Autism and medical disorders: a review of the literature

Genesis, modelling and methodological remedies to autism heterogeneity

Diagnostic criteria used in autism research have undergone a shift towards the inclusion of a larger population, paralleled by increasing, but variable, estimates of autism prevalence across clinical settings and continents. A categorical diagnosis of autism spectrum disorder is now consistent with large variations in language, intelligence, comorbidity, and severity, leading to a heterogeneous sample of individuals, increasingly distant from the initial prototypical descriptions. We review the history of autism diagnosis and subtyping, and the evidence of heterogeneity in autism at the cognitive, neurological, and genetic levels. We describe two strategies to address the problem of heterogeneity: clustering, and truncated-compartmentalized enrollment strategy based on prototype recognition. The advances made using clustering methods have been modest. We present an alternative, new strategy for dissecting autism heterogeneity, emphasizing incorporation of prototypical samples in research cohorts, comparison of subgroups defined by specific ranges of values for the clinical specifiers, and retesting the generality of neurobiological results considered to be acquired from the entire autism spectrum on prototypical cohorts defined by narrow specifiers values.

Targeting Shank3 deficiency and paresthesia in autism spectrum disorder: A brief review

Autism spectrum disorder (ASD) includes a group of multifactorial neurodevelopmental disorders characterized by impaired social communication, social interaction, and repetitive behaviors. Several studies have shown an association between cases of ASD and mutations in the genes of SH3 and multiple ankyrin repeat domain protein 3 (SHANK3). These genes encode many cell adhesion molecules, scaffold proteins, and proteins involved in synaptic transcription, protein synthesis, and degradation. They have a profound impact on all aspects of synaptic transmission and plasticity, including synapse formation and degeneration, suggesting that the pathogenesis of ASD may be partially attributable to synaptic dysfunction. In this review, we summarize the mechanism of synapses related to Shank3 in ASD. We also discuss the molecular, cellular, and functional studies of experimental models of ASD and current autism treatment methods targeting related proteins.

Sensory Profiles in School-Aged Children with Autism Spectrum Disorder: A Descriptive Study Using the Sensory Processing Measure-2 (SPM-2)

Background: Sensory reactivity is considered one of the diagnostic criteria for Autism Spectrum Disorders (ASD) and has been associated with poorer functional outcomes, behavioral difficulties, and autism severity across the lifespan. The characterization of the sensory processing in ASD has thus become crucial to identify the sensory and motor features influencing the development of personal autonomy. Objectives: The present study has two aims: (1) to compare the sensory processing between school-aged children with ASD and typically developing peers (TD); (2) to evaluate whether, within the ASD sample, the cognitive level and reported sensory symptoms explain the scores exhibited at the Sensory Processing Measure (SPM-2). Methods: The SPM-2 test was administered to the parents of 105 children with ASD and 70 TD. The ASD group was further subdivided into two groups, namely high and low functioning based on their cognitive level (High Functioning (HF), IQ > 80; Low Functioning (LF), IQ < 80). Results: ASD children exhibited higher scores throughout the SPM-2 total score and its multiple subscales. Within ASD, while HF and LF children did not differ in terms of the SPM-2 total score, a significant difference was found for the hearing, social participation, and balance and motion subscales. Conclusions: Aside from classical knowledge that the ASD population suffers from sensory processing disorders, we revealed that different sensory patterns are associated with high or low cognitive functioning. Beyond its neurobiological interest, such knowledge may be of fundamental importance for individualizing psychoeducational interventions in preschool- and school-aged children and later developmental stages.

Autism spectrum disorder and kidney disease

Neurodevelopmental impairments have been recognised as a major association of paediatric kidney disease and bladder dysfunction, presenting challenges to clinicians and families to provide reasonable adjustments in order to allow access to investigations and treatments. Autism spectrum disorder (ASD) is a common neurodevelopmental disorder characterised by impairments in social interaction/communication and repetitive sensory-motor behaviours. Mental health, learning and physical co-morbidities are common. There is emerging evidence that ASD and kidney disease have some overlaps with genetic copy number variants and environmental factors contributing to shared pathogenesis. Prevalence rates of ASD in kidney disease are currently not known. A high index of suspicion of underlying ASD is required when a young person presents with communication difficulties, anxiety or behaviour that challenges, which should then trigger referral for a neurodevelopmental and behavioural assessment. We discuss practical approaches for providing care, which include understanding methods of communication and sensory, behavioural and environmental adaptations.

Pain Modulation Mechanisms in ASD Adults

We tested endogenous pain modulation mechanisms in adults with autism spectrum disorders (ASD). Nineteen ASD adults without intellectual disabilities were included, matched with 19 healthy volunteers on the basis of sex and chronological age. An experimental pain model was used to measure excitatory and inhibitory pain mechanisms in a single session. Statistical analyses indicated that endogenous pain modulation mechanisms in ASD group did not differ significantly from those of healthy adults. The pain scores were very disparate in ASD group with a greater range of extreme scores than in control group. Unlike schizophrenic patients, there was no systematic dysfunction of endogenous excitatory pain modulation mechanisms, but the high variability requires to be wise to interpret the results and formulate conclusion.

Overview and Introduction to Autism Spectrum Disorder (ASD)

Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder generally manifesting in the first few years of life and tending to persist into adolescence and adulthood. It is characterized by deficits in communication and social interaction and restricted, repetitive patterns of behavior, interests, and activities. It is a disorder with multifactorial etiology. In this chapter, we will focus on the most important and common epidemiological studies, pathogenesis, screening, and diagnostic tools along with an explication of genetic testing in ASD.

Structural and Functional Aberrations of the Auditory Brainstem in Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a neurodevelopmental condition associated with difficulties in the social, communicative, and behavioral domains. Most cases of ASD arise from an unknown etiologic process, but there are numerous risk factors, including comorbidities and maternal exposures. Although it is not part of the diagnostic criteria, hearing difficulties ranging from deafness to hyperacusis are present in the majority of persons with ASD. High-functioning children with ASD have been found to have significantly slower and asymmetric auditory brainstem reflexes. Additionally, histopathological studies of postmortem brainstems in decedents who had ASD have consistently revealed significantly fewer neurons in auditory nuclei compared with those in people who did not have ASD. The authors review the literature implicating auditory dysfunction in ASD along with results from human study participants and postmortem human brain tissue. Together, these results implicate significant structural and functional abnormalities in the auditory brainstem in ASD and support the utility of auditory testing to screen for ASD.

Outpatient Psychotherapy for Adults with High-Functioning Autism Spectrum Condition: Utilization, Treatment Satisfaction, and Preferred Modifications

Many adults with autism spectrum condition (ASC) desire outpatient psychotherapy (PT). This study compared reasons for seeking PT, experiences with PT, and modifications preferred with respect to PT of individuals with ASC to non-autistic individuals with depression (MDD). Furthermore, factors predictive for treatment satisfaction were identified in individuals with ASC. A total of 262 adults with ASC without intellectual impairment and 304 non-autistic controls with MDD were surveyed. In this pilot study both groups predominantly sought treatment for depressiveness. A low level of expertise with autism was the main reason for being declined by therapists and a contributing factor to the overall treatment dissatisfaction of patients with ASC. ASC patients desire adjustments such as written communication, and clearly structured sessions.

Pre- and Postsurgical Orthodontics in Patients with Moebius Syndrome

The authors report a combined orthodontic-surgical correction of an adult patient's malocclusion affected by Moebius Syndrome (MS). The treatment was conducted at the Dentistry Unit and the Maxillofacial Surgery Unit of the University Hospital of Parma. Treatment of malocclusion was performed after the correction of facial mimic mobility with smile surgery. The postoperative stability and orthodontic results were good and the correction of the morphological problems related to the syndrome was very satisfactory.

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.

Abnormal Sleep Patterns Associated with Autism

Statements have recurrently been made about the high rate of sleep problems reported in children with autism, particularly difficulty initiating and maintaining sleep at appropriate times of the night and day. Autism itself is frequently associated with the presence of learning disability and a variety of other medical conditions. These often coexisting factors are themselves associated with sleep abnormalities and therefore caution is needed when attempting to assess the relationship between autism and sleep abnormalities. Detailed consideration of the various possible causes of sleep problems is required to reach meaningful diagnostic and treatment decisions. The present account reviews the published work on sleep disturbance and autism, highlighting theoretical and practical issues which need further attention. Methods of assessing and treating sleep disorders are also discussed, with special consideration of factors related to autism which may affect the choice of method.

Associated Medical Disorders and Disabilities in Children with Autistic Disorder

A population-based survey was conducted among 152,732 Finnish children and adolescents aged under 16 years and living in northern Finland. Diagnoses and associated medical conditions were derived from the hospital and institutional records of this area. One hundred and eighty-seven children with DSM-IV autistic disorder were identified. Associated medical disorders or associated disorders of known or suspected genetic origin were found in 12.3 percent, including tuberous sclerosis, Down syndrome, fragile X syndrome, Klinefelter syndrome, XYY syndrome, chromosome 17 deletion, chromosome 46, XX, dup(8)(p) and mitochondriopathy. Other associated medical disorders identified were epilepsy, hydrocephalus, foetal alcohol syndrome and cerebral palsy. Hearing impairments were found in 8.6 percent and severe impairment of vision in 3.7 percent of the individuals with autistic disorder. Medical disorders seem to have a special impact on the genesis of autistic disorder and need to be thoroughly examined in each child with autistic disorder.

Autism and Learning Disability

In this article a short overview is given of the relationship between autism and learning disability. Autism exists with any level of intelligence, but many individuals with autism suffer also from learning disability. Although both disorders show overlap in some behaviours they are different in many aspects. Are they distinct syndromes which influence each other, or do they belong to a broad spectrum of a condition?

Functional Connectivity of the Caudal Anterior Cingulate Cortex Is Decreased in Autism

The anterior cingulate cortex (ACC) is frequently reported to have functionally distinct sub-regions that play key roles in different intrinsic networks. However, the contribution of the ACC, which is connected to several cortical areas and the limbic system, to autism is not clearly understood, although it may be involved in dysfunctions across several distinct but related functional domains. By comparing resting-state fMRI data from persons with autism and healthy controls, we sought to identify the abnormalities in the functional connectivity (FC) of ACC sub-regions in autism. The analyses found autism-related reductions in FC between the left caudal ACC and the right rolandic operculum, insula, postcentral gyrus, superior temporal gyrus, and the middle temporal gyrus. The FC (z-scores) between the left caudal ACC and the right insula was negatively correlated with the Stereotyped Behaviors and Restricted Interests scores of the autism group. These findings suggest that the caudal ACC is recruited selectively in the pathomechanism of autism.

Barriers to healthcare for people on the autism spectrum

Purpose

– Adults on the autism spectrum experience difficulties in receiving health care, and health care providers face difficulties in offering health care to adults on the autism spectrum. The purpose of this paper is first, to assess the various difficulties and second, to provide strategies to overcome them.

Design/methodology/approach

– In this qualitative research project, current barriers and facilitators to health care services were sampled from a collaboration of autistic self-advocates and autism professionals in Berlin, Germany. The findings were complemented by a review of practical guidelines and research about the service accessibility of patients on the autism spectrum.

Findings

– A comprehensive list of barriers to health care was compiled and structured according to various aspects, such as “making appointments”, “waiting area”, “communication”, and “examination”. Strategies considering the perceptual and communicative peculiarities of autism were found to improve access to health care for autistic adults.

Practical implications

– Providing access to the health care system may improve the diagnosis and treatment of mental and somatic illnesses, and thereby, the health status and quality of life for people on the autism spectrum. This recognition of the needs of adults on the autism spectrum may serve as a model for other areas in society, such as education and employment.

Originality/value

– Data acquisition in this project is of special value because it resulted from collaboration between an autistic self-advocacy organization and professionals working in the field of intellectual developmental disabilities considering the experiences of autistic adults in the entire range of intellectual functioning.

MRI or not to MRI! Should brain MRI be a routine investigation in children with autistic spectrum disorders?

To evaluate the routine usage of Magnetic Resonance Imaging (MRI) of brain and estimate the prevalence of brain abnormalities in children presenting to the Neurodevelopment Clinic of Al-Khadra Hospital (NDC-KH), Tripoli, Libya with autistic spectrum disorders (ASD). The records of all children with ASD presented to NDC-KH over 4-year period (from January 2009 to December 2012) were reviewed. All MRIs were acquired with a 1.5-T Philips (3-D T1, T2, FLAIR coronal and axial sequences). MRIs were reported to be normal, abnormal or no significant abnormalities by a consultant neuroradiologist. One thousand and seventy-five children were included in the study. Seven hundred and eighty-two children (72.7 %) had an MRI brain of whom 555 (71 %) were boys. 26 children (24 males and 2 females) (3.3 %) demonstrated MRI abnormalities (8 leukodystrophic changes, 4 periventricular leukomalacia, 3 brain atrophy, 2 tuberous sclerosis, 2 vascular changes, 1 pineoblastoma, 1 cerebellar angioma, 1 cerebellar hypoplasia, 3 agenesis of corpus callosum, 1 neuro-epithelial cyst). An unexpectedly high rate of MRI abnormalities was found in the first large series of clinical MRI investigations in children with autism. These results could contribute to further research into the pathogenesis of autistic spectrum disorder.

Childhood autism in India: A case-control study using tract-based spatial statistics analysis

CONTEXT

Autism is a serious behavioral disorder among young children that now occurs at epidemic rates in developing countries like India. We have used tract-based spatial statistics (TBSS) of diffusion tensor imaging (DTI) measures to investigate the microstructure of primary neurocircuitry involved in autistic spectral disorders as compared to the typically developed children.

OBJECTIVE

To evaluate the various white matter tracts in Indian autistic children as compared to the controls using TBSS.

MATERIALS AND METHODS

Prospective, case-control, voxel-based, whole-brain DTI analysis using TBSS was performed. The study included 19 autistic children (mean age 8.7 years ± 3.84, 16 males and 3 females) and 34 controls (mean age 12.38 ± 3.76, all males). Fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), and axial diffusivity (AD) values were used as outcome variables.

RESULTS

Compared to the control group, TBSS demonstrated multiple areas of markedly reduced FA involving multiple long white matter tracts, entire corpus callosum, bilateral posterior thalami, and bilateral optic tracts (OTs). Notably, there were no voxels where FA was significantly increased in the autism group. Increased RD was also noted in these regions, suggesting underlying myelination defect. The MD was elevated in many of the projections and association fibers and notably in the OTs. There were no significant changes in the AD in these regions, indicating no significant axonal injury. There was no significant correlation between the FA values and Childhood Autism Rating Scale.

CONCLUSION

This is a first of a kind study evaluating DTI findings in autistic children in India. In our study, DTI has shown a significant fault with the underlying intricate brain wiring system in autism. OT abnormality is a novel finding and needs further research.

The association between congenital anomalies and autism spectrum disorders in a Finnish national birth cohort

AIM

The first aim of this study was to evaluate the association between different subgroups of autism spectrum disorders (ASDs) (childhood autism, Asperger syndrome, and pervasive developmental disorder/pervasive developmental disorder - not otherwise specified [PDD/PDD-NOS]) and congenital anomalies. Second, we assessed the association among intellectually disabled children with ASDs in the subgroups of childhood autism and PDD/PDD-NOS.

METHOD

Nationwide population-based register data for children with a diagnosis of ASD (n=4449; 3548 males, 901 females) were collected during years 1987-2000 from the Finnish Hospital Discharge Register. Data on congenital anomalies were derived from the National Register of Congenital Malformations. Conditional logistic regression models were used as a statistical method. The association between ASD subgroups and congenital anomalies was stratified by the presence or absence of intellectual disability.

RESULTS

Congenital anomalies occurred more frequently in all subgroups of ASD than in comparison participants (adjusted odds ratio [OR] for major congenital anomalies 1.8, 95% confidence interval [CI] 1.5-2.2, p<0.001). The association between congenital anomalies and childhood autism (OR 2.4, 95% CI 1.6-3.6, p<0.001) and between congenital anomalies and PDD/PDD-NOS (OR 3.7, 95% CI 2.4-5.7, p<0.001) among children with an intellectual disability was strong but remained significant also without intellectual disability (childhood autism: OR 1.7, 95% CI 1.3-2.3, p<0.001; PDD/PDD-NOS: OR 2.3, 95% CI 1.9-2.8, p<0.001).

INTERPRETATION

The results suggest a significant association between ASDs and congenital anomalies regardless of the ASD subgroup. The association between childhood autism and PDD/PDD-NOS and congenital anomalies is stronger among children with intellectual disability is stronger than among those without intellectual disability. These results may have relevance in examining early risk factors in autism during fetal neurodevelopment.

Organization of the human superior olivary complex in 15q duplication syndromes and autism spectrum disorders

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by a number of behavioral and social features. Although the etiology of most cases of ASD is idiopathic, a significant number of cases can be attributed to genetic causes, such as chromosome 15q duplications [dup(15q)]. Recent neuropathological investigations have provided evidence for distinct patterns of heterotopias and dysplasias in ASD and subjects with both ASD and dup(15q). Individuals with ASD characteristically have hearing difficulties and we have previously demonstrated significant and consistent hypoplasia in a number of auditory brainstem nuclei in subjects with ASD. Herein, we compare results from a morphometric investigation of auditory brainstem nuclei in subjects with ASD, dup(15q) and controls. Our observations in subjects with ASD support our previous reports. However, in subjects with dup(15q), we find significantly fewer neurons and in many nuclei, neurons were significantly smaller than in ASD subjects. Finally, we find a notably higher incidence of ectopic neurons in dup(15q). These results suggest that in the brainstem, these neuropathological conditions may evolve from some of the same developmental errors but are distinguished on microscopic features.

Atypical perception of affective prosody in Autism Spectrum Disorder

Autism Spectrum Disorder (ASD) is characterized by impairments in language and social–emotional cognition. Yet, findings of emotion recognition from affective prosody in individuals with ASD are inconsistent. This study investigated emotion recognition and neural processing of affective prosody in high-functioning adults with ASD relative to neurotypical (NT) adults. Individuals with ASD showed mostly typical brain activation of the fronto-temporal and subcortical brain regions in response to affective prosody. Yet, the ASD group showed a trend towards increased activation of the right caudate during processing of affective prosody and rated the emotional intensity lower than NT individuals. This is likely associated with increased attentional task demands in this group, which might contribute to social–emotional impairments.

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This study investigated processing of affective prosody in ASD

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Including 19 high-functioning adults with ASD and 20 neurotypical (NT) adults

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Using behavioral measures for emotion recognition and fMRI

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Individuals with ASD showed lower ratings of emotional intensity than NT

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A trend towards increased activation of caudate during affective prosody in ASD

Intact brain processing of musical emotions in autism spectrum disorder, but more cognitive load and arousal in happy vs. sad music

Music is a potent source for eliciting emotions, but not everybody experience emotions in the same way. Individuals with autism spectrum disorder (ASD) show difficulties with social and emotional cognition. Impairments in emotion recognition are widely studied in ASD, and have been associated with atypical brain activation in response to emotional expressions in faces and speech. Whether these impairments and atypical brain responses generalize to other domains, such as emotional processing of music, is less clear. Using functional magnetic resonance imaging, we investigated neural correlates of emotion recognition in music in high-functioning adults with ASD and neurotypical adults. Both groups engaged similar neural networks during processing of emotional music, and individuals with ASD rated emotional music comparable to the group of neurotypical individuals. However, in the ASD group, increased activity in response to happy compared to sad music was observed in dorsolateral prefrontal regions and in the rolandic operculum/insula, and we propose that this reflects increased cognitive processing and physiological arousal in response to emotional musical stimuli in this group.

How do children with autism spectrum disorders express pain? A comparison with developmentally delayed and typically developing children

There is a lack of knowledge about pain reactions in children with autism spectrum disorders (ASD), who have often been considered as insensitive to pain. The objective of this study was to describe the facial, behavioral and physiological reactions of children with ASD during venipuncture and to compare them to the reactions of children with an intellectual disability and nonimpaired control children. We also examined the relation between developmental age and pain reactions. The sample included 35 children with ASD, 32 children with an intellectual disability, and 36 nonimpaired children. The children were videotaped during venipuncture and their heart rate was recorded. Facial reactions were assessed using the Child Facial Coding System (CFCS) and behavioral reactions were scored using the Noncommunicating Children's Pain Checklist (NCCPC). A linear mixed-effects model showed that children's reactions increased between baseline and venipuncture and decreased between the end of venipuncture and the recovery period. There was no significant difference between groups regarding the amount of facial, behavioral and physiological reactions. However, behavioral reactions seemed to remain high in children with ASD after the end of the venipuncture, in contrast with children in the 2 other groups. Moreover, we observed a significant decrease in pain expression with age in nonimpaired children, but no such effect was found regarding children with ASD. The data reveal that children with ASD displayed a significant pain reaction in this situation and tend to recover more slowly after the painful experience. Improvement in pain assessment and management in this population is necessary.

Auditory processing and sensory behaviours in children with autism spectrum disorders as revealed by mismatch negativity

Sensory dysfunctions may underlie key characteristics in children with Autism Spectrum Disorders (ASD). The current study aimed to investigate auditory change detection in children with ASD in order to determine event-related potentials to meaningless and meaningful speech stimuli. 11 high functioning boys with a diagnosis of autism spectrum disorders (mean age=13.0; SD=1.08) and 11 typically developing boys (mean age=13.7; SD=1.5) participated in a mismatch negativity (MMN) paradigm. Results revealed that compared to TD controls, the children with ASD showed significantly reduced MMN responses to both words and pseudowords in the frontal regions of the brain and also a significant reduction in their activation for words in the Central Parietal regions. In order to test the relationship between sensory processing and auditory processing, children completed the Adult and Adolescent Sensory Profile. As predicted, the children with ASD showed more extreme sensory behaviours and were significantly higher than their typically developing controls across three of the sensory quadrants (sensory sensitivity, low registration and sensory avoidance). Importantly, only auditory sensory sensitivity was able to account for the differences displayed for words in the frontal and central parietal regions when controlling for the effect of group, revealing an inverse relationship of the higher sensory sensitivity scores the less activation in response for words. We discuss how the expression of sensory behaviours in ASD may result in deficient neurophysiological mechanisms underlying automatic language processing.

A comparison of social cognitive profiles in children with autism spectrum disorders and attention-deficit/hyperactivity disorder: a matter of quantitative but not qualitative difference?

The aim of this study was to compare social cognitive profiles of children and adolescents with Autism Spectrum Disorders (ASD) and ADHD. Participants diagnosed with an ASD (n = 137) were compared to participants with ADHD (n = 436) on tests of facial and vocal affect recognition, social judgment and problem-solving, and parent- and teacher-report of social functioning. Both groups performed significantly worse than the normative sample on all measures. Although the ASD group had more severe deficits, the pattern of deficits was surprisingly similar between groups, suggesting that social cognitive deficit patterns may be more similar in ASD and ADHD than previously thought. Thus, like those with ASDs, individuals with ADHD may also need to be routinely considered for treatments targeting social skills.

Excess mortality and causes of death in autism spectrum disorders: a follow up of the 1980s Utah/UCLA autism epidemiologic study

This study's purpose was to investigate mortality among individuals with autism spectrum disorders (ASD) ascertained during a 1980s statewide autism prevalence study (n = 305) in relation to controls. Twenty-nine of these individuals (9.5 %) died by the time of follow up, representing a hazard rate ratio of 9.9 (95 % CI 5.7-17.2) in relation to population controls. Death certificates identified respiratory, cardiac, and epileptic events as the most common causes of death. The elevated mortality risk associated with ASD in the study cohort appeared related to the presence of comorbid medical conditions and intellectual disability rather than ASD itself suggesting the importance of coordinated medical care for this high risk sub-population of individuals with ASD.

Predictive properties of the A-TAC inventory when screening for childhood-onset neurodevelopmental problems in a population-based sample

BACKGROUND

Identifying children with childhood-onset neurodevelopmental problems (NDPs, defined here as autism spectrum disorders [ASDs], attention-deficit/hyperactivity disorder [AD/HD], tic disorders [TDs], learning disorders [LDs] and development coordination disorder), using easily administered screening instruments, is a prerequisite for epidemiological research. Such instruments are also clinically useful to prioritize children for comprehensive assessments, to screen risk groups, and to follow controls.Autism-Tics, ADHD, and other Co-morbidities inventory (A-TAC) was developed to meet these requirements; here the A-TAC's prospective and psychometric properties are examined, when used in a population-based, epidemiological setting.

METHODS

Since 2004, parents of all Swedish twins have been asked to take part in an ongoing, nation-wide twin study (The Child and Adolescent Twin Study in Sweden). The study includes the A-TAC, carried out as a telephone interview with parents of twins aged 9 or 12. In the present study, screen-positive twins from three birth year cohorts (1993-1995) were invited to a comprehensive clinical follow-up (blinded for previous screening results) together with their co-twins and randomly selected, healthy controls at age 15 (Total N = 452).

RESULTS

Sensitivity and specificity of A-TAC scores for predicting later clinical diagnoses were good to excellent overall, with values of the area under the receiver operating characteristics curves ranging from 0.77 (AD/HD) to 0.91 (ASDs). Among children who were screen-positive for an ASD, 48% received a clinical diagnosis of ASDs. For AD/HD, the corresponding figure was also 48%, for LDs 16%, and for TDs 60%. Between 4% and 35% of screen-positive children did not receive any diagnosis at the clinical follow-up three years later. Among screen-negative controls, prevalence of ASDs, AD/HD, LDs, and TDs was 0%, 7%, 4%, and 2%, respectively.

CONCLUSIONS

The A-TAC appeared to be a valid instrument to assess NDPs in this population-based, longitudinal study. It has good-to-excellent psychometric properties, with an excellent ability to distinguish NDPs (mainly ASDs) from non-NDPs at least three years after the screening evaluations, although specific diagnoses did not correspond closely to actual clinical diagnoses.

Towards identification of individual etiologies by resolving genomic and biological conundrums in patients with autism spectrum disorders

Recent genomic research into autism spectrum disorders (ASD) has revealed a remarkably complex genetic architecture. Large numbers of common variants, copy number variations and single nucleotide variants have been identified, yet each of them individually afforded only a small phenotypic impact. A polygenic model in which multiple genes interact either in an additive or a synergistic way appears the most plausible for the majority of ASD patients. Based on recently identified ASD candidate genes, transgenic mouse models for neuroligins/neurorexins and genes such as Cntnap2, Cntn5, Tsc1, Tsc2, Akt3, Cyfip1, Scn1a, En2, Slc6a4, and Bckdk have been generated and studied with respect to behavioral and neuroanatomical phenotypes and sensitivity to drug treatments. From these models, a few clues for potential pharmacologic intervention emerged. The Fmr1, Shank2 and Cntn5 knockout mice exhibited alterations of glutamate receptors, which may become a target for pharmacologic modulation. Some of the phenotypes of Mecp2 knockout mice can be ameliorated by administering IGF1. In the near future, comprehensive genotyping of individual patients and siblings combined with the novel insights generated from the transgenic animal studies may provide us with personalized treatment options. Eventually, autism may indeed turn out to be a phenotypically heterogeneous group of disorders ('autisms') caused by combinations of changes in multiple possible candidate genes, being different in each patient and requiring for each combination of mutations a distinct, individually tailored treatment.

Patterns of contact with hospital for children with an autism spectrum disorder: a Danish register-based study

The aim of this study was to study patterns of contact with hospital for children with autism spectrum disorder (ASD) using Danish population based register data. We included all children born in Denmark from 1994 through 2002. We found that children diagnosed with ASD had an increased rate of contact with hospital, almost regardless of the cause for the hospital contact. Given the overall association between hospital contact for various causes and ASD observed in these data, hospital data should be used cautiously in future studies searching for associations between a specific disease and ASD. If the increased rate of hospital contact overall for children with ASD is not considered, then misleading over interpretations might be made of observed associations between specific diseases and ASD.

The Child and Adolescent Twin Study in Sweden (CATSS)

The Child and Adolescent Twin Study in Sweden (CATSS) is an ongoing longitudinal twin study targeting all twins born in Sweden since July 1, 1992. Since 2004, parents of twins are interviewed regarding the children's somatic and mental health and social environment in connection with their 9th or 12th birthdays (CATSS-9/12). By January 2010, 8,610 parental interviews concerning 17,220 twins had been completed, with an overall response rate of 80%. At age 15 (CATSS-15) and 18 (CATSS-18), twins and parents complete questionnaires that, in addition to assessments of somatic and mental health, include measures of personality development and psychosocial adaptation. Twin pairs in CATSS-9/12 with one or both twins screening positive for autism spectrum disorders, attention deficit/hyperactivity disorder, tic disorders, developmental coordination disorder, learning disorders, oppositional defiant disorder, conduct disorder, obsessive-compulsive disorder, and/or eating problems have been followed with in-depth questionnaires on family, social environment and personality, and subsequently by clinical assessments at age 15 together with randomly selected population controls, including 195 clinically assessed twin pairs from the first 2 year cohorts (CATSS-15/DOGSS). This article describes the cohorts and study groups, data collection, and measures used. Prevalences, distributions, heritability estimates, ages at onset, and sex differences of mental health problems in the CATSS-9/12, that were analyzed and found to be overall comparable to those of other clinical and epidemiological studies. The CATSS study has the potential of answering important questions on the etiology of childhood mental health problems and their role in the development of later adjustment problems.

Differences between the pattern of developmental abnormalities in autism associated with duplications 15q11.2-q13 and idiopathic autism

The purposes of this study were to identify differences in patterns of developmental abnormalities between the brains of individuals with autism of unknown etiology and those of individuals with duplications of chromosome 15q11.2-q13 (dup[15]) and autism and to identify alterations that may contribute to seizures and sudden death in the latter. Brains of 9 subjects with dup(15), 10 with idiopathic autism, and 7 controls were examined. In the dup(15) cohort, 7 subjects (78%) had autism, 7 (78%) had seizures, and 6 (67%) had experienced sudden unexplained death. Subjects with dup(15) autism were microcephalic, with mean brain weights 300 g less (1,177 g) than those of subjects with idiopathic autism (1,477 g; p<0.001). Heterotopias in the alveus, CA4, and dentate gyrus and dysplasia in the dentate gyrus were detected in 89% of dup(15) autism cases but in only 10% of idiopathic autism cases (p < 0.001). By contrast, cerebral cortex dysplasia was detected in 50% of subjects with idiopathic autism and in no dup(15) autism cases (p<0.04). The different spectrum and higher prevalence of developmental neuropathologic findings in the dup(15) cohort than in cases with idiopathic autism may contribute to the high risk of early onset of seizures and sudden death.

[Autism and pain - a literature review]

The purpose of the present article was to assess the available literature concerning pain and autism. First, authors summarized the published articles on pain reactivity in people with autism. Second, the hypotheses envisaged to explain the presence of expressive particularities in people with autism spectrum disorders were reviewed; these included endogenous opioid excess theory, sensorial abnormalities and sociocommunicative deficit. Finally, the present review dealt with the tools available to assess and manage pain in people with autism. In conclusion, the authors revealed the need for more research to obtain more consensual data and provided some recommendations in this domain that were under exploited by the scientific community. From a clinical point of view, more knowledge about pain in people with autism should enable the development of specific assessment tools and, consequently, better pain management in daily care.

Social communication difficulties and autism spectrum disorder in young children with optic nerve hypoplasia and/or septo-optic dysplasia

AIM

the aim of this study was to study systematically social, communication, and repetitive/restrictive (SCRR) behavioural difficulties and clinical autism spectrum disorder (ASD) in children with optic nerve hypoplasia (ONH) and/or septo-optic dysplasia (SOD), and to investigate the relationship between visual impairment, SCRR difficulties, ASD, and cognition.

METHOD

a case-note study of clinic records from a specialist developmental vision service was completed. Standardized assessments of vision and development and clinician judgements about SCRR difficulties and clinical ASD were made by a multidisciplinary team.

RESULTS

a total of 45 females and 38 males (mean age 3y 5mo; range 10mo-6y 10mo) with ONH or SOD and profound visual impairment (PVI) or severe visual impairment (SVI) were assessed. A total of 58% of children had at least one SCRR difficulty, and 31% had a clinical diagnosis of ASD. The prevalence of ASD was slightly higher in children with SOD than in children with ONH (36% vs 26%) also slightly more frequent in children with PVI than in children with SVI (36% vs 27%). The prevalence of SCRR difficulties was statistically higher in children with PVI than in children with SVI (p=0.003). Clinical ASD was most likely to be diagnosed between 2 years 4 months and 4 years 6 months. Development was significantly delayed in children with ASD compared with children without social communication difficulties (p=0.001).

INTERPRETATION

children with SVI or PVI are at risk of SCRR difficulties and clinical ASD. Children with ONH and/or SOD and visual impairment have a similar risk of developing clinical ASD as other visual impairment groups. However, ASD prevalence data from this study are a minimum estimate, as some young children may have developed ASD behaviours in later childhood. Developmental surveillance for children with ONH and/or SOD should continue until at least the age of 4 years 6 months.

The neuropathology of autism: defects of neurogenesis and neuronal migration, and dysplastic changes

Autism is characterized by a broad spectrum of clinical manifestations including qualitative impairments in social interactions and communication, and repetitive and stereotyped patterns of behavior. Abnormal acceleration of brain growth in early childhood, signs of slower growth of neurons, and minicolumn developmental abnormalities suggest multiregional alterations. The aim of this study was to detect the patterns of focal qualitative developmental defects and to identify brain regions that are prone to developmental alterations in autism. Formalin-fixed brain hemispheres of 13 autistic (4–60 years of age) and 14 age-matched control subjects were embedded in celloidin and cut into 200-μm-thick coronal sections, which were stained with cresyl violet and used for neuropathological evaluation. Thickening of the subependymal cell layer in two brains and subependymal nodular dysplasia in one brain is indicative of active neurogenesis in two autistic children. Subcortical, periventricular, hippocampal and cerebellar heterotopias detected in the brains of four autistic subjects (31%) reflect abnormal neuronal migration. Multifocal cerebral dysplasia resulted in local distortion of the cytoarchitecture of the neocortex in four brains (31%), of the entorhinal cortex in two brains (15%), of the cornu Ammonis in four brains and of the dentate gyrus in two brains. Cerebellar flocculonodular dysplasia detected in six subjects (46%), focal dysplasia in the vermis in one case, and hypoplasia in one subject indicate local failure of cerebellar development in 62% of autistic subjects. Detection of flocculonodular dysplasia in only one control subject and of a broad spectrum of focal qualitative neuropathological developmental changes in 12 of 13 examined brains of autistic subjects (92%) reflects multiregional dysregulation of neurogenesis, neuronal migration and maturation in autism, which may contribute to the heterogeneity of the clinical phenotype.

Begleitsymptomatik bei tief greifenden Entwicklungsstörungen

Fragestellung: Kinder und Jugendliche mit tief greifenden Entwicklungsstörungen zeigen neben der Kernsymptomatik eine Vielzahl assoziierter Erkrankungen i. S. von genetischen Syndromen oder neurologischen Erkrankungen, die für die Behandlung und den Verlauf der Störung von Bedeutung sind. In der vorliegenden Arbeit wird die Art und Häufigkeit dieser somatischen Begleiterscheinungen in Relation zur Intelligenz der Patienten analysiert. Methodik: Die Stichprobe besteht aus 601 Patienten, bei denen zwischen 1997 und 2007 in der Abteilung für Entwicklungsstörungen des Heckscher-Klinikums die Diagnose einer tief greifenden Entwicklungsstörung gestellt wurde. Neben genetischen Syndromen wurden auch neurologische Störungen erfasst. Ergebnisse: 373 (62 %) der Patienten hatten eine, 121 (20 %) zwei Diagnosen auf der Achse IV des multiaxialen Klassifikationsschemas. Genetische Störungen wurden bei insgesamt 6 % (N = 37) der Stichprobe festgestellt. Die häufigsten neurologischen Diagnosen waren Bewegungsstörungen (N = 214; 35.6 %) und Epilepsien (N = 98; 16.3 %). Patienten mit einer Intelligenzminderung zeigen häufiger somatische Begleiterscheinungen als Patienten ohne Intelligenzminderung. Schlussfolgerungen: Tief greifende Entwicklungsstörungen sind komplexe Störungsbilder, die überzufällig häufig einhergehen mit neurologischen Störungen und einem breiten Spektrum an genetischen Syndromen. Kinder mit autistischen Störungen und einer Intelligenzminderung zeigen mehr Begleiterkrankungen und sind in der psychosozialen Anpassung deutlicher beeinträchtigt als Kinder mit autistischen Störungen ohne Intelligenzminderung.

Epileptiform discharges in psychiatric patients: a controversy in need of resurrection

The current view of the psychiatric significance of inter-ictal spike discharges (IIS) in nonepileptic, psychiatric patients is that the discharges are "incidental" and are of no clinical significance. Hence, despite a voluminous literature suggestive that such discharges may have clinical relevance, electroencephalograms are hardly ever recorded in nonepileptic psychiatric patients. This literature is briefly summarized, and one detailed example of a disorder (i.e., autistic spectrum disorders) where such discharges are particularly common is provided. The argument is made that this is an area of psychiatry that is under-investigated and that research devoted to elucidating the mechanisms of development of IIS, their possible clinical relevance, and the role of anticonvulsants in managing such patients, could be very profitable.

MRI findings in 77 children with non-syndromic autistic disorder

Background

The clinical relevance of MR scanning in children with autism is still an open question and must be considered in light of the evolution of this technology. MRI was judged to be of insufficient value to be included in the standard clinical evaluation of autism according to the guidelines of the American Academy of Neurology and Child Neurology Society in 2000 [1]. However, this statement was based on results obtained from small samples of patients and, more importantly, included mostly insufficient MRI sequences. Our main objective was to evaluate the prevalence of brain abnormalities in a large group of children with a non-syndromic autistic disorder (AD) using T1, T2 and FLAIR MRI sequences.

Methodology

MRI inspection of 77 children and adolescents with non-syndromic AD (mean age 7.4±3.6) was performed. All met the DSM-IV and ADI –R criteria for autism. Based on recommended clinical and biological screenings, we excluded patients with infectious, metabolic or genetic diseases, seizures or any other neurological symptoms. Identical MRI inspections of 77 children (mean age 7.0±4.2) without AD, developmental or neurological disorders were also performed. All MRIs were acquired with a 1.5-T Signa GE (3-D T1-FSPGR, T2, FLAIR coronal and axial sequences). Two neuroradiologists independently inspected cortical and sub-cortical regions. MRIs were reported to be normal, abnormal or uninterpretable.

Principal Findings

MRIs were judged as uninterpretable in 10% (8/77) of the cases. In 48% of the children (33/69 patients), abnormalities were reported. Three predominant abnormalities were observed, including white matter signal abnormalities (19/69), major dilated Virchow–Robin spaces (12/69) and temporal lobe abnormalities (20/69). In all, 52% of the MRIs were interpreted as normal (36/69 patients).

Conclusions

An unexpectedly high rate of MRI abnormalities was found in the first large series of clinical MRI investigations in non-syndromic autism. These results could contribute to further etiopathogenetic research into autism.

Diagnosticando o transtorno autista: aspectos fundamentais e considerações práticas

Tendo como base modelos de prática diagnóstica implementados em outros países, o objetivo do artigo é oferecer uma revisão geral acerca do que vem a ser o transtorno autista e dos fatores críticos que devem ser considerados durante o processo diagnóstico. São discutidos aspectos dos critérios diagnósticos e também das comorbidades, incidência, etiologia e diretrizes para a prática diagnóstica. Tais diretrizes incluem formas de exploração de sintomas de risco durante exames de rotina realizados por profissionais que trabalham com a população infantil e elementos básicos necessários para a realização de uma avaliação minuciosa e criteriosa por uma equipe interdisciplinar. Isso inclui, por exemplo, o uso de instrumentos específicos auxiliares no diagnóstico, elementos importantes para a avaliação médica e psicológica e encaminhamentos para serviços adequados de intervenção e apoio.

Hypothesis: dysregulation of methylation of brain-expressed genes on the X chromosome and autism spectrum disorders

The hypothesis is set forth that dysregulation of brain-expressed genes on the X chromosome constitutes the major predisposition to autism spectrum disorders (ASDs). This dysregulation, mediated by hypomethylation or hypermethylation of CpG sites within gene promoters, leads to overexpression or partial silencing of one or more brain-expressed genes, which in turn results in an unbalanced production of the proteins responsible for brain structure and function. This hypothesis accommodates the predominantly sporadic occurrence (95%), the male excess (4:1), and the usual absence of malformations or other syndromic manifestations in ASDs.

The effects of intellectual functioning on the range of core symptoms of autism spectrum disorders

Autism spectrum disorders (ASD) are a class of conditions categorized by communication problems, ritualistic behaviors, and inappropriate social behaviors. While there is much evidence to support a genetic link for ASD, an identified genetic marker remains elusive. As such, practitioners place considerable emphasis on traditional measures of intelligence and adaptive behavior to aid in diagnosis. Despite the fact that these measures are commonplace, little research has been conducted to shed light on whether deficits in intellectual functioning affect the range of core symptoms for ASD. This study represents a first attempt to determine whether level of IQ has an effect on the expression of ASD symptoms in adults with intellectual disability (ID). Three hundred and six adults, 151 with both ASD and ID and 155 with ID alone, were evaluated with respect to the nature and extent of their ASD symptoms and intellectual functioning. Individuals with autism displayed a higher number of symptoms than those with pervasive developmental disorder-not otherwise specified (PDD-NOS) on all three domains of impairment (social, communication, repetitive behaviors). As expected, persons with ID alone evinced far fewer symptoms than both these groups. IQ level was found to be a moderator for expression of ASD symptoms for the entire sample but not for the autism group.

Lack of effects of vagus nerve stimulation on drug-resistant epilepsy in eight pediatric patients with autism spectrum disorders: a prospective 2-year follow-up study

Vagus nerve stimulation (VNS) therapy has been reported to reduce seizure frequency in some children with drug-resistant epilepsy who are not suitable candidates for epilepsy surgery. It has been suggested that there may be positive cognitive and/or behavioral effects independent of seizure control. We describe the effects of VNS with respect to seizure frequency, cognition, and autistic symptoms and behavior in eight children and adolescents with medically intractable epilepsy and autism. In comparison to baseline, seizure frequency had not decreased in anyone in our series at the 2-year follow-up. In three cases, minor improvements in general functioning were noted, but there were no positive cognitive effects. This open prospective pilot study highlights the need for more prospective studies to prevent false expectations of improvement in this severely disabled group.