Neurodevelopmental impairments in children with septo-optic dysplasia spectrum conditions: a systematic review

BACKGROUND

Septo-optic dysplasia (SOD) is a rare condition diagnosed in children with two or more of the following: hypopituitarism, midline brain abnormalities, and optic nerve hypoplasia. Children with SOD experience varied visual impairment and endocrine dysfunction. Autistic-like behaviours have been reported; however, their nature and prevalence remain to be fully understood. The present systematic review aimed to explore the type and prevalence of neurodevelopmental impairments in children with SOD spectrum conditions.

METHODS

The search was conducted in PubMed, EMBASE, and PsycInfo. Hand-searching reference lists of included studies was conducted. All peer-reviewed, observational studies assessing behavioural and cognitive impairments or autism spectrum disorder (ASD) symptoms in children (< 18 years) with SOD, optic nerve hypoplasia, and SOD-plus were included. Studies were excluded if they did not report standardised measures of neurodevelopmental impairments or ASD outcomes.

RESULTS

From 2132 screened articles, 20 articles reporting data from a total of 479 children were included in prevalence estimates. Of 14 studies assessing cognitive-developmental outcomes, 175 of 336 (52%) children presented with intellectual disability or developmental delay. A diagnosis of ASD or clinical level of symptoms was observed in 65 of 187 (35%) children across five studies. Only five studies assessed for dysfunction across behavioural, emotional, or social domains and reported impairments in 88 of 184 (48%) of children assessed.

LIMITATIONS

Importantly, high heterogeneity among the samples in relation to their neuroanatomical, endocrine, and optic nerve involvement meant that it was not possible to statistically assess the relative contribution of these confounding factors to the specific neurodevelopmental phenotype. This was further limited by the variation in study designs and behavioural assessments used across the included studies, which may have increased the risk of information bias.

CONCLUSIONS

This systematic review suggests that the prevalence of neurodevelopmental impairments in children within the SOD spectrum may be high. Clinicians should therefore consider including formal assessments of ASD symptoms and neurodevelopmental impairments alongside routine care. There is, additionally, a need for further research to define and validate a standardised battery of tools that accurately identify neurodevelopmental impairments in SOD spectrum conditions, and for research to identify the likely causal mechanisms.

Children's total blindness as a risk factor for early parent-child relationships: preliminary findings from an Italian sample

Background

Vision provides crucial information for parent-child attunement that scaffolds social development from the first months of life. Congenital blindness might affect both parental wellbeing and children's behavior during parent-child interaction. In this study, we compared families of young children with total versus partial blindness to understand the link between residual vision, parenting stress and perceived social support, and children's behavior during parent-child interaction.

Methods

Participants were 42 white parents (21 fathers and 21 mothers) and their congenitally blind children (14 females, mean age = 14.81 months, SD = 10.46) with no co-occurring disability, recruited at the Robert Hollman Foundation rehabilitation centers in Italy. Parents' scores on the Parenting Stress Index and Multidimensional Scale of Perceived Social Support questionnaires, as well as children's behaviors signaling joint engagement during video-recorded episodes of parent-child interaction, were compared between the Total Blindness (TB, n = 12 children with no light perception or light perception in the dark but no quantifiable visual acuity) and Partial Blindness (PB, n = 9 children with a residual visual acuity below 3/60) groups.

Results

We found that parents of TB children had higher parenting stress and lower perceived social support scores than parents of PB children. In fathers, total stress and stress linked to perceiving the child as difficult negatively correlated with perceived support from friends. There was no difference in the time TB and PB children spent displaying joint engagement behaviors during parent-child interaction. However, TB children directed their gaze and face less often toward their parents than PB children. We observed a trend of association between this behavior and maternal stress.

Conclusion

These preliminary results suggest that the complete absence of vision from birth has adverse effects on stress linked to parenting and parental perceived social support. These findings support the importance of early family-centered interventions that extend to the parents' communities and facilitate the parent-child dyad's communication through non-visual behaviors. Replication is warranted in larger and more diverse samples.

Children with autism spectrum disorders and severe visual impairments: Some general principles for intervention according to the perspective of clinical psychology of disability

In the last decades, an increasing number of researchers addressed the relationship between autism spectrum disorders (ASD) and severe visual impairment (SVI) (like blindness or very low visual acuity) and nowadays autism could be considered one of the most reported coexisting developmental disorders in children with blindness or other severe visual impairment. As ASD and SVI’ signs and symptoms affect functioning and quality of life and different domains of functioning of children with this comorbidity, it is very important to support individuals and their families as soon as possible in the cycle of life and to promote specific interventions aimed to promote developmental potential of everyone with both ASD and VI, based on the unique balance between strengths, needs and abilities of everyone. Children and individuals with SVI and ASD and SVI are a very heterogeneous group, both about the areas of social interaction, communication, and behaviour, as well as about visual abilities and about all the other aspects of their neuropsychological and functional profiles that are influenced by their visual impairments itself, their ASD itself and the combination of them. In this paper, we aim to discuss some general principles useful to design and to develop specific interventions and to promote inclusion of children with ASD and SVI.

Autism and Visual impairment: A First Approach to a Complex Relationship

Since the first half of the 20th century there has been an interest in the study of the relationship between autism and autistic-like clinical features and with visual impairments. Autism Spectrum disorders are one of the more worldwide-studied neurodevelopmental disorder with an increasing prevalence in the last ten years. Visual impairment is a condition which derives from several causes (genetic, constitutional, injuries, nutritional and environmental ones). Again, it is a kind of spectrum and an overarching category, because visual impairments range from refractive errors (myopia, hyperopia, astigmatism), to amblyopia, strabismus, and to partial and total blindness. Since the first study of Keeler (1956) which described autistic-like patterns in five preschool children who were totally blind due to retinopathy of prematurity (ROP), a growing number of researchers addressed the relationship between autism and visual impairment. In this paper we focused on it, aiming to discuss on some lessons learned in this field and to discuss some open questions since the first research in this field.

Prevalence of Ophthalmologic Diagnoses in Children With Autism Spectrum Disorder Using the Optum Dataset: APopulation-Based Study

PURPOSE

Autism spectrum disorder (ASD) affects an estimated 1.85% of children in the United States and is increasing in prevalence. Any relationship between ophthalmologic disorders and ASD is poorly understood. The purpose of this study was to calculate the prevalence of ophthalmologic disorders in children with ASD.

DESIGN

Population-based retrospective cohort study.

METHODS

Setting: claims data from Optum Labs Data Warehouse, a longitudinal real-world data asset with de-identified administrative claims and electronic health records data. StudyPopulation: children ≤18 years of age at the time of first claim between 2007 and 2013.

OBSERVATION

diagnosis of pervasive developmental disorder (PDD) or autistic disorder (AD) according to International Classification of Disease-9th edition (ICD-9) codes. MainOutcomeMeasurements: prevalence of an ophthalmologic diagnosis (amblyopia, strabismus, optic neuropathy, nystagmus, or retinopathy of prematurity) by ICD-9 codes in typically developing (TD) controls and children with PDD and AD. Adjusted odds ratios (OR) for each diagnosis were calculated using multivariate logistic regression models.

RESULTS

Claims from more than 10 million children were included. The prevalence of any ophthalmologic diagnosis considered in this study was 3.5% in TD controls, 12.5% in children with PDD (adjusted OR, 3.22; 95% confidence interval [CI, ], 3.16-3.29; P < .001), and 13.5% in children with AD (adjusted OR, 3.23; 95% CI, 3.15-3.31; P < .001).

CONCLUSIONS

Population-based data suggested an increased risk of ophthalmologic diagnoses in children with ASD. Future research is necessary to further clarify the relationship between ophthalmologic disorders and autistic symptoms and severity.

Congenital blindness and autism spectrum disorder (ASD): diagnostic challenges and intervention options

The case of a 6-year-old boy with congenital blindness and features suggestive of autism spectrum disorder (ASD) is reported. He presented to a developmental paediatrician with global developmental delay, worsening self-injurious behaviours and difficulties in social interaction, transitions and interactive play. He demonstrated poor response to his name, rigidity, repetitive behaviours and had a sensory profile suggestive of ASD. This paper discusses the challenges in diagnosing and managing ASD in visually impaired children.

Ophthalmologic disorders and risk factors in children with autism spectrum disorder

PURPOSE

To report the results of our review of all children with autism spectrum disorder (ASD) who underwent complete pediatric ophthalmologic examination at our institution over a 10-year period.

METHODS

The medical records of all children (0-17 years of age) with a diagnosis of ASD seen at University of California, Davis, over a 10-year period were reviewed retrospectively. Demographic data, birth history, genetic testing results, neuropsychiatric comorbidities, and ophthalmologic findings were extracted from the record. Multiple logistic regression was used to identify risk factors for ophthalmologic disorders.

RESULTS

A total of 2,555 children with ASD were seen at the university over the study period, of whom 380 (15%) were evaluated in the ophthalmology clinic. Eye examination revealed an ophthalmic diagnosis in 71% of children, of which the most common were significant refractive error (42%), strabismus (32%), and amblyopia (19%). Optic neuropathy occurred in 14 children (4%). Cerebral palsy was a significant risk factor for refractive error (OR = 3.22; P = 0.016), strabismus (OR = 3.59; P = 0.012), amblyopia (OR = 3.49; P = 0.0097), and optic neuropathy (OR = 14.0; P = 0.0009).

CONCLUSIONS

Ophthalmic disorders were found in 71% of children with ASD evaluated at our university-based ophthalmology clinic. The rates of significant refractive error, strabismus, amblyopia, and optic neuropathy exceeded those of the general pediatric population. ASD and cerebral palsy may have additive risk for these disorders.

Pilot study: Sensory integration processing disorders in children with optic nerve hypoplasia spectrum

This study aimed to explore the sensory processing profiles of children with the spectrum of optic nerve hypoplasia (ONH). Caregivers completed the Short Sensory Profile (SSP), the Social Communication Questionnaire (SCQ), and the Vineland Adaptive Behaviour Scale (VABS) interview. The study demonstrated that children with ONH present with sensory integration dysfunction (SID), in their intact senses, and that autistic spectrum condition (ASC) was the best predictor of SID, rather than visual loss, or level of intellectual disability in these children. The results indicate that assessment and monitoring of SID in children with ONH is crucial.

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.

Optic nerve hypoplasia in children and adolescents; prevalence, ocular characteristics and behavioural problems

PURPOSE

To report prevalence, ocular characteristics and coexisting behavioural problems in children and adolescents with optic nerve hypoplasia (ONH), which is a common cause of visual impairment in children in western countries, often associated with neurological or endocrinological problems and where autism has been reported in severe cases with blindness.

METHODS

This is a population-based cross-sectional study of patients <20 years of age who had been diagnosed with ONH and lived in the county of Stockholm in December 2009. Ophthalmological assessments including fundus photographs with optic disc analyses were made. A questionnaire was used to screen for behaviour and development.

RESULTS

The prevalence of ONH in all living children <18 years of age in Stockholm was 17.3/100 000 with a prevalence of visual impairment (<0.3) of 3.9/100 000. In total, 66 patients, median age 9.3 years (0.6-19.4), 36 with bilateral and 30 with unilateral ONH, were included in the current study; 53 were re-examined clinically, group A, and 13 agreed to retrospective analyses of existing medical records, group B. Analyses of the optic discs were made in fundus photographs from 53 patients comparing a semi-automated (Retinal Size Tool) and a manual method (Zeki). There was a strong curvilinear correlation (r(S)  = -0.91 p < 0.0001 for both eyes). Behavioural problems were more common (p < 0.05) in bilateral ONH.

CONCLUSION

Optic nerve hypoplasia is a common ocular malformation with a prevalence of 17.3/100 000 children and adolescents <18 years of age in Stockholm. Unilateral ONH seems as common as bilateral.

Autism assessment in children with optic nerve hypoplasia and other vision impairments

AIM

This study examined the utility of standard autism diagnostic measures in nine children (aged 5-9y) with severe vision impairment and a range of social and language functioning.

METHOD

The Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview, Revised (ADI-R) were systematically modified and used to assess symptoms of autism in children with vision less than or equal to 20/800, the majority of whom had optic nerve hypoplasia. The results of the assessments, including analysis of symptom patterns, were compared with expert autism diagnoses.

RESULTS

Modified autism measures demonstrated good agreement with clinical diagnoses. Symptoms found to be most and least reliable in discriminating autism from behaviors common to most children with congenital vision impairment are described. Comparisons of current behavior with parent-reported behaviors from a younger age suggested that some symptoms of autism in very young children who are congenitally blind may improve with age.

INTERPRETATION

The ADOS and ADI-R are useful for clinical assessment and for advancing research efforts to understand autism symptoms in children with vision impairment. However, some autistic symptoms in very young children may change over time, and developmental changes should be closely monitored.

Optic nerve hypoplasia syndrome: a review of the epidemiology and clinical associations

OPINION STATEMENT

BACKGROUND

Optic nerve hypoplasia (ONH) has developed into a leading cause of congenital blindness. The frequently associated features of hypopituitarism and absent septum pellucidum were felt to have embryonic linkage as "septo-optic dysplasia" or "de Morsier's syndrome." More recent studies have suggested these associations are independent of one another. This review provides an assessment of the historical and recent evidence linking neuroradiologic, endocrinologic and developmental morbidity in patients with ONH. The prenatal risk factors, heritability, and genetic mutations associated with ONH are described.

RESULTS

Recognition of the critical association of ONH with hypopituitarism should be attributed to William Hoyt, not Georges de Morsier. De Morsier never described a case of ONH or recognized its association with hypopituitarism or missing septum pellucidum. Hypopituitarism is caused by hypothalamic dysfunction. This, and other more recently identified associations with ONH, such as developmental delay and autism, are independent of septum pellucidum development. Other common neuroradiographic associations such as corpus callosum hypoplasia, gyrus dysplasia, and cortical heterotopia may have prognostic significance. The predominant prenatal risk factors for ONH are primiparity and young maternal age. Presumed risk factors such as prenatal exposure to drugs and alcohol are not supported by scrutiny of the literature. Heritability and identified gene mutations in cases of ONH are rare.

CONCLUSION

Children with ONH require monitoring for many systemic, developmental, and even life-threatening problems independent of the severity of ONH and presence of brain malformations including abnormalities of the septum pellucidum. "Septo-optic dysplasia" and "de Morsier's syndrome" are historically inaccurate and clinically misleading terms.