Social-emotional instability in individuals with Rett syndrome: parents' experiences with second stage behaviour

The association between prenatal psychosocial factors and autism spectrum disorder in offspring at 3 years: a prospective cohort study

PURPOSE

Few studies of risk factors for autism spectrum disorder (ASD) have been prospective in design or investigated the role of psychosocial factors measured during pregnancy. We aimed to investigate associations between prenatal psychosocial factors and risk of ASD in offspring, as part of a multicenter prospective cohort study of more than 2000 mother-child pairs.

METHODS

Nulliparous women aged 18-35 years, living in Pennsylvania, USA, were interviewed during pregnancy and multiple times postpartum over the course of a 3-year period. There were 2388 mothers who completed the Screen for Social Interaction Toddler Version (SSI-T), a measure of risk of ASD, when their child was 3-years old. Multivariable logistic regression models were used to investigate the associations between prenatal psychosocial factors-including total scores on three scales (social-support, stress and depression), trouble paying for basic needs, mental illness diagnosis and use of antidepressants-and risk of ASD in offspring at the age of 3-years, controlling for relevant confounding variables.

RESULTS

There were 102 children (4.3%) who were scored as at-risk of ASD at 3-years. Prenatal psychosocial factors that were significantly associated with risk of ASD in the adjusted models were lower social-support (p < 0.001); stress (p = 0.003): depression (< 0.001), trouble paying for basic needs (p = 0.012), mental illness diagnosis (p = 0.016), and use of antidepressants (p < 0.001).

CONCLUSION

These findings suggest that maternal experience of adverse psychosocial factors during pregnancy may be important intrauterine exposures related to the pathogenesis of ASD.

Meaningful Improvements in Rett Syndrome: A Qualitative Study of Caregivers

BACKGROUND

Rett syndrome is a rare neurodevelopmental disorder primarily affecting females. This syndrome is associated with many comorbidities and impairments related to motor function, breathing, sleep, expressive language, and repetitive hand movements. The Rett Syndrome Behaviour Questionnaire (RSBQ) is one measure used to assess changes in Rett syndrome-related manifestations or core symptoms. Little is known about how caregivers think about meaningful changes in the items that make up the RSBQ scale.

METHODS

This qualitative study explored how caregivers of individuals with Rett syndrome viewed changes in the symptoms covered in the RSBQ. We conducted semistructured interviews with 40 caregivers and employed thematic analysis, identifying themes using an iterative process.

RESULTS

Two factors characterized caregivers' thoughts about meaningful changes in Rett syndrome manifestations. First, general features of these symptoms rendered them bothersome: the extent of bother compared to other symptoms, if or how they prevented desirable behaviors and their temporal qualities. Second, caregivers evaluated the meaning of improvements by considering the decrease in bother and the potential benefits of change. Improvements had social and psychological consequences for individuals with Rett syndrome and caregivers. In addition, implications for health, fine and gross motor skills, and communication were also substantial.

Experimental Examination and Social Validation of a Microswitch Intervention to Improve Choice-Making and Activity Engagement for Six Girls with Rett Syndrome

Background: The use of assistive technology, specifically microswitches, with children with RTT has been shown to effectively moderate the impact of their disability on their quality of life^- by facilitating access to meaningful leisure and other activities. Objectives: This study aimed to evaluate the effectiveness of a microswitch intervention on increased choice making, engagement in a targeted sorting activity, and indices of happiness, and decreased stereotypic behaviors for six girls with Rett syndrome. Targeted dependent variables were also assessed at six months post-intervention. Following the intervention study, 90 external raters completed a social validation procedure. Method: An ABABAB experimental sequence was implemented for each participant with a cross-over effect. A social validation assessment involving 90 external raters was carried out. Results: Data emphasized an improved performance for each participants involved (i.e., adaptive responses). Five participants showed a capacity of independent choice. One participant seemed to be closely linked to the position of the container. Social raters favorably endorsed the use of the program since they positively evaluated the use of the technology on all the dimensions investigated. Conclusion: A microswitch intervention may improve choice making and activity engagement for children with Rett syndrome. Further research is needed on the development of more sophisticated forms of individualized technological options to improve opportunities for enhanced engagement and choice-making for individuals with RTT.

Rett syndrome (MECP2) and succinic semialdehyde dehydrogenase (ALDH5A1) deficiency in a developmentally delayed female

BACKGROUND

We present a patient with Rett syndrome (RTT; MECP2) and autosomal-recessive succinic semialdehyde dehydrogenase deficiency (SSADHD; ALDH5A1 (aldehyde dehydrogenase 5a1 = SSADH), in whom the current phenotype exhibits features of SSADHD (hypotonia, global developmental delay) and RTT (hand stereotypies, gait anomalies).

METHODS

γ-Hydroxybutyric acid (GHB) was quantified by UPLC-tandem mass spectrometry, while mutation analysis followed standard methodology of whole-exome sequencing.

RESULTS

The biochemical hallmark of SSADHD, GHB was increased in the proband's dried bloodspot (DBS; 673 µM; previous SSADHD DBSs (n = 7), range 124-4851 µM); control range (n = 2,831), 0-78 µM. The proband was compound heterozygous for pathogenic ALDH5A1 mutations (p.(Asn418IlefsTer39); maternal; p.(Gly409Asp); paternal) and a de novo RTT nonsense mutation in MECP2 (p.Arg255*).

CONCLUSION

The major inhibitory neurotransmitter, γ-aminobutyric acid (GABA), is increased in SSADHD but normal in RTT, although there are likely regional changes in GABA receptor distribution. GABAergic anomalies occur in both disorders, each featuring an autism spectrum phenotype. What effect the SSADHD biochemical anomalies (elevated GABA, GHB) might play in the neurodevelopmental/epileptic phenotype of our patient is currently unknown.

"Living an Obstacle Course": A Qualitative Study Examining the Experiences of Caregivers of Children with Rett Syndrome

Background: Rett syndrome has considerable effects on the quality of life of affected children, impairing everyday activities and potentially impacting the life of both the caregivers and the family. Our aim was to explore the experiences of a group of caregivers of children with Rett syndrome with regards to living and caring for their children. Methods: We conducted a qualitative case study to examine how 31 caregivers of children with Rett syndrome perceived living with their children. Data were collected through in-depth interviews, focus groups, researchers’ field notes and caregivers’ personal documents. A thematic analysis was performed following the Consolidated Criteria for Reporting Qualitative Research (COREQ) guideline. Results: The experience of being a caregiver of a child with Rett syndrome was expressed as being akin to an “obstacle course”, and was described via three main themes: (a) looking for answers, with two subthemes identified, namely ‘the first symptoms’, and ‘the need for a diagnosis’; (b) managing day to day life, with the subthemes ‘applying treatments’, and ‘learning to care’; and (c) money matters. Conclusions: Rett syndrome has a considerable impact on the lives of the caregivers involved. The health-care process and the management of economic resources are some of the aspects highlighted by caregivers. These findings have important implications for the planning of support services, health systems and health policies.

Quality of life related to clinical features in patients with Rett syndrome and their parents: a systematic review

Patients with a neurodevelopmental disorder such as Rett syndrome (RS), as well as their families, have complex needs that affect their quality of life (QoL). Therefore, both families and patients with RS must be provided with multidisciplinary health care that can identify the clinical features that most affect their QoL and mental health risks. The main objective of this paper is to provide a comprehensive overview of the QoL subdimensions of families affected by RS, including both the parents and children. We conducted a systematic review, following PRISMA criteria, of the data in the PubMed, PsycINFO, Cuiden, and LILACS databases. The results indicated that when considering the family as a whole, RS equally affects the physical and psychological QoL dimensions; the next most affected was the social dimension. According to parents' reports, seizures are one of the main factors that decreases their QoL. Thus, from a clinical point of view, controlling seizure activity of children with RS is the main way of improving the QoL of their parents. Interventions in patients affected by RS should be based on the improvement of visual contact and concentration, reducing somnolence, and increasing mobility. The subdimensions of QoL that were most affected in parents of girls with RS were those related to mental health and feelings of well-being.

Key issues in Rett syndrome: emotional, behavioural and autonomic dysregulation (EBAD) - a target for clinical trials

Complex neurodevelopmental disorders need multi-disciplinary treatment approaches for optimal care. The clinical effectiveness of treatments is limited in patients with rare genetic syndromes with multisystem morbidity. Emotional and behavioural dysregulation is common across many neurodevelopmental disorders. It can manifest in children across multiple diagnostic groups, including those on the autism spectrum and in rare genetic syndromes such as Rett Syndrome (RTT). There is, however a remarkable scarcity in the literature on the impact of the autonomic component on emotional and behavioural regulation in these disorders, and on the longer-term outcomes on disorder burden.RTT is a debilitating and often life-threatening disorder involving multiple overlapping physiological systems. Autonomic dysregulation otherwise known as dysautonomia is a cardinal feature of RTT characterised by an imbalance between the sympathetic and parasympathetic arms of the autonomic nervous system. Unlocking the autonomic component of emotional and behavioural dysregulation would be central in reducing the impairment seen in patients with RTT. In this vein, Emotional, Behavioural and Autonomic Dysregulation (EBAD) would be a useful construct to target for treatment which could mitigate burden and improve the quality of life of patients.RTT can be considered as a congenital dysautonomia and because EBAD can give rise to impairments occurring in multiple overlapping physiological systems, understanding these physiological responses arising out of EBAD would be a critical part to consider when planning treatment strategies and improving clinical outcomes in these patients. Biometric guided pharmacological and bio-feedback therapy for the behavioural and emotional aspects of the disorder offers an attracting perspective to manage EBAD in these patients. This can also allow for the stratification of patients into clinical trials and could ultimately help streamline the patient care pathway for optimal outcomes.The objectives of this review are to emphasise the key issues relating to the management of EBAD in patients with RTT, appraise clinical trials done in RTT from the perspective of autonomic physiology and to discuss the potential of EBAD as a target for clinical trials.