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Herrera-Pino J, Benedetti-Isaac J, Ripoll-Córdoba D, Camargo L, Castillo-Tamara EE, Morales-Asencio B, Perea-Castro E, Torres Zambrano M, Ducassou A, Flórez Y, Porto MF, Gargiulo PA, Zurita-Cueva B, Caldichoury N, Coronado JC, Castellanos C, Ramírez-Penso C, López N. Effectiveness of deep brain stimulation on refractory aggression in pediatric patients with autism and severe intellectual disability: meta-analytic review. BMC Pediatr 2024; 24:487. [PMID: 39080575 PMCID: PMC11290060 DOI: 10.1186/s12887-024-04920-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 07/01/2024] [Indexed: 08/02/2024] Open
Abstract
Some patients with autism and severe intellectual disability may experience uncontrolled aggression, causing serious injury or harm to others, and the therapeutic ineffectiveness of traditional pharmacological and behavioral treatment may aggravate symptoms. Deep brain stimulation (DBS) has been tested in patients with little evidence in children and adolescents. Therefore, we analyzed the efficacy and safety of DBS in refractory aggression in pediatric subjects with autism (ASD) and severe intelligence deficit (ID).Methods A meta-analytic review of Web of Science (WOS) and Scopus articles, following Prisma criteria. A total of 555 articles were identified, but after applying the inclusion criteria, only 18 were analyzed. The review of the registries and the extraction of information was performed by 2 independent groups, to reduce the evaluator's bias. For the description of the results, pediatric patients with ASD or ID present in each registry, with an application of specialized scales (Overt aggression scale, OAS, and THE modified version of the OAS, MOAS) pre and post-DBS, with a clinical follow-up of at least 12 months, were considered valid. Clinical improvement was calculated using tests of aggressiveness. In each registry with available data and then pooling the means of all patients in the OAS and MOAS, the effect size of DBS (overall and per study) was estimated. Finally, the adapted NOS scale was applied to rate the studies' quality and level of bias.Results In the studies analyzed, 65/100 were pediatric patients, with a mean age of 16.8 years. Most of the studies were conducted in South America and Europe. In all teams, aggressive behavior was intractable, but only 9 groups (53/65) applied specialized scales to measure aggressiveness, and of these, only 51 subjects had a follow-up of at least 12 months. Thus, in 48/51 a clinical improvement of patients was estimated (94.2%), with a considerable overall effect size (OAS: d = 4.32; MOAS: d = 1.46). However, adverse effects and complications were found in 13/65 subjects undergoing DBS. The brain target with the most evidence and the fewest side effects was the posteromedial hypothalamic nuclei (pHypN). Finally, applying the adapted NOS scale, quality, and bias, only 9 studies show the best indicators.Conclusion An optimal level of efficacy was found in only half of the publications. This is mainly due to design errors and irrelevant information in the reports. We believe that DBS in intractable aggressiveness in children and adolescents with ASD and severe ID can be safe and effective if working groups apply rigorous criteria for patient selection, interdisciplinary assessments, objective scales for aggressiveness, and known surgical targets.
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Affiliation(s)
- Jorge Herrera-Pino
- College of Medicine, Florida International University, 11200 SW 8Th St, Miami, FL, 33199, USA
| | - Juancarlos Benedetti-Isaac
- Clinica Neurocardiovascular, Neurodinamia, Tv. 54 #21a-75, Cartagena, Colombia
- Misericordia International Clinic, Cra. 74 #76-105, Barranquilla, 080001, Colombia
| | - Daniela Ripoll-Córdoba
- Departamento de Ciencias Sociales, Universidad de La Costa, Cl. 58 #55 - 66, Barranquilla, 080002, Colombia
| | - Loida Camargo
- Facultad de Medicina, Universidad de Cartagena, Campus Zaragocilla, Cartagena de Indias, Bolívar, 130014, Colombia
| | - Edgard E Castillo-Tamara
- Facultad de Medicina, Universidad del Sinú, Provincia de Cartagena, Calle 30 #20-71, Cartagena de Indias, Bolívar, 130001, Colombia
| | - Breiner Morales-Asencio
- Departamento de Ciencias Sociales, Universidad de La Costa, Cl. 58 #55 - 66, Barranquilla, 080002, Colombia
| | - Esther Perea-Castro
- Clinica Neurocardiovascular, Neurodinamia, Tv. 54 #21a-75, Cartagena, Colombia
| | | | | | - Yuliana Flórez
- Departamento de Ciencias Sociales, Universidad de La Costa, Cl. 58 #55 - 66, Barranquilla, 080002, Colombia
| | - María F Porto
- Department of Cognition, Development and Educational Psychology, Universitat de Barcelona and Bellvitge Institute for Biomedical Research (IDIBELL), Carrer de La Feixa Llarga, L'Hospitalet de Llobregat, Barcelona, 08907, Spain
| | - Pascual A Gargiulo
- Laboratorio de Neurociencias y Psicología Experimental (CONICET), Departamento de Patología, Facultad de Ciencias Médicas, Universidad Nacional de Cuyo. Parque General San Martín, Mendoza, M5502JMA, Argentina
| | - Boris Zurita-Cueva
- Departamento de Neurocirugía, Omni Hospital, Avenida abel Romeo Castillo y ave. Tanca Marengo., Guayaquil, 090513, Ecuador
| | - Nicole Caldichoury
- Departamento de Ciencias Sociales, Universidad de Los Lagos, Av Alberto-Hertha Fuchslocher 1305, Osorno, Los Lagos, Chile
| | - Juan-Carlos Coronado
- Facultad de Salud, Universidad Católica de Temuco, Montt 56, Temuco, Araucanía, 4780000, Chile
| | - Cesar Castellanos
- Instituto Dominicano para el Estudio de la Salud Integral y la Psicología Aplicada (IDESIP), C. Eugenio Deschamps No.5, Santo Domingo, 10014, República Dominicana
| | - Cleto Ramírez-Penso
- Departamento de Neurocirugía, Director general del Centro Cardio-Neuro-Oftalmológico y Trasplante (CECANOT), C/ Federico Velázquez #1, Sector Maria Auxiliadora, Santo Domingo, República Dominicana
- Sociedad Dominicana de Neurología y Neurocirugía (Pax- President), F38M+CHM, Santo Domingo, 10106, República Dominicana
| | - Norman López
- Departamento de Ciencias Sociales, Universidad de La Costa, Cl. 58 #55 - 66, Barranquilla, 080002, Colombia.
- Escuela de Kinesiología, Facultad de Salud, Universidad Santo Tomás, Manuel Rodríguez 060, Temuco, 4790870, Chile.
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Mazza JADS, Ferreira LS, Martins-Vieira ADF, Beserra DDL, Rodrigues VA, Malcher-Lopes R, Caixeta FV. Clinical and Family Implications of Cannabidiol (CBD)-Dominant Full-Spectrum Phytocannabinoid Extract in Children and Adolescents with Moderate to Severe Non-Syndromic Autism Spectrum Disorder (ASD): An Observational Study on Neurobehavioral Management. Pharmaceuticals (Basel) 2024; 17:686. [PMID: 38931353 PMCID: PMC11206937 DOI: 10.3390/ph17060686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/09/2024] [Accepted: 05/16/2024] [Indexed: 06/28/2024] Open
Abstract
Autism Spectrum Disorder (ASD) encompasses a wide range of neurodevelopmental conditions characterized by deficits in social interaction, communication and behavior. Current pharmacological options are limited and feature significant side effects. In this study, we conducted a retrospective, observational, and cross-sectional cohort study to evaluate the effects of Cannabidiol (CBD)-dominant, full-spectrum cannabis extract, containing Tetrahydrocannabinol (THC) in a ratio of 33:1 (CBD:THC), on non-syndromic children and adolescents (5-18 years old) with moderate to severe ASD. Thirty volunteers were recruited, underwent neuropsychological evaluations and were treated with individualized doses of CBD-dominant extract. Clinical assessments were conducted by the designated clinician. Additionally, parents or caregivers were independently interviewed to assess perceived treatment effects. We found significant improvements in various symptomatic and non-symptomatic aspects of ASD, with minimal untoward effects, as reported by both clinical assessments and parental perceptions. The observed improvements included increased communicative skills, attention, learning, eye contact, diminished aggression and irritability, and an overall increase in both the patient's and family's quality of life. Despite its limitations, our findings suggest that treatment with full-spectrum CBD-dominant extract may be a safe and effective option for core and comorbid symptoms of ASD, and it may also increase overall quality of life for individuals with ASD and their families.
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Affiliation(s)
- Jeanne Alves de Souza Mazza
- University Hospital of Brasilia, Campus Darcy Ribeiro, Brasilia 70840-901, Brazil; (J.A.d.S.M.); (L.S.F.); (D.D.L.B.); (V.A.R.)
| | - Lisiane Seguti Ferreira
- University Hospital of Brasilia, Campus Darcy Ribeiro, Brasilia 70840-901, Brazil; (J.A.d.S.M.); (L.S.F.); (D.D.L.B.); (V.A.R.)
| | - Alice de Faria Martins-Vieira
- Department of Physiological Sciences, University of Brasilia, Campus Darcy Ribeiro, Brasilia 70910-900, Brazil; (A.d.F.M.-V.); (R.M.-L.)
| | - Doris Day Lopes Beserra
- University Hospital of Brasilia, Campus Darcy Ribeiro, Brasilia 70840-901, Brazil; (J.A.d.S.M.); (L.S.F.); (D.D.L.B.); (V.A.R.)
| | - Victor Alves Rodrigues
- University Hospital of Brasilia, Campus Darcy Ribeiro, Brasilia 70840-901, Brazil; (J.A.d.S.M.); (L.S.F.); (D.D.L.B.); (V.A.R.)
| | - Renato Malcher-Lopes
- Department of Physiological Sciences, University of Brasilia, Campus Darcy Ribeiro, Brasilia 70910-900, Brazil; (A.d.F.M.-V.); (R.M.-L.)
| | - Fabio V. Caixeta
- Department of Physiological Sciences, University of Brasilia, Campus Darcy Ribeiro, Brasilia 70910-900, Brazil; (A.d.F.M.-V.); (R.M.-L.)
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Regian N, Mittal A, Chammany M, Rai HP, Rommen M. Navigating Community-Based Psychiatry Care of Pediatric Patients in Low-Resource Settings: A Case Report. Cureus 2024; 16:e59506. [PMID: 38826973 PMCID: PMC11144047 DOI: 10.7759/cureus.59506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Accepted: 05/01/2024] [Indexed: 06/04/2024] Open
Abstract
This case report examines the experience of a nine-year-old male with autism spectrum disorder (ASD) who was admitted to his rural community emergency department (ED) for the treatment of aggressive behaviors, agitation, and violence. Despite a high prevalence of such behaviors within the autistic pediatric population, multiple inpatient facilities that offer pediatric psychiatric services refused to transfer his care. Many other commonly used resources and treatment modalities were also not available, resulting in a nine-day ED boarding experience with minimal symptomatic improvement. Pharmacotherapy was utilized, but nationally recommended guidelines were not appropriately followed. Although this case is one of many pediatric patients who received inadequate psychiatric care from their local ED, it is significant in identifying specific areas of improvement within Northeast Louisiana psychiatric healthcare. This case report of a nine-year-old male with autism underlines the hardships faced by patients and their families due to the gaps in our current healthcare infrastructure and emphasizes the importance of protocols and resources for patient populations with higher-than-average wellness needs.
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Affiliation(s)
- Natalie Regian
- Medical School, Edward Via College of Osteopathic Medicine, Monroe, USA
| | - Ajay Mittal
- Medical School, Edward Via College of Osteopathic Medicine, Monroe, USA
- Nephrology, University of Florida College of Medicine, Gainesville, USA
| | - Michael Chammany
- Medical School, Edward Via College of Osteopathic Medicine, Monroe, USA
| | - Hitesh P Rai
- Research, Edward Via College of Osteopathic Medicine, Monroe, USA
| | - Michael Rommen
- Clinical Medicine/Emergency Medicine, Edward Via College of Osteopathic Medicine, Monroe, USA
- Emergency Medicine, St. Francis Medical Center, Monroe, USA
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Bartel RL, Knight JR, Worsham W, Bilder DA. Discordance Between Psychiatric Diagnoses and Medication Use in Children and Adults With Autism Presenting in Crisis. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2024; 22:150-161. [PMID: 38680982 PMCID: PMC11046722 DOI: 10.1176/appi.focus.20230027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
Autistic individuals experience high rates of behavioral crises that present to healthcare providers for medication management. Co-occurring psychiatric conditions and psychotropic medication use are common among this patient population. Particularly for those with limited expressive language, evaluating for the presence of psychiatric and medical conditions that could contribute to distress is a critical component of crisis management. A records review study was completed on 126 autistic individuals for whom medical decision-making support was requested from The Huntsman Mental Health Institute Neurobehavior Consultation Service. Crisis manifestations and historical information were provided by the parent or caregiver through an online questionnaire. Nearly all individuals presented with behavioral (96.8%) and emotional (96.8%) symptoms; 97.6% received at least one co-occurring psychiatric diagnosis. Additionally, 75.4% of parents or caregivers endorsed the presence of a medical condition that they believed could be contributing to the crisis presentation. Most individuals (92.1%) were prescribed at least one psychotropic medication; 69.8% were taking an antipsychotic, suggesting a history of treatment resistance. The alignment between psychotropic medications and psychiatric diagnoses was evaluated in the context of prior studies and reviews on psychiatric management in autistic and neurotypical populations. Several individuals were taking a combination of medications that included both indicated and contraindicated medications for the psychiatric disorder diagnosed, likely contributing to treatment resistance. Identifying discordance between psychotropic medication use and psychiatric conditions present offers an opportunity to pursue better treatment outcomes for autistic individuals, particularly for those experiencing treatment-resistant agitation.
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Affiliation(s)
- Roxanne L Bartel
- Department of Psychiatry, Huntsman Mental Health Institute (Bartel, Bilder); and School of Medicine (Knight), University of Utah, Salt Lake City; Department of Psychiatry, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire (Worsham)
| | - Jacob R Knight
- Department of Psychiatry, Huntsman Mental Health Institute (Bartel, Bilder); and School of Medicine (Knight), University of Utah, Salt Lake City; Department of Psychiatry, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire (Worsham)
| | - Whitney Worsham
- Department of Psychiatry, Huntsman Mental Health Institute (Bartel, Bilder); and School of Medicine (Knight), University of Utah, Salt Lake City; Department of Psychiatry, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire (Worsham)
| | - Deborah A Bilder
- Department of Psychiatry, Huntsman Mental Health Institute (Bartel, Bilder); and School of Medicine (Knight), University of Utah, Salt Lake City; Department of Psychiatry, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire (Worsham)
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da Rosa ALST, Bezerra OS, Rohde LA, Graeff-Martins AS. Exploring clozapine use in severe psychiatric symptoms associated with autism spectrum disorder: A scoping review. J Psychopharmacol 2024; 38:324-343. [PMID: 38576151 DOI: 10.1177/02698811241241384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
BACKGROUND Patients with autism spectrum disorder (ASD) may experience severe psychiatric symptoms, often unresponsive to conventional pharmacological therapies, highlighting the need for more effective alternatives. AIMS This study aims to map and synthesize evidence on the use of clozapine as a therapeutic option for managing severe psychiatric symptomatology co-occurring with ASD. METHODS We conducted a scoping review on multiple sources following the JBI guidelines. The search strategy was inclusive, targeting both peer-reviewed publications and gray literature presenting empirical data on the use of clozapine therapy for patients with ASD accompanied by comorbid psychiatric symptoms. Two independent evaluators performed the selection of studies, data extraction, and critical appraisal. RESULTS The review included 46 studies, encompassing 122 ASD individuals who received clozapine therapy. The sources of evidence comprise 31 case reports, 8 case series, 6 retrospective observational studies, and 1 quasi-experimental prospective study. The tables present the findings along with a narrative summary. Clozapine treatment demonstrated benefits in four groups of severe and treatment-resistant psychiatric symptoms in ASD patients: disruptive behaviors, psychotic symptoms, catatonia, and mood symptoms. Although side effects were common, tolerability was generally satisfactory. However, severe adverse events, such as seizures, moderate neutropenia, and myocarditis, underscore the need for intensive clinical monitoring. CONCLUSIONS While clozapine shows promise as a pharmacological intervention for severe psychopathologies in ASD, more rigorous clinical studies are required to elucidate its efficacy and safety in this population. The limited robustness of the evidence calls for caution, signaling an early research stage into this topic.
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Affiliation(s)
- André Luiz Schuh Teixeira da Rosa
- Graduate Program of Psychiatry and Behavioral Sciences, Department of Psychiatry, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Olivia Sorato Bezerra
- Child Neurology Unit, Department of Pediatrics, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Luis Augusto Rohde
- Graduate Program of Psychiatry and Behavioral Sciences, Department of Psychiatry, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Ana Soledade Graeff-Martins
- Graduate Program of Psychiatry and Behavioral Sciences, Department of Psychiatry, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
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Dell’Osso L, Bonelli C, Nardi B, Giovannoni F, Pronestì C, Cremone IM, Amatori G, Pini S, Carpita B. Rethinking Clozapine: Lights and Shadows of a Revolutionary Drug. Brain Sci 2024; 14:103. [PMID: 38275523 PMCID: PMC10813979 DOI: 10.3390/brainsci14010103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
The current literature globally highlights the efficacy of Clozapine in several psychiatric disorders all over the world, with an FDA indication for reducing the risk of repeated suicidal behavior in patients with schizophrenia or schizoaffective disorder. A growing field of research is also stressing a possible broader beneficial effect of Clozapine in promoting neuroprotection and neurotrophism. However, this drug is linked to several life-threatening side effects, such as agranulocytosis, myocarditis and seizures, that limit its use in daily clinical practice. For this work, a search was performed on PubMed using the terms "Clozapine indications", "Clozapine adverse effects", "Clozapine regenerative effects", and "Clozapine neuroplasticity" with the aim of reviewing the scientific literature on Clozapine's treatment indications, adverse effects and potential regenerative role. The results confirmed the efficacy of clozapine in clinical practice, although limited by its adverse effects. It appears crucial to raise awareness among clinicians about the potential benefits of using Clozapine, as well educating medical personnel about its risks and the early identification of possible adverse effects and their management.
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Affiliation(s)
| | - Chiara Bonelli
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, 67 Via Roma, 56126 Pisa, Italy; (L.D.); (B.N.); (F.G.); (C.P.); (I.M.C.); (G.A.); (S.P.); (B.C.)
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Argonis RA, Pedapati EV, Dominick KC, Harris K, Lamy M, Fosdick C, Schmitt L, Shaffer RC, Smith E, Will M, McDougle CJ, Erickson CA. Patterns in Medication Use for Treatment of Depression in Autistic Spectrum Disorder. J Autism Dev Disord 2023:10.1007/s10803-023-06126-z. [PMID: 37751093 DOI: 10.1007/s10803-023-06126-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION Depression impacts many individuals with autism spectrum disorder (ASD), carrying increased risk of functional impairment, hospitalization, and suicide. Prescribing medication to target depression in patients with ASD occurs despite limited available systematic data describing medication management of depression in this population. PURPOSE The purpose of this study is to discover prescribing patterns for individuals with MDD and ASD during this time period (2004-2012) to inform current and future prescribing practices with historical data. METHOD Drawing from a large clinical database describing the prescribing practices in patients with ASD, we identified 166 individuals with ASD (mean age 14.5 ± 8.3 years old) who received medication targeting symptoms of depression. We report prescribing rates for specific drugs, drug treatment duration, and reasons for drug discontinuation when applicable. RESULTS Sertraline, mirtazapine, and fluoxetine were the three most commonly prescribed medications to treat comorbid depression for this patient population. Among 241 drug starts, 123 (49%) drug treatments were continued at the final reviewed follow-up visit (average treatment duration of ± 0.72 years). The most common reason for discontinuation across all medications prescribed was loss of or lack of effectiveness. CONCLUSION This study raises concern that standard of care pharmacological treatments for depression in individuals with ASD may be less effective than in neurotypical populations. There remains a need to develop effective interventions for depression specifically tailored to the needs of individuals with ASD.
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Affiliation(s)
- Riley A Argonis
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 4002, Cincinnati, OH, 45229, USA
| | - Ernest V Pedapati
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 4002, Cincinnati, OH, 45229, USA
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kelli C Dominick
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 4002, Cincinnati, OH, 45229, USA
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Katherine Harris
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 4002, Cincinnati, OH, 45229, USA
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Martine Lamy
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 4002, Cincinnati, OH, 45229, USA
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Cara Fosdick
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 4002, Cincinnati, OH, 45229, USA
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Lauren Schmitt
- Division of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rebecca C Shaffer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Elizabeth Smith
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Meredith Will
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Christopher J McDougle
- Massachusetts General Hospital, Boston, MA, USA
- Lurie Center for Autism, Lexington, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Craig A Erickson
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 4002, Cincinnati, OH, 45229, USA.
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Gouveia FV, Diwan M, Martinez RCR, Giacobbe P, Lipsman N, Hamani C. Reduction of aggressive behaviour following hypothalamic deep brain stimulation: Involvement of 5-HT 1A and testosterone. Neurobiol Dis 2023:106179. [PMID: 37276987 DOI: 10.1016/j.nbd.2023.106179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/23/2023] [Accepted: 05/30/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Aggressive behaviour (AB) may occur in patients with different neuropsychiatric disorders. Although most patients respond to conventional treatments, a small percentage continue to experience AB despite optimized pharmacological management and are considered to be treatment-refractory. For these patients, hypothalamic deep brain stimulation (pHyp-DBS) has been investigated. The hypothalamus is a key structure in the neurocircuitry of AB. An imbalance between serotonin (5-HT) and steroid hormones seems to exacerbate AB. OBJECTIVES To test whether pHyp-DBS reduces aggressive behaviour in mice through mechanisms involving testosterone and 5-HT. METHODS Male mice were housed with females for two weeks. These resident animals tend to become territorial and aggressive towards intruder mice placed in their cages. Residents had electrodes implanted in the pHyp. DBS was administered for 5 h/day for 8 consecutive days prior to daily encounters with the intruder. After testing, blood and brains were recovered for measuring testosterone and 5-HT receptor density, respectively. In a second experiment, residents received WAY-100635 (5-HT1A antagonist) or saline injections prior to pHyp-DBS. After the first 4 encounters, the injection allocation was crossed, and animals received the alternative treatment during the next 4 days. RESULTS DBS-treated mice showed reduced AB that was correlated with testosterone levels and an increase in 5-HT1A receptor density in the orbitofrontal cortex and amygdala. Pre-treatment with WAY-100635 blocked the anti-aggressive effect of pHyp-DBS. CONCLUSIONS This study shows that pHyp-DBS reduces AB in mice via changes in testosterone and 5-HT1A mechanisms.
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Affiliation(s)
- Flavia Venetucci Gouveia
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, Canada; Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, Canada.
| | - Mustansir Diwan
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, Canada
| | - Raquel C R Martinez
- Division of Neuroscience, Hospital Sírio-Libanês, São Paulo, Brazil; LIM/23, Institute of Psychiatry, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | - Peter Giacobbe
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada; Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Nir Lipsman
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, Canada; Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, Canada; Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, Toronto, Canada; Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Clement Hamani
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, Canada; Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, Canada; Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, Toronto, Canada; Division of Neurosurgery, University of Toronto, Toronto, Canada.
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Marini S, D'Agostino L, Ciamarra C, Gentile A. Deep brain stimulation for autism spectrum disorder. World J Psychiatry 2023; 13:174-181. [PMID: 37303931 PMCID: PMC10251363 DOI: 10.5498/wjp.v13.i5.174] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/09/2023] [Accepted: 03/29/2023] [Indexed: 05/19/2023] Open
Abstract
Deep brain stimulation (DBS) is a medical treatment that aims to obtain therapeutic effects by applying chronic electrical impulses in specific brain structures and neurological circuits. Over the years, DBS has been studied for the treatment of many psychiatric disorders. Scientific research on the use of DBS in people with autism has focused this interest mainly on treatment-resistant obsessive-compulsive disorder, drug-resistant epilepsy, self-injurious behaviors (SIB), and aggressive behaviors toward the self. Autism spectrum disorder (ASD) includes a group of developmental disabilities characterized by patterns of delay and deviance in the development of social, communicative, and cognitive skills and the presence of repetitive and stereotyped behaviors as well as restricted interests. People with autism often have numerous medical and psychiatric comorbidities that worsen the quality of life of patients and their caregivers. Obsessive-compulsive symptoms can be found in up to 81.3% of people with autism. They are often severe, refractory to treatment, and particularly difficult to treat. SIB has a high prevalence in severely retarded individuals and is often associated with autism. Drug treatment of both autism and SIB presents a therapeutic challenge. To describe the current state of the art regarding the efficacy of DBS in people with ASD, a literature search was conducted for relevant studies using the PubMed database. Thirteen studies have been considered in this paper. Up to date, DBS has been used for the stimulation of the nucleus accumbens, globus pallidus internus, anterior limb of the internal capsule, ventral anterior limb of the internal capsule, basolateral amygdala, ventral capsule and ventral striatum, medial forebrain bundle, and posterior hypothalamus. In the total sample of 16 patients, 4 were adolescents, and 12 were adults. All patients had symptoms resistant to multiple drug therapy. Many patients taken into consideration by the studies showed clinical improvements as evidenced by the scores of the psychopathological scales used. In some cases, clinical improvements have varied over time, which may require further investigation. Among the new therapeutic perspectives, DBS could be a valid option. However, further, and more in-depth research is needed in this field.
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Affiliation(s)
- Stefano Marini
- Department of Mental Health, National Health Service, Termoli 86039, Italy
| | - Lucia D'Agostino
- Department of Mental Health, National Health Service, Termoli 86039, Italy
| | - Carla Ciamarra
- Department of Mental Health, National Health Service, Termoli 86039, Italy
| | - Alessandro Gentile
- Department of Mental Health, National Health Service, Termoli 86039, Italy
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10
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Correia BSB, de Moraes Pontes JG, Nani JVS, Villalta F, Mor NC, Bordini D, Brunoni D, Brentani H, Mari JJ, Hayashi MAF, Tasic L. 1H NMR Metabolomics and Lipidomics To Monitor Positive Responses in Children with Autism Spectrum Disorder Following a Guided Parental Intervention: A Pilot Study. ACS Chem Neurosci 2023; 14:1137-1145. [PMID: 36808953 DOI: 10.1021/acschemneuro.2c00735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
Autism spectrum disorder (ASD) is a complex neurodevelopmental condition that is characterized by patients displaying at least two out of the classical symptoms, such as impaired social communication, impaired interactions, and restricted repetitive behavior. Early parent-mediated interventions, such as video modeling for parental training, were demonstrated to be a successful low-cost way to deliver care for children with ASD. Nuclear magnetic resonance (NMR)-based metabolomics/lipidomics has been successfully employed in several mental disorder studies. Metabolomics and lipidomics of 37 ASD patients (children, aged 3-8 years), who were divided into two groups, one control group with no parental-training intervention (N = 18) and the other in which the parents were trained by a video modeling intervention (ASD parental training, N = 19), were analyzed by proton NMR spectroscopy. Patients in the ASD parental-training group sera were seen to have increased glucose, myo-inositol, malonate, proline, phenylalanine, and gangliosides in their blood serum, while cholesterol, choline, and lipids were decreased, compared to the control group, who received no parental-training. Taken together, we demonstrated here significant changes in serum metabolites and lipids in ASD children, previously demonstrated to show clinical positive effects following a parental training intervention based on video modeling, delivered over 22 weeks. We demonstrate the value of applying metabolomics and lipidomics to identify potential biomarkers for clinical interventions follow-up in ASD.
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Affiliation(s)
- Banny Silva Barbosa Correia
- Chemical Biology Laboratory, Department of Organic Chemistry, Institute of Chemistry, Universidade Estadual de Campinas (UNICAMP), Campinas, SP 13083-970, Brazil
| | - João Guilherme de Moraes Pontes
- Chemical Biology Laboratory, Department of Organic Chemistry, Institute of Chemistry, Universidade Estadual de Campinas (UNICAMP), Campinas, SP 13083-970, Brazil
| | - João Victor Silva Nani
- Departamento de Farmacologia, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo, SP 04044-020, Brazil.,National Institute for Translational Medicine (INCT-TM, CNPq), Ribeirão Preto 14026, Brazil
| | - Fabian Villalta
- Chemical Biology Laboratory, Department of Organic Chemistry, Institute of Chemistry, Universidade Estadual de Campinas (UNICAMP), Campinas, SP 13083-970, Brazil
| | - Natalia Cristina Mor
- Faculty of Pharmaceutical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas, SP 13083-970, Brazil
| | - Daniela Bordini
- Department of Psychiatry, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP/EPM), São Paulo, SP 04044-020, Brazil
| | - Décio Brunoni
- Department of Genetics and Morphology, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP/EPM), São Paulo, SP 04044-020, Brazil
| | - Helena Brentani
- Departamento de Psiquiatria da FMUSP, University of São Paulo (USP), São Paulo, SP 05403-903, Brazil
| | - Jair Jesus Mari
- Department of Psychiatry, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP/EPM), São Paulo, SP 04044-020, Brazil
| | - Mirian A F Hayashi
- Departamento de Farmacologia, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo, SP 04044-020, Brazil.,National Institute for Translational Medicine (INCT-TM, CNPq), Ribeirão Preto 14026, Brazil
| | - Ljubica Tasic
- Chemical Biology Laboratory, Department of Organic Chemistry, Institute of Chemistry, Universidade Estadual de Campinas (UNICAMP), Campinas, SP 13083-970, Brazil
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11
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Osman HA, Haridi M, Gonzalez NA, Dayo SM, Fatima U, Sheikh A, Puvvada CS, Soomro FH, Khan S. A Systematic Review of the Efficacy of Early Initiation of Speech Therapy and Its Positive Impact on Autism Spectrum Disorder. Cureus 2023; 15:e35930. [PMID: 37050996 PMCID: PMC10085252 DOI: 10.7759/cureus.35930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/09/2023] [Indexed: 03/11/2023] Open
Abstract
Autism spectrum disorder (ASD) is a condition that consists predominantly of an apparent early delay in communication and social skills. Among the multiple identified etiologies, genetics play a key role. The implementation of early interventional therapy for children with ASD is starting to show promising results. A few medical databases were used to collect multiple published types of research, which were thoroughly screened. Ultimately, a small amount was selected according to the defined eligibility criteria. The 12 articles that were reviewed involved a more significant number of boys than girls, and most clinical trials displayed the importance of starting early therapy. Astonishingly, the overwhelming effects of the COVID-19 pandemic did not affect the continuation of speech therapy in certain areas. In addition, studies emphasize knowledge scarcity, insufficient resources in certain areas, and the demand to educate the community. Conversely, no difference in the level of severity was noted with the implementation of early therapy. Early therapy, chiefly speech therapy used to treat children with ASD, demonstrated favorable outcomes. Communities require awareness about the condition on a broader scale to educate caregivers on early alarming symptoms. All in all, additional exploration needs to be done.
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12
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Blenkush N, Cunningham M. Elimination of Refractory Aggression and Self-Injury With Contingent Skin Shock. J Neuropsychiatry Clin Neurosci 2023:appineuropsych21020049. [PMID: 36785944 DOI: 10.1176/appi.neuropsych.21020049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Affiliation(s)
- Nathan Blenkush
- Judge Rotenberg Educational Center, Canton, Mass. (Blenkush); Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, Mass. (Cunningham)
| | - Miles Cunningham
- Judge Rotenberg Educational Center, Canton, Mass. (Blenkush); Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, Mass. (Cunningham)
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13
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Oztan O, Zyga O, Stafford DEJ, Parker KJ. Linking oxytocin and arginine vasopressin signaling abnormalities to social behavior impairments in Prader-Willi syndrome. Neurosci Biobehav Rev 2022; 142:104870. [PMID: 36113782 PMCID: PMC11024898 DOI: 10.1016/j.neubiorev.2022.104870] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 09/06/2022] [Accepted: 09/12/2022] [Indexed: 11/19/2022]
Abstract
Prader-Willi syndrome (PWS) is a genetic neurodevelopmental disorder. Global hypothalamic dysfunction is a core feature of PWS and has been implicated as a driver of many of PWS's phenotypic characteristics (e.g., hyperphagia-induced obesity, hypogonadism, short stature). Although the two neuropeptides (i.e., oxytocin [OXT] and arginine vasopressin [AVP]) most implicated in mammalian prosocial functioning are of hypothalamic origin, and social functioning is markedly impaired in PWS, there has been little consideration of how dysregulation of these neuropeptide signaling pathways may contribute to PWS's social behavior impairments. The present article addresses this gap in knowledge by providing a comprehensive review of the preclinical and clinical PWS literature-spanning endogenous neuropeptide measurement to exogenous neuropeptide administration studies-to better understand the roles of OXT and AVP signaling in this population. The preponderance of evidence indicates that OXT and AVP signaling are indeed dysregulated in PWS, and that these neuropeptide pathways may provide promising targets for therapeutic intervention in a patient population that currently lacks a pharmacological strategy for its debilitating social behavior symptoms.
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Affiliation(s)
- Ozge Oztan
- 1201 Welch Road, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94305, USA
| | - Olena Zyga
- 1201 Welch Road, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94305, USA
| | - Diane E J Stafford
- Center for Academic Medicine, 453 Quarry Road, Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Palo Alto, CA 94304, USA
| | - Karen J Parker
- 1201 Welch Road, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA 94305, USA; 300 Pasteur Drive, Department of Comparative Medicine, Stanford University, Stanford, CA 94305, USA.
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14
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Yan H, Elkaim LM, Venetucci Gouveia F, Huber JF, Germann J, Loh A, Benedetti-Isaac JC, Doshi PK, Torres CV, Segar DJ, Elias GJB, Boutet A, Cosgrove GR, Fasano A, Lozano AM, Kulkarni AV, Ibrahim GM. Deep brain stimulation for extreme behaviors associated with autism spectrum disorder converges on a common pathway: a systematic review and connectomic analysis. J Neurosurg 2022; 137:699-708. [PMID: 35061980 DOI: 10.3171/2021.11.jns21928] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 11/16/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Individuals with autism spectrum disorder (ASD) may display extreme behaviors such as self-injury or aggression that often become refractory to psychopharmacology or behavioral intervention. Deep brain stimulation (DBS) is a surgical alternative that modulates brain circuits that have yet to be clearly elucidated. In the current study the authors performed a connectomic analysis to identify brain circuitry engaged by DBS for extreme behaviors associated with ASD. METHODS A systematic review was performed to identify prior reports of DBS as a treatment for extreme behaviors in patients with ASD. Individual patients' perioperative imaging was collected from corresponding authors. DBS electrode localization and volume of tissue activated modeling were performed. Volumes of tissue activated were used as seed points in high-resolution normative functional and structural imaging templates. The resulting individual functional and structural connectivity maps were pooled to identify networks and pathways that are commonly engaged by all targets. RESULTS Nine patients with ASD who were receiving DBS for symptoms of aggression or self-injurious behavior were identified. All patients had some clinical improvement with DBS. Connectomic analysis of 8 patients (from the systematic review and unpublished clinical data) demonstrated a common anatomical area of shared circuitry within the anterior limb of the internal capsule. Functional analysis of 4 patients identified a common network of distant brain areas including the amygdala, insula, and anterior cingulate engaged by DBS. CONCLUSIONS This study presents a comprehensive synopsis of the evidence for DBS in the treatment of extreme behaviors associated with ASD. Using network mapping, the authors identified key circuitry common to DBS targets.
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Affiliation(s)
- Han Yan
- 1Division of Neurosurgery, Department of Surgery, University of Toronto
- 2Division of Neurosurgery, The Hospital for Sick Children, Toronto
- 3Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario
| | - Lior M Elkaim
- 4Division of Neurosurgery, McGill University, Montreal, Quebec
| | | | - Joelene F Huber
- 6Divisions of Paediatric Medicine and Developmental Paediatrics, Department of Paediatrics, The Hospital for Sick Children, Toronto
| | | | - Aaron Loh
- 7University Health Network, Toronto, Ontario, Canada
| | - Juan Carlos Benedetti-Isaac
- 8Stereotactic and Functional Neurosurgery Division, International Misericordia Clinic, Barranquilla, Colombia
| | - Paresh K Doshi
- 9Department of Stereotactic and Functional Neurosurgery, Jaslok Hospital and Research Centre, Mumbai, India
| | - Cristina V Torres
- 10Department of Neurosurgery, University Hospital La Princesa, Madrid, Spain
| | - David J Segar
- 11Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Alexandre Boutet
- 7University Health Network, Toronto, Ontario, Canada
- 12Joint Department of Medical Imaging, University of Toronto
| | - G Rees Cosgrove
- 11Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alfonso Fasano
- 13Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Toronto
- 14Division of Neurology, University of Toronto
- 15Krembil Brain Institute, Toronto
| | - Andres M Lozano
- 7University Health Network, Toronto, Ontario, Canada
- 12Joint Department of Medical Imaging, University of Toronto
| | - Abhaya V Kulkarni
- 1Division of Neurosurgery, Department of Surgery, University of Toronto
- 2Division of Neurosurgery, The Hospital for Sick Children, Toronto
- 3Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario
| | - George M Ibrahim
- 1Division of Neurosurgery, Department of Surgery, University of Toronto
- 2Division of Neurosurgery, The Hospital for Sick Children, Toronto
- 16Institute of Biomedical Engineering, University of Toronto; and
- 17Institute of Medical Science, University of Toronto, Ontario, Canada
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15
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Yan H, Siegel L, Breitbart S, Gorodetsky C, Fasano A, Rahim A, Loh A, Kulkarni AV, Ibrahim GM. An open-label prospective pilot trial of nucleus accumbens deep brain stimulation for children with autism spectrum disorder and severe, refractory self-injurious behavior: study protocol. Pilot Feasibility Stud 2022; 8:24. [PMID: 35109924 PMCID: PMC8808966 DOI: 10.1186/s40814-022-00988-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 01/20/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Children and youth with autism spectrum disorder (ASD) may manifest self-injurious behaviors (SIB) that may become severe and refractory with limited pharmacologic or behavioral treatment options. Here, we present the protocol of a prospective, mixed-methods study to assess the safety and efficacy of deep brain stimulation (DBS) of the nucleus accumbens (NAcc) for children and youth with ASD and severe, refractory SIB. METHODS This is a prospective, single-center, single-cohort, open-label, non-randomized pilot trial of 6 patients. Participants will be recruited through specialized behavioral clinics with persistent severe and refractory SIB following standard and intensive interventions. Following NAcc-DBS, participants will be enrolled in the study for 12 months. The primary objectives of the study are safety and feasibility, assessed by rate of recruitment and identification of factors impacting adherence to follow-up and study protocol. Potential treatment efficacy will be assessed by changes in the Children's Yale-Brown Obsessive-Compulsive Scale in ASD (CYBOCS-ASD), the Behavior Problems Index (BPI), the Inventory of Statements about Self-Injury (ISAS) and the Repetitive Behavior Scale-Revised (RBS-R) questionnaires. Additional clinical outcomes will be assessed, including measures of participant and caregiver quality of life, actigraph measurements, and positron emission tomography (PET) changes following DBS. DISCUSSION This study will be the first to evaluate the effect of DBS of the NAcc on a pediatric population in a controlled, prospective trial. Secondary outcomes will improve the understanding of behavioral, neuro-imaging, and electrophysiologic changes in children with ASD and SIB treated with DBS. This trial will provide an estimated effect size of NAcc-DBS for severe refractory SIB in children with ASD in preparation for future comparative trials. TRIAL REGISTRATION Registration on ClinicalTrials.gov was completed on 12 June 2019 with the Identifier: NCT03982888 .
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Affiliation(s)
- Han Yan
- Division of Neurosurgery, The Hospital for Sick Children, 555 University Avenue, Room 1503, Toronto, ON, M5G 1X8, Canada.,Institute of Health of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Lauren Siegel
- Neurosciences and Mental Health Program, The Hospital for Sick Children, 555 University Avenue, Room 1503, Toronto, ON, M5G 1X8, Canada
| | - Sara Breitbart
- Division of Neurosurgery, The Hospital for Sick Children, 555 University Avenue, Room 1503, Toronto, ON, M5G 1X8, Canada.,Neurosciences and Mental Health Program, The Hospital for Sick Children, 555 University Avenue, Room 1503, Toronto, ON, M5G 1X8, Canada
| | | | - Alfonso Fasano
- Division of Neurology, The Hospital for Sick Children, Toronto, Canada.,Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Toronto, Ontario, Canada. Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Krembil Brain Institute, Toronto, Ontario, Canada.,CenteR for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, ON, Canada
| | - Aliya Rahim
- Neurosciences and Mental Health Program, The Hospital for Sick Children, 555 University Avenue, Room 1503, Toronto, ON, M5G 1X8, Canada.,Surrey Place, Toronto, Ontario, Canada
| | - Alvin Loh
- Surrey Place, Toronto, Ontario, Canada.,Division of Developmental Paediatrics, Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Abhaya V Kulkarni
- Division of Neurosurgery, The Hospital for Sick Children, 555 University Avenue, Room 1503, Toronto, ON, M5G 1X8, Canada.,Institute of Health of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - George M Ibrahim
- Division of Neurosurgery, The Hospital for Sick Children, 555 University Avenue, Room 1503, Toronto, ON, M5G 1X8, Canada. .,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada. .,Institute of Biomedical Engineering, University of Toronto, Toronto, Canada. .,Institute of Medical Science, University of Toronto, Toronto, Canada.
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16
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Koziarz F, Roncadin C, Kata A, Duku E, Cauwenbergs A, Mahoney W, Di Rezze B, Anderson C, Drmic I, Eerkes J, Dekker K, Georgiades K, Hoult L, Kraus de Camargo O, Ng O, Rosenbaum P, Mesterman R, Gentles SJ, Robertson S, Bennett T, Georgiades S. Investigating the Associations Between Child Autistic Symptoms, Socioeconomic Context, and Family Life: A Pilot Study. FRONTIERS IN REHABILITATION SCIENCES 2021; 2:748346. [PMID: 36188822 PMCID: PMC9397991 DOI: 10.3389/fresc.2021.748346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/21/2021] [Indexed: 11/13/2022]
Abstract
Objective: The day-to-day experience of families with an Autistic child may be shaped by both, child characteristics and available resources, which often are influenced by the socioeconomic context of the family. Using a socioecological approach, this study explored the quantitative associations between child autistic symptoms, family socioeconomic status, and family life. Methods: Data came from the Pediatric Autism Research Cohort—PARC Study (pilot). Parents of children with a recent diagnosis of autism completed a set of assessments, including the Autism Family Experience Questionnaire, Autism Impact Measure, and a Sociodemographic Questionnaire. A series of multiple, iterative linear regression models were constructed to ascertain quantitative associations between child autistic symptoms, socioeconomic context, and family life. Results: A total of 50 children (mean age: 76 months; SD: 9.5 months; and 84% male) with data on the variables of interest were included in the analysis. The frequency of child autistic symptoms was associated with family life outcomes (p = 0.02 and R2 = 24%). Once autistic symptom frequency, symptom impact, and sociodemographic variables were considered, parents of higher educational attainment reported worse family life outcomes compared to their lesser-educated counterparts. This cumulative regression model had considerable explanatory capability (p = 0.01, R2 = 40%). Conclusion: This study demonstrates the utility of using a socioecological approach to examine the dynamic interplay between child characteristics and family circumstances. Our findings suggest that family life for parents (of an autistic child) who have obtained higher education is reported (by the parents themselves) as less satisfactory compared to that of parents without higher education, once adjusted for the autistic symptom frequency of child, symptom impact, and income. These findings can inform the design and delivery of more family-centered care pathways during the years following a diagnosis of autism.
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Affiliation(s)
- Frank Koziarz
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- *Correspondence: Frank Koziarz
| | - Caroline Roncadin
- Autism Program, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Anna Kata
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Eric Duku
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Amber Cauwenbergs
- Autism Program, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - William Mahoney
- Autism Program, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Briano Di Rezze
- Rehabilitation Sciences, McMaster University, Hamilton, ON, Canada
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, ON, Canada
| | - Colleen Anderson
- Autism Program, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Irene Drmic
- Autism Program, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Judy Eerkes
- Autism Program, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Kathleen Dekker
- Autism Program, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Katholiki Georgiades
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Lorraine Hoult
- Autism Program, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Olaf Kraus de Camargo
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, ON, Canada
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Olivia Ng
- Autism Program, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Peter Rosenbaum
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, ON, Canada
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Ronit Mesterman
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Stephen J. Gentles
- Department of Psychiatry and Behavioural Neurosciences, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
- Department of Community Health, Wilfrid Laurier University, Waterloo, ON, Canada
| | - Sue Robertson
- Autism Program, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Teresa Bennett
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Stelios Georgiades
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
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17
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Henneberry E, Lamy M, Dominick KC, Erickson CA. Decades of Progress in the Psychopharmacology of Autism Spectrum Disorder. J Autism Dev Disord 2021; 51:4370-4394. [PMID: 34491511 DOI: 10.1007/s10803-021-05237-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2021] [Indexed: 12/14/2022]
Abstract
Recent decades have been marked by a wave drug treatment research in autism spectrum disorder (ASD). This work has resulted in improved ability to treat commonly occurring behavioral challenges associated with ASD including most prominently irritability marked by aggression, self-injurious behavior, and severe tantrums. While treatment of interfering behavior has progressed in our field, there remain several areas of unmet medical need including most prominently a lack of any approved drug therapies for the core, defining symptoms of autism. We outline the progress to date in the field of autism drug treatment while taking a future look forward into how decades of work can inform better future steps in this field.
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Affiliation(s)
- Erin Henneberry
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 4002, Cincinnati, OH, 45229, USA
| | - Martine Lamy
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 4002, Cincinnati, OH, 45229, USA.,Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati School of Medicine, Cincinnati, USA
| | - Kelli C Dominick
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 4002, Cincinnati, OH, 45229, USA.,Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati School of Medicine, Cincinnati, USA
| | - Craig A Erickson
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 4002, Cincinnati, OH, 45229, USA. .,Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati School of Medicine, Cincinnati, USA.
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18
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Gouveia FV, Germann J, Elias GJ, Hamani C, Fonoff ET, Martinez RCR. Case report: 5 Years follow-up on posterior hypothalamus deep brain stimulation for intractable aggressive behaviour associated with drug-resistant epilepsy. Brain Stimul 2021; 14:1201-1204. [PMID: 34371210 DOI: 10.1016/j.brs.2021.07.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/15/2021] [Accepted: 07/31/2021] [Indexed: 12/17/2022] Open
Affiliation(s)
- Flavia Venetucci Gouveia
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, Canada; Division of Neuroscience, Sírio-Libanês Hospital, São Paulo, Brazil.
| | - Jürgen Germann
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Gavin Jb Elias
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Clement Hamani
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, Canada; Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, Canada; Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Erich Talamoni Fonoff
- Department of Neurology, University of São Paulo School of Medicine and Integrated Clinic of Neuroscience, São Paulo, Brazil
| | - Raquel Chacon Ruiz Martinez
- Division of Neuroscience, Sírio-Libanês Hospital, São Paulo, Brazil; LIM 23, Institute of Psychiatry, University of Sao Paulo, School of Medicine, São Paulo, Brazil.
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19
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Contreras Lopez WO, Navarro PA, Gouveia FV, Fonoff ET, Lebrun I, Auada AVV, Lopes Alho EJ, Martinez RCR. Directional Deep Brain Stimulation of the Posteromedial Hypothalamus for Refractory Intermittent Explosive Disorder: A Case Series Using a Novel Neurostimulation Device and Intraoperative Microdialysis. World Neurosurg 2021; 155:e19-e33. [PMID: 34325026 DOI: 10.1016/j.wneu.2021.07.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/17/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Intermittent explosive disorder (IED) is a psychiatric disorder characterized by recurrent outbursts of aggressive behavior. Deep brain stimulation (DBS) in the posteromedial nucleus of the hypothalamus (pHyp) is an alternative therapy for extreme cases and shows promising results. Intraoperative microdialysis can help elucidate the neurobiological mechanism of pHyp-DBS. We sought to evaluate efficacy and safety of pHyp-DBS using 8-contact directional leads in patients with refractory IED (rIED) and the accompanying changes in neurotransmitters. METHODS This was a prospective study in which patients with a diagnosis of rIED were treated with pHyp-DBS for symptom alleviation. Bilateral pHyp-DBS was performed with 8-contact directional electrodes. Follow-up was performed at 3, 6, and 12 months after surgery. RESULTS Four patients (3 men, mean age 27 ± 2.8 years) were included. All patients were diagnosed with rIED and severe intellectual disability. Two patients had congenital rubella, one had a co-diagnosis of infantile autism, and the fourth presented with drug-resistant epilepsy. There was a marked increase in the levels of gamma-aminobutyric acid and glycine during intraoperative stimulation. The average improvement in aggressive behavior in the last follow-up was 6 points (Δ: 50%, P = 0.003) while also documenting an important improvement of the Short Form Health Survey in all domains except bodily pain. No adverse events associated with pHyp-DBS were observed. CONCLUSIONS This is the first study to show the safety and beneficial effect of directional lead pHyp-DBS in patients with rIED and to demonstrate the corresponding mechanism of action through increases in gamma-aminobutyric acid and glycine concentration in the pHyp.
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Affiliation(s)
- William Omar Contreras Lopez
- Nemod Research Group, Universidad Autónoma de Bucaramanga, Bucaramanga, Colombia; Division of Functional Neurosurgery, Department of Neurosurgery, FOSCAL Clinic, Bucaramanga, Colombia.
| | - Paula Alejandra Navarro
- Division of Functional Neurosurgery, Department of Neurosurgery, FOSCAL Clinic, Bucaramanga, Colombia; Department of Epidemiology, School of Medicine, Universidad de los Andes, Bogotá, Colombia
| | | | - Erich Talamoni Fonoff
- Department of Neurology, University of São Paulo School of Medicine and Integrated Clinic of Neuroscience, São Paulo, Brazil
| | - Ivo Lebrun
- Biochemistry and Biophysics Laboratory, Butantan Institute, University of Sao Paulo, Sao Paulo, Brazil
| | - Aline V V Auada
- Biochemistry and Biophysics Laboratory, Butantan Institute, University of Sao Paulo, Sao Paulo, Brazil
| | - Eduardo Joaquim Lopes Alho
- Department of Neurology, University of São Paulo School of Medicine and Integrated Clinic of Neuroscience, São Paulo, Brazil
| | - Raquel C R Martinez
- LIM 23, Institute of Psychiatry, University of Sao Paulo, School of Medicine, Sao Paulo, Brazil; Division of Neuroscience, Sírio-Libanês Hospital, São Paulo, Brazil
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20
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Gouveia FV, Germann J, Devenyi GA, Fonoff ET, Morais RMCB, Brentani H, Chakravarty MM, Martinez RCR. Bilateral Amygdala Radio-Frequency Ablation for Refractory Aggressive Behavior Alters Local Cortical Thickness to a Pattern Found in Non-refractory Patients. Front Hum Neurosci 2021; 15:653631. [PMID: 34177490 PMCID: PMC8219880 DOI: 10.3389/fnhum.2021.653631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 05/03/2021] [Indexed: 12/02/2022] Open
Abstract
Aggressive behaviors comprise verbal and/or physical aggression directed toward oneself, others, or objects and are highly prevalent among psychiatric patients, especially patients diagnosed with autism spectrum disorder and severe intellectual disabilities. Some of these patients are considered refractory to treatment, and functional neurosurgery targeting the amygdala can result in widespread plastic brain changes that might reflect ceasing of some abnormal brain function, offering symptom alleviation. This study investigated cortical thickness changes in refractory aggressive behavior patients that were treated with bilateral amygdala ablation and compared to control patients presenting non-refractory aggressive behavior [three refractory and seven non-refractory patients, all males diagnosed with autism spectrum disorder (ASD) and intellectual disabilities]. The Overt Aggression Scale (OAS) was used to quantify behavior and magnetic resonance imaging was performed to investigate cortical thickness. Before surgery, both groups presented similar total OAS score, however refractory patients presented higher physical aggression against others. After surgery the refractory group showed 88% average reduction of aggressive behavior. Imaging analysis showed that while refractory patients present an overall reduction in cortical thickness compared to non-refractory patients across both timepoints, the local pattern of thickness difference found in areas of the neurocircuitry of aggressive behavior present before surgery is diminished and no longer detected after surgery. These results corroborate the hypotheses on induction of widespread neuronal plasticity following functional neurosurgical procedures resulting in modifications in brain morphology and improvement in behavior. Further studies are necessary to determine the underlying cause of these morphological changes and to better understand and improve treatment options.
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Affiliation(s)
- Flavia Venetucci Gouveia
- Biological Sciences Platform, Sunnybrook Research Institute, Toronto, ON, Canada.,Division of Neuroscience, Sirio-Libanês Hospital, São Paulo, Brazil
| | - Jürgen Germann
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada.,Cerebral Imaging Centre, Douglas Mental Health University Institute, McGill University, Montreal, QC, Canada
| | - Gabriel A Devenyi
- Cerebral Imaging Centre, Douglas Mental Health University Institute, McGill University, Montreal, QC, Canada.,Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Erich T Fonoff
- Department of Neurology, Division of Functional Neurosurgery of the Institute of Psychiatry, University of São Paulo, Medical School, São Paulo, Brazil
| | - Rosa M C B Morais
- Division of Neuroscience, Sirio-Libanês Hospital, São Paulo, Brazil.,LIM/23, Department of Psychiatry, University of São Paulo, Medical School, São Paulo, Brazil
| | - Helena Brentani
- LIM/23, Department of Psychiatry, University of São Paulo, Medical School, São Paulo, Brazil
| | - M Mallar Chakravarty
- Cerebral Imaging Centre, Douglas Mental Health University Institute, McGill University, Montreal, QC, Canada.,Department of Psychiatry, McGill University, Montreal, QC, Canada.,Department of Biological and Biomedical Engineering, McGill University, Montreal, QC, Canada
| | - Raquel C R Martinez
- Division of Neuroscience, Sirio-Libanês Hospital, São Paulo, Brazil.,LIM/23, Department of Psychiatry, University of São Paulo, Medical School, São Paulo, Brazil
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21
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Yadollahikhales G, Blenkush N, Cunningham M. Response patterns for individuals receiving contingent skin shock aversion intervention to treat violent self-injurious and assaultive behaviours. BMJ Case Rep 2021; 14:e241204. [PMID: 33962925 PMCID: PMC8108683 DOI: 10.1136/bcr-2020-241204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 11/03/2022] Open
Abstract
A small proportion of patients with intellectual disabilities (IDs) and/or autism spectrum disorder (ASD) exhibit extraordinarily dangerous self-injurious and assaultive behaviours that persist despite long-term multidisciplinary interventions. These uncontrolled behaviours result in physical and emotional trauma to the patients, care providers and family members. A graduated electronic decelerator (GED) is an aversive therapy device that has been shown to reduce the frequency of severe problem behaviours by 97%. Within a cohort of 173 patients, we have identified the four most common patterns of response: (1) on removal of GED, behaviours immediately return, and GED is reinstated; (2) GED is removed for periods of time (faded) and reinstated if and when behaviours return; (3) a low frequency of GED applications maintains very low rates of problem behaviours; and (4) GED is removed permanently after cessation of problem behaviours. GED is intended as a therapeutic option only for violent, treatment-resistant patients with ID and ASD.
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Affiliation(s)
| | - Nathan Blenkush
- Division of Applied Behavioral Analysis, Judge Rotenberg Educational Center, Canton, Massachusetts, USA
| | - Miles Cunningham
- Department of Psychiatry, Harvard Medical School, McLean Hospital, Belmont, Massachusetts, USA
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22
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Baranova J, Dragunas G, Botellho MCS, Ayub ALP, Bueno-Alves R, Alencar RR, Papaiz DD, Sogayar MC, Ulrich H, Correa RG. Autism Spectrum Disorder: Signaling Pathways and Prospective Therapeutic Targets. Cell Mol Neurobiol 2021; 41:619-649. [PMID: 32468442 DOI: 10.1007/s10571-020-00882-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/16/2020] [Indexed: 12/11/2022]
Abstract
The Autism Spectrum Disorder (ASD) consists of a prevalent and heterogeneous group of neurodevelopmental diseases representing a severe burden to affected individuals and their caretakers. Despite substantial improvement towards understanding of ASD etiology and pathogenesis, as well as increased social awareness and more intensive research, no effective drugs have been successfully developed to resolve the main and most cumbersome ASD symptoms. Hence, finding better treatments, which may act as "disease-modifying" agents, and novel biomarkers for earlier ASD diagnosis and disease stage determination are needed. Diverse mutations of core components and consequent malfunctions of several cell signaling pathways have already been found in ASD by a series of experimental platforms, including genetic associations analyses and studies utilizing pre-clinical animal models and patient samples. These signaling cascades govern a broad range of neurological features such as neuronal development, neurotransmission, metabolism, and homeostasis, as well as immune regulation and inflammation. Here, we review the current knowledge on signaling pathways which are commonly disrupted in ASD and autism-related conditions. As such, we further propose ways to translate these findings into the development of genetic and biochemical clinical tests for early autism detection. Moreover, we highlight some putative druggable targets along these pathways, which, upon further research efforts, may evolve into novel therapeutic interventions for certain ASD conditions. Lastly, we also refer to the crosstalk among these major signaling cascades as well as their putative implications in therapeutics. Based on this collective information, we believe that a timely and accurate modulation of these prominent pathways may shape the neurodevelopment and neuro-immune regulation of homeostatic patterns and, hopefully, rescue some (if not all) ASD phenotypes.
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Affiliation(s)
- Juliana Baranova
- Department of Biochemistry, Chemistry Institute, University of São Paulo, Avenida Professor Lineu Prestes 748, Butantã, São Paulo, SP, 05508-000, Brazil
| | - Guilherme Dragunas
- Department of Pharmacology, Institute of Biomedical Sciences, University of São Paulo, Avenida Professor Lineu Prestes 1524, Butantã, São Paulo, SP, 05508-000, Brazil
| | - Mayara C S Botellho
- Department of Biochemistry, Chemistry Institute, University of São Paulo, Avenida Professor Lineu Prestes 748, Butantã, São Paulo, SP, 05508-000, Brazil
| | - Ana Luisa P Ayub
- Department of Pharmacology, Federal University of São Paulo, Rua Pedro de Toledo 669, Vila Clementino, São Paulo, SP, 04039-032, Brazil
| | - Rebeca Bueno-Alves
- Department of Biochemistry, Chemistry Institute, University of São Paulo, Avenida Professor Lineu Prestes 748, Butantã, São Paulo, SP, 05508-000, Brazil
| | - Rebeca R Alencar
- Department of Biochemistry, Chemistry Institute, University of São Paulo, Avenida Professor Lineu Prestes 748, Butantã, São Paulo, SP, 05508-000, Brazil
| | - Debora D Papaiz
- Department of Pharmacology, Federal University of São Paulo, Rua Pedro de Toledo 669, Vila Clementino, São Paulo, SP, 04039-032, Brazil
| | - Mari C Sogayar
- Department of Biochemistry, Chemistry Institute, University of São Paulo, Avenida Professor Lineu Prestes 748, Butantã, São Paulo, SP, 05508-000, Brazil
- Cell and Molecular Therapy Center, School of Medicine, University of São Paulo, Rua Pangaré 100 (Edifício NUCEL), Butantã, São Paulo, SP, 05360-130, Brazil
| | - Henning Ulrich
- Department of Biochemistry, Chemistry Institute, University of São Paulo, Avenida Professor Lineu Prestes 748, Butantã, São Paulo, SP, 05508-000, Brazil
| | - Ricardo G Correa
- NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, 10901 North Torrey Pines Road, La Jolla, CA, 92037, USA.
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23
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Gouveia FV, Germann J, de Morais R, Fonoff ET, Hamani C, Alho EJ, Brentani H, Martins AP, Devenyi G, Patel R, Steele C, Gramer R, Chakravarty M, Martinez RCR. Longitudinal Changes After Amygdala Surgery for Intractable Aggressive Behavior: Clinical, Imaging Genetics, and Deformation-Based Morphometry Study-A Case Series. Neurosurgery 2021; 88:E158-E169. [PMID: 33026432 DOI: 10.1093/neuros/nyaa378] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 06/27/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Intractable aggressive behavior (iAB) is a devastating behavioral disorder that may affect psychiatric patients. These patients have reduced quality of life, are more challenging to treat as they impose a high caregiver burden and require specialized care. Neuromodulatory interventions targeting the amygdala, a key hub in the circuitry of aggressive behavior (AB), may provide symptom alleviation. OBJECTIVE To Report clinical and imaging findings from a case series of iAB patients treated with bilateral amygdala ablation. METHODS This series included 4 cases (3 males, 19-32 years old) who underwent bilateral amygdala radiofrequency ablation for iAB hallmarked by life-threatening self-injury and social aggression. Pre- and postassessments involved full clinical, psychiatric, and neurosurgical evaluations, including scales quantifying AB, general agitation, quality of life, and magnetic resonance imaging (MRI). RESULTS Postsurgery assessments revealed decreased aggression and agitation and improved quality of life. AB was correlated with testosterone levels and testosterone/cortisol ratio in males. No clinically significant side effects were observed. Imaging analyses showed preoperative amygdala volumes within normal populational range and confirmed lesion locations. The reductions in aggressive symptoms were accompanied by significant postsurgical volumetric reductions in brain areas classically associated with AB and increases in regions related to somatosensation. The local volumetric reductions are found in areas that in a normal brain show high expression levels of genes related to AB (eg, aminergic transmission) using gene expression data provided by the Allen brain atlas. CONCLUSION These findings provide new insight into the whole brain neurocircuitry of aggression and suggest a role of altered somatosensation and possible novel neuromodulation targets.
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Affiliation(s)
- Flavia Venetucci Gouveia
- Laboratory of Neuromodulation, Teaching and Research Institute, Hospital Sirio-Libanes, Sao Paulo, Brazil.,Sunnybrook Research Institute, Toronto, Canada
| | - Jürgen Germann
- CIC, Douglas Mental Health University Institute, McGill University, Montreal, Canada
| | - Rosa de Morais
- PROTEA, Department of Psychiatry, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Erich Talamoni Fonoff
- Department of Neurology, Division of Functional Neurosurgery, Institute of Psychiatry, Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | - Clement Hamani
- Sunnybrook Research Institute, Toronto, Canada.,Department of Neurology, Division of Functional Neurosurgery, Institute of Psychiatry, Medical School, University of Sao Paulo, Sao Paulo, Brazil.,Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Eduardo Joaquim Alho
- Department of Neurology, Division of Functional Neurosurgery, Institute of Psychiatry, Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | - Helena Brentani
- Department of Psychiatry, Medical School, University of Sao Paulo, Sao Paulo, Brazil.,National Institute of Developmental Psychiatry for Children and Adolescents, CNPq, Sao Paulo, Brazil
| | - Ana Paula Martins
- PROTEA, Department of Psychiatry, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Gabriel Devenyi
- CIC, Douglas Mental Health University Institute, McGill University, Montreal, Canada
| | - Raihaan Patel
- CIC, Douglas Mental Health University Institute, McGill University, Montreal, Canada
| | - Christopher Steele
- CIC, Douglas Mental Health University Institute, McGill University, Montreal, Canada
| | - Robert Gramer
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Mallar Chakravarty
- CIC, Douglas Mental Health University Institute, McGill University, Montreal, Canada
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24
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Berel C, Mossé U, Wils J, Cousin L, Imbert L, Gerardin P, Chaumette B, Lamoureux F, Ferrafiat V. Interest of Fluvoxamine as an Add-On to Clozapine in Children With Severe Psychiatric Disorder According to CYP Polymorphisms: Experience From a Case Series. Front Psychiatry 2021; 12:669446. [PMID: 34234701 PMCID: PMC8255476 DOI: 10.3389/fpsyt.2021.669446] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 05/21/2021] [Indexed: 01/24/2023] Open
Abstract
Despite its drastic efficacy in resistant psychiatric disorders, clozapine remains rarely used in youth due to its side effects. Clozapine plasma level is determined through its metabolism involving several isoforms of cytochromes 450 (CYP450) family. Isoform CYP1A2 appears as a limiting enzyme involved in the metabolism of clozapine, while isoforms 2C19, 2D6, 3A4, and 3A5 also contribute in a minor way. Clozapine efficacy is limited by a significant inter-patient variability in exposure according to CYP's polymorphisms. Clozapine plasma levels may be increased with CYP inhibitors such as fluvoxamine. This drug is a potent enzymatic inhibitor of CYP1A2 and, to a lesser extent, of CYP3A4 and CYP2D6. Hence, in case of CYP's polymorphisms in youth, the use of fluvoxamine as add-on to clozapine could help in reaching clinical and biological efficacy and allowing lower clozapine dosage and a better tolerance profile as it has already been described in adults. We report four pediatric cases with severe psychiatric disorders underlying our experience with CYP polymorphism explorations and the use of fluvoxamine as add-on to clozapine. Our four patients clinically improved after the introduction of fluvoxamine, enhancing clozapine metabolism and therefore the clozapine plasma level within therapeutic range. Despite the interesting results of fluvoxamine, we report a severe issue of tolerance for one patient, emphasizing the need for caution regarding possible drug interactions when fluvoxamine is considered. Hence, we propose a detailed step-by-step multidisciplinary protocol.
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Affiliation(s)
- Camille Berel
- Child and Adolescent Psychiatric Unit, URHEA, CHSR Sotteville les Rouen, Sotteville les Rouen, France
| | - Ulysse Mossé
- Child and Adolescent Psychiatric Unit, URHEA, CHSR Sotteville les Rouen, Sotteville les Rouen, France
| | - Julien Wils
- Department of Pharmacology - Toxicology and Pharmacogenetics, Rouen University Hospital, Rouen, France.,Normandie Univ, UNIROUEN, Inserm U1096, Rouen, France
| | - Lauriane Cousin
- Child and Adolescent Psychiatric Department, CHRU Lille, Lille, France
| | - Laurent Imbert
- Department of Pharmacology - Toxicology and Pharmacogenetics, Rouen University Hospital, Rouen, France
| | - Priscille Gerardin
- Child and Adolescent Psychiatric Unit, URHEA, CHSR Sotteville les Rouen, Sotteville les Rouen, France.,Child and Adolescent Psychiatric Department, CHU Charles Nicolle, Rouen, France
| | - Boris Chaumette
- Institut de Psychiatrie et Neurosciences de Paris, INSERM UMR 1266, Université de Paris, GDR3557-Institut de Psychiatrie, Paris, France.,GHU Paris Psychiatrie et Neurosciences, Paris, France.,Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Fabien Lamoureux
- Department of Pharmacology - Toxicology and Pharmacogenetics, Rouen University Hospital, Rouen, France.,Normandie Univ, UNIROUEN, Inserm U1096, Rouen, France
| | - Vladimir Ferrafiat
- Child and Adolescent Psychiatric Unit, URHEA, CHSR Sotteville les Rouen, Sotteville les Rouen, France.,Child and Adolescent Psychiatric Department, CHU Charles Nicolle, Rouen, France
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25
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The Safety and Effectiveness of High-Dose Propranolol as a Treatment for Challenging Behaviors in Individuals With Autism Spectrum Disorders. J Clin Psychopharmacol 2020; 40:122-129. [PMID: 32134849 DOI: 10.1097/jcp.0000000000001175] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE/BACKGROUND Individuals with autism spectrum disorders present with social communication deficits and a rigid adherence to sameness. Along with these symptoms, many individuals also present with severe challenging behaviors that place themselves as well as their families and communities at risk for injury. For these individuals, new and effective treatments are acutely needed. Propranolol has been used worldwide for over 50 years. Its primary indication is for hypertension, but there is evidence that, at higher doses, propranolol inhibits rage and anger through its effects on the central nervous system. This effect has been demonstrated in a variety of neuropsychiatric disorders. METHODS/PROCEDURES Here, we present 46 retrospective analyses of clinical cases that were followed by a psychiatrist. Propranolol was prescribed as an add-on to the patients' existing medications. The doses ranged from 120 to 960 mg per day (mean = 462 mg). FINDINGS/RESULTS Thirty-nine (85%) of 46 patients were found to be much improved or very much improved on the physician-rated Clinical Global Impression Improvement scale. There were few side effects noted, with only 2 subjects unable to tolerate the propranolol. IMPLICATIONS/CONCLUSIONS It appears that high-dose propranolol can be given safely with minimal adverse cardiovascular problems, provided that close clinical monitoring is maintained. A more rigorous clinical trial is needed to elucidate and verify its clinical utility, clinical practice parameters, and the effects of propranolol as a monotherapy versus as an add-on to the patient's existing medication regimen.
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26
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Espadas C, Ballester P, Londoño AC, Almenara S, Aguilar V, Belda C, Pérez E, Peiró AM. Multimorbidity and psychotropic polypharmacy among participants with autism spectrum disorder with intellectual disability. Psychiatry Res 2020; 292:113321. [PMID: 32738553 DOI: 10.1016/j.psychres.2020.113321] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 07/20/2020] [Indexed: 12/25/2022]
Abstract
Nowadays, adults with autism spectrum disorder (ASD) experience several comorbidities whose treatment implies a wide range of psychotropic prescriptions. This study aimed to evaluate medication-related safety, drug-drug interactions, and psychotropics prescription trends. We conducted an observational and multicentric pharmacovigilance study in subjects with ASD and Intellectual disability (ID, n = 83). Clinical information (diagnoses, ongoing medications, comorbidities [multimorbidity ≥ 4 chronic health conditions]) and psychotropic prescriptions (polypharmacy ≥ 4 chronic drugs, daily drug doses, co-prescription) were registered. Ethical approval for this study was obtained. Participants (30±10 years old, 86% men, BMI 27±6 kg/m2) displayed 37% multimorbidity (mean of 3, IQR 2-4), and 57% polypharmacy (13% out of dose recommended range). Most drugs prescribed were psychotropic risperidone which is related to nervous system comorbidities (18% epilepsy, 16% insomnia, and 14% psychotic agitations). Risperidone and quetiapine were co-prescribed in 60% of the cases without any monitoring adverse event routine. The rates of multimorbidity and polypharmacy, among our young adults with ASD and ID, are concerning. Data suggest the need to develop a pharmacovigilance monitoring system to evaluate prescription accuracy, long-term safety of ongoing medications, and the fixed doses in this autistic population with associated ID.
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Affiliation(s)
- Cristina Espadas
- Occupational Observatory, Miguel Hernández University of Elche, Alicante, Spain
| | - Pura Ballester
- Neuropharmacology on Pain (NED) group, Alicante Institute for Health and Biomedical Research (ISABIAL Foundation), Alicante, Spain.
| | - Ana Carolina Londoño
- Psychiatry Service, Department of Health of Alicante - General Hospital, Alicante, Spain; Clinical Pharmacology Unit, Department of Health of Alicante - General Hospital, Alicante, Spain
| | - Susana Almenara
- Clinical Pharmacology Unit, Department of Health of Alicante - General Hospital, Alicante, Spain
| | - Víctor Aguilar
- Centro San Rafael, Residential facility, Alicante, Spain
| | - César Belda
- Centro Infanta Leonor, Autism Association, Alicante, Spain
| | - Enrique Pérez
- Psychiatry Service, Department of Health of Alicante - General Hospital, Alicante, Spain
| | - Ana María Peiró
- Neuropharmacology on Pain (NED) group, Alicante Institute for Health and Biomedical Research (ISABIAL Foundation), Alicante, Spain; Clinical Pharmacology Unit, Department of Health of Alicante - General Hospital, Alicante, Spain
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27
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Gouveia FV, Germann J, Devenyi GA, Morais RMCB, Santos APM, Fonoff ET, Hamani C, Brentani H, Chakravarty MM, Martinez RCR. Refractoriness of aggressive behaviour to pharmacological treatment: cortical thickness analysis in autism spectrum disorder. BJPsych Open 2020; 6:e85. [PMID: 32762791 PMCID: PMC7453794 DOI: 10.1192/bjo.2020.71] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/23/2020] [Accepted: 07/12/2020] [Indexed: 01/22/2023] Open
Abstract
Aggressive behaviour is a highly prevalent and devastating condition in autism spectrum disorder resulting in impoverished quality of life. Gold-standard therapies are ineffective in about 30% of patients leading to greater suffering. We investigated cortical thickness in individuals with autism spectrum disorder with pharmacological-treatment-refractory aggressive behaviour compared with those with non-refractory aggressive behaviour and observed a brain-wide pattern of local increased thickness in key areas related to emotional control and overall decreased cortical thickness in those with refractory aggressive behaviour, suggesting refractoriness could be related to specific morphological patterns. Elucidating the neurobiology of refractory aggressive behaviour is crucial to provide insights and potential avenues for new interventions.
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Affiliation(s)
| | - Jürgen Germann
- University Health Network; and CIC, Douglas Mental Health University Institute, McGill University, Canada
| | - Gabriel A. Devenyi
- CIC, Douglas Mental Health University Institute, McGill University; and Department of Psychiatry, McGill University, Canada
| | - Rosa M. C. B. Morais
- Hospital Sirio-Libanes; and Department of Psychiatry, University of Sao Paulo, Medical School, Brazil
| | | | - Erich T. Fonoff
- Department of Neurology, Division of Functional Neurosurgery of the Institute of Psychiatry, University of Sao Paulo, Medical School, Brazil
| | - Clement Hamani
- Sunnybrook Research Institute; Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre; and Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Helena Brentani
- Department of Psychiatry, University of Sao Paulo, Medical School, Brazil
| | - M. Mallar Chakravarty
- CIC, Douglas Mental Health University Institute, McGill University, Canada; Department of Psychiatry, McGill University, Canada; and Department of Biological and Biomedical Engineering, McGill University, Canada
| | - Raquel C. R. Martinez
- Hospital Sirio-Libanes; and Department of Psychiatry, University of Sao Paulo, Medical School, Brazil
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28
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Lewis AS, Picciotto MR. Regulation of aggressive behaviors by nicotinic acetylcholine receptors: Animal models, human genetics, and clinical studies. Neuropharmacology 2020; 167:107929. [PMID: 32058178 PMCID: PMC7080580 DOI: 10.1016/j.neuropharm.2019.107929] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 12/18/2019] [Accepted: 12/25/2019] [Indexed: 12/12/2022]
Abstract
Neuropsychiatric disorders are frequently complicated by aggressive behaviors. For some individuals, existing behavioral and psychopharmacological treatments are ineffective or confer significant side effects, necessitating development of new ways to treat patients with severe aggression. Nicotinic acetylcholine receptors (nAChRs) are a large and diverse family of ligand-gated ion channels expressed throughout the brain that influence behaviors highly relevant for neuropsychiatric disorders, including attention, mood, and impulsivity. Nicotine and other drugs targeting nAChRs can reduce aggression in animal models of offensive, defensive, and predatory aggression, as well as in human laboratory studies. Human genetic studies have suggested a relationship between the CHRNA7 gene encoding the alpha-7 nAChR and aggressive behavior, although these effects are heterogeneous and strongly influenced by genetic background and environment. Here we review animal, human genetic, and clinical studies supporting a consistent role of nicotine and nAChR signaling in modulation of aggressive behaviors. We integrate findings from recent studies of aggression neuroscience, discuss the circuitry that may be involved in these effects of nAChRs, and identify multiple key questions that must be answered prior to safe and effective translation for human patients. This article is part of the special issue on 'Contemporary Advances in Nicotine Neuropharmacology'.
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Affiliation(s)
- Alan S Lewis
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA; Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Cognitive Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Vanderbilt Brain Institute, Vanderbilt University, Nashville, TN, USA.
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Abstract
The use of medical cannabis in children is rapidly growing. While robust evidence currently exists only for pure cannabidiol (CBD) to treat specific types of refractory epilepsy, in most cases, artisanal strains of CBD-rich medical cannabis are being used to treat children with various types of refractory epilepsy or irritability associated with autism spectrum disorder (ASD). Other common pediatric disorders that are being considered for cannabis treatment are Tourette syndrome and spasticity. As recreational cannabis use during youth is associated with serious adverse events and medical cannabis use is believed to have a relatively high placebo effect, decisions to use medical cannabis during childhood and adolescence should be made with caution and based on evidence. This review summarizes the current evidence for safety, tolerability, and efficacy of medical cannabis in children with epilepsy and in children with ASD. The main risks associated with use of Δ9-tetrahydrocannabinol (THC) and CBD in the pediatric population are described, as well as the debate regarding the use of whole-plant extract to retain a possible "entourage effect" as opposed to pure cannabinoids that are more standardized and reproducible.
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Affiliation(s)
- Adi Aran
- To whom correspondence should be addressed. E-mail:
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30
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Zheng W, Hu Y, Chen D, Li Y, Wang S. [Improvement of a mouse model of valproic acid-induced autism]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2019; 39:718-723. [PMID: 31270052 DOI: 10.12122/j.issn.1673-4254.2019.06.14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To establish an improved mouse model of valproic acid (VPA)-induced autism that better mimics human autism. METHODS We established mouse models of autism in female C57 mice by intraperitoneal injection of sodium valproate either at a single dose (600 mg/kg) on day 12.5 after conception (conventional group) or in two doses of 300 mg/kg each on days 10 and 12 after conception (modified group), and the control mice were injected with saline only on day 12.5. The responses of the mice to VPA injection, the uterus, mortality rate, and abortion rate were compared among the 3 groups. The morphology and development of the offspring mice were assessed, and their behavioral ontogeny was evaluated using 3- chambered social test, social test, juvenil play test, and open field test. RESULTS The mortality and abortion rates were significantly lower in the modified model group than in the conventional group (P < 0.01). Compared with those in the control group, the offspring mice in both the conventional group and the modified group showed developmental disorders (P < 0.05). The mortality rate of the newborn mice was significantly lower in the modified group than in the conventional group with a rate of curvy tail of up to 100% (P < 0.001). The offspring mice in both the modified group and conventional group exhibited autism-like behavioral abnormalities, including social disorder and repetitive stereotyped behavior (P < 0.05). CONCLUSIONS The mouse model of autism established using the modified method better mimics human autism with reduced mortality and abortion rates of the pregnant mice and also decreased mortality rate of the newborn mice.
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Affiliation(s)
- Wenxia Zheng
- College of Basic Medicine, Chongqing Medical University, Chongqing 400016, China
| | - Yuling Hu
- College of Basic Medicine, Chongqing Medical University, Chongqing 400016, China
| | - Di Chen
- College of Basic Medicine, Chongqing Medical University, Chongqing 400016, China
| | - Yingbo Li
- College of Basic Medicine, Chongqing Medical University, Chongqing 400016, China
| | - Shali Wang
- College of Basic Medicine, Chongqing Medical University, Chongqing 400016, China
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Gouveia FV, Hamani C, Fonoff ET, Brentani H, Alho EJL, de Morais RMCB, de Souza AL, Rigonatti SP, Martinez RCR. Amygdala and Hypothalamus: Historical Overview With Focus on Aggression. Neurosurgery 2019; 85:11-30. [PMID: 30690521 PMCID: PMC6565484 DOI: 10.1093/neuros/nyy635] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 01/08/2019] [Indexed: 12/29/2022] Open
Abstract
Aggressiveness has a high prevalence in psychiatric patients and is a major health problem. Two brain areas involved in the neural network of aggressive behavior are the amygdala and the hypothalamus. While pharmacological treatments are effective in most patients, some do not properly respond to conventional therapies and are considered medically refractory. In this population, surgical procedures (ie, stereotactic lesions and deep brain stimulation) have been performed in an attempt to improve symptomatology and quality of life. Clinical results obtained after surgery are difficult to interpret, and the mechanisms responsible for postoperative reductions in aggressive behavior are unknown. We review the rationale and neurobiological characteristics that may help to explain why functional neurosurgery has been proposed to control aggressive behavior.
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Affiliation(s)
| | - Clement Hamani
- Department of Neurology, Division of Functional Neurosurgery of the Institute of Psychiatry, University of Sao Paulo School, Medicine School, Sao Paulo, Brazil
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Erich Talamoni Fonoff
- Department of Neurology, Division of Functional Neurosurgery of the Institute of Psychiatry, University of Sao Paulo School, Medicine School, Sao Paulo, Brazil
| | - Helena Brentani
- Department of Psychiatry, University of Sao Paulo, Medical School, Sao Paulo, Brazil
- National Institute of Developmental Psychiatry for Children and Adolescents, CNPq, Sao Paulo, Brazil
| | - Eduardo Joaquim Lopes Alho
- Department of Neurology, Division of Functional Neurosurgery of the Institute of Psychiatry, University of Sao Paulo School, Medicine School, Sao Paulo, Brazil
| | | | - Aline Luz de Souza
- Department of Neurology, Division of Functional Neurosurgery of the Institute of Psychiatry, University of Sao Paulo School, Medicine School, Sao Paulo, Brazil
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Goodwin MS, Mazefsky CA, Ioannidis S, Erdogmus D, Siegel M. Predicting aggression to others in youth with autism using a wearable biosensor. Autism Res 2019; 12:1286-1296. [PMID: 31225952 DOI: 10.1002/aur.2151] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/03/2019] [Accepted: 05/14/2019] [Indexed: 12/28/2022]
Abstract
Unpredictable and potentially dangerous aggressive behavior by youth with Autism Spectrum Disorder (ASD) can isolate them from foundational educational, social, and familial activities, thereby markedly exacerbating morbidity and costs associated with ASD. This study investigates whether preceding physiological and motion data measured by a wrist-worn biosensor can predict aggression to others by youth with ASD. We recorded peripheral physiological (cardiovascular and electrodermal activity) and motion (accelerometry) signals from a biosensor worn by 20 youth with ASD (ages 6-17 years, 75% male, 85% minimally verbal) during 69 independent naturalistic observation sessions with concurrent behavioral coding in a specialized inpatient psychiatry unit. We developed prediction models based on ridge-regularized logistic regression. Our results suggest that aggression to others can be predicted 1 min before it occurs using 3 min of prior biosensor data with an average area under the curve of 0.71 for a global model and 0.84 for person-dependent models. The biosensor was well tolerated, we obtained useable data in all cases, and no users withdrew from the study. Relatively high predictive accuracy was achieved using antecedent physiological and motion data. Larger trials are needed to further establish an ideal ratio of measurement density to predictive accuracy and reliability. These findings lay the groundwork for the future development of precursor behavior analysis and just-in-time adaptive intervention systems to prevent or mitigate the emergence, occurrence, and impact of aggression in ASD. Autism Res 2019, 12: 1286-1296. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Unpredictable aggression can create a barrier to accessing community, therapeutic, medical, and educational services. The present study evaluated whether data from a wearable biosensor can be used to predict aggression to others by youth with autism spectrum disorder (ASD). Results demonstrate that aggression to others can be predicted 1 min before it occurs with high accuracy, laying the groundwork for the future development of preemptive behavioral interventions and just-in-time adaptive intervention systems to prevent or mitigate the emergence, occurrence, and impact of aggression to others in ASD.
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Affiliation(s)
- Matthew S Goodwin
- Department of Health Sciences, Northeastern University, Boston, Massachusetts
| | - Carla A Mazefsky
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stratis Ioannidis
- Department of Electrical and Computer Engineering, Northeastern University, Boston, Massachusetts
| | - Deniz Erdogmus
- Department of Electrical and Computer Engineering, Northeastern University, Boston, Massachusetts
| | - Matthew Siegel
- Maine Medical Center Research Institute, Portland, Maine
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Ang KQP, Loh PR. Mental Health and Coping in Parents of Children with Autism Spectrum Disorder (ASD) in Singapore: An Examination of Gender Role in Caring. J Autism Dev Disord 2019; 49:2129-2145. [PMID: 30706349 DOI: 10.1007/s10803-019-03900-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Research has supported the notion that gender plays a significant role in coping and mental health outcome among parents of children with ASD. The current study aims to examine gender role in the relationship between mental health outcome and coping in parents of children with ASD in Singapore. This study involved 97 fathers and 106 mothers of children with ASD completing self-report questionnaires. MANOVA revealed mothers experienced significantly higher stress levels than fathers. Stress was a significant predictor of depression for fathers but not for mothers. Regression analyses found use of active avoidance coping moderated the relationship between stress and depression in both parents. Implications of these findings on intervention are discussed.
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Affiliation(s)
| | - Pek Ru Loh
- National Institute of Education, Nanyang Technological University, 1 Nanyang Walk, Singapore, 637616, Singapore
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Shamay-Tsoory SG, Saporta N, Marton-Alper IZ, Gvirts HZ. Herding Brains: A Core Neural Mechanism for Social Alignment. Trends Cogn Sci 2019; 23:174-186. [DOI: 10.1016/j.tics.2019.01.002] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 11/25/2018] [Accepted: 01/02/2019] [Indexed: 12/19/2022]
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Doshi PK, Hegde A, Desai A. Nucleus Accumbens Deep Brain Stimulation for Obsessive-Compulsive Disorder and Aggression in an Autistic Patient: A Case Report and Hypothesis of the Role of Nucleus Accumbens in Autism and Comorbid Symptoms. World Neurosurg 2019; 125:387-391. [PMID: 30797934 DOI: 10.1016/j.wneu.2019.02.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/11/2019] [Accepted: 02/12/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Autism spectrum disorder represents a set of developmental disorders characterized by lack of social interaction and verbal and nonverbal communication in the first 3 years of life. It is also associated with several comorbidities, including epilepsy, aggression, self-mutilating behavior, and obsessive-compulsive behavior. In some cases, obsessive-compulsive disorder (OCD) develops. The nucleus accumbens (NAc) plays a key role in reward circuitry and is involved in the control of OCD and aggression. CASE DESCRIPTION A 42-year-old woman with autism was offered NAc deep brain stimulation for her comorbidities of OCD and aggression. The NAc was targeted using standard stereotactic methods, and postoperative scans confirmed the position of the active electrode to be within the NAc. The patient experienced significant symptom relief. At 1-year follow-up, the Yale-Brown Obsessive Compulsive Scale score for OCD, excluding items 1-5 of the scale, improved from 19 to 5. Hamilton Depression Scale and Hamilton Anxiety Scale scores similarly improved from 20 to 15 and from 30 to 18, respectively. Social Communication Questionnaire Current version for autism score improved from 26 to 16. Subscores for reciprocal social interactionimproved from 13 to 8; for communication improved from 5 to 4; and for restricted, repetitive, and stereotyped patterns of behavior improved from 6 to 3. CONCLUSIONS This case report illustrated the role of the NAc in OCD and aggression in an autistic patient. We discussed the role of the NAc as a target to explain the outcome of this case.
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Affiliation(s)
- Paresh K Doshi
- Department of Neurosurgery, Jaslok Hospital and Research Centre, Mumbai, India.
| | - Anaita Hegde
- Department of Pediatrics, Jaslok Hospital and Research Centre, Mumbai, India
| | - Amit Desai
- Department of Psychiatry, Jaslok Hospital and Research Centre, Mumbai, India
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Goodwin MS, Özdenizci O, Cumpanasoiu C, Tian P, Guo Y, Stedman A, Peura C, Mazefsky C, Siegel M, Erdoğmuş D, Ioannidis S. Predicting Imminent Aggression Onset in Minimally-Verbal Youth with Autism Spectrum Disorder Using Preceding Physiological Signals. INTERNATIONAL CONFERENCE ON PERVASIVE COMPUTING TECHNOLOGIES FOR HEALTHCARE : [PROCEEDINGS]. INTERNATIONAL CONFERENCE ON PERVASIVE COMPUTING TECHNOLOGIES FOR HEALTHCARE 2018; 2018:201-207. [PMID: 30420938 DOI: 10.1145/3240925.3240980] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
We test the hypothesis that changes in preceding physiological arousal can be used to predict imminent aggression proximally before it occurs in youth with autism spectrum disorder (ASD) who are minimally verbal (MV-ASD). We evaluate this hypothesis through statistical analyses performed on physiological biosensor data wirelessly recorded from 20 MV-ASD youth over 69 independent naturalistic observations in a hospital inpatient unit. Using ridge-regularized logistic regression, results demonstrate that, on average, our models are able to predict the onset of aggression 1 minute before it occurs using 3 minutes of prior data with a 0.71 AUC for global, and a 0.84 AUC for person-dependent models.
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Affiliation(s)
| | | | | | - Peng Tian
- Northeastern University, Boston, MA, USA,
| | - Yuan Guo
- Northeastern University, Boston, MA, USA,
| | - Amy Stedman
- Maine Medical Center Research Institute, Portland, ME, USA,
| | | | | | - Matthew Siegel
- Maine Medical Center Research Institute, Portland, ME, USA,
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Aran A, Cassuto H, Lubotzky A, Wattad N, Hazan E. Brief Report: Cannabidiol-Rich Cannabis in Children with Autism Spectrum Disorder and Severe Behavioral Problems—A Retrospective Feasibility Study. J Autism Dev Disord 2018; 49:1284-1288. [DOI: 10.1007/s10803-018-3808-2] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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38
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Hosie S, Malone DT, Liu S, Glass M, Adlard PA, Hannan AJ, Hill-Yardin EL. Altered Amygdala Excitation and CB1 Receptor Modulation of Aggressive Behavior in the Neuroligin-3 R451C Mouse Model of Autism. Front Cell Neurosci 2018; 12:234. [PMID: 30123111 PMCID: PMC6085410 DOI: 10.3389/fncel.2018.00234] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 07/16/2018] [Indexed: 12/28/2022] Open
Abstract
Understanding neuronal mechanisms underlying aggression in patients with autism spectrum disorder (ASD) could lead to better treatments and prognosis. The Neuroligin-3 (NL3)R451C mouse model of ASD has a heightened aggressive phenotype, however the biological mechanisms underlying this behavior are unknown. It is well established that NL3R451C mice have imbalanced excitatory and inhibitory synaptic activity in the hippocampus and somatosensory cortex. The amygdala plays a role in modulating aggressive behavior, however potential changes in synaptic activity in this region have not previously been assessed in this model. We investigated whether aggressive behavior is robustly present in mice expressing the R451C mutation, following back-crossing onto a congenic background strain. Endocannabinoids influence social interaction and aggressive behavior, therefore we also studied the effects of cannabinoid receptor 1 (CB1) agonist on NL3R451C mice. We report that NL3R451C mice have increased amplitude of miniature excitatory postsynaptic currents (EPSCs) with a concomitant decrease in the amplitude of inhibitory postsynaptic currents (IPSCs) in the basolateral amygdala. Importantly, we demonstrated that NL3R451C mice bred on a C57Bl/6 background strain exhibit an aggressive phenotype. Following non-sedating doses (0.3 and 1.0 mg/kg) of the CB1 receptor agonist WIN55,212-2 (WIN), we observed a significant reduction in aggressive behavior in NL3R451C mice. These findings demonstrate altered synaptic activity in the basolateral amygdala and suggest that the NL3R451C mouse model is a useful preclinical tool to understand the role of CB1 receptor function in aggressive behavior.
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Affiliation(s)
- Suzanne Hosie
- School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, Australia
| | - Daniel T Malone
- Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Stephanie Liu
- Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Michelle Glass
- Department of Pharmacology, University of Auckland, Auckland, New Zealand
| | - Paul Anthony Adlard
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Anthony John Hannan
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia.,Department of Anatomy and Neuroscience, University of Melbourne, Parkville, VIC, Australia
| | - Elisa L Hill-Yardin
- School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, Australia.,Department of Physiology, University of Melbourne, Parkville, VIC, Australia
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Dominick KC, Wink LK, Pedapati EV, Shaffer R, Sweeney JA, Erickson CA. Risperidone Treatment for Irritability in Fragile X Syndrome. J Child Adolesc Psychopharmacol 2018; 28:274-278. [PMID: 29394101 DOI: 10.1089/cap.2017.0057] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The goal of this study was to assess the effectiveness of risperidone monoantipsychotic therapy targeting irritability in patients with Fragile X syndrome (FXS) in a naturalistic outpatient clinical setting. METHODS We examined the use of risperidone, predominantly in combination with other nonantipsychotic psychotropic agents, targeting irritability in 21 male patients with FXS with a retrospective analysis of a prospectively collected large developmental disabilities-specific treatment database. Mean age at start of treatment, treatment duration, final dose, body mass index (BMI), and Clinical Global Impressions-Improvement (CGI-I) Scale score at final visit were determined, and changes with treatment were analyzed using paired t-tests. RESULTS Mean age at start of treatment was 14.0 years. The final mean dose of risperidone was 2.5 mg/day. The mean duration of treatment was 22 months. Seven (33.33%) participants were considered treatment responders based on the CGI-I. Change in BMI between initiation and cessation of treatment episode was not significant, however, these data were only available for a subset (n = 11) of patients. CONCLUSIONS Risperidone may be effective in the treatment of irritability in males with FXS. The overall effectiveness of monoantipsychotic treatment with risperidone was limited in this study compared with previous published reports; however, this may be the result of differences in outcome measures as well as a reflection of the level of functioning and severity of irritability in this sample.
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Affiliation(s)
- Kelli C Dominick
- 1 Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio
| | - Logan K Wink
- 1 Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio
| | - Ernest V Pedapati
- 1 Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio
| | - Rebecca Shaffer
- 1 Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio
| | - John A Sweeney
- 2 Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati , Cincinnati, Ohio
| | - Craig A Erickson
- 1 Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio
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A Randomized Placebo-Controlled Cross-Over Pilot Study of Riluzole for Drug-Refractory Irritability in Autism Spectrum Disorder. J Autism Dev Disord 2018; 48:3051-3060. [DOI: 10.1007/s10803-018-3562-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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41
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Tomeny TS, Rankin JA, Baker LK, Eldred SW, Barry TD. Discrepancy in perceived social support among typically developing siblings of youth with autism spectrum disorder. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2018; 23:594-606. [PMID: 29552896 DOI: 10.1177/1362361318763973] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Social support can buffer against stressors often associated with having family members with autism spectrum disorder. This study included 112 parents and typically developing siblings of children with autism spectrum disorder. Relations between self-reported typically developing sibling emotional and behavioral problems and discrepancy between social support frequency and importance were examined via polynomial regression with response surface analysis. Typically developing siblings who described social support as frequent and important reported relatively few problems. Typically developing siblings who reported social support as highly important but infrequent exhibited the highest emotional and behavioral difficulties. Thus, typically developing siblings with little support who view support as highly important may be particularly responsive to social support improvement efforts.
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Rankin JA, Tomeny TS, Barry TD. Multi-informant assessment of siblings of youth with autism spectrum disorder: Parent-child discrepancies in at-risk classification. RESEARCH IN DEVELOPMENTAL DISABILITIES 2017; 68:78-87. [PMID: 28743046 DOI: 10.1016/j.ridd.2017.07.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/23/2017] [Accepted: 07/13/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND The behavioral and emotional functioning of typically-developing (TD) siblings of youth with autism spectrum disorder (ASD) has been frequently assessed in the literature; however, these assessments typically include only one informant, rarely considering differences between parent and self-reports of sibling adjustment. AIMS This study examined parent-youth reported informant discrepancies in behavioral and emotional functioning, including whether parent and youth reports yielded the same conclusions regarding TD sibling risk status. METHODS, PROCEDURES, AND RESULTS Among 113 parents and TD siblings of youth with ASD, TD siblings self-reported more overall, conduct, hyperactivity, and peer problems (compared to parent reports). Although few siblings were considered at-risk, those who were identified were not usually identified as at-risk on both informants' reports. Moreover, ASD symptoms, broader autism phenotype symptoms, parent mental health concerns, and social support from parents were all related to differences in at-risk classification between parent- and sibling self-report. CONCLUSIONS AND IMPLICATIONS This paper highlights the necessity of multi-informant reporting when considering TD sibling psychological functioning. WHAT THIS PAPER ADDS This study helps to address gaps in the literature on assessment of emotional and behavioral functioning of TD siblings of youth with ASD. The results highlight the importance of utilizing both parent- and self-report when identifying TD siblings at-risk for maladjustment. Although few siblings were considered at-risk, those who were identified were not usually identified as such on both informants' reports, and a variety of sibling- and parent-factors were associated with differences in at-risk classification. Thus, inclusion and examination of both parent- and self-report of TD sibling psychological functioning is vital for accurately identifying numbers of TD siblings at-risk of maladjustment.
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Affiliation(s)
- James A Rankin
- The University of Alabama, Department of Psychology, Box 870348, Tuscaloosa, AL, 35487, USA.
| | - Theodore S Tomeny
- The University of Alabama, Department of Psychology, Box 870348, Tuscaloosa, AL, 35487, USA.
| | - Tammy D Barry
- Washington State University, Department of Psychology, Pullman, WA, 99164, USA.
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Abstract
An increasing number of case reports and series document the safe and effective use of electroconvulsive therapy (ECT) in children, adolescents, and young adults with autism spectrum disorder who engage in severe, intractable, repetitive self-injurious behavior (SIB) without environmental or operant function. Although the treatment is very effective for such patients, they typically remain highly dependent on frequent maintenance ECT (M-ECT) to maintain suppression of the SIB achieved during the acute course. Some patients receive M-ECT as frequently as once every 5 days. Such a regimen is quite burdensome for the patient and the patient's family, and the long-term effects of such regimens, starting as early as childhood, are unknown. In this review, we explore the expanding literature supporting the use of ECT for suppressing severe SIB associated with autism spectrum disorder. We also focus on the possible development of alternate nonconvulsive focal forms of brain stimulation, which might replace frequent M-ECT or reduce how frequently a patient needs to receive it. Although there are scarce clinical data currently available supporting these latter treatments, future studies are clearly indicated.
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Wink LK, Pedapati EV, Horn PS, McDougle CJ, Erickson CA. Multiple Antipsychotic Medication Use in Autism Spectrum Disorder. J Child Adolesc Psychopharmacol 2017; 27:91-94. [PMID: 26465194 PMCID: PMC5335810 DOI: 10.1089/cap.2015.0123] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The purpose of this study was to explore the use of multiple antipsychotic medications in patients with autism spectrum disorder (ASD) by reviewing the longitudinal medication management of 1100 patients consecutively treated for behavioral symptoms associated with ASD at a tertiary care specialty clinic. METHODS We identified all patients with ASD treated with daily doses of two or more antipsychotics for at least two visits at our clinic. For each patient meeting inclusion criteria, diagnostic and demographic data were collected. To evaluate clinical need and effectiveness of antipsychotic medications in this sample, we reviewed symptoms targeted with each antipsychotic medication and concomitant medications prescribed. Clinical Global Impressions-Severity (CGI-S) and Clinical Global Impressions-Improvement (CGI-I) scale ratings had been completed at the time of each visit, and the duration of treatment with antipsychotic medications was determined. To evaluate the safety and tolerability of antipsychotic medication use in ASD, we reviewed reported adverse effects and calculated body mass index (BMI) change with treatment. RESULTS Seventy patients met the inclusion criteria (6.4% of our sample). The majority of patients were moderately to severely ill Caucasian males, as determined by baseline mean CGI-S of 4.7 (SD = 0.8), and were diagnosed with autistic disorder and comorbid intellectual disability. The mean age was 15.1 years (SD = 10.9), the primary targeted symptoms were agitation/irritability, physical aggression, and self-injury. The majority of patients remained on two or more antipsychotics for >1 year. In this population, patients demonstrated greater symptomatic improvement and generally tolerated treatment without significant adverse effects. CONCLUSIONS The use of two or more antipsychotic medications may be increasingly common in patients with ASD. This retrospective study demonstrates that this treatment approach may be of some clinical benefit, and is generally well tolerated. Prospective studies focusing on the efficacy and safety of concomitant antipsychotic medication usage in ASD should be considered.
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Affiliation(s)
- Logan K. Wink
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ernest V. Pedapati
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Paul S. Horn
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Christopher J. McDougle
- Lurie Center for Autism, Departments of Psychiatry and Pediatrics, Massachusetts General Hospital and MassGeneral Hospital for Children, Harvard Medical School, Boston, Massachusetts
| | - Craig A. Erickson
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Park HR, Kim IH, Kang H, Lee DS, Kim BN, Kim DG, Paek SH. Nucleus accumbens deep brain stimulation for a patient with self-injurious behavior and autism spectrum disorder: functional and structural changes of the brain: report of a case and review of literature. Acta Neurochir (Wien) 2017; 159:137-143. [PMID: 27807672 DOI: 10.1007/s00701-016-3002-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 10/18/2016] [Indexed: 01/19/2023]
Abstract
The aim of this report was to investigate the clinical outcome of deep brain stimulation (DBS) for autism spectrum disorder (ASD) and the functional and structural changes in the brain after DBS. We present a 14-year-old boy with ASD and self-injurious behavior (SIB) refractory with medical and behavioral therapy. He was treated by bilateral nucleus accumbens (NAc) DBS. Remarkable clinical improvement was observed following NAc DBS. Brain fluorodeoxyglucose-positron emission tomography (FDG-PET) and magnetic resonance imaging (MRI) volumetric studies revealed that the metabolism in the prefrontal and the frontal cortex as well as the occipital cortex was markedly decreased in association with the decreased cortical volumes in those areas 2 years after NAc DBS. The therapeutic potential of NAc DBS is suggested for the clinical improvement of patients with ASD and SIB with structural and functional changes after DBS.
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Affiliation(s)
- Hye Ran Park
- Department of Neurosurgery, Soonchunhyang University Seoul Hospital, Seoul, South Korea
| | - In Hyang Kim
- Department of Child and Adolescent Psychiatry, Department of Psychiatry, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyejin Kang
- Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong Soo Lee
- Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Bung-Nyun Kim
- Department of Child and Adolescent Psychiatry, Department of Psychiatry, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong Gyu Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, South Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, 110-744, Republic of Korea
| | - Sun Ha Paek
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, South Korea.
- Department of Neurosurgery, Seoul National University Hospital, Seoul, 110-744, Republic of Korea.
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Prescription Drug Use and Polypharmacy Among Medicaid-Enrolled Adults with Autism: A Retrospective Cross-Sectional Analysis. Drugs Real World Outcomes 2016; 3:409-425. [PMID: 27873285 PMCID: PMC5127876 DOI: 10.1007/s40801-016-0096-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background A lack of gold standard treatment for autism spectrum disorders (ASD), no clear ASD management guidelines, and lack of evidence-based pharmacological interventions other than aripiprazole and risperidone elevate the risk of off-label prescribing and adverse effects among individuals with ASD, more so among adults. Objective The aim of this study was to identify and compare the types of prescription drug use, rates of polypharmacy, and characteristics associated with polypharmacy among adults with and without ASD in a retrospective cross-sectional analysis of a three-state Medicaid Analytic eXtract database (2000–2008). Methods Adults aged 22–64 years with ASD (ICD9-CM code: 299.xx) were propensity score-matched to ‘no ASD’ controls by age, sex, and race. General polypharmacy (≥6 unique classes of prescription drugs in a year) and psychotropic polypharmacy (≥3 unique prescription drug classes of psychotropic medications within a 90-day period) were the main study outcomes. Chi-square tests for rates, t tests for mean number of claims, and multivariate logistic regressions for likelihood of prescription drug use and polypharmacy were run. Results Annually, almost 75% of adults with ASD had >20 prescription drug claims compared with 33% of adults without ASD. Around 85% of adults with ASD used at least one psychotropic drug class compared with 42% of adults without ASD. Highly common psychotropics were antipsychotics (66%ASD vs 20%noASD), anticonvulsants (59%ASD vs 20%noASD), and anxiolytics/hypnotics/sedatives (21%ASD vs 11%noASD). Other than psychotropics, many adults with ASD used medical prescription drugs such as antimicrobials (47%), dermatologic agents (48%), respiratory agents (38%), gastrointestinal agents (31%), alternative medications (25%), antiparkinsonian agents (22.6%), antihyperlipidemics/statins (7.3%), and immunologics (2.0%). Rates of general (48%ASD vs 32%noASD) and psychotropic polypharmacy (19%ASD vs 6%noASD) were significantly higher in the ASD group. Conclusion Prescription drug use and polypharmacy rates among adults with ASD are substantially higher than those in an age-, sex-, and race-matched cohort of adults without ASD. Adults with ASD frequently use therapeutic treatments other than psychotropics. Healthcare providers, who usually report low confidence in treating patients with ASD, should play an active role in constant monitoring of prescription drug use patterns and patient response to interventions. Prescribers and caregivers are encouraged to make decisions after weighing the benefits and risks associated with a pharmacological treatment. Further investigations into the common use of any alternative treatments that can affect a patient’s response to core treatments should also be conducted. Electronic supplementary material The online version of this article (doi:10.1007/s40801-016-0096-z) contains supplementary material, which is available to authorized users.
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Wink LK, Badran I, Pedapati EV, Sorensen R, Benton SC, Johnson MC, Wissel G, Erickson CA. Clozapine for Drug-Refractory Irritability in Individuals with Developmental Disability. J Child Adolesc Psychopharmacol 2016; 26:843-846. [PMID: 26986554 DOI: 10.1089/cap.2015.0216] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVES In this case series, we describe the acute clinical impact and tolerability of rapid titration of clozapine for treatment of refractory irritability in five hospitalized youth with developmental disability. We offer this descriptive report in an effort to expand the evidence base guiding treatment of refractory aggression in this population. METHODS Five youth with developmental disability and severe irritability were admitted to a 10-bed psychiatric crisis stabilization unit where they received thorough psychiatric and medical evaluation. Informed consent was obtained in each case, and each patient underwent rapid titration onto clozapine. Clozapine monitoring guidelines were followed for all patients throughout treatment, and clinical severity at baseline and improvement with treatment was measured by use of the Clinical Global Impressions-Severity scale (CGI-S) and the Clinical Global Impressions-Improvement scale (CGI-I). RESULTS One female and four males diagnosed with developmental disability and at least one other psychiatric diagnosis, mean age of 13.1 ± 2.1 years, and mean CGI-S at baseline of 5.8, each received clozapine treatment by rapid titration. The mean therapeutic total daily dose of clozapine was 380 ± 200 mg. All patients demonstrated acute clinical improvement with the mean final CGI-I of 2.0, or "much improved." CONCLUSION These initial results support the potential utility of clozapine rapid titration for treatment of severe refractory irritability in youth with developmental disability. These patients tolerated clozapine treatment in the short term. Future studies are needed to thoroughly evaluate the long-term safety of clozapine treatment in this population.
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Affiliation(s)
- Logan K Wink
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine , Cincinnati, Ohio
| | - Ismail Badran
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine , Cincinnati, Ohio
| | - Ernest V Pedapati
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine , Cincinnati, Ohio
| | - Rena Sorensen
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine , Cincinnati, Ohio
| | - Stacy C Benton
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine , Cincinnati, Ohio
| | - Mark C Johnson
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine , Cincinnati, Ohio
| | - Gregory Wissel
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine , Cincinnati, Ohio
| | - Craig A Erickson
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine , Cincinnati, Ohio
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Ghanizadeh A, Tordjman S, Jaafari N. Aripiprazole for treating irritability in children & adolescents with autism: A systematic review. Indian J Med Res 2016; 142:269-75. [PMID: 26458342 PMCID: PMC4669861 DOI: 10.4103/0971-5916.166584] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND & OBJECTIVES No clear therapeutic benefits of antipsychotics have been reported for the treatment of behavioural symptoms in autism. This systematic review provides an assessment of evidence for treating irritability in autism by aripiprazole. METHODS The databases of MEDLINE/PubMed and Google Scholar were searched for relevant articles about the effect of aripiprazole in children with autism. The articles were searched according to the inclusion and exclusion criteria specifed for this review. All the double-blind, controlled, randomized, clinical trials examining the efficacy of aripiprazole for treating children and adolescents with autism were included. RESULTS From the 93 titles identified, 26 were irrelevant and 58 were evaluated for more details. Only five articles met the inclusive criteria. The evidence from precise randomized double blind clinical trials of aripiprazole for the treatment of autism in children and adolescents was convincing enough to recommend aripiprazole. Adverse effects were not very common and were usually mild. INTERPRETATION & CONCLUSIONS Current evidence suggests that aripiprazole is as effective and safe as risperidone for treating irritability in autism. However, further studies with larger sample size and longer duration are required.
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Affiliation(s)
- Ahmad Ghanizadeh
- Research Center for Psychiatry & Behavioral Sciences; Department of Psychiatry; Substance Abuse Research Center; Department of Neuroscience, School of Advanced Medical Sciences & Technologies, Shiraz University of Medical Sciences, Shiraz, France
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Sinha S, McGovern RA, Sheth SA. Deep brain stimulation for severe autism: from pathophysiology to procedure. Neurosurg Focus 2016; 38:E3. [PMID: 26030703 DOI: 10.3171/2015.3.focus1548] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Autism is a heterogeneous neurodevelopmental disorder characterized by early-onset impairment in social interaction and communication and by repetitive, restricted behaviors and interests. Because the degree of impairment may vary, a spectrum of clinical manifestations exists. Severe autism is characterized by complete lack of language development and potentially life-threatening self-injurious behavior, the latter of which may be refractory to medical therapy and devastating for affected individuals and their caretakers. New treatment strategies are therefore needed. Here, the authors propose deep brain stimulation (DBS) of the basolateral nucleus of the amygdala (BLA) as a therapeutic intervention to treat severe autism. The authors review recent developments in the understanding of the pathophysiology of autism. Specifically, they describe the genetic and environmental alterations that affect neurodevelopment. The authors also highlight the resultant microstructural, macrostructural, and functional abnormalities that emerge during brain development, which create a pattern of dysfunctional neural networks involved in socioemotional processing. They then discuss how these findings implicate the BLA as a key node in the pathophysiology of autism and review a reported case of BLA DBS for treatment of severe autism. Much progress has been made in recent years in understanding the pathophysiology of autism. The BLA represents a logical neurosurgical target for treating severe autism. Further study is needed that considers mechanistic and operative challenges.
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Affiliation(s)
- Saurabh Sinha
- 1Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; and
| | - Robert A McGovern
- 2Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Sameer A Sheth
- 2Department of Neurological Surgery, Columbia University Medical Center, New York, New York
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Reduction of Aggressive Episodes After Repeated Transdermal Nicotine Administration in a Hospitalized Adolescent with Autism Spectrum Disorder. J Autism Dev Disord 2016; 45:3061-6. [PMID: 25982311 DOI: 10.1007/s10803-015-2471-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Aggression remains a major cause of morbidity in patients with autism spectrum disorder (ASD). Current pharmacotherapy for aggression is not always effective and is often associated with morbidity. Nicotinic acetylcholinergic neurotransmission may play a prominent role in ASD pathophysiology based on human and animal studies, and preclinical studies show nicotine administration can reduce aggression-related behaviors. Transdermal nicotine has been used to treat agitation in neuropsychiatric conditions with cholinergic dysfunction. Here we report the use of transdermal nicotine as an adjunctive medication to treat aggression in a hospitalized adolescent with ASD. Nicotine patch was recurrently well tolerated, and reduced the need for emergency medication and restraint. These findings suggest further study of transdermal nicotine for aggression comorbid with ASD is warranted.
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