Methylphenidate for pervasive developmental disorders: safety and efficacy of acute single dose test and ongoing therapy: an open-pilot study

Revisiting stimulant use for emotional dysregulation in attention-deficit/hyperactivity disorder (ADHD)

INTRODUCTION

Emotional dysregulation (ED) symptoms are present in a considerable portion of patients with attention-deficit/hyperactivity disorder (ADHD). In recent years, an increasing number of studies investigated the effects of stimulant medications on ED in patients with ADHD.

AREAS COVERED

A narrative review of the literature on stimulant treatment for ED is provided, including controlled and observational clinical studies conducted on pediatric and adult samples and neurobiological investigations. Positive effects of stimulants on irritability have been demonstrated in children. Comorbidity with disruptive behavior disorders (DBD) and disruptive mood dysregulation disorder does not prevent stimulant effectiveness. Methylphenidate has also been found to reduce temper problems, affective instability, and emotional over-reactivity in adults with ADHD, although with variable effect sizes. A variety of adverse emotional effects have been reported, especially at high doses and in special populations. However, several possible confounders of treatment-emergent ED have been highlighted. Finally, according to neuroimaging studies, stimulants may mitigate emotional processing anomalies associated with ADHD.

EXPERT OPINION

The findings are consistent with models including ED within the core features of ADHD. Stimulant treatment should be prioritized over antipsychotics in ADHD-DBD. It remains to be elucidated whether other medications may be more effective in specific populations with ADHD and/or ED.

A perspective on molecular signalling dysfunction, its clinical relevance and therapeutics in autism spectrum disorder

Intellectual disability (ID) and autism spectrum disorder (ASD) are neurodevelopmental disorders that have become a primary clinical and social concern, with a prevalence of 2-3% in the population. Neuronal function and behaviour undergo significant malleability during the critical period of development that is found to be impaired in ID/ASD. Human genome sequencing studies have revealed many genetic variations associated with ASD/ID that are further verified by many approaches, including many mouse and other models. These models have facilitated the identification of fundamental mechanisms underlying the pathogenesis of ASD/ID, and several studies have proposed converging molecular pathways in ASD/ID. However, linking the mechanisms of the pathogenic genes and their molecular characteristics that lead to ID/ASD has progressed slowly, hampering the development of potential therapeutic strategies. This review discusses the possibility of recognising the common molecular causes for most ASD/ID based on studies from the available models that may enable a better therapeutic strategy to treat ID/ASD. We also reviewed the potential biomarkers to detect ASD/ID at early stages that may aid in diagnosis and initiating medical treatment, the concerns with drug failure in clinical trials, and developing therapeutic strategies that can be applied beyond a particular mutation associated with ASD/ID.

Methylphenidate Use for Emotional Dysregulation in Children and Adolescents with ADHD and ADHD and ASD: A Naturalistic Study

Emotional dysregulation (ED) is common in attention-deficit/hyperactivity disorder (ADHD). Nonetheless, research on ADHD in children with autism spectrum disorder (ASD) and ADHD is still ongoing. Several studies suggest that methylphenidate (MPH) may be effective for ED in ADHD, while there is not enough evidence about its use in ASD with comorbid ADHD. This naturalistic study aims to investigate the effectiveness of immediate- and extended-release MPH in the treatment of ED in 70 children and adolescents (6–18 years), with a diagnosis of ADHD (n = 41) and of ASD with comorbid ADHD (n = 29), using the Child Behavior Checklist—Attention/Aggressive/Anxious (CBCL-AAA). Their parents completed the CBCL twice—first during the summer medication-free period, that is, at least one month after drug interruption; and again after three months of treatment restart. Results demonstrate that MPH is associated with a statistically significant reduction in ED in ADHD and ASD, without substantial adverse events, supporting the use of psychostimulants for the treatment of ED in these neurodevelopmental disorders.

ASD with ADHD vs. ASD and ADHD alone: a study of the QbTest performance and single-dose methylphenidate responding in children and adolescents

BACKGROUND

The continuous performance task (CPT) may help identify coexistent attention deficit hyperactivity disorder (ADHD) in autism spectrum disorder (ASD). The Quantified behavior Test (QbTest) combines a CPT and motion-tracking data to assess ADHD symptoms. This study aimed to evaluate the QbTest performance of children and adolescents with ASD plus ADHD, including estimating the effects of single-dose methylphenidate (MPH). To achieve these aims, (1) the QbTest performances were evaluated in ASD alone, ASD plus ADHD, and ADHD alone, and (2) the effects on the QbTest performance of single-dose MPH before and after intake were estimated across the groups. It was assumed that the ASD plus ADHD performance, including the MPH response, would preferably resemble the performance in ADHD alone, rather than ASD alone.

METHODS

Retrospective data were analyzed for 482 children and adolescents: 69 with ASD alone, 142 with ASD plus ADHD (ASD/ADHD), and 271 with ADHD alone. For 343 subjects, the QbTest was performed before and up to four hours after a single-dose MPH intake. A summary index of the CPT and motion-capture data was provided for QbTest cardinal parameters.

RESULTS

Of 12 QbTest parameters assessed before given MPH, the ASD/ADHD group had scores in line with the ASD group regarding four parameters and the ADHD group regarding nine parameters. Significant differences between groups were seen with respect to QbInattention (p > 0.05); the lowest scores in ASD and the highest in ADHD. Those with ASD/ADHD and ADHD had similar QbActivity and QbImpulsivity scores, but significantly higher than those with ASD. After MPH intake, scores for QbActivity decreased similarly in ASD/ADHD and ADHD, as well as scores for QbImpulsivity. QbImpulsivity increased in ASD. QbInattention scores decreased similarly in all groups after MPH intake.

CONCLUSIONS

Children and adolescents with ASD plus ADHD exhibited more atypical QbTest performances than those with ASD alone, while most of their performances were similar to those observed in ADHD alone. In addition, a single dose of MPH mitigated attention deficits and decreased hyperactivity while improved impulsivity in these children. Prospective studies should further clarify the role of the QbTest in the diagnostic and therapeutic interventions in ASD with ADHD.

The pediatric psychopharmacology of autism spectrum disorder: A systematic review - Part I: The past and the present

Autism Spectrum Disorder (ASD) is a severe and lifelong neurodevelopmental disorder, with high social costs and a dramatic burden on the quality of life of patients and family members. Despite its high prevalence, reaching 1/54 children and 1/45 adults in the United States, no pharmacological treatment is still directed to core symptoms of ASD, encompassing social and communication deficits, repetitive behaviors, restricted interests, and abnormal sensory processing. The purpose of this review is to provide an overview of the state-of-the-art of psychopharmacological therapy available today for ASD in children and adolescents, in order to foster best practices and to organize new strategies for future research. To date, atypical antipsychotics such as risperidone and aripiprazole represent the first line of intervention for hyperactivity, impulsivity, agitation, temper outbursts or aggression towards self or others. Tricyclic antidepressants are less prescribed because of uncertain efficacy and important side effects. SSRIs, especially fluoxetine and sertraline, may be effective in treating repetitive behaviors (anxiety and obsessive-compulsive symptoms) and irritability/agitation, while mirtazapine is more helpful with sleep problems. Low doses of buspirone have shown some efficacy on restrictive and repetitive behaviors in combination with behavioral interventions. Stimulants, and to a lesser extent atomoxetine, are effective in reducing hyperactivity, inattention and impulsivity also in comorbid ASD-ADHD, although with somewhat lower efficacy and greater incidence of side effects compared to idiopathic ADHD. Clonidine and guanfacine display some efficacy on hyperactivity and stereotypic behaviors. For several other drugs, case reports and open-label studies suggest possible efficacy, but no randomized controlled trial has yet been performed. Research in the pediatric psychopharmacology of ASD is still faced with at least two major hurdles: (a) Great interindividual variability in clinical response and side effect sensitivity is observed in the ASD population. This low level of predictability would benefit from symptom-specific treatment algorithms and from biomarkers to support drug choice; (b) To this date, no psychoactive drug appears to directly ameliorate core autism symptoms, although some indirect improvement has been reported with several drugs, once the comorbid target symptom is abated.

Cognitive and behavioural flexibility: neural mechanisms and clinical considerations

Cognitive and behavioural flexibility permit the appropriate adjustment of thoughts and behaviours in response to changing environmental demands. Brain mechanisms enabling flexibility have been examined using non-invasive neuroimaging and behavioural approaches in humans alongside pharmacological and lesion studies in animals. This work has identified large-scale functional brain networks encompassing lateral and orbital frontoparietal, midcingulo-insular and frontostriatal regions that support flexibility across the lifespan. Flexibility can be compromised in early-life neurodevelopmental disorders, clinical conditions that emerge during adolescence and late-life dementias. We critically evaluate evidence for the enhancement of flexibility through cognitive training, physical activity and bilingual experience.

Effects of Extended-Release Methylphenidate Treatment on Cognitive Task Performance in Children with Autism Spectrum Disorder and Attention-Deficit/Hyperactivity Disorder

Objective: To examine the effectiveness of four doses of psychostimulant medication, combining extended-release methylphenidate (ER-MPH) in the morning with immediate-release MPH (IR-MPH) in the afternoon, on cognitive task performance. Method: The sample comprised 24 children (19 boys and 5 girls) who met the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revision (DSM-IV-TR) criteria for an autism spectrum disorder (ASD) on the Autism Diagnostic Interview-R and the Autism Diagnostic Observation Schedule, and had significant symptoms of attention-deficit/hyperactivity disorder (ADHD). This sample consisted of elementary school-age, community-based children (mean chronological age = 8.8 years, SD = 1.7; mean intelligence quotient = 85; SD = 16.8). Effects of placebo and three dose levels of ER-MPH (containing 0.21, 0.35, and 0.48 mg/kg equivalent of IR-MPH) on cognitive task performance were compared using a within-subject, crossover, placebo-controlled design. Each of the four MPH dosing regimens (placebo, low-dose MPH, medium-dose MPH, and high-dose MPH) was administered for 1 week; the dosing order was counterbalanced across children. Results: MPH treatment was associated with significant performance gains on cognitive tasks tapping sustained attention, selective attention, and impulsivity/inhibition. Dose/response was generally linear in the dose range studied, with no evidence of deterioration in performance at higher MPH doses in the dose range studied. Conclusion: The results of this study suggest that MPH formulations are associated with significant improvements on cognitive task performance in children with ASD and ADHD.

Methylphenidate in Autism Spectrum Disorder: A Long-Term Follow up Naturalistic Study

Autism spectrum disorder (ASD) often co-occurs with attention deficit/hyperactivity disorder (ADHD). Although methylphenidate (MPH) efficacy and safety are well-demonstrated for ADHD, evidences are scant in the context of ASD. This naturalistic study aimed to analyze long-term MPH efficacy and safety in 40 ADHD children and adolescents with comorbid ASD, comparing them with 40 ones affected by ADHD without ASD. Treatment lasted from 6 to 156 months (longer than 24 months in more than three quarters of patients). Efficacy and safety were measured by clinical global impression and children global assessment scales; influence of intellectual functioning was examined. Comparisons between groups were made by Wilcoxon or Friedmann tests; relationships between functioning scores and other characteristics were analyzed by ordinal logistic and linear regression. Results demonstrated that MPH in patients with ASD was associated with significative reduction of illness severity, clinical improvement and amelioration of global functioning, without significant differences with patients having ADHD without ASD. The trend of reduction of illness severity and increase of global functioning were favorably related with intellectual functioning. No serious adverse events were reported. The findings showed that long-term MPH was effective and well-tolerated in ADHD children and adolescents with comorbid high functioning ASD.

A prospective open-label trial of long-acting liquid methylphenidate for the treatment of attention deficit/hyperactivity disorder in intellectually capable adults with autism spectrum disorder

Objectives: This treatment trial is aimed at assessing the short-term tolerability and efficacy of liquid-formulation extended-release methylphenidate (MPH-ER) for the treatment of attention deficit/hyperactivity disorder (ADHD) in adults with high-functioning autism spectrum disorder (HF-ASD).Methods: A 6-week open-label trial (ClinicalTrials.gov: NCT02096952) was conducted in 15 HF-ASD adults (mean age 24.9 ± 4.6; male, 12 (80%)) suffering from moderate-severe ADHD. MPH-ER was administered based on a flexible titration schedule. Efficacy was assessed on clinician- and self-rated measures. Tolerability was assessed by documenting treatment-emergent adverse events (AEs) and other safety measures.Results: Short-term MPH-ER treatment was associated with significant improvement in ADHD severity (Adult ADHD Investigator Symptom Report Scale (AISRS) mean change (MC), -22.8 ± 8.8, P < 0.001; Adult ADHD Self-Report Scale (ASRS) MC, -8.2 ± 15.3, P < 0.001). Twelve (80%) participants were deemed responders, based on ≥30% reduction in AISRS score and an ADHD Clinical Global Impression-Improvement score ≤2. MPH-ER was well-tolerated (treatment-limiting AEs, 1/15; severe AEs, 1/15) at mean dose of 48.7 ± 15 mg/day. AEs were transient and experienced by 13/15 (87%) participants at mild to moderate severity. Frequently reported AEs were as typically expected (headache (53%), insomnia (33%), anxiety (33%), decreased appetite (27%)).Conclusions: Our findings suggest that MPH-ER is effective and well-tolerated in the treatment of ADHD in HF-ASD adults.

Pharmacotherapy of ADHD in Adults With Autism Spectrum Disorder: Effectiveness and Side Effects

Objective: Symptoms of ADHD are expected to be more difficult to treat in patients with a combination of ADHD and autism spectrum disorder (ASD) as opposed to only ADHD. Little evidence is available on the influence of ASD on the effects of pharmacotherapy in adults with ADHD. This study addresses this gap. Method: 60 adults with ADHD and comorbid ASD were selected from an outpatient clinic and compared with 226 adults from the same clinic with only ADHD. Similar treatment regimens were received. Results: Significant decreases in symptoms of ADHD were found in both groups. A diagnosis of ASD did not affect the reduction in symptoms of ADHD. No significant group differences in side effects or vital signs were found. Conclusion: Results show that medication for ADHD can effectively and safely be prescribed to patients with ADHD and comorbid ASD. Suggestions for future research are discussed.

The effect of stimulants on irritability in autism comorbid with ADHD: a systematic review

Introduction: While there is a very high rate of comorbidity of autism and ADHD, there are controversies about prescribing stimulants in children with autism. This is a systematic review about the effect of stimulants on irritability in children with both autism and ADHD. Methods: A systematic review was conducted to study the possible effect of stimulants on irritability in autism and ADHD using the databases of PubMed, Scopus, EMBASE, and ScienceDirect in September 2018. Eligible clinical trials of stimulants in the treatment of Autism and ADHD without restriction of language were included. The primary outcome was irritability score. The full texts of relevant articles were studied, and their references were scanned for any possible related article. Results: Out of 1,315 citations, there were 26 relevant articles. Of the relevant articles, 16 were not interventional studies and were excluded. There were 10 interventional studies. None of them considered irritability as a main outcome. Also, none of them studied the effect of stimulants on irritability in autism plus ADHD. Current uncontrolled evidence about the association of stimulants with irritability is controversial. Conclusion: The current evidence is not enough to support or discourage the effect of stimulants on irritability in children and adolescents with both autism and ADHD. Well-designed controlled clinical trials need to be conducted for this ignored research area.

Current Enlightenment About Etiology and Pharmacological Treatment of Autism Spectrum Disorder

Autistic Spectrum Disorder (ASD) is a complex neurodevelopmental brain disorder characterized by two core behavioral symptoms, namely impairments in social communication and restricted/repetitive behavior. The molecular mechanisms underlying ASD are not well understood. Recent genetic as well as non-genetic animal models contributed significantly in understanding the pathophysiology of ASD, as they establish autism-like behavior in mice and rats. Among the genetic causes, several chromosomal mutations including duplications or deletions could be possible causative factors of ASD. In addition, the biochemical basis suggests that several brain neurotransmitters, e.g., dopamine (DA), serotonin (5-HT), gamma-amino butyric acid (GABA), acetylcholine (ACh), glutamate (Glu) and histamine (HA) participate in the onset and progression of ASD. Despite of convincible understanding, risperidone and aripiprazole are the only two drugs available clinically for improving behavioral symptoms of ASD following approval by Food and Drug Administration (FDA). Till date, up to our knowledge there is no other drug approved for clinical usage specifically for ASD symptoms. However, many novel drug candidates and classes of compounds are underway for ASD at different phases of preclinical and clinical drug development. In this review, the diversity of numerous aetiological factors and the alterations in variety of neurotransmitter generation, release and function linked to ASD are discussed with focus on drugs currently used to manage neuropsychiatric symptoms related to ASD. The review also highlights the clinical development of drugs with emphasis on their pharmacological targets aiming at improving core symptoms in ASD.

Methylphenidate for children and adolescents with autism spectrum disorder

BACKGROUND

Children with autistic spectrum disorder (ASD) frequently present with inattention, impulsivity and hyperactivity, which are the cardinal symptoms of attention deficit hyperactivity disorder (ADHD). The effectiveness of methylphenidate, a commonly used ADHD treatment, is therefore of interest in these children.

OBJECTIVES

To assess the effects of methylphenidate for symptoms of ADHD (inattention, impulsivity and hyperactivity) and ASD (impairments in social interaction and communication, and repetitive, restricted or stereotypical behaviours) in children and adolescents aged 6 to 18 years with ASD.

SEARCH METHODS

In November 2016, we searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, 11 other databases and two trials registers. We also checked reference lists and contacted study authors and pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that investigated the effect of methylphenidate versus placebo on the core symptoms of ASD or ADHD-like symptoms, or both, in children aged 6 to 18 years who were diagnosed with ASD or pervasive developmental disorder. The primary outcome was clinical efficacy, defined as an improvement in ADHD-like symptoms (inattention, impulsivity and hyperactivity) and in the core symptoms of ASD (impaired social interaction, impaired communication, and stereotypical behaviours), and overall ASD. Secondary outcomes examined were: rate of adverse events; caregiver well-being; need for institutionalisation, special schooling or therapy to achieve learning outcomes; and overall quality of life.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. We combined outcome measures that used different psychometric scales, where clinically appropriate. We used a coefficient of 0.6 to calculate standard deviations and adjust for the studies' cross-over design. We considered a standardised mean difference (SMD) of 0.52 as the minimum clinically relevant inter-treatment difference. We applied the GRADE rating for strength of evidence for each outcome.

MAIN RESULTS

The studies: we included four cross-over studies, with a total of 113 children aged 5 to 13 years, most of whom (83%) were boys. We included two studies with five-year-old children since we were unable to obtain the disaggregated data for those aged six years and above, and all other participants were in our target age range. All participants resided in the USA. The duration of treatment in the cross-over phase was one week for each dose of methylphenidate. Studies used a range of outcome scales, rated by parents, teachers or both; clinicians; or programme staff. We report parent-rated outcomes separately. Risk of bias: we considered three trials to be at high risk of bias due to selective reporting and all trials to be at unclear risk of bias for blinding of participants and assessors, due to the potential for recognising the side effects of methylphenidate. We judged all trials to be at low or unclear risk of bias for other items. Primary outcomes: the meta-analysis suggested that high-dose methylphenidate (0.43 mg/kg/dose to 0.60 mg/kg/dose) had a significant and clinically relevant benefit on hyperactivity, as rated by teachers (SMD -0.78, 95% confidence interval (CI) -1.13 to -0.43; 4 studies, 73 participants; P < 0.001; low-quality evidence) and parents (mean difference (MD) -6.61 points, 95% CI -12.19 to -1.03, rated on the hyperactivity subscale of the Aberrant Behviour Checklist, range 0 to 48; 2 studies, 71 participants; P = 0.02; low-quality evidence). Meta-analysis also showed a significant but not clinically relevant benefit on teacher-rated inattention (MD -2.72 points, 95% CI -5.37 to -0.06, rated on the inattention subscale of the Swanson, Nolan and Pelham, Fourth Version questionnaire, range 0 to 27; 2 studies, 51 participants; P = 0.04; low-quality evidence). There were inadequate data to conduct a meta-analysis on the symptom of impulsivity. There was no evidence that methylphenidate worsens the core symptoms of ASD or benefits social interaction (SMD -0.51, 95% CI -1.07 to 0.05; 3 studies, 63 participants; P = 0.07; very low-quality evidence), stereotypical behaviours (SMD -0.34, 95% CI -0.84 to 0.17; 3 studies, 69 participants; P = 0.19; low-quality evidence), or overall ASD (SMD -0.53, 95% CI -1.26 to 0.19; 2 studies, 36 participants; P = 0.15; low-quality evidence), as rated by teachers. There were inadequate data to conduct a meta-analysis on the symptom of impaired communication.

SECONDARY OUTCOMES

no data were available for the secondary outcomes of caregiver well-being; need for institutionalisation, special schooling options or therapy to achieve learning outcomes; or overall quality of life. No trials reported serious adverse events. The only adverse effect that was significantly more likely with treatment was reduced appetite as rated by parents (risk ratio 8.28, 95% CI 2.57 to 26.73; 2 studies, 74 participants; P < 0.001; very low-quality evidence). Subgroup analysis by dose did not identify any significant differences in effect on our primary outcomes between low-, medium- or high-dose ranges.

AUTHORS' CONCLUSIONS

We found that short-term use of methylphenidate might improve symptoms of hyperactivity and possibly inattention in children with ASD who are tolerant of the medication, although the low quality of evidence means that we cannot be certain of the true magnitude of any effect. There was no evidence that methylphenidate has a negative impact on the core symptoms of ASD, or that it improves social interaction, stereotypical behaviours, or overall ASD. The evidence for adverse events is of very low quality because trials were short and excluded children intolerant of methylphenidate in the test-dose phase. Future RCTs should consider extending the duration of treatment and follow-up. The minimum clinically important difference also needs to be confirmed in children with ASD using outcome scales validated for this population.

Effects associated with on- and off-label stimulant treatment of core autism and ADHD symptoms exhibited by children with autism spectrum disorder

OBJECTIVE

Families of children with autism spectrum disorder are barraged by different treatment options. Some of these options have the support of empirical evidence while others do not. Stimulant treatments are typically utilized to treat symptoms of ADHD indicating an on-label use of such treatment.

METHODS

This study examines the association of stimulant treatment with the on- (symptoms of ADHD) and off- (symptoms of ASD) label symptoms among children with ASD via a non-clinical, population-based sample.

RESULTS

Results indicate no significant association of stimulant treatment with a reduction of on- or off-label symptoms among children with ASD.

CONCLUSION

Stimulant medications utilized in the treatment of DSM core symptoms of autism spectrum disorder would be considered an off-label use because there is limited evidence to support that stimulants are effective in treating core symptoms of ASD, which is supported by the results of the current study.

Bipolar disorder in adults with Asperger׳s Syndrome: a systematic review

BACKGROUND

Asperger׳s Syndrome (AS) is a neurodevelopmental disorder included in the Autism Spectrum (ASD). The current literature shows growing evidence of a high rate of comorbidity between AS and other psychiatric disorders, particularly Bipolar Disorder (BD). We reviewed available epidemiological and clinical data on BD-AS comorbidity and its diagnostic and therapeutic implications

METHODS

A systematic review of the literature was conducted through PubMed, Scopus and Psych-Info using combinations of the following search terms: Asperger׳s Syndrome, Bipolar Disorder, depression, mood disorder, psychiatric comorbidity, treatment, mood stabilizers, anticonvulsants, antipsychotics, and antidepressants.

RESULTS

BD prevalence in adults with AS ranges from 6% to 21.4% of the cases. Relatives of patients with AS showed a doubled risk of being affected by BD and a BD prevalence near to 10%. When comorbid with AS, BD assumes peculiar features which might shape its under-recognition or misdiagnosis (especially schizophrenia when psychotic symptoms are prominent). Although controlled data on pharmacological treatments in BD-AS comorbidity are substantially lacking, information is derived by open observations, case series and chart reviews. Mood stabilizers should be considered the first choice, and antipsychotics, especially second generation drugs (SGA) with 5-HT2a antagonism, have been shown useful in controlling psychotic and behavioral symptoms and improving social withdrawal. Some evidence of efficacy for the treatment of anxiety, obsessive-compulsive symptoms and depression is reported for SSRI antidepressants. The use of these drugs should be carefully monitored, because activation with hypomanic or manic switches is reported up to 54% of the treated subjects.

CONCLUSION

BD in AS patients is frequent, usually it onsets during adolescence and is often characterized by atypical presentation, making its correct identification particularly difficult. A correct diagnosis of BD in AS individuals has relevant implications on the choice of adequate psychopharmacological, psycho-social and rehabilitative treatments.

The comorbidity of ADHD and autism spectrum disorder

ADHD and autism spectrum disorder are common psychiatric comorbidities to each another. In addition, there is behavioral, biological and neuropsychological overlap between the two disorders. There are also several important differences between autism spectrum disorder and ADHD. Treatment strategies for the comorbid condition will also be reviewed. Future areas of research and clinical need will be discussed.

Prefrontal activation during inhibitory control measured by near-infrared spectroscopy for differentiating between autism spectrum disorders and attention deficit hyperactivity disorder in adults

The differential diagnosis of autism spectrum disorders (ASDs) and attention deficit hyperactivity disorder (ADHD) based solely on symptomatic and behavioral assessments can be difficult, even for experts. Thus, the development of a neuroimaging marker that differentiates ASDs from ADHD would be an important contribution to this field. We assessed the differences in prefrontal activation between adults with ASDs and ADHD using an entirely non-invasive and portable neuroimaging tool, near-infrared spectroscopy. This study included 21 drug-naïve adults with ASDs, 19 drug-naïve adults with ADHD, and 21 healthy subjects matched for age, sex, and IQ. Oxygenated hemoglobin concentration changes in the prefrontal cortex were assessed during a stop signal task and a verbal fluency task. During the stop signal task, compared to the control group, the ASDs group exhibited lower activation in a broad prefrontal area, whereas the ADHD group showed underactivation of the right premotor area, right presupplementary motor area, and bilateral dorsolateral prefrontal cortices. Significant differences were observed in the left ventrolateral prefrontal cortex between the ASDs and ADHD groups during the stop signal task. The leave-one-out cross-validation method using mean oxygenated hemoglobin changes yielded a classification accuracy of 81.4% during inhibitory control. These results were task specific, as the brain activation pattern observed during the verbal fluency task did not differentiate the ASDs and ADHD groups significantly. This study therefore provides evidence of a difference in left ventrolateral prefrontal activation during inhibitory control between adults with ASDs and ADHD. Thus, near-infrared spectroscopy may be useful as an auxiliary tool for the differential diagnosis of such developmental disorders.

Efficacy of atomoxetine for the treatment of ADHD symptoms in patients with pervasive developmental disorders: a prospective, open-label study

OBJECTIVE

Atomoxetine's tolerance and efficacy were studied in 24 patients with pervasive developmental disorder and symptoms of ADHD.

METHOD

Prospective, open-label, 16-week study was performed, using the variables of the Clinical Global Impression Scale and the Conners' Scale, among others.

RESULTS

A significant difference was found between pre- and posttreatment scores as well as a significant reduction was found on the scales used. Only five patients presented adverse events.

CONCLUSION

Atomoxetine therefore appears to be a useful drug, pointing to the need for larger, randomized, controlled, double-blind studies to confirm its efficacy versus placebo and in comparison with other treatment options.

Effects of extended release methylphenidate treatment on ratings of attention-deficit/hyperactivity disorder (ADHD) and associated behavior in children with autism spectrum disorders and ADHD symptoms

OBJECTIVE

The purpose of this study was to examine the behavioral effects of four doses of psychostimulant medication, combining extended-release methylphenidate (MPH) in the morning with immediate-release MPH in the afternoon.

METHOD

The sample comprised 24 children (19 boys; 5 girls) who met American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV-TR) criteria for an autism spectrum disorder (ASD) on the Autism Diagnostic Interview-Revised (ADI-R) and the Autism Diagnostic Observation Schedule (ADOS), and had significant symptoms of attention-deficit/hyperactivity disorder (ADHD). This sample consisted of elementary school-age, community-based children (mean chronological age=8.8 years, SD=1.7; mean intelligence quotient [IQ]=85; SD=16.8). Effects of four dose levels of MPH on parent and teacher behavioral ratings were investigated using a within-subject, crossover, placebo-controlled design.

RESULTS

MPH treatment was associated with significant declines in hyperactive and impulsive behavior at both home and school. Parents noted significant declines in inattentive and oppositional behavior, and improvements in social skills. No exacerbation of stereotypies was noted, and side effects were similar to those seen in typically developing children with ADHD. Dose response was primarily linear in the dose range studied.

CONCLUSIONS

The results of this study suggest that MPH formulations are efficacious and well-tolerated for children with ASD and significant ADHD symptoms.

Pharmacotherapy of autism spectrum disorders

Although no pharmacological or behavioral therapy has currently proven effective for treating all core symptoms of autism, many dysfunctional behaviors may be treated pharmacologically. Drug treatments should always be part of a comprehensive management plan that includes behavioral and educational interventions, and should be focused on specific targets. Several classes of psychotropic medications have been used to decrease the wide range of "maladaptive" or "interfering" behaviors and associated medical problems that can interfere with relationships and physical health and hinder the implementation of various non-pharmacological interventions. Atypical neuroleptics have been shown to be useful in the treatment of behavioral symptoms in autism. Attention deficit and hyperactivity disorder medications may be effective for counteracting the additional features of hyperactivity and short attention span. Antiepileptic drugs and selective serotonin reuptake inhibitors have shown promising results, but there are no specific indications for them as of yet. With respect to potential drug targets, some clinical features are caused by a dysfunction in neurochemical signaling systems, and thus may improve with selective pharmacological interventions acting on specific abnormal neurobiological pathways. Recent animal studies can be useful models for understanding the common pathogenic pathways leading to autism spectrum disorders (ASDs), and have the potential to offer new biologically focused treatment options.

Clinical practice pathways for evaluation and medication choice for attention-deficit/hyperactivity disorder symptoms in autism spectrum disorders

BACKGROUND AND OBJECTIVE

Hyperactivity, impulsivity, and inattention (referred to as "ADHD [attention-deficit/hyperactivity disorder] symptoms") occur in 41% to 78% of children with autism spectrum disorders (ASDs). These symptoms often affect quality of life, interfering with learning or interventions that target primary ASD symptoms. This practice pathway describes the guidelines for evaluation and treatment of children and adolescents with ASD and comorbid ADHD symptoms.

METHODS

Current research in this area is limited, and, therefore, these recommendations are based on a systematic literature review and expert consensus in the Autism Speaks Autism Treatment Network Psychopharmacology Committee.

RESULTS

The recommended practice pathway includes the Symptom Evaluation Pathway for systematic assessment of ADHD symptoms across settings; examination for comorbid sleep, medical, or psychiatric comorbidities that may contribute to symptoms; and evaluation of behavioral interventions that may ameliorate these symptoms. For children for whom medication is being considered to target the ADHD symptoms, the medication choice pathway provides guidance on the selection of the appropriate agent based on a review of available research, assessment of specific advantages and disadvantages of each agent, and dosing considerations.

CONCLUSIONS

These recommendations provide a framework for primary care providers treating children who have ASD and ADHD symptoms. Our systematic review of the current evidence indicates the need for more randomized controlled trials of the medications for ADHD symptoms in ASD. There will also be a need for studies of the effectiveness of these practice pathways in the future.

Komorbiditäten bei Autismus-Spektrum-Erkrankungen

Zahlreiche körperliche und psychopathologische Störungsbilder treten häufig bei Autismus-Spektrum-Erkrankungen auf. Derzeit wird diskutiert, ob zusätzlich auftretende psychopathologische Symptome eine eigene kategoriale komorbide Störung darstellen und als solche diagnostiziert werden dürfen oder ob sie als Teil der autistischen Störung zu verstehen sind. Anhand der Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) wird ausgehend vom aktuellen Forschungsstand und eigener Forschungsergebnisse beispielhaft dargestellt, welche Voraussetzung für eine komorbide Störung erfüllt sein sollten und welche Bedingungen sich aufgrund neurobiologischer Ergebnisse aus dem Bereich der Molekularbiologie, Neuropsychologie und Bildgebung für Ätiologie, Früherkennung, pharmakologische und psychotherapeutische Behandlung, Verlauf und den kategorialen Klassifikationsansatz ergeben.

Psychopharmacological treatment of ADHD symptoms in children with autism spectrum disorder

One of the most frequently reported behavioral concerns among children with autism spectrum disorder (ASD) is high rates of activity and inattention, symptoms that are often associated with attention deficit hyperactivity disorder (ADHD). Although there is a considerable body of research regarding the appropriate treatment of ADHD symptoms among typically developing children, the research among children with ASD is more limited. The evidence to date suggests that medication response rates among children with ASD are considerably lower than among typically developing children and that children with ASD tend to be at greater risk for experiencing side effects. The purpose of the present paper is to review the available research on the treatment of ADHD symptoms in children with ASD. This paper summarizes the data on a range of pharmacological options and provides specific recommendations for how best to clinically manage these symptoms.

Management of symptoms in children with autism spectrum disorders: a comprehensive review of pharmacologic and complementary-alternative medicine treatments

In the care of children with autism spectrum disorders (ASD), medical treatment is typically considered an adjunct to educational and behavioral interventions. Nonetheless, large proportions of children with ASD are managed medically and receive both pharmacologic and complementary-alternative medicine (CAM) treatments. Although many medical treatments have been studied in children with ASD, studies vary widely in terms of the sample, sample size, research design, purposes of treatment, and measurements of change. Surprisingly, comprehensive reviews of the options for medical management in ASD are lacking, particularly reviews that address both pharmacologic and CAM treatments. Furthermore, reviews to date tend to emphasize general effects of medication; this perspective contradicts medical practice, which targets particular symptoms during treatment selection and monitoring. This review of 115 studies adds to the ASD treatment literature by (1) including studies of individuals 0 to 22 years of age; (2) aggregating studies of pharmacologic treatments and CAM treatments; and importantly, (3) organizing treatment response by ASD symptoms, differentiating core and associated symptoms.

Diagnostik und Therapie von Autismus-Spektrum-Störungen im Kindesalter

Bei Autismus-Spektrum-Störungen (ASD) handelt es sich um komplexe Störungsbilder, die gerade im Kindesalter aufgrund der vielfältigen Differentialdiagnosen einer multidisziplinären und mehrschrittigen Diagnostik bedürfen. Eine Früherkennung autistischer Störungen ist ab dem zweiten Lebensjahr möglich. Standardisierte Verfahren verbessern die diagnostische Validität, erfordern jedoch eine fundierte kinder- und jugendpsychiatrische Expertise. Generell ist in der Behandlung ein ganzheitlicher, die Gesamtentwicklung des Kindes mit ASD umfassender Therapie- und Förderansatz zu verfolgen. Früh beginnende, intensive, verhaltenstherapeutische Interventionen unter Einbezug der Eltern haben sich als wirksam erwiesen. Die pharmakologische Behandlung von begleitenden Auffälligkeiten kann als ergänzende Maßnahme sinnvoll sein, da das Ansprechen auf pädagogische und psychotherapeutische Maßnahmen hierdurch verbessert werden kann.

Randomized, placebo-controlled, crossover study of methylphenidate for attention-deficit/hyperactivity disorder symptoms in preschoolers with developmental disorders

OBJECTIVE

The aim of this study was to investigate the short-term efficacy and safety of methylphenidate (MPH) to treat attention-deficit/hyperactivity disorder (ADHD) symptoms in an understudied population of preschoolers with pervasive developmental disorder (PDD) or intellectual disability (ID).

METHODS

Fourteen preschoolers with developmental disorders (DD, n = 14; PDD, n = 12; ID, n = 2) underwent MPH titration in a single-blind manner followed by a 4-week double-blind crossover phase. Each child was administered placebo for 2 weeks and "optimal dose" for 2 weeks. The primary outcome measure was the Diagnostic and Statistical Manual of Mental Disorders, 4(th) edition (DSM-IV) ADHD subscale of the Conners' Parent Rating Scale-Revised (CPRS-R-DSM-IV-ADHD).

RESULTS

MPH improved parent-rated ADHD symptoms of the preschoolers; 50% were rated as responders. The CPRS-R-DSM-IV-ADHD subscale was significant for the PDD subgroup (p = 0.005, Cohen d = 0.97) and marginally significant for the entire DD sample (p = 0.08, Cohen d = 0.50). Half of the preschoolers experienced side effects with MPH, including reports of increased stereotypic behavior, upset stomach, sleep-related difficulties, and emotional lability. One child discontinued during titration due to side effects.

CONCLUSION

The predominant direction of response in these preschoolers with both ADHD and PDD/ID favored MPH, even though the response was more subtle and variable than in older and typically developing children. Due to high rates of adverse effects, preschoolers should be monitored closely.

Child and adolescent psychopharmacology update

Understanding pediatric psychopharmacology often is an important part of the practice of a general psychiatrist, as a substantial number of children and adolescents are affected by a major psychiatric illness. A general psychiatrist should consider some key issues before he or she begins prescribing psychotropic medications to children and adolescents. Some agents that are effective in adults may not be effective in youths, and similarly, medications that are well tolerated in adults may be associated with accentuated or additional risks when prescribed to young people. This article is an effort to summarize the recent advances in medication therapy of the pediatric population and bring the general psychiatrist up to date on the evidence-based psychopharmacologic treatment of children and adolescents.

Treatment of Inattention, Overactivity, and Impulsiveness in Autism Spectrum Disorders

We reviewed the recent literature on medicines used to manage inattention, impulsiveness, and overactivity in children with pervasive developmental disorders (autistic disorder, pervasive developmental disorder not otherwise specified, Asperger's disorder) using computer searches of pharmacologic studies. A substantial number of reports were identified and summarized. The literature tends to be dominated by uncontrolled studies, although the number of controlled trials is growing. Findings are described for psychostimulants, noradrenergic reuptake inhibitors, antipsychotics, alpha adrenergic agonists, antidepressants, anxiolytics, cholinesterase inhibitors, N-methyl-D-aspartate receptor blockers, and antiepileptic mood stabilizers. Evidence for a positive effect is strongest for psychostimulants, noradrenergic reuptake inhibitors, antipsychotics, and alpha adrenergic agonists. Evidence for efficacy seems weakest for newer antidepressants, anxiolytics, and mood stabilizers.

Pharmacological treatment options for autism spectrum disorders in children and adolescents

Autism and other pervasive developmental disorders (PDDs) are frequently associated with dysfunctional behaviors and are characterized by deficits in socialization, communication, and behavioral rigidity. Despite the absence of a pharmacological cure for PDDs, many of the dysfunctional, coinciding behaviors may be treated pharmacologically. This article reviews what is known about the efficacy and tolerability of pharmacological interventions for the treatment of children and adolescents suffering from autistic spectrum disorders.

Stimulant medication treatment of target behaviors in children with autism: a population-based study

OBJECTIVE

This study provides detailed information about stimulant medication treatment for the target symptoms of hyperactivity, impulsivity, disinhibition, and inattention in children with autism.

METHODS

In a previous study, 124 subjects fulfilling DSM-IV-based research criteria for autistic disorder were identified among all 0-21 year old residents of Olmsted County, MN from 1976-1997. For each of these 124 children with research-identified autism, information was abstracted on all prescribed psychopharmacological medications.

RESULTS

Psychostimulants were used to treat 52.4% (N = 65) of the 124 subjects. The median total duration of psychostimulant treatment was 4.0 years. There were 398 episodes of psychostimulant treatment. Favorable responses were associated with 69.4% of treatment episodes. Of the 398 episodes of stimulant treatment, 16.8% were associated with a documented side effect. At least one side effect was experienced by 66% of the children.

CONCLUSION

These results indicate that psychostimulants are commonly prescribed for children with autism, and suggest that these medications may improve the target symptoms of hyperactivity, impulsivity, disinhibition and inattention.

The status of pharmacotherapy for autism spectrum disorders

The use of pharmacologic agents as a component of treatment for children and adults with autism spectrum disorders is common and a substantial body of literature describing controlled and open-label clinical trials now exists to guide clinical practice. Empiric evidence of efficacy of risperidone, methylphenidate and some selective serotonin re-uptake inhibitors for maladaptive behaviors commonly associated with autism spectrum disorders has increased substantially in recent years. Preliminary controlled trials of valproate, atomoxetine, alpha-2 adrenergic agonists and olanzapine are promising. In addition to traditional psychotropic medications, investigators have examined the potential role of a variety of agents with glutamatergic or cholinergic mechanisms, and the results warrant further investigation. Although psychotropic medications are effective in treating some important associated behaviors, evidence of significant impact on the core features of autism spectrum disorders is very limited.

Psychopharmakologie autistischer Störungen

Zusammenfassung: Die Wirksamkeit pharmakologischer Interventionen beim Autismus wird derzeit vermehrt untersucht. Ziele der Interventionen sind vor allem ausagierende Begleitstörungen, die die Anwendung anderer therapeutischer Interventionen beträchtlich stören können, während die Kernsymptome des Autismus kaum beeinflussbar sind. Darüber hinaus fehlt derzeit die Evaluation von Kombinationstherapien, die in der praktischen klinischen Arbeit aber keine unwesentliche Rolle spielen. Es bleibt abzuwarten, ob in Zukunft die Wirksamkeit der Kombination von verhaltenstherapeutischen mit psychopharmakologischen Interventionen sowie der (mitunter sinnvoll erscheinenden) Kombination mehrerer Medikamente untersucht werden. Neuere Psychopharmaka erleichtern offensichtlich die Anwendung bei autistischen Störungen, auch aufgrund ihrer besseren Verträglichkeit. Die Verfügbarkeit von Studien mit einiger methodischer Sicherheit nimmt aber deutlich zu.

What do we know about the serotonergic genetic heterogeneity in attention-deficit/hyperactivity and autistic disorders?

BACKGROUND

Shared candidate gene regions point to a link between autistic disorders and attention-deficit/hyperactivity disorder (ADHD). Although they represent nosologically different diagnoses, the disorders do show some shared symptoms, above all inattention. For both disorders, the association with the serotonergic system is a focus of current research.

SAMPLING AND METHODS

The current work provides an overview of serotonergic mechanisms in ADHD and autistic disorders as well as the resulting pharmacogenetic approaches.

RESULTS

No uniform picture emerges either for ADHD or for autistic disorders. In pharmacogenetic terms, there are some isolated studies on associations between serotonergic mechanisms and pharmacotherapy. For the area of autism, such studies are still lacking.

CONCLUSIONS

The presented serotonergic mechanisms show relationships of this polymorphism to ADHD and autistic disorders, but they do not result in a uniform picture. The overlaps can best be explained by a dimensional classification approach. As yet, only a small number of studies on attentional disorders in autism and ADHD using shared samples have been carried out. With regard to diagnostics and therapy, analyses on the etiology of the attentional disorder of ADHD and autism are required.

An update on pharmacologic treatments for autism spectrum disorders

Increasingly recognized over the past 20 years, autism spectrum disorders (ASD) are heterogeneous. Medication treatments remain fundamentally ameliorative, so prioritizing symptoms and matching medications to the patient's constellation of symptoms remains the psychopharmacologic approach to ASD. Atypical antipsychotic medications and glutamatergic agents are receiving increased attention, and antidepressants are being examined for specific symptoms and for younger patients who have autism. Large multisite networks (Research Units on Pediatric Psychopharmacology; Studies to Advance Autism Research and Treatment) have been constructed to expedite studies to elucidate effective treatments for ASD. Findings from these networks are coupled with those from recent independent trials.

Autism spectrum disorders: emerging pharmacotherapy

Autism, Asperger and other pervasive developmental disorders (PDDs) are an increasingly commonly identified group of conditions wherein patients experience significant difficulty in social interactions, communicating with others, and inflexible adherence to unusual, unhelpful and frequently stereotyped routines and behaviour. These autism spectrum disorders are now being diagnosed earlier in life (approximately 15 months), and often remain a chronic, daily burden for those afflicted. In addition to the often profound impact on an individual's quality of life, the familial, social and economic burdens of PDDs can be enormous. No treatments are curative, and most pharmacological treatments are employed to treat specific troubling symptoms rather than the core features of the disorder itself. Therefore, more effective pharmacotherapies are desperately needed. This review describes current and emerging pharmacotherapies that may advance care of people with PDDs.

Pharmacotherapy of pervasive developmental disorders in children and adolescents

Pervasive developmental disorders (PDDs) are severe psychiatric disorders characterised by impaired social interaction, reduced verbal and nonverbal communication, and restricted and stereotyped patterns of interest and behaviour, with onset in the first 3 years of life. As part of a multimodal approach that includes educational and behavioural interventions, appropriate use of pharmacotherapy in patients with PDDs can improve some symptoms and behaviours and increase the patient's response to nonpharmacological interventions. Pharmacotherapy is aimed at stabilising the dysregulated systems that are thought to underlie the abnormal behaviours, namely the serotonergic and dopaminergic systems.This paper critically reviews the available literature on the pharmacotherapy of PDDs in children and adolescents. Pharmacological, efficacy and safety data on drugs acting on serotonin (serotonergic agents such as clomipramine, fluoxetine, paroxetine, sertraline, citalopram and fluvoxamine), on both serotonin and norepinephrine (venlafaxine and mirtazapine), dopamine (dopamine-blocking antipsychotics such as haloperidol and pimozide), and on both serotonin and dopamine (atypical antipsychotics such as clozapine, risperidone, olanzapine, quetiapine and ziprasidone) are presented. The paper concludes with a brief discussion of other psychotropic medications, such as the opioid antagonists, alpha-adrenoceptor agonists (clonidine and guanfacine), psychostimulants, mood stabilisers, glutamatergic compounds (lamotrigine, amantadine), buspirone, and secretin. Available evidence suggests that atypical antipsychotics (mainly risperidone and olanzapine) are particularly indicated when more serious behavioural symptoms, such as aggression, self-injurious behaviours and hyperactivity, are prominent. Serotonergic agents may be effective in children with repetitive phenomena or affective symptoms. Social relatedness is more frequently refractory to both atypical antipsychotics and serotonergic agents. Further research into the drug treatment of PDDs, including placebo-controlled trials and long-term, naturalistic follow-up studies of large samples of patients of different age ranges, is warranted.