Medical treatment of autism spectrum disorders

EEG findings and clinical severity and quality of life in non-epileptic patients with autism spectrum disorders

Electroencephalogram (EEG) abnormalities could be seen in up to 60% of non-epileptic children with autism spectrum disorder (ASD). They have been used as biomarkers of ASD severity. The objective of our study is to identify EEG abnormalities in children with different degrees of ASD severity based on the Autism Treatment Evaluation Checklist (ATEC). We also want to assess the quality of life for children with ASD. All of the children underwent at least one hour of sleep-deprived EEG. Forty-five children were enrolled, of whom 42 were male. EEG abnormalities were found in 10 (22.2%) children, predominantly in the bilateral frontal areas. There were no differences in EEG findings among the mild, moderate, and severe ASD groups. The severity of ASD was associated with female sex (p-value = 0.013), ASD with attention deficit hyperactivity disorder (ADHD) (p-value = 0.032), ASD children taking medications (p-value = 0.048), and a lower Pediatric Quality of Life Inventory (PedsQL) (p-value <0.001). Social and emotional domains were the most problematic for health-related quality of life in ASD children, according to parent reports of PedsQL. Further studies with a larger sample size will help to clarify the potential associations between EEG abnormalities and the severity of ASD, as well as the impact on quality of life.

Indifference or hypersensitivity? Solving the riddle of the pain profile in individuals with autism

ABSTRACT

Excitatory-inhibitory (E/I) imbalance is a mechanism that underlies autism spectrum disorder, but it is not systematically tested for pain processing. We hypothesized that the pain modulation profile (PMP) in autistic individuals is characterized by less efficient inhibitory processes together with a facilitative state, indicative of a pronociceptive PMP. Fifty-two adults diagnosed with autism and 52 healthy subjects, age matched and sex matched, underwent quantitative sensory testing to assess the function of the (1) pain facilitatory responses to phasic, repetitive, and tonic heat pain stimuli and (2) pain inhibitory processes of habituation and conditioned pain modulation. Anxiety, pain catastrophizing, sensory, and pain sensitivity were self-reported. The autistic group reported significantly higher pain ratings of suprathreshold single ( P = 0.001), repetitive (46°C- P = 0.018; 49°C- P = 0.003; 52°C- P < 0.001), and tonic ( P = 0.013) heat stimuli that were cross correlated ( r = 0.48-0.83; P < 0.001) and associated with sensitivity to daily life pain situations ( r = 0.39-0.45; P < 0.005) but not with psychological distress levels. Hypersensitivity to experimental pain was attributed to greater autism severity and sensory hypersensitivity to daily stimuli. Subjects with autism efficiently inhibited phasic but not tonic heat stimuli during conditioned pain modulation. In conclusion, in line with the E/I imbalance mechanism, autism is associated with a pronociceptive PMP expressed by hypersensitivity to daily stimuli and experimental pain and less-efficient inhibition of tonic pain. The latter is an experimental pain model resembling clinical pain. These results challenge the widely held belief that individuals with autism are indifferent to pain and should raise caregivers' awareness of pain sensitivity in autism.

Co-occurring conditions in children with Down syndrome and autism: a retrospective study

BACKGROUND

Down syndrome (DS) is one of the most common genetic causes of intellectual disability, and it is associated with an increased incidence of numerous co-occurring conditions. Autism spectrum disorder (ASD) is common in persons with DS, with rates reported as high as 39%. However, little is known regarding co-occurring conditions in children with both DS and ASD.

METHODS

A single-center retrospective review of prospective longitudinally collected clinical data was performed. Any patient with a confirmed diagnosis of DS evaluated at a large, specialized Down Syndrome Program in a tertiary pediatric medical center between March 2018 and March 2022 was included. A standardized survey which included demographic and clinical questions was administered during each clinical evaluation.

RESULTS

In total, 562 individuals with DS were included. The median age was 10 years (IQR: 6.18-13.92). Of this group, 72 (13%) had a co-occurring diagnosis of ASD (DS+ASD). Individuals with DS+ASD were more likely to be male (OR 2.23, CI 1.29-3.84) and had higher odds of a current or prior diagnosis of constipation (OR 2.19, CI 1.31-3.65), gastroesophageal reflux (OR 1.91, CI 1.14-3.21), behavioral feeding difficulties (OR 2.71, CI 1.02-7.19), infantile spasms (OR 6.03, CI 1.79-20.34) and scoliosis (OR 2.73, CI 1.16-6.40). There were lower odds of congenital heart disease in the DS+ASD group (OR 0.56, CI 0.34-0.93). There was no observed difference in prematurity or Neonatal Intensive Care Unit complications between groups. Individuals with DS+ASD had similar odds of having a history of congenital heart defect requiring surgery to those with DS only. Furthermore, there was no difference in rates of autoimmune thyroiditis or celiac disease. There was also no difference in rates of diagnosed co-occurring neurodevelopmental or mental health conditions in this cohort, including anxiety disorders and attention-deficit/hyperactivity disorder.

CONCLUSIONS

This study identifies a variety of medical conditions which are more frequent in children with DS+ASD than DS alone, providing important information for the clinical management of these patients. Future research should investigate the role of some of these medical conditions in the development of ASD phenotypes, and whether there may be distinct genetic and metabolic contributions towards these conditions.

Catecholaminergic and cholinergic neuromodulation in autism spectrum disorder: A comparison to attention-deficit hyperactivity disorder

Autism spectrum disorder (ASD) is a heterogeneous neurodevelopmental disorder characterized by social impairments and restricted, repetitive behaviors. Treatment of ASD is notoriously difficult and might benefit from identification of underlying mechanisms that overlap with those disturbed in other developmental disorders, for which treatment options are more obvious. One example of the latter is attention-deficit hyperactivity disorder (ADHD), given the efficacy of especially stimulants in treatment of ADHD. Deficiencies in catecholaminergic systems [dopamine (DA), norepinephrine (NE)] in ADHD are obvious targets for stimulant treatment. Recent findings suggest that dysfunction in catecholaminergic systems may also be a factor in at least a subgroup of ASD. In this review we scrutinize the evidence for catecholaminergic mechanisms underlying ASD symptoms, and also include in this analysis a third classic ascending arousing system, the acetylcholinergic (ACh) network. We complement this with a comprehensive review of DA-, NE-, and ACh-targeted interventions in ASD, and an exploratory search for potential treatment-response predictors (biomarkers) in ASD, genetically or otherwise. Based on this review and analysis we propose that (1) stimulant treatment may be a viable option for an ASD subcategory, possibly defined by genetic subtyping; (2) cerebellar dysfunction is pronounced for a relatively small ADHD subgroup but much more common in ASD and in both cases may point toward NE- or ACh-directed intervention; (3) deficiency of the cortical salience network is sizable in subgroups of both disorders, and biomarkers such as eye blink rate and pupillometric data may predict the efficacy of targeting this underlying deficiency via DA, NE, or ACh in both ASD and ADHD.

Empirical Study of Autism Spectrum Disorder Diagnosis Using Facial Images by Improved Transfer Learning Approach

Autism spectrum disorder (ASD) is a neurological illness characterized by deficits in cognition, physical activities, and social skills. There is no specific medication to treat this illness; only early intervention can improve brain functionality. Since there is no medical test to identify ASD, a diagnosis might be challenging. In order to determine a diagnosis, doctors consider the child's behavior and developmental history. The human face can be used as a biomarker as it is one of the potential reflections of the brain and thus can be used as a simple and handy tool for early diagnosis. This study uses several deep convolutional neural network (CNN)-based transfer learning approaches to detect autistic children using the facial image. An empirical study is conducted to select the best optimizer and set of hyperparameters to achieve better prediction accuracy using the CNN model. After training and validating with the optimized setting, the modified Xception model demonstrates the best performance by achieving an accuracy of 95% on the test set, whereas the VGG19, ResNet50V2, MobileNetV2, and EfficientNetB0 achieved 86.5%, 94%, 92%, and 85.8%, accuracy, respectively. Our preliminary computational results demonstrate that our transfer learning approaches outperformed existing methods. Our modified model can be employed to assist doctors and practitioners in validating their initial screening to detect children with ASD disease.

Clinical Targeted Panel Sequencing Analysis in Clinical Evaluation of Children with Autism Spectrum Disorder in China

Autism spectrum disorder (ASD) is an early-onset neurodevelopmental disorder in which genetics play a major role. Molecular diagnosis may lead to a more accurate prognosis, improved clinical management, and potential treatment of the condition. Both copy number variations (CNVs) and single nucleotide variations (SNVs) have been reported to contribute to the genetic etiology of ASD. The effectiveness and validity of clinical targeted panel sequencing (CTPS) designed to analyze both CNVs and SNVs can be evaluated in different ASD cohorts. CTPS was performed on 573 patients with the diagnosis of ASD. Medical records of positive CTPS cases were further reviewed and analyzed. Additional medical examinations were performed for a group of selective cases. Positive molecular findings were confirmed by orthogonal methods. The overall positive rate was 19.16% (109/569) in our cohort. About 13.89% (79/569) and 4.40% (25/569) of cases had SNVs only and CNVs only findings, respectively, while 0.9% (5/569) of cases had both SNV and CNV findings. For cases with SNVs findings, the SHANK3 gene has the greatest number of reportable variants, followed by gene MYT1L. Patients with MYT1L variants share common and specific clinical characteristics. We found a child with compound heterozygous SLC26A4 variants had an enlarged vestibular aqueduct syndrome and autistic phenotype. Our results showed that CTPS is an effective molecular diagnostic tool for ASD. Thorough clinical and genetic evaluation of ASD can lead to more accurate diagnosis and better management of the condition.

Nursing care for pediatric patients with autism spectrum disorders: A cross-sectional survey of perceptions and strategies

PURPOSE

The purpose of this study is to describe nursing staff perspectives about caring for children with autism spectrum disorders (ASD) in the hospital, strategies they use to support care, and relationships between these factors.

DESIGN AND METHODS

A descriptive, cross-sectional survey design with nursing staff at a large pediatric hospital system in the United States was employed. The researcher-designed, pilot-tested survey assessed participant demographics, knowledge about ASD, perceived effectiveness caring for children with ASD, previous training, and current strategy use. Data analysis involved descriptive statistics, correlations, and group comparisons based on interaction frequency with the population and previous training.

RESULTS

The participants involved 90 pediatric hospital nursing staff members providing direct care. Respondents demonstrated 90% accurate knowledge of the characteristics of ASD. Self-reported effectiveness in caring for children with ASD did not correlate with knowledge and significantly correlated with an increased number of strategies. Nursing staff with frequent interaction with people with ASD or those with previous training reported significantly more strategies to care for children with ASD. Only 35% of participants reported that they have adequate strategies to care for children with ASD in the hospital.

PRACTICE IMPLICATIONS

Having more strategies was the factor associated with higher self-efficacy, so training for nursing staff should focus on increasing the number of strategies to use with children with ASD in the hospital and provide mechanisms to collaborate with other professionals to individualize strategies to meet each child's needs.

Evaluating sleep quality using the CSHQ-Autism

BACKGROUND

Sleep problems are common in autistic children and adversely impact daytime functioning. The Children's Sleep Habits Questionnaire (CSHQ) [39] was developed from a community-based sample of children and has validated a cut-off score of 41. Katz et al. [50] developed an abbreviated 23-item four-factor version of the CSHQ, which may be useful when assessing sleep in autistic children. However, a cut-off value has not yet been developed.

OBJECTIVE

Our objective was to develop and validate a cut-off for the CSHQ-autism total score in order to identify sleep problems among autistic children. We hypothesized that the derived cut-off value for the CSHQ-autism would perform better than the original CSHQ cut at 41 on validation in a sample of autistic children.

METHODS

Age-specific cut-off values were developed and validated using receiver operating characteristic analysis.

RESULTS

The derived cut-off values for the CSHQ-autism total score were 34, 35, 33, and 35 for the 2-3, 4-10, 11-17, and 2-17 years age groups, respectively. On validation, all cut-off values performed with moderate to high sensitivity (76.6-82.4%) and moderate specificity (69.1-75.5%), while the original CSHQ cut at 41 had high sensitivity (89.9-93.0%) but low specificity (42.6-57.7%). Using McNemar's tests, the CSHQ-autism had significantly higher specificity but lower sensitivity than the original CSHQ cut at 41 in all age groups.

CONCLUSIONS

The CSHQ-autism cut-off values performed better overall than the original CSHQ cut at 41 in a sample of autistic children. The CSHQ-autism cut-off can help identify sleep problems among autistic children.

Comorbidity and health services' usage in children with autism spectrum disorder: a nested case-control study

AIMS

Children with autism spectrum disorder (ASD) tend to suffer from various medical comorbidities. We studied the comorbidity burden and health services' utilisation of children with ASD to highlight potential aetiologies and to better understand the medical needs of these children.

METHODS

In this nested case-control study, ASD cases and controls - matched by age, sex and ethnicity in a 1:5 ratio - were sampled from all children born between 2009 and 2016 at a tertiary medical centre. Data were obtained from the hospital's electronic database. Comorbid diagnoses were classified according to pathophysiological aetiology and anatomical/systemic classification of disease. Standard univariate and multivariate statistics were used to demonstrate comorbidities and health services' utilisation patterns that are significantly associated with ASD.

RESULTS

ASD children had higher rates of comorbidities according to both pathophysiological and anatomical/systemic classifications (p < 0.001). The most marked significant differences were observed for: hearing impairments (OR = 4.728; 95% CI 2.207-10.127) and other auricular conditions (OR = 5.040; 95% CI 1.759-14.438); neurological (OR = 8.198; 95% CI 5.690-11.813) and ophthalmological (OR = 3.381; 95% CI 1.617-7.068) conditions; and ADD/ADHD (OR = 3.246; 95% CI 1.811-5.818). A subgroup analysis revealed a more profound case-control difference in anaemia rates among girls than in boys (OR = 3.25; 95% CI 1.04-10.19 v. OR = 0.74; 95% CI 0.33-1.64 respectively) and an opposite trend (larger differences in males than in females in cardiovascular diseases (OR = 1.99; 95% CI 1.23-3.23 v. OR = 0.76; 95% CI 0.17-3.45, respectively)). In addition, larger case-control differences were seen among Bedouin children than in Jewish children in a number of medical comorbidities (Breslow-Day test for homogeneity of odds ratio p-value <0.05). Finally, we found that children with ASD tended to be referred to the emergency department and to be admitted to the hospital more frequently than children without ASD, even after adjusting for their comorbidity burden (aOR = 1.28; 95% CI 1.08-1.50 and aOR = 1.28; 95% CI 1.11-1.47 for >1 referrals and admissions per year, respectively).

CONCLUSIONS

The findings of this study contribute to the overall understanding of comorbid conditions and health services' utilisation for children with ASD. The higher prevalences of comorbidities and healthcare services' utilisation for children with ASD highlight the additional medical burden associated with this condition.

Identification, Evaluation, and Management of Children With Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a common neurodevelopmental disorder with reported prevalence in the United States of 1 in 59 children (approximately 1.7%). Core deficits are identified in 2 domains: social communication/interaction and restrictive, repetitive patterns of behavior. Children and youth with ASD have service needs in behavioral, educational, health, leisure, family support, and other areas. Standardized screening for ASD at 18 and 24 months of age with ongoing developmental surveillance continues to be recommended in primary care (although it may be performed in other settings), because ASD is common, can be diagnosed as young as 18 months of age, and has evidenced-based interventions that may improve function. More accurate and culturally sensitive screening approaches are needed. Primary care providers should be familiar with the diagnostic criteria for ASD, appropriate etiologic evaluation, and co-occurring medical and behavioral conditions (such as disorders of sleep and feeding, gastrointestinal tract symptoms, obesity, seizures, attention-deficit/hyperactivity disorder, anxiety, and wandering) that affect the child's function and quality of life. There is an increasing evidence base to support behavioral and other interventions to address specific skills and symptoms. Shared decision making calls for collaboration with families in evaluation and choice of interventions.  This single clinical report updates the 2007 American Academy of Pediatrics clinical reports on the evaluation and treatment of ASD in one publication with an online table of contents and section view available through the American Academy of Pediatrics Gateway to help the reader identify topic areas within the report.

Modification of the Children's Sleep Habits Questionnaire for Children with Autism Spectrum Disorder

Sleep problems are common in children with autism spectrum disorder (ASD) and adversely impact daytime functioning. Although no questionnaires have been developed to assess sleep in children with ASD, the 33-item Children's Sleep Habits Questionnaire (CSHQ) is widely used in this population. We examined the factor structure of the CSHQ in 2872 children (age 4-10 years) enrolled in the Autism Treatment Network. A four-factor solution (Sleep Initiation and Duration, Sleep Anxiety/Co-Sleeping, Night Waking/Parasomnias, and Daytime Alertness) with 5-6 items per factor explained 75% of the total variation. Ten items failed to load on any factor. This abbreviated 23-item four-factor version of this measure may be useful when assessing sleep in children with ASD.

Salivary Factors Related to Caries in Children with Autism

Many predisposing factors to caries are present in autism, however, it is unlikely that autistic patients exhibit higher caries indexes than the rest of the population.

OBJECTIVE

To evaluate salivary factors related to caries in autistic patients.

STUDY DESIGN

34 autistics and 34 controls aged between 4-13 years old were included. Decayed, missing, and filled teeth (DMFT) index and oral hygiene simplified index (IHO-S) were assessed, as well as, pH, total proteins, phosphate, calcium and IgA in saliva. All data were analyzed by chi² and Student t tests for independent samples. P values<0.05 were considered statistically significant.

RESULTS

Autistic patients showed less caries than controls (p≤0.001), DMFT was 1±1 and 3±2 respectively (p≤0.001). In relation to IHO-S, values increased (p=0.008) in autistic patients (2.25±0.78) compared to controls (1.79±0.59), however Salivary ph means were similar (7.20±0.48 and 7.27±0.34 respectively). Decreased calcium levels (p=0.013) were observed in autistics (0.621±0.35 mmol/L) compared to controls (0.89±0.51 mmol/L), but phosphate levels were similar (6.17±4.22 M, 5.51±4.86 M respectively). When total proteins of saliva were assessed, autistics showed a slight increment (2.65±1.81 mg/mL) compared to controls (2.24±1.27 mg/mL) and zymography showed a higher proteolytic activity in autistic children. Finally, IgA concentration reached 116.55±90.97 μg/mL in autistics and 161.61 ± 193.37μg/mL (p=0.527) in the control group.

CONCLUSIONS

Even though patients with autism exhibited a poorer oral hygiene, caries indexes were lower, calcium levels in saliva were found to be lesser and phosphate levels higher.

Predicting sleep problems in children with autism spectrum disorders

BACKGROUND

Sleep difficulties in children with autism spectrum disorders (ASD) have been well-established.

AIMS

To develop a model to predict sleep problems in children with ASD.

METHODS AND PROCEDURES

A sample of children in the Autism Speaks-Autism Treatment Network (ATN) registry without parent-reported sleep problems at baseline and with sleep problem (yes/no) data at first annual followup was randomly split into training (n = 527) and test (n = 518) samples. Model predictors were selected using the training sample, and a threshold for classifying children at risk was determined. Comparison of the predicted and true sleep problem status of the test sample yielded model performance measures.

OUTCOMES AND RESULTS

In a multivariable model aggressive behavior among children with no sleep problems reported at baseline was associated with having more sleep problems at the first annual follow-up visit. This model performed in the test sample with high sensitivity and accurate prediction of low risk.

CONCLUSIONS AND IMPLICATIONS

Among children with ASD aggressive behavior independently predicts sleep problems. The model's high sensitivity for identifying children at risk and its accurate prediction of low risk can help with treatment and prevention of sleep problems. Further data collection may provide better prediction through methods requiring larger samples.

Frequency and association of mitochondrial genetic variants with neurological disorders

Mitochondria are small cytosolic organelles and the main source of energy production for the cells, especially in the brain. This organelle has its own genome, the mitochondrial DNA (mtDNA), and genetic variants in this molecule can alter the normal energy metabolism in the brain, contributing to the development of a wide assortment of Neurological Disorders (ND), including neurodevelopmental syndromes, neurodegenerative diseases and neuropsychiatric disorders. These ND are comprised by a heterogeneous group of syndromes and diseases that encompass different cognitive phenotypes and behavioral disorders, such as autism, Asperger's syndrome, pervasive developmental disorder, attention deficit hyperactivity disorder, Huntington disease, Leigh Syndrome and bipolar disorder. In this work we carried out a Systematic Literature Review (SLR) to identify and describe the mitochondrial genetic variants associated with the occurrence of ND. Most of genetic variants found in mtDNA were associated with Single Nucleotide Polimorphisms (SNPs), ~79%, with ~15% corresponding to deletions, ~3% to Copy Number Variations (CNVs), ~2% to insertions and another 1% included mtDNA replication problems and genetic rearrangements. We also found that most of the variants were associated with coding regions of mitochondrial proteins but were also found in regulatory transcripts (tRNA and rRNA) and in the D-Loop replication region of the mtDNA. After analysis of mtDNA deletions and CNV, none of them occur in the D-Loop region. This SLR shows that all transcribed mtDNA molecules have mutations correlated with ND. Finally, we describe that all mtDNA variants found were associated with deterioration of cognitive (dementia) and intellectual functions, learning disabilities, developmental delays, and personality and behavior problems.

Family-Driven Goals to Improve Care for Children With Autism Spectrum Disorder

OBJECTIVES

Constipation and insomnia are not consistently identified and treated in children with autism spectrum disorder (ASD) despite their high prevalence and deleterious impact in this population. To standardize care, a constipation practice pathway and an insomnia practice pathway were previously developed by Autism Treatment Network clinicians. Our objective was to implement and refine these practice pathways in clinical settings.

METHODS

Eleven Autism Treatment Network sites participated in a Learning Collaborative (ie, multidisciplinary quality improvement team) and chose to implement either the constipation or insomnia practice pathway in the clinical setting. Families set intervention goals (eg, increase stool frequency, decrease nighttime awakenings) before treatment. Each site began implementation with 1 patient and then increased implementation by factors of 5. Before each increase, the Learning Collaborative evaluated progress and refined the practice pathways. Process improvement was measured primarily by duration until goal attainment and by percentage of families who meet their goals.

RESULTS

Across sites, 82 children with ASD and constipation and 101 children with ASD and insomnia were managed. Difficulties with intervention adherence and communication between providers and families were reported and were subsequently improved with parallel refinements to both practice pathways. The most notable modification was incorporating a goal-setting session in which families generated their own intervention goals (ie, family-driven goals). In this quality improvement initiative, 75% of families met at least 1 constipation or insomnia goal, with the median time to improvement being 6 weeks.

CONCLUSIONS

By integrating a family-centered approach into the standardization of care, constipation and insomnia practice pathways may improve engagement, adherence, and management of medical conditions in children with ASD.

A Profile on Emergency Department Utilization in Adolescents and Young Adults with Autism Spectrum Disorders

There has been an increase in utilization of the Emergency Department (ED) in individuals with autism spectrum disorder (ASD) which may reflect a deficit of services (Green et al., Journal of the American Academy of Child and Adolescent Psychiatry 40(3):325-332, 2001; Gurney et al., Archives of Pediatric and Adolescent Medicine 160:825-830, 2006; Leichtman et al., American Journal of Orthopsyhciatry 72(2):227-235, 2001). The current study examined the rates of ED utilization between 2005 and 2013 in ASD youth 12- to 21-years-old. Adolescents with ASD accessed ED services four times as often as adolescents without ASD. Older adolescents and those living in rural areas showed a significant increase in ED visits over time. Post hoc analysis revealed increased ED utilization for females and behavioral health ED services over time. Better access to and greater understanding of services for adolescents with ASD is a critical need.

Extracting autism spectrum disorder data from the electronic health record

BACKGROUND

Little is known about the health care utilization patterns of individuals with pediatric autism spectrum disorder (ASD).

OBJECTIVES

Electronic health record (EHR) data provide an opportunity to study medical utilization and track outcomes among children with ASD.  Methods: Using a pediatric, tertiary, academic hospital's Epic EHR, search queries were built to identify individuals aged 2-18 with International Classification of Diseases, Ninth Revision (ICD-9) codes, 299.00, 299.10, and 299.80 in their records. Codes were entered in the EHR using four different workflows: (1) during an ambulatory visit, (2) abstracted by Health Information Management (HIM) for an encounter, (3) recorded on the patient problem list, or (4) added as a chief complaint during an Emergency Department visit. Once individuals were identified, demographics, scheduling, procedures, and prescribed medications were extracted for all patient-related encounters for the period October 2010 through September 2012.

RESULTS

There were 100,000 encounters for more than 4,800 unique individuals. Individuals were most frequently identified with an HIM abstracted code (82.6%) and least likely to be identified by a chief complaint (45.8%). Categorical frequency for reported race (2 = 816.5, p < 0.001); payor type (2 = 354.1, p < 0.001); encounter type (2 = 1497.0, p < 0.001); and department (2 = 3722.8, p < 0.001) differed by search query. Challenges encountered included, locating available discrete data elements and missing data.

CONCLUSIONS

This study identifies challenges inherent in designing inclusive algorithms for identifying individuals with ASD and demonstrates the utility of employing multiple extractions to improve the completeness and quality of EHR data when conducting research.

An online ASD learning module for pediatric health care professionals

Purpose

Youth with autism spectrum disorder (ASD) often have co-occurring health care needs and are likely to come into contact with several health care professionals over their lives. At the hospital, youth with ASD may require specialized supports to optimize health care experiences and for medical services to be delivered safely. At present, there is a limited understanding of how to best support this patient population. The purpose of this paper is to develop, implement, and evaluate an online training module for hospital staff about ASD.

Design/methodology/approach

To evaluate participants’ perceived utility of the learning tool, a post-module survey was administered.

Findings

In all, 102 health care professionals and other hospital staff completed the training and evaluation measure. Majority of participants had prior ASD-focused education (66 percent) and had experience working with at least 20 youths with ASD (57 percent). Majority of participants (88 percent) perceived the information from the module to be helpful in their daily work and reported that they learned something new (63 percent). Participants were interested in receiving additional ASD online module training opportunities on topics including: hands-on behavior management strategies, in-hospital resources, guidance on treatment adherence, and ASD training geared specifically to protection services staff.

Originality/value

The results from this evaluation have important practice implications for hospital staff working with patients with ASD and their families. Evidence-based strategies were easily accessible for staff and the module can be feasibly built upon and expanded as well as disseminated beyond the current hospital setting.

Daily living pain assessment in children with autism: Exploratory study

This study aims to broaden knowledge about pain expression and assessment in daily life situations in children with Autism Spectrum Disorder (ASD). The goals are to provide a description of the responses of the GED-DI, the French version of the NCCPC, and to test the internal structure validity of this scale. Thirty five children with ASD were included in this study (mean age=58months; mean developmental age=32months). The French version of the NCCPC was filled in by parents. Descriptive analysis of responses shows that children with ASD express pain through varied and common behaviours, related to different expressive markers (vocal, facial, activity, etc.). Behaviours more specific to the symptomology and disturbances of ASD are also displayed. A four-factor solution (negative emotional reaction, idiosyncratic expression, hyper-vigilance reaction, pain expression) emerges from an exploratory factor analysis that explains 54.4% of the total variance. Correlation coefficients show good psychometric qualities in terms of internal consistency, factorial validity and discriminant validity. This study provides new data about pain expression in daily life situations and shows that the French version of NCCPC adjusted to ASD children is relevant to assess pain in daily life situations.

Varenicline in Autism: Theory and Case Report of Clinical and Biochemical Changes

OBJECTIVE

To explore the potential benefits of varenicline (CHANTIX^®), a highly specific partial agonist of neuronal α4β2 nicotinic acetylcholine receptors (nAChR), for autistic symptoms, and present resulting biochemical changes in light of dopamine-related genotype.

METHODS

The clinical and biochemical changes exhibited by a 19-year-old severely autistic man following the use of low-dose varenicline in an ABA experiment of nature, and his genotype, were extracted from chart review. Clinical outcome was measured by the Ohio Autism Clinical Impression Scale and 12 relevant urine and saliva metabolites were measured by Neuroscience Laboratory.

RESULTS

With varenicline, this patient improved clinically and autonomic biochemical indicators in saliva and urine normalized, including dopamine, 3,4-dihydroxyphenylacetic acid (DOPAC), epinephrine, norepinephrine, taurine, and histamine levels. In addition, with varenicline, the dopamine D1 receptor (DRD1) antibody titer as well as the percent of baseline calmodulin-dependent protein kinase II (CaM KII) activity dropped significantly. When varenicline stopped, he deteriorated; when it was resumed, he again improved. Doses of 0.5, 1, and 2 mg daily were tried before settling on a dose of 1.5 mg daily. He has remained on varenicline for over a year with no noticeable side effects.

CONCLUSION

This report is, to the best of our knowledge, only the second to demonstrate positive effects of varenicline in autism, the first to show it in a severe case, and the first to show normalization of biochemical parameters related to genotype. As with the previous report, these encouraging results warrant further controlled research before clinical recommendations can be made.

Sleep Difficulties and Medications in Children With Autism Spectrum Disorders: A Registry Study

OBJECTIVES

Sleep difficulties are common in children with autism spectrum disorders, with wide-ranging effects on the child's daytime behavior. We reviewed data within our Autism Speaks Autism Treatment Network Registry to determine the prevalence of sleep difficulties and patterns of medication use.

METHODS

Data from 1518 children ages 4 to 10 years were analyzed to determine the number of children documented to have sleep difficulties by parent-completed questionnaires and clinician-completed forms and how these findings related to the use of sleep medications.

RESULTS

The Children's Sleep Habits Questionnaire total score was ≥41 (associated with clinically significant sleep problems in past research) in 71% of children. The prevalence of sleep diagnoses was less frequent (30% of children aged 4-10 years; P < .0001). Medications for sleep were prescribed in 46% of 4- to 10-year-olds given a sleep diagnosis. The most common medication used for sleep was melatonin followed by α-agonists, with a variety of other medications taken for sleep (anticonvulsants, antidepressants, atypical antipsychotics, and benzodiazepines). Children taking medications for sleep had worse daytime behavior and pediatric quality of life than children not taking sleep medications.

CONCLUSIONS

Parent concerns about sleep may not be reflected in the information gathered during a clinic visit, supporting the need to develop screening practice pathways for sleep in autism spectrum disorders. Furthermore, many medications taken for sleep have adverse effects, supporting the need for evidence-based interventions in this population.

Reliability and Validity of the Pediatric Quality of Life Inventory With Individuals With Intellectual and Developmental Disabilities

The Pediatric Quality of Life Inventory (PedsQL) measures health-related quality of life, a growing area of research, particularly among individuals with disabilities. This research is necessary to fully understand the varied needs of the population and, ultimately, ensure that those needs are being met. The current study assessed the reliability and validity of the PedsQL in individuals with intellectual and developmental disabilities, including individuals with autism spectrum disorder. Participants included 359 caregivers of children, youth, and young adults with IDD. Caregivers completed the PedsQL 4.0 Generic Core Scales questions regarding the individual's physical health and the Strengths and Difficulties Questionnaire. The PedsQL achieved excellent reliability across scales, and distinguished healthy individuals from those with chronic health conditions, as well as individuals with ASD from those without. Factor analysis confirmed a 5-factor model, with moderate to high criterion validity. The PedsQL shows sound psychometric properties and may be a useful tool to measure psychosocial functioning in this population.

Exploring perceptions and use of the electronic health record by parents of children with autism spectrum disorder: A qualitative study

This qualitative project used structured interviews with nine parents to examine perceptions of the electronic health record (EHR) and associated patient portal in the treatment of their child's autism spectrum disorder. Thematic analysis identified six complementary themes including: Familiarity and exposure to the EHR, changing experience of care (streamlining appointments, providing more rapid medical record access, increasing clinician awareness of the complexity of their child's medical treatment, and facilitating prescriptions), portal use, patient/EHR/portal interaction, interoperability, and mother as care coordinator. While aware of the patient portal, only one-third had registered to use it and these parents reported only limited use. In general, perceptions of the electronic health record are positive, but the patient portal has yet to have needed consumer adoption. Further research and functionality are needed to increase portal registration and greater portal integration in patient care.

Care of children with autism spectrum disorder

Autism spectrum disorder (ASD) is both common and complicated. Many children with ASD are not identified until school age. The primary care physician (PCP) plays a vital role in recognizing the symptoms of ASD and in making referrals for definitive diagnosis. Most children with ASD also have co-occurring learning, medical, and/or mental health problems that require collaboration across the educational, medical, and mental health systems. This article reviews the symptoms of ASD, screening tools for school-aged children suspected of having ASD, and the PCP's role in identifying ASD and managing co-occurring conditions in the primary care medical home.

Sleep problems in children with autism spectrum disorder: examining the contributions of sensory over-responsivity and anxiety

OBJECTIVES

Children with autism spectrum disorder (ASD) are at high risk for sleep problems. Previous research suggests that sensory problems and anxiety may be related to the development and maintenance of sleep problems in children with ASD. However, the relationships among these co-occurring conditions have not been previously studied. The current study examined the interrelations of these symptoms in a large well-characterized sample of children and adolescents with ASD.

METHODS

The current study examined the relationships among sleep problems, sensory over-responsivity, and anxiety in 1347 children enrolled in the Autism Speaks Autism Treatment Network. The primary measures included the Children's Sleep Habits Questionnaire, the Child Behavior Checklist, and the Short Sensory Profile.

RESULTS

In bivariate correlations and multivariate path analyses, anxiety was associated with all types of sleep problems (ie, bedtime resistance, sleep-onset delay, sleep duration, sleep anxiety, and night wakings; p < 0.01 to p < 0.001; small to medium effect sizes). Sensory over-responsivity (SOR) was correlated with all sleep problems in bivariate analyses (p < 0.01 to p < 0.001; small effect sizes). In multivariate path models, SOR remained significantly associated with all sleep problems except night awakenings for older children, while SOR was no longer significantly associated with bedtime resistance or sleep anxiety for younger children.

CONCLUSIONS

Children with ASD who have anxiety and SOR may be particularly predisposed to sleep problems. These findings suggest that some children with ASD and sleep disturbance may have difficulties with hyperarousal. Future research using physiological measures of arousal and objective measures of sleep are needed.

Parent-based sleep education for children with autism spectrum disorders

This study provided sleep education to parents of children with autism spectrum disorder (ASD) to determine whether an individual or group format was more effective in improving sleep and aspects of daytime behavior and family functioning. Eighty children, ages 2-10 years, with ASD and sleep onset delay completed the study. Actigraphy and parent questionnaires were collected at baseline and 1 month after treatment. Mode of education did not affect outcomes. Sleep latency, insomnia subscales on the Children's Sleep Habits Questionnaire, and other outcomes related to child and family functioning improved with treatment. Parent-based sleep education, delivered in relatively few sessions, was associated with improved sleep onset delay in children with ASD. Group versus individualized education did not affect outcome.

Treating the whole person with autism: the proceedings of the Autism Speaks National Autism Conference

The identification of autism spectrum disorders has increased dramatically over the past decade, with the latest estimates indicating prevalence as high as 1 in 54 boys. There is greater awareness of medical conditions that co-occur with autism and expansion of treatment options. Closer scrutiny has led to refinement of the diagnostic criteria, and there have been advances in genetics examining potential causal factors. Transition to adulthood is an area of growing concern, and professionals and families require guidance on this issue. This article summarizes the proceedings of the Autism Speaks conference on Treating the Whole Person with Autism: Care across the Lifespan. The conference was organized with the intent of providing a forum for both families and professionals to learn about the most current research in the field. Dr. Sue Swedo provides important background information regarding the changes in the diagnostic criteria for autism spectrum disorders. She particularly deals with the concerns of individuals and families that their autism diagnosis may change. Recommendations for genetic testing and its interpretation are provided by Dr. David Miller. His discussion helps make sense of the utility of genetic testing for ASD, along with demonstration of the complexity of determining which genetic factors are doing what and through which pathways. Dr. Jeremy Veenstra-VanderWeele provides useful background information on how medicines are initially identified and for what purpose and goes on to describe the present and future treatments in pharmacology. Medical issues are addressed by Dr. Paul Carbone, especially the coordination of comprehensive services through the medical home model of care. Dr. Julie Lounds Taylor concludes with guidance on preparation for adulthood, a topic of great importance to families as their child matures and for the professionals who will help guide this transition.

Comorbidity clusters in autism spectrum disorders: an electronic health record time-series analysis

OBJECTIVE

The distinct trajectories of patients with autism spectrum disorders (ASDs) have not been extensively studied, particularly regarding clinical manifestations beyond the neurobehavioral criteria from the Diagnostic and Statistical Manual of Mental Disorders. The objective of this study was to investigate the patterns of co-occurrence of medical comorbidities in ASDs.

METHODS

International Classification of Diseases, Ninth Revision codes from patients aged at least 15 years and a diagnosis of ASD were obtained from electronic medical records. These codes were aggregated by using phenotype-wide association studies categories and processed into 1350-dimensional vectors describing the counts of the most common categories in 6-month blocks between the ages of 0 to 15. Hierarchical clustering was used to identify subgroups with distinct courses.

RESULTS

Four subgroups were identified. The first was characterized by seizures (n = 120, subgroup prevalence 77.5%). The second (n = 197) was characterized by multisystem disorders including gastrointestinal disorders (prevalence 24.3%) and auditory disorders and infections (prevalence 87.8%), and the third was characterized by psychiatric disorders (n = 212, prevalence 33.0%). The last group (n = 4316) could not be further resolved. The prevalence of psychiatric disorders was uncorrelated with seizure activity (P = .17), but a significant correlation existed between gastrointestinal disorders and seizures (P < .001). The correlation results were replicated by using a second sample of 496 individuals from a different geographic region.

CONCLUSIONS

Three distinct patterns of medical trajectories were identified by unsupervised clustering of electronic health record diagnoses. These may point to distinct etiologies with different genetic and environmental contributions. Additional clinical and molecular characterizations will be required to further delineate these subgroups.

Perspectives on the use of stem cells for autism treatment

Autism and autism spectrum disorders (ASDs) are complex neurodevelopmental disorders. ASDs are clinically defined by deficits in communication, social skills, and repetitive and/or restrictive interests and behaviours. With the prevalence rates for ASDs rapidly increasing, the need for effective therapies for autism is a priority for biomedical research. Currently available medications do not target the core symptoms, can have markedly adverse side-effects, and are mainly palliative for negative behaviours. The development of molecular and regenerative interventions is progressing rapidly, and medicine holds great expectations for stem cell therapies. Cells could be designed to target the observed molecular mechanisms of ASDs, that is, abnormal neurotransmitter regulation, activated microglia, mitochondrial dysfunction, blood-brain barrier disruptions, and chronic intestinal inflammation. Presently, the paracrine, secretome, and immunomodulatory effects of stem cells would appear to be the likely mechanisms of application for ASD therapeutics. This review will focus on the potential use of the various types of stem cells: embryonic, induced pluripotential, fetal, and adult stem cells as targets for ASD therapeutics.

Perspectives on the use of stem cells for autism treatment

Autism and autism spectrum disorders (ASDs) are complex neurodevelopmental disorders. ASDs are clinically defined by deficits in communication, social skills, and repetitive and/or restrictive interests and behaviours. With the prevalence rates for ASDs rapidly increasing, the need for effective therapies for autism is a priority for biomedical research. Currently available medications do not target the core symptoms, can have markedly adverse side-effects, and are mainly palliative for negative behaviours. The development of molecular and regenerative interventions is progressing rapidly, and medicine holds great expectations for stem cell therapies. Cells could be designed to target the observed molecular mechanisms of ASDs, that is, abnormal neurotransmitter regulation, activated microglia, mitochondrial dysfunction, blood-brain barrier disruptions, and chronic intestinal inflammation. Presently, the paracrine, secretome, and immunomodulatory effects of stem cells would appear to be the likely mechanisms of application for ASD therapeutics. This review will focus on the potential use of the various types of stem cells: embryonic, induced pluripotential, fetal, and adult stem cells as targets for ASD therapeutics.

ADHD and autism: differential diagnosis or overlapping traits? A selective review

According to DSM-IV TR and ICD-10, a diagnosis of autism or Asperger Syndrome precludes a diagnosis of attention-deficit/hyperactivity disorder (ADHD). However, despite the different conceptualization, population-based twin studies reported symptom overlap, and a recent epidemiologically based study reported a high rate of ADHD in autism and autism spectrum disorders (ASD). In the planned revision of the DSM-IV TR, dsm5 (www.dsm5.org), the diagnoses of autistic disorder and ADHD will not be mutually exclusive any longer. This provides the basis of more differentiated studies on overlap and distinction between both disorders. This review presents data on comorbidity rates and symptom overlap and discusses common and disorder-specific risk factors, including recent proteomic studies. Neuropsychological findings in the areas of attention, reward processing, and social cognition are then compared between both disorders, as these cognitive abilities show overlapping as well as specific impairment for one of both disorders. In addition, selective brain imaging findings are reported. Therapeutic options are summarized, and new approaches are discussed. The review concludes with a prospectus on open questions for research and clinical practice.

The co-morbidity burden of children and young adults with autism spectrum disorders

OBJECTIVES

Use electronic health records Autism Spectrum Disorder (ASD) to assess the comorbidity burden of ASD in children and young adults.

STUDY DESIGN

A retrospective prevalence study was performed using a distributed query system across three general hospitals and one pediatric hospital. Over 14,000 individuals under age 35 with ASD were characterized by their co-morbidities and conversely, the prevalence of ASD within these comorbidities was measured. The comorbidity prevalence of the younger (Age<18 years) and older (Age 18-34 years) individuals with ASD was compared.

RESULTS

19.44% of ASD patients had epilepsy as compared to 2.19% in the overall hospital population (95% confidence interval for difference in percentages 13.58-14.69%), 2.43% of ASD with schizophrenia vs. 0.24% in the hospital population (95% CI 1.89-2.39%), inflammatory bowel disease (IBD) 0.83% vs. 0.54% (95% CI 0.13-0.43%), bowel disorders (without IBD) 11.74% vs. 4.5% (95% CI 5.72-6.68%), CNS/cranial anomalies 12.45% vs. 1.19% (95% CI 9.41-10.38%), diabetes mellitus type I (DM1) 0.79% vs. 0.34% (95% CI 0.3-0.6%), muscular dystrophy 0.47% vs 0.05% (95% CI 0.26-0.49%), sleep disorders 1.12% vs. 0.14% (95% CI 0.79-1.14%). Autoimmune disorders (excluding DM1 and IBD) were not significantly different at 0.67% vs. 0.68% (95% CI -0.14-0.13%). Three of the studied comorbidities increased significantly when comparing ages 0-17 vs 18-34 with p<0.001: Schizophrenia (1.43% vs. 8.76%), diabetes mellitus type I (0.67% vs. 2.08%), IBD (0.68% vs. 1.99%) whereas sleeping disorders, bowel disorders (without IBD) and epilepsy did not change significantly.

CONCLUSIONS

The comorbidities of ASD encompass disease states that are significantly overrepresented in ASD with respect to even the patient populations of tertiary health centers. This burden of comorbidities goes well beyond those routinely managed in developmental medicine centers and requires broad multidisciplinary management that payors and providers will have to plan for.

Mitochondrial dysfunction in autism spectrum disorders: a systematic review and meta-analysis

A comprehensive literature search was performed to collate evidence of mitochondrial dysfunction in autism spectrum disorders (ASDs) with two primary objectives. First, features of mitochondrial dysfunction in the general population of children with ASD were identified. Second, characteristics of mitochondrial dysfunction in children with ASD and concomitant mitochondrial disease (MD) were compared with published literature of two general populations: ASD children without MD, and non-ASD children with MD. The prevalence of MD in the general population of ASD was 5.0% (95% confidence interval 3.2, 6.9%), much higher than found in the general population (≈ 0.01%). The prevalence of abnormal biomarker values of mitochondrial dysfunction was high in ASD, much higher than the prevalence of MD. Variances and mean values of many mitochondrial biomarkers (lactate, pyruvate, carnitine and ubiquinone) were significantly different between ASD and controls. Some markers correlated with ASD severity. Neuroimaging, in vitro and post-mortem brain studies were consistent with an elevated prevalence of mitochondrial dysfunction in ASD. Taken together, these findings suggest children with ASD have a spectrum of mitochondrial dysfunction of differing severity. Eighteen publications representing a total of 112 children with ASD and MD (ASD/MD) were identified. The prevalence of developmental regression (52%), seizures (41%), motor delay (51%), gastrointestinal abnormalities (74%), female gender (39%), and elevated lactate (78%) and pyruvate (45%) was significantly higher in ASD/MD compared with the general ASD population. The prevalence of many of these abnormalities was similar to the general population of children with MD, suggesting that ASD/MD represents a distinct subgroup of children with MD. Most ASD/MD cases (79%) were not associated with genetic abnormalities, raising the possibility of secondary mitochondrial dysfunction. Treatment studies for ASD/MD were limited, although improvements were noted in some studies with carnitine, co-enzyme Q10 and B-vitamins. Many studies suffered from limitations, including small sample sizes, referral or publication biases, and variability in protocols for selecting children for MD workup, collecting mitochondrial biomarkers and defining MD. Overall, this evidence supports the notion that mitochondrial dysfunction is associated with ASD. Additional studies are needed to further define the role of mitochondrial dysfunction in ASD.

Autism spectrum disorders: is mesenchymal stem cell personalized therapy the future?

Autism and autism spectrum disorders (ASDs) are heterogeneous neurodevelopmental disorders. They are enigmatic conditions that have their origins in the interaction of genes and environmental factors. ASDs are characterized by dysfunctions in social interaction and communication skills, in addition to repetitive and stereotypic verbal and nonverbal behaviours. Immune dysfunction has been confirmed with autistic children. There are no defined mechanisms of pathogenesis or curative therapy presently available. Indeed, ASDs are still untreatable. Available treatments for autism can be divided into behavioural, nutritional, and medical approaches, although no defined standard approach exists. Nowadays, stem cell therapy represents the great promise for the future of molecular medicine. Among the stem cell population, mesenchymal stem cells (MSCs) show probably best potential good results in medical research. Due to the particular immune and neural dysregulation observed in ASDs, mesenchymal stem cell transplantation could offer a unique tool to provide better resolution for this disease.

Diagnosing Autism in Individuals with Known Genetic Syndromes: Clinical Considerations and Implications for Intervention

Assessing symptoms of autism in persons with known genetic syndromes associated with intellectual and/or developmental disability is a complex clinical endeavor. We suggest that a developmental approach to evaluation is essential to reliably teasing apart global impairments from autism-specific symptomology. In this chapter, we discuss our assumptions about autism spectrum disorders, the process of conducting a family-focused, comprehensive evaluation with behaviorally complex children and some implications for intervention in persons with co-occurring autism and known genetic syndromes.

Genetic controls balancing excitatory and inhibitory synaptogenesis in neurodevelopmental disorder models

Proper brain function requires stringent balance of excitatory and inhibitory synapse formation during neural circuit assembly. Mutation of genes that normally sculpt and maintain this balance results in severe dysfunction, causing neurodevelopmental disorders including autism, epilepsy and Rett syndrome. Such mutations may result in defective architectural structuring of synaptic connections, molecular assembly of synapses and/or functional synaptogenesis. The affected genes often encode synaptic components directly, but also include regulators that secondarily mediate the synthesis or assembly of synaptic proteins. The prime example is Fragile X syndrome (FXS), the leading heritable cause of both intellectual disability and autism spectrum disorders. FXS results from loss of mRNA-binding FMRP, which regulates synaptic transcript trafficking, stability and translation in activity-dependent synaptogenesis and plasticity mechanisms. Genetic models of FXS exhibit striking excitatory and inhibitory synapse imbalance, associated with impaired cognitive and social interaction behaviors. Downstream of translation control, a number of specific synaptic proteins regulate excitatory versus inhibitory synaptogenesis, independently or combinatorially, and loss of these proteins is also linked to disrupted neurodevelopment. The current effort is to define the cascade of events linking transcription, translation and the role of specific synaptic proteins in the maintenance of excitatory versus inhibitory synapses during neural circuit formation. This focus includes mechanisms that fine-tune excitation and inhibition during the refinement of functional synaptic circuits, and later modulate this balance throughout life. The use of powerful new genetic models has begun to shed light on the mechanistic bases of excitation/inhibition imbalance for a range of neurodevelopmental disease states.