in pervasive developmental disorder not otherwise specified to clarify the etiological and clinical features.

Intonation and emotion in autistic spectrum disorders

The classic picture of an autistic individual includes an impoverished ability to interpret or express emotion. The prosody of spoken language in autistic children is thought to lack emotional content. In this study, the verbal intonation of children with autism was examined and compared to that of children with Asperger Syndrome (AS) and normal controls (ctrl). Utterances elicited by repetition and by spontaneous story completion were analyzed by quantifying phonetic features (pitch, amplitude, and length) and comparing them to subjective ratings of produced emotion (happy, sad or angry). Since the most consistent phonetic correlate of these emotional targets has been demonstrated to be pitch range, speakers with autistic spectrum disorders were expected to have decreased pitch range; however in the repetition task, autistic subjects actually had a larger pitch range than the other groups. Other measures of intonation including amplitude, duration, and location of pitch peak revealed defects that are more complex than predicted. In spontaneous speech, autistic subjects performed more poorly on both phonetic targets and subjective ratings than ctrls, and AS subjects fell between autistics and normals.

Autism and the development of face processing

Autism is a pervasive developmental condition, characterized by impairments in non-verbal communication, social relationships and stereotypical patterns of behavior. A large body of evidence suggests that several aspects of face processing are impaired in autism, including anomalies in gaze processing, memory for facial identity and recognition of facial expressions of emotion. In search of neural markers of anomalous face processing in autism, much interest has focused on a network of brain regions that are implicated in social cognition and face processing. In this review, we will focus on three such regions, namely the STS for its role in processing gaze and facial movements, the FFA in face detection and identification and the amygdala in processing facial expressions of emotion. Much evidence suggests that a better understanding of the normal development of these specialized regions is essential for discovering the neural bases of face processing anomalies in autism. Thus, we will also examine the available literature on the normal development of face processing. Key unknowns in this research area are the neuro-developmental processes, the role of experience and the interactions among components of the face processing system in shaping each of the specialized regions for processing faces during normal development and in autism.

Brief Report: Effect of Maternal Age on Severity of Autism

The etiology of autism is complex, consisting of unknown genetic and environmental factors. Previous studies have revealed that maternal age is increased in autism compared to controls, making it a possible risk factor. This study examined the effects of maternal age on autism severity using IQ as a measure of cognitive severity and selected subtests of the Child Behavior Checklist (CBCL) as measures of social severity. A sample of 154 subjects with autism spectrum disorders was obtained from the Stanford Neuropsychiatry/Pervasive Developmental Disorder (PDD) clinic. Results indicate that there is no relationship between IQ or selected CBCL subtests and maternal age, suggesting that maternal age does not influence the severity of autism as measured by these indicators.

Parental perceptions and use of complementary and alternative medicine practices for children with autistic spectrum disorders in private practice

The prevalence of autistic spectrum disorder (ASD) in the United States is approximately 1 in 150 children. Many health care providers are unaware of parental beliefs and treatments, both medical and complementary, that parents use for their child with ASD. Understanding these beliefs and practices concerning diagnosis, cause, and utilization of medical and complementary care may help physicians provide better comprehensive care. Parents of children with ASD from 2 private practices-one in New York and one in New Jersey-were mailed a 6-page, self-administered survey. In addition to demographics and ASD type, the survey asked parents who diagnosed their child and if there was a perceived delay in that diagnosis; whether they believed there was any causal reason for their child's autism; what chronic symptoms, if any, their child experiences; and, if they had used any complementary and/or alternative therapies and at whose recommendation. Respondents included 77 of the 150 parents (51%) contacted. Most children were diagnosed by a neurologist and/or developmental pediatrician (54% and 47%, respectively). Average perceived delay in diagnosis was 18 months. Parents most frequently cited immunizations (54%), genetic predisposition (53%), and environmental exposure (38%) as a cause of their child's autism. Approximately half of children were reported as having at least one gastrointestinal, neurological, and/or allergic symptom; more than a third had immunological symptoms. Almost all parents (95%) indicated some use of complementary and alternative medicine (CAM) therapies, with most of the self-reported referrals generated from a physician or nurse (44%). Systemic complaints, parental beliefs, and use of CAM practices warrant open discussion by all health care professionals who provide care to this population.

Health-related quality of life in parents of school-age children with Asperger Syndrome or High-Functioning Autism

BACKGROUND

The estimated prevalence rate of Pervasive Developmental Disorders (PDD) in children is 6 per 1.000. Parenting children who are intellectually impaired and have PDDs is known to be linked to the impaired well-being of the parents themselves. However, there is still little available data on health-related quality of life (HRQL) in parents of children with Asperger Syndrome (AS) and High-Functioning Autism (HFA), or other PDD diagnoses in children of normal intelligence. The present study aimed to evaluate aspects of HRQL in parents of school-age children with AS/HFA and the correlates with child behaviour characteristics.

METHODS

The sample consisted of 31 mothers and 30 fathers of 32 children with AS/HFA and 30 mothers and 29 fathers of 32 age and gender matched children with typical development. Parental HRQL was surveyed by the use of the 12 Item Short Form Health Survey (SF-12) which measures physical and mental well-being. The child behaviour characteristics were assessed using the structured questionnaires: The High-Functioning Autism Spectrum Screening Questionnaire (ASSQ) and The Strengths and Difficulties Questionnaire (SDQ).

RESULTS

The mothers of children with AS/HFA had lower SF-12 scores than the controls, indicating poorer physical health. The mothers of children with AS/HFA also had lower physical SF-12 scores compared to the fathers. In the AS/HFA group, maternal health was related to behaviour problems such as hyperactivity and conduct problems in the child.

CONCLUSION

Mothers but not fathers of children with AS/HFA reported impaired HRQL, and there was a relationship between maternal well-being and child behaviour characteristics.

Chromosomal anomalies in individuals with autism: a strategy towards the identification of genes involved in autism

We review the different strategies currently used to try to identify susceptibility genes for idiopathic autism. Although identification of genes is usually straightforward in Mendelian disorders, it has proved to be much more difficult to establish in polygenic disorders like autism. Neither genome screens of affected siblings nor the large number of association studies using candidate genes have resulted in finding autism susceptibility genes. We focus on the alternative approach of 'positional cloning' through chromosomal aberrations in individuals with autism. In particular, balanced aberrations such as reciprocal translocations or inversions offer a unique opportunity, since only the genes in the breakpoint regions are candidate genes. This approach, in combination with others, is likely to produce results in the coming years.

Autism and pervasive developmental disorders

The quantity and quality of research into autism and related conditions have increased dramatically in recent years. Consequently we selectively review key accomplishments and highlight directions for future research. More consistent approaches to diagnosis and more rigorous assessment methods have significantly advanced research, although the boundaries of the 'broader phenotype' remain to be defined and the validity of Asperger's disorder as a discrete syndrome remains controversial. Recent epidemiological studies have shown that Autism Spectrum Disorders are common, but there continues to be debate about the causes of the increase in the frequency with which autism is diagnosed. Psychological research has helped to develop new developmental models for the disorder and there have also been significant advances in the molecular genetics of autism and understanding of the underlying neurobiological processes. Areas important for future research include the study of autism as it first develops, i.e., in infants and very young children, and of specific processes (psychological and neurobiological) which underlie the disorder. Significant challenges lie ahead in evaluating the growing number of treatments for autism and in integrating the results of research into treatment and educational settings.