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O'Sullivan R, Bissell S, Agar G, Spiller J, Surtees A, Heald M, Clarkson E, Khan A, Oliver C, Bagshaw AP, Richards C. Exploring an objective measure of overactivity in children with rare genetic syndromes. J Neurodev Disord 2024; 16:18. [PMID: 38637764 PMCID: PMC11025271 DOI: 10.1186/s11689-024-09535-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 04/05/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Overactivity is prevalent in several rare genetic neurodevelopmental syndromes, including Smith-Magenis syndrome, Angelman syndrome, and tuberous sclerosis complex, although has been predominantly assessed using questionnaire techniques. Threats to the precision and validity of questionnaire data may undermine existing insights into this behaviour. Previous research indicates objective measures, namely actigraphy, can effectively differentiate non-overactive children from those with attention-deficit hyperactivity disorder. This study is the first to examine the sensitivity of actigraphy to overactivity across rare genetic syndromes associated with intellectual disability, through comparisons with typically-developing peers and questionnaire overactivity estimates. METHODS A secondary analysis of actigraphy data and overactivity estimates from The Activity Questionnaire (TAQ) was conducted for children aged 4-15 years with Smith-Magenis syndrome (N=20), Angelman syndrome (N=26), tuberous sclerosis complex (N=16), and typically-developing children (N=61). Actigraphy data were summarized using the M10 non-parametric circadian rhythm variable, and 24-hour activity profiles were modelled via functional linear modelling. Associations between actigraphy data and TAQ overactivity estimates were explored. Differences in actigraphy-defined activity were also examined between syndrome and typically-developing groups, and between children with high and low TAQ overactivity scores within syndromes. RESULTS M10 and TAQ overactivity scores were strongly positively correlated for children with Angelman syndrome and Smith-Magenis syndrome. M10 did not substantially differ between the syndrome and typically-developing groups. Higher early morning activity and lower evening activity was observed across all syndrome groups relative to typically-developing peers. High and low TAQ group comparisons revealed syndrome-specific profiles of overactivity, persisting throughout the day in Angelman syndrome, occurring during the early morning and early afternoon in Smith-Magenis syndrome, and manifesting briefly in the evening in tuberous sclerosis complex. DISCUSSION These findings provide some support for the sensitivity of actigraphy to overactivity in children with rare genetic syndromes, and offer syndrome-specific temporal descriptions of overactivity. The findings advance existing descriptions of overactivity, provided by questionnaire techniques, in children with rare genetic syndromes and have implications for the measurement of overactivity. Future studies should examine the impact of syndrome-related characteristics on actigraphy-defined activity and overactivity estimates from actigraphy and questionnaire techniques.
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Affiliation(s)
- Rory O'Sullivan
- School of Psychology, University of Birmingham, Birmingham, UK.
- Cerebra Network for Neurodevelopmental Disorders, University of Birmingham, Birmingham, UK.
| | - Stacey Bissell
- School of Psychology, University of Birmingham, Birmingham, UK
- Cerebra Network for Neurodevelopmental Disorders, University of Birmingham, Birmingham, UK
| | - Georgie Agar
- School of Life & Health Sciences, Aston University, Birmingham, UK
| | - Jayne Spiller
- School of Psychology and Vision Sciences, University of Leicester, Leicester, UK
| | - Andrew Surtees
- School of Psychology, University of Birmingham, Birmingham, UK
| | - Mary Heald
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, Lancashire, UK
| | | | - Aamina Khan
- Cerebra Network for Neurodevelopmental Disorders, University of Birmingham, Birmingham, UK
- School of Life & Health Sciences, Aston University, Birmingham, UK
| | | | - Andrew P Bagshaw
- School of Psychology, University of Birmingham, Birmingham, UK
- Centre for Human Brain Health, University of Birmingham, Birmingham, UK
| | - Caroline Richards
- School of Psychology, University of Birmingham, Birmingham, UK
- Cerebra Network for Neurodevelopmental Disorders, University of Birmingham, Birmingham, UK
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Barbier M, Thirtamara Rajamani K, Netser S, Wagner S, Harony-Nicolas H. Altered neural activity in the mesoaccumbens pathway underlies impaired social reward processing in Shank3-deficient rats. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.12.05.570134. [PMID: 38106179 PMCID: PMC10723340 DOI: 10.1101/2023.12.05.570134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Social behaviors are crucial for human connection and belonging, often impacted in conditions like Autism Spectrum Disorder (ASD). The mesoaccumbens pathway (VTA and NAc) plays a pivotal role in social behavior and is implicated in ASD. However, the impact of ASD-related mutations on social reward processing remains insufficiently explored. This study focuses on the Shank3 mutation, associated with a rare genetic condition and linked to ASD, examining its influence on the mesoaccumbens pathway during behavior, using the Shank3-deficient rat model. Our findings indicate that Shank3-deficient rats exhibit atypical social interactions and have difficulty adjusting behavior based on reward values, associated with modified neuronal activity of VTA dopaminergic and GABAergic neurons and reduced dopamine release in the NAc. Moreover, we demonstrate that manipulating VTA neuronal activity can normalize this behavior, providing insights into the effects of Shank3 mutations on social reward and behavior, and identify a potential neural pathway for intervention.
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Affiliation(s)
- Marie Barbier
- Department of Psychiatry, Faculty of Natural Sciences, University of Haifa, Haifa, Israel
- Seaver Autism Center for Research and Treatment, Faculty of Natural Sciences, University of Haifa, Haifa, Israel
- Department of Neuroscience, Faculty of Natural Sciences, University of Haifa, Haifa, Israel
- Friedman Brain Institute, Faculty of Natural Sciences, University of Haifa, Haifa, Israel
| | - Keerthi Thirtamara Rajamani
- Department of Psychiatry, Faculty of Natural Sciences, University of Haifa, Haifa, Israel
- Seaver Autism Center for Research and Treatment, Faculty of Natural Sciences, University of Haifa, Haifa, Israel
- Department of Neuroscience, Faculty of Natural Sciences, University of Haifa, Haifa, Israel
- Friedman Brain Institute, Faculty of Natural Sciences, University of Haifa, Haifa, Israel
| | - Shai Netser
- Sagol Department of Neurobiology, Faculty of Natural Sciences, University of Haifa, Haifa, Israel
| | - Shlomo Wagner
- Sagol Department of Neurobiology, Faculty of Natural Sciences, University of Haifa, Haifa, Israel
| | - Hala Harony-Nicolas
- Department of Psychiatry, Faculty of Natural Sciences, University of Haifa, Haifa, Israel
- Seaver Autism Center for Research and Treatment, Faculty of Natural Sciences, University of Haifa, Haifa, Israel
- Department of Neuroscience, Faculty of Natural Sciences, University of Haifa, Haifa, Israel
- Friedman Brain Institute, Faculty of Natural Sciences, University of Haifa, Haifa, Israel
- Mindich Child Health and Development Institute at the Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Al-Jawahiri R, Stokes L, Smith H, McNeill A, Freeth M. Short report: Behavioural characterisation of SOX11 syndrome. RESEARCH IN DEVELOPMENTAL DISABILITIES 2023; 143:104623. [PMID: 37924570 DOI: 10.1016/j.ridd.2023.104623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 10/06/2023] [Accepted: 10/18/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND SOX11 syndrome is a rare condition caused by deletions or de novo point mutations of the SOX11 gene. SOX11 is a transcription factor gene that plays an important role in brain development. AIMS The aim of this study was to quantitatively evaluate the behavioural profiles of individuals with SOX11 syndrome. METHODS AND PROCEDURES The Vineland Adaptive Behaviour Scales 3 (VABS-3) and the Social Responsiveness Scale 2 (SRS-2) were completed by parents of 21 children and young adults with SOX11 syndrome. OUTCOMES AND RESULTS Most were found to have borderline (33 %) or mild (39 %) impairment in adaptive behaviour, with more difficulties in communication and daily living than socialisation in the cohort overall. Most (90 %) were found to exhibit clinically relevant levels of autistic traits, with 62 % scoring in the "severe" range, though social motivation was observed to be a relative strength in the cohort overall. CONCLUSIONS AND IMPLICATIONS This study presents the first standardised evaluation of adaptive behaviour and autistic traits of individuals with SOX11 syndrome. This will improve clinicians, educators and parents' understanding of SOX11 syndrome.
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Affiliation(s)
| | - Louis Stokes
- University of Sheffield, Sheffield S10 2TN, United Kingdom
| | - Harriet Smith
- University of Sheffield, Sheffield S10 2TN, United Kingdom
| | | | - Megan Freeth
- University of Sheffield, Sheffield S10 2TN, United Kingdom.
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van Balkom ID, Burdeus-Olavarrieta M, Cooke J, de Cuba AG, Turner A. Consensus recommendations on mental health issues in Phelan-McDermid syndrome. Eur J Med Genet 2023; 66:104770. [PMID: 37085014 DOI: 10.1016/j.ejmg.2023.104770] [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: 11/21/2022] [Revised: 04/12/2023] [Accepted: 04/18/2023] [Indexed: 04/23/2023]
Abstract
Phelan-McDermid syndrome is a rare genetic condition caused by a deletion encompassing the 22q13.3 region or a pathogenic variant of the gene SHANK3. The clinical presentation is variable, but main characteristics include global developmental delay/intellectual disability (ID), marked speech impairment or delay, along with other features like hypotonia and somatic or psychiatric comorbidities. This publication delineates mental health, developmental and behavioural themes across the lifetime of individuals with PMS as informed by parents/caregivers, experts, and other key professionals involved in PMS care. We put forward several recommendations based on the available literature concerning mental health and behaviour in PMS. Additionally, this article aims to improve our awareness of the importance of considering developmental level of the individual with PMS when assessing mental health and behavioural issues. Understanding how the discrepancy between developmental level and chronological age may impact concerning behaviours offers insight into the meaning of those behaviours and informs care for individuals with PMS, enabling clinicians to address unmet (mental health) care needs and improve quality of life.
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Affiliation(s)
- Ingrid Dc van Balkom
- Jonx, Department of (Youth) Mental Health and Autism, Lentis Psychiatric Institute, Groningen, the Netherlands; Rob Giel Research Centre, Department of Psychiatry, University Medical Center Groningen, Groningen, the Netherlands.
| | - Monica Burdeus-Olavarrieta
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, IiSGM, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; School of Psychology, Universidad Autónoma, Madrid, Spain
| | - Jennifer Cooke
- Forensic and Neurodevelopmental Sciences Department, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, United Kingdom
| | - A Graciela de Cuba
- Jonx, Department of (Youth) Mental Health and Autism, Lentis Psychiatric Institute, Groningen, the Netherlands
| | - Alison Turner
- Phelan-McDermid Syndrome Foundation UK, 99 Highgate W Hill, London, N6 6NR, United Kingdom
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Schön M, Pablo L, Julián N, Mattina T, Gunnarsson C, Hadzsiev K, Verpelli C, Bourgeron T, Sarah J, van Ravenswaaij-Arts CMA, Hennekam RC. Definition and clinical variability of SHANK3-related Phelan-McDermid syndrome. Eur J Med Genet 2023; 66:104754. [PMID: 37003575 DOI: 10.1016/j.ejmg.2023.104754] [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: 12/10/2022] [Revised: 03/14/2023] [Accepted: 03/26/2023] [Indexed: 04/03/2023]
Abstract
Phelan-McDermid syndrome (PMS) is an infrequently described syndrome that presents with a disturbed development, neurological and psychiatric characteristics, and sometimes other comorbidities. As part of the development of European medical guidelines we studied the definition, phenotype, genotype-phenotype characteristics, and natural history of the syndrome. The number of confirmed diagnoses of PMS in different European countries was also assessed and it could be concluded that PMS is underdiagnosed. The incidence of PMS in European countries is estimated to be at least 1 in 30,000. Next generation sequencing, including analysis of copy number variations, as first tier in diagnostics of individuals with intellectual disability will likely yield a larger number of individuals with PMS than presently known. A definition of PMS by its phenotype is at the present not possible, and therefore PMS-SHANK3 related is defined by the presence of SHANK3 haploinsufficiency, either by a deletion involving region 22q13.2-33 or a pathogenic/likely pathogenic variant in SHANK3. In summarizing the phenotype, we subdivided it into that of individuals with a 22q13 deletion and that of those with a pathogenic/likely pathogenic SHANK3 variant. The phenotype of individuals with PMS is variable, depending in part on the deletion size or, whether only a variant of SHANK3 is present. The core phenotype in the domains development, neurology, and senses are similar in those with deletions and SHANK3 variants, but individuals with a SHANK3 variant more often are reported to have behavioural disorders and less often urogenital malformations and lymphedema. The behavioural disorders may, however, be a less outstanding feature in individuals with deletions accompanied by more severe intellectual disability. Data available on the natural history are limited. Results of clinical trials using insulin-like growth factor I (IGF-1), intranasal insulin, and oxytocin are available, other trials are in progress. The present guidelines for PMS aim at offering tools to caregivers and families to provide optimal care to individuals with PMS.
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Affiliation(s)
- Michael Schön
- Institute for Anatomy and Cell Biology, Ulm University, Germany.
| | - Lapunzina Pablo
- Instituto de Genética Médica y Molecular (INGEMM)-IdiPAZ, Hospital Universitario La Paz, CIBERER, Centro de Investigación Biomédica en Red de Enfermedades Raras, ISCIII; ITHACA-European Reference Network, Hospital La Paz, Madrid, Spain
| | - Nevado Julián
- Instituto de Genética Médica y Molecular (INGEMM)-IdiPAZ, Hospital Universitario La Paz, CIBERER, Centro de Investigación Biomédica en Red de Enfermedades Raras, ISCIII; ITHACA-European Reference Network, Hospital La Paz, Madrid, Spain
| | - Teresa Mattina
- Department of Biomedical and Biotechnological Sciences, Medical Genetics, University of Catania, Catania, Italy
| | - Cecilia Gunnarsson
- Department of Clinical Genetics and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Centre for Rare Diseases in South East Region of Sweden, Linköping University, Linköping, Sweden
| | - Kinga Hadzsiev
- Department of Medical Genetics, Medical School, University of Pécs, Pécs, Hungary
| | | | - Thomas Bourgeron
- Génétique Humaine et Fonctions Cognitives, Institut Pasteur, UMR3571 CNRS, Université de Paris Cité, IUF, 75015, Paris, France
| | - Jesse Sarah
- Department of Neurology, Ulm University, Germany
| | | | - Raoul C Hennekam
- Department of Pediatrics, Amsterdam University Medical Center, Amsterdam, the Netherlands
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Walinga M, Jesse S, Alhambra N, Van Buggenhout G. Consensus recommendations on altered sensory functioning in Phelan-McDermid syndrome. Eur J Med Genet 2023; 66:104726. [PMID: 36796507 DOI: 10.1016/j.ejmg.2023.104726] [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: 11/04/2022] [Revised: 01/30/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023]
Abstract
Altered sensory functioning is often observed in individuals with SHANK3 related Phelan-McDermid syndrome (PMS). Compared to typically developing individuals and individuals with an autism spectrum disorder, it has been suggested that there are distinctive features of sensory functioning in PMS. More hyporeactivity symptoms and less hyperreactivity and sensory seeking behaviour are seen, particularly in the auditory domain. Hypersensitivity to touch, possible overheating or turning red easily and reduced pain response are often seen. In this paper the current literature on sensory functioning in PMS is reviewed and recommendations for caregivers, based on consensus within the European PMS consortium, are given.
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Affiliation(s)
- Margreet Walinga
- University of Groningen, University Medical Center Groningen, Dept. Genetics, Groningen, the Netherlands.
| | - Sarah Jesse
- University of Ulm, Department of Neurology, Ulm, Germany
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Serrada-Tejeda S, Martínez-Piédrola RM, Máximo-Bocanegra N, Sánchez-Herrera-Baeza P, Pérez-de-Heredia-Torres M. Descriptive Analysis of Adaptive Behavior in Phelan–McDermid Syndrome and Autism Spectrum Disorder. Front Neurosci 2022; 16:893003. [PMID: 35864987 PMCID: PMC9295709 DOI: 10.3389/fnins.2022.893003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/07/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction The variety in symptomatology and clinical presentation of individuals diagnosed with Phelan-McDermid Syndrome (PMS) can delay medical diagnosis, so identifying specific neurobehavioral variables and facilitating differential diagnosis with patients with idiopathic Autism Spectrum Disorder (ASD) can guide early detection. Methods A descriptive analysis of the level of adaptive behavior in 50 patients diagnosed with PMS was performed (SHANK3deletion: N = 44; SHANKmutation: N = 6). Subsequently, a comparative analysis was performed with 28 children aged between 4 years and 6 years and 11 months (SHANK3deletion = 14; ASD = 14). Differences between the two groups were evaluated and Bonferroni correction was applied for multiple comparisons. Results Differences were identified in the variables of communication (z = −2.715, p = 0.007), Self-Direction (z = −2.199, p = 0.028) and social participation (z = −3.190, p = 0.001), with better adaptive behavior skills being observed in participants with a SHANK3mutation. Better adaptive skills in the sample of participants with ASD, were found and statistically significant differences were identified in the variables of academic skills (z = −3.084, p = 0.002), use of community resources (z = −1.889, p = 0.050) and health and safety (z = −2.90, p = 0.004). Conclusion Participants with SHANK3mutation show better communication and social participation skills than those with a diagnosis of SHANK3deletion. The observed differences between ASD and individuals with PMS reflect deficits in practical and conceptual adaptive skills that may limit and hinder daily adaptive functioning.
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Bissell S, Oliver C, Moss J, Heald M, Waite J, Crawford H, Kothari V, Rumbellow L, Walters G, Richards C. The behavioural phenotype of SATB2-associated syndrome: a within-group and cross-syndrome analysis. J Neurodev Disord 2022; 14:25. [PMID: 35350986 PMCID: PMC8966214 DOI: 10.1186/s11689-022-09426-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 02/14/2022] [Indexed: 11/10/2022] Open
Abstract
Background SATB2-associated syndrome (SAS) is a multisystem neurodevelopmental disorder characterised by intellectual disability, speech delay, and craniofacial anomalies. Although the clinical presentation of SAS is well-delineated, behaviours associated with SAS are less well-defined. Given the varied social profile reported in SAS of a ‘jovial’ predisposition and autistic behaviours, there may be phenotypic overlap with both Angelman syndrome (AS) and non-syndromal autism. This study aimed to describe behaviours in SAS in relation to chronological age and level of ability and contrast aspects of the behavioural phenotype with AS and non-syndromal autism. Methods Informant report questionnaire measures of behaviour, emotion, and autism characteristics were completed for 81 individuals with SAS (aged 1–36 years; 43 male). Within-group associations were analysed, and categorical data were compared between pre-school (1–5 years), school-age (6–15 years), and adolescent and adult SAS sub-groups (16 years and over). Cross-syndrome subscale and item-level analyses were conducted for 63 individuals with SAS (aged 1–27 years; 31 male), who were matched according to age and level of ability to 63 individuals with AS (aged 2–25 years; 32 male) and 63 individuals with non-syndromal autism (aged 3–26 years; 53 male). Results In SAS, higher rates of overactivity were moderately associated with lower self-help ability, and higher general anxiety scores were reported for males compared with females. Cross-syndrome subscale analyses uncovered several significant differences (p < .01), with comparatively low rates of stereotyped behaviour, overactivity, insistence on sameness and positive affect, and comparatively greater interest and pleasure and compulsive behaviour in individuals with SAS. Item-level analyses revealed a distinct profile of repetitive and autistic behaviours. Limitations Developmental analysis was based on a cross-sectional rather than a longitudinal research design, the contribution of pain and sleep to behaviour was not explored, and molecular genetic testing to determine genotype–phenotype behavioural relationships was not possible. Conclusions This study highlights the importance of behavioural comparisons to well-delineated groups and the utility of fine-grained item-level analyses to elucidate aspects of behaviour that might be syndrome related or shared across neurodevelopmental disorders. Future research is needed to further describe the distinctive repetitive and autistic behavioural phenotype in SAS. Supplementary Information The online version contains supplementary material available at 10.1186/s11689-022-09426-0.
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Affiliation(s)
- Stacey Bissell
- School of Psychology, University of Birmingham, Edgbaston, Birmingham, UK.
| | - Chris Oliver
- School of Psychology, University of Birmingham, Edgbaston, Birmingham, UK
| | - Joanna Moss
- School of Psychology, University of Surrey, Guildford, Surrey, UK
| | - Mary Heald
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, Lancashire, UK
| | - Jane Waite
- School of Health and Life Sciences, Aston University, Birmingham, UK
| | - Hayley Crawford
- Mental Health and Wellbeing Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Vishakha Kothari
- School of Psychology, University of Birmingham, Edgbaston, Birmingham, UK
| | - Lauren Rumbellow
- School of Psychology, University of Birmingham, Edgbaston, Birmingham, UK
| | - Grace Walters
- School of Psychology, University of Birmingham, Edgbaston, Birmingham, UK
| | - Caroline Richards
- School of Psychology, University of Birmingham, Edgbaston, Birmingham, UK
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Cammarata-Scalisi F, Callea M, Martinelli D, Willoughby CE, Tadich AC, Araya Castillo M, Lacruz-Rengel MA, Medina M, Grimaldi P, Bertini E, Nevado J. Clinical and Genetic Aspects of Phelan-McDermid Syndrome: An Interdisciplinary Approach to Management. Genes (Basel) 2022; 13:504. [PMID: 35328058 PMCID: PMC8955098 DOI: 10.3390/genes13030504] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/08/2022] [Accepted: 03/10/2022] [Indexed: 02/04/2023] Open
Abstract
Phelan-McDermid syndrome (PMS) is a rare, heterogeneous, and complex neurodevelopmental disorder. It is generally caused by a heterozygous microdeletion of contiguous genes located in the distal portion of the long arm of chromosome 22, including the SHANK3 gene. Sequence variants of SHANK3, including frameshift, nonsense mutations, small indels and splice site mutations also result in PMS. Furthermore, haploinsufficiency in SHANK3 has been suggested as the main cause of PMS. SHANK3 is also associated with intellectual disability, autism spectrum disorder and schizophrenia. The phenotype of PMS is variable, and lacks a distinctive phenotypic characteristic, so the clinical diagnosis should be confirmed by genetic analysis. PMS is a multi-system disorder, and clinical care must encompass various specialties and therapists. The role of risperidone, intranasal insulin, insulin growth factor 1, and oxytocin as potential therapeutic options in PMS will be discussed in this review. The diagnosis of PMS is important to provide an appropriate clinical evaluation, treatment, and genetic counseling.
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Affiliation(s)
- Francisco Cammarata-Scalisi
- Pediatric Service, Regional of Antofagasta Hospital, Antofagasta 1240835, Chile; (F.C.-S.); (A.C.T.); (M.M.)
| | - Michele Callea
- Pediatric Dentistry and Special Dental Care Unit, Meyer Children’s University Hospital, 50139 Florence, Italy
| | - Diego Martinelli
- Unit of Metabolism, Bambino Gesù Children’s Research Hospital IRCCS, 00165 Rome, Italy
| | - Colin Eric Willoughby
- Genomic Medicine, Biomedical Sciences Research Institute, Ulster University, Coleraine Campus, Coleraine BT52 1SA, Northern Ireland, UK;
| | - Antonio Cárdenas Tadich
- Pediatric Service, Regional of Antofagasta Hospital, Antofagasta 1240835, Chile; (F.C.-S.); (A.C.T.); (M.M.)
| | | | | | - Marco Medina
- Pediatric Service, Regional of Antofagasta Hospital, Antofagasta 1240835, Chile; (F.C.-S.); (A.C.T.); (M.M.)
| | - Piercesare Grimaldi
- Department of Public Health and Pediatric Sciences, University of Torino, 10126 Torino, Italy;
| | - Enrico Bertini
- Unit of Neuromuscular and Neurodegenerative Disorders, Laboratory of Molecular Medicine, Department of Neurosciences, Bambino Gesu’ Children’s Research Hospital IRCCS, 00165 Rome, Italy;
| | - Julián Nevado
- Instituto de Genética Médica y Molecular (INGEMM), Instituto de Investigación del Hospital Universitario La Paz (IdIPaz), 28046 Madrid, Spain; or
- Centro de Investigación Biomédica en RED de Enfermedades Raras (CIBERER), 28046 Madrid, Spain
- ITHACA, European Reference Network on Rare Congenital Malformations and Rare Intellectual Disability, Hospital La Paz, 28046 Madrid, Spain
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Behavior Problems and Social Competence in Fragile X Syndrome: A Systematic Review. Genes (Basel) 2022; 13:genes13020280. [PMID: 35205326 PMCID: PMC8871871 DOI: 10.3390/genes13020280] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/27/2022] [Accepted: 01/28/2022] [Indexed: 02/06/2023] Open
Abstract
Fragile X syndrome (FXS) causes intellectual disability and is the known leading cause of autism. Common problems in FXS include behavior and social problems. Along with syndromic characteristics and autism comorbidity, environmental factors might influence these difficulties. This systematic review focuses on the last 20 years of studies concerning behavior and social problems in FXS, considering environmental and personal variables that might influence both problems. Three databases were reviewed, leading to fifty-one studies meeting the inclusion criteria. Attention deficit hyperactivity disorder (ADHD) problems remain the greatest behavior problems, with behavioral problems and social competence being stable during the 20 years. Some developmental trajectories might have changed due to higher methodological control, such as aggressive behavior and attention problems. The socialization trajectory from childhood to adolescence remains unclear. Comorbidity with autism in individuals with FXS increased behavior problems and worsened social competence profiles. At the same time, comparisons between individuals with comorbid FXS and autism and individuals with autism might help define the comorbid phenotype. Environmental factors and parental characteristics influenced behavior problems and social competence. Higher methodological control is needed in studies including autism symptomatology and parental characteristics. More studies comparing autism in FXS with idiopathic autism are needed to discern differences between conditions.
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Rysstad AL, Kildahl AN, Skavhaug JO, Dønnum MS, Helverschou SB. Case study: organizing outpatient pharmacological treatment of bipolar disorder in autism, intellectual disability and Phelan-McDermid syndrome (22q13.3 deletion syndrome). INTERNATIONAL JOURNAL OF DEVELOPMENTAL DISABILITIES 2022; 68:378-387. [PMID: 35603006 PMCID: PMC9122368 DOI: 10.1080/20473869.2020.1756113] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Phelan-McDermid syndrome (PHMDS)/22q13.3 deletion syndrome is a rare genetic disorder associated with autism spectrum disorder (ASD), intellectual disability (ID), and bipolar disorder. While numerous cases have been reported describing successful pharmacological treatment of bipolar disorder in PHMDS, there is currently little guidance available on how to organize and execute such treatment. The aim of the current case study was to explore how pharmacological treatment of bipolar disorder in PHMDS may be organized and evaluated in an outpatient setting. Through a complex process of try and fail, including systematic evaluation of any change to the intervention and never implementing more than one change at the time, the patient gradually improved, regaining his communicative and adaptive skills. Four years passed from referral to this result was achieved. Organizing assessment and treatment as a collaborative effort involving specialized mental health professionals, professional caregivers and the patient's family proved feasible. Many of the challenges present in assessment of psychiatric disorder in individuals with ASD and ID are likely to be present also in evaluation of treatment effects, particularly in disorders where symptoms occur in phases. The approach described in the current paper may contribute to reducing the impact of these challenges.
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Affiliation(s)
- Anne Langseth Rysstad
- Section for Intellectual Disabilities and Autism, Vestre Viken Hospital Trust, Asker, Norway
- Correspondence to: Anne Langseth Rysstad Section for Intellectual Disabilities and Autism, Seksjon utviklingshemming og autisme – Blakstad psyk. avd., Vestre Viken HF, Postboks 800, Asker, 3004Drammen.
| | - Arvid Nikolai Kildahl
- Regional Section Mental Health, Intellectual Disabilities/Autism, Oslo University Hospital, Oslo, Norway
- NevSom Norwegian Centre of Expertise for Neurodevelopmental Disorders and Hypersomnias, Oslo University Hospital, Oslo, Norway
| | - Jon Olav Skavhaug
- Section for Intellectual Disabilities and Autism, Vestre Viken Hospital Trust, Asker, Norway
| | - Monica Stolen Dønnum
- Section for Intellectual Disabilities and Autism, Vestre Viken Hospital Trust, Asker, Norway
| | - Sissel Berge Helverschou
- NevSom Norwegian Centre of Expertise for Neurodevelopmental Disorders and Hypersomnias, Oslo University Hospital, Oslo, Norway
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12
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Guillory SB, Baskett VZ, Grosman HE, McLaughlin CS, Isenstein EL, Wilkinson E, Weissman J, Britvan B, Trelles MP, Halpern DB, Buxbaum JD, Siper PM, Wang AT, Kolevzon A, Foss-Feig JH. Social visual attentional engagement and memory in Phelan-McDermid syndrome and autism spectrum disorder: a pilot eye tracking study. J Neurodev Disord 2021; 13:58. [PMID: 34863106 PMCID: PMC8903604 DOI: 10.1186/s11689-021-09400-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The current study used eye tracking to investigate attention and recognition memory in Phelan-McDermid syndrome (PMS), a rare genetic disorder characterized by intellectual disability, motor delays, and a high likelihood of comorbid autism spectrum disorder (ASD). Social deficits represent a core feature of ASD, including decreased propensity to orient to or show preference for social stimuli. METHODS We used a visual paired-comparison task with both social and non-social images, assessing looking behavior to a novel image versus a previously viewed familiar image to characterize social attention and recognition memory in PMS (n = 22), idiopathic ASD (iASD, n = 38), and typically developing (TD) controls (n = 26). The idiopathic ASD cohort was divided into subgroups with intellectual disabilities (ID; developmental quotient < 70) and without (developmental quotient > 70) and the PMS group into those with and without a co-morbid ASD diagnosis. RESULTS On measures of attention, the PMS group with a comorbid ASD diagnosis spent less time viewing the social images compared to non-social images; the rate of looking back and forth between images was lowest in the iASD with ID group. Furthermore, while all groups demonstrated intact recognition memory when novel non-social stimuli were initially presented (pre-switch), participants with PMS showed no preference during the post-switch memory presentation. In iASD, the group without ID, but not the group with ID, showed a novelty preference for social stimuli. Across indices, individuals with PMS and ASD performed more similarly to PMS without ASD and less similarly to the iASD group. CONCLUSION These findings demonstrate further evidence of differences in attention and memory for social stimuli in ASD and provide contrasts between iASD and PMS.
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Affiliation(s)
- Sylvia B Guillory
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1230, New York, NY, 10029, USA
| | | | - Hannah E Grosman
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1230, New York, NY, 10029, USA
| | - Christopher S McLaughlin
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1230, New York, NY, 10029, USA
| | | | - Emma Wilkinson
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1230, New York, NY, 10029, USA
| | - Jordana Weissman
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1230, New York, NY, 10029, USA
| | - Bari Britvan
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1230, New York, NY, 10029, USA
| | - M Pilar Trelles
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1230, New York, NY, 10029, USA.,Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Danielle B Halpern
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1230, New York, NY, 10029, USA
| | - Joseph D Buxbaum
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1230, New York, NY, 10029, USA.,Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, USA.,Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, USA.,Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Paige M Siper
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1230, New York, NY, 10029, USA.,Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - A Ting Wang
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1230, New York, NY, 10029, USA
| | - Alexander Kolevzon
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1230, New York, NY, 10029, USA.,Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, USA.,Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Jennifer H Foss-Feig
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, USA. .,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1230, New York, NY, 10029, USA. .,Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, USA.
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13
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Srivastava S, Condy E, Carmody E, Filip-Dhima R, Kapur K, Bernstein JA, Berry-Kravis E, Powell CM, Soorya L, Thurm A, Buxbaum JD, Sahin M, Kolevzon AL. Parent-reported measure of repetitive behavior in Phelan-McDermid syndrome. J Neurodev Disord 2021; 13:53. [PMID: 34740315 PMCID: PMC8570010 DOI: 10.1186/s11689-021-09398-7] [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: 04/06/2021] [Accepted: 10/14/2021] [Indexed: 12/03/2022] Open
Abstract
Background Phelan McDermid syndrome (PMS) is a neurogenetic condition associated with a high prevalence of intellectual disability (ID) and autism spectrum disorder (ASD). This study provides a more comprehensive and quantitative profile of repetitive behaviors within the context of ID seen with the condition. Methods Individuals age 3–21 years with a confirmed PMS diagnosis participated in a multicenter observational study evaluating the phenotype and natural history of the disorder. We evaluated data collected from this study pertaining to repetitive behaviors from the Repetitive Behavior Scales-Revised (RBS-R). Results There were n = 90 participants who were part of this analysis. Forty-seven percent (n = 42/90) were female, and the average age at baseline evaluation was 8.88 ± 4.72 years. The mean best estimate IQ of the cohort was 26.08 ± 17.67 (range = 3.4–88), with n = 8 with mild ID (or no ID), n = 20 with moderate ID, and n = 62 with severe-profound ID. The RBS-R total overall score was 16.46 ± 13.9 (compared to 33.14 ± 20.60 reported in previous studies of ASD) (Lam and Aman, 2007), and the total number of items endorsed was 10.40 ± 6.81 (range = 0–29). After statistical correction for multiple comparisons, IQ correlated with the RBS-R stereotypic behavior subscale score (rs = − 0.33, unadjusted p = 0.0014, adjusted p = 0.01) and RBS-R stereotypic behavior total number of endorsed items (rs = − 0.32, unadjusted p = 0.0019, adjusted p = 0.01). IQ did not correlate with any other RBS-R subscale scores. Conclusions The RBS-R total overall score in a PMS cohort appears milder compared to individuals with ASD characterized in previous studies. Stereotypic behavior in PMS may reflect cognitive functioning.
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Affiliation(s)
- Siddharth Srivastava
- Department of Neurology, Rosamund Stone Zander Translational Neuroscience Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Emma Condy
- Neurodevelopmental and Behavioral Phenotyping Service, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Erin Carmody
- Department of Neurology, Rosamund Stone Zander Translational Neuroscience Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rajna Filip-Dhima
- Department of Neurology, Rosamund Stone Zander Translational Neuroscience Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kush Kapur
- Department of Neurology, Rosamund Stone Zander Translational Neuroscience Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan A Bernstein
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Elizabeth Berry-Kravis
- Department of Pediatrics, Rush University Medical Center, Chicago, IL, USA.,Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA.,Department of Biochemistry, Rush University Medical Center, Chicago, IL, USA
| | - Craig M Powell
- Department of Neurobiology, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA.,Civitan International Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Latha Soorya
- Department of Psychiatry, Rush University Medical Center, Chicago, IL, USA
| | - Audrey Thurm
- Neurodevelopmental and Behavioral Phenotyping Service, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Joseph D Buxbaum
- Seaver Autism Center for Research and Treatment, Mount Sinai School of Medicine, New York, NY, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY, USA.,Department of Neuroscience, Mount Sinai School of Medicine, New York, NY, USA
| | - Mustafa Sahin
- Department of Neurology, Rosamund Stone Zander Translational Neuroscience Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,F.M. Kirby Neurobiology Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - A Lexander Kolevzon
- Seaver Autism Center for Research and Treatment, Mount Sinai School of Medicine, New York, NY, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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14
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Vogels A, Droogmans G, Vergaelen E, Van Buggenhout G, Swillen A. Recent developments in Phelan-McDermid syndrome research: an update on cognitive development, communication and psychiatric disorders. Curr Opin Psychiatry 2021; 34:118-122. [PMID: 33278153 DOI: 10.1097/yco.0000000000000672] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the literature on cognitive development, communication, behavioral or psychiatric aspects in Phelan-McDermid syndrome (PMS) and to discuss the clinical implications and recommendations of these summarized findings. RECENT FINDINGS PMS is often associated with severe communication impairments, behavioral or psychiatric problems and regression. These challenges may adversely affect and impair the quality of life of the individual with PMS and his family. SUMMARY Individuals with PMS experience intellectual disability, communication and behavioral/psychiatric challenges, such as catatonia, bipolar disorder and regression across the lifespan. Providing appropriate guidance and support to them and their families demands a better understanding of these challenges.
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Affiliation(s)
- Annick Vogels
- Center for Human Genetics, University Hospital Gasthuisberg
- Department of Human Genetics
| | | | - Elfi Vergaelen
- University Psychiatric Center, Mind Body Research Group, KU Leuven (University of Leuven), Leuven, Belgium
| | - Griet Van Buggenhout
- Center for Human Genetics, University Hospital Gasthuisberg
- Department of Human Genetics
| | - Ann Swillen
- Center for Human Genetics, University Hospital Gasthuisberg
- Department of Human Genetics
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15
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Ziats CA, Patterson WG, Friez M. Syndromic Autism Revisited: Review of the Literature and Lessons Learned. Pediatr Neurol 2021; 114:21-25. [PMID: 33189026 DOI: 10.1016/j.pediatrneurol.2020.06.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/01/2020] [Accepted: 06/19/2020] [Indexed: 11/29/2022]
Abstract
Autism spectrum disorder is a neurodevelopmental disorder characterized by deficits in communication, stereotyped behaviors, restricted interests, and impaired social skills. The severity of the neurobehavioral phenotype is variable and historically has been distinguished based on the presence or absence of additional symptoms, termed syndromic and nonsyndromic or idiopathic autism, respectively. However, although the advancement in genetic molecular technologies has brought an increased understanding of the pathophysiology of autism, most of this success has been in the diagnosis of syndromic disease, whereas the etiology of nonsyndromic autism remains less understood. Here we review the common and rare genetic syndromes that feature autism, specifically highlighting deletion and duplication syndromes, chromosomal anomalies, and monogenic disorders. We show that the study of syndromic autism provides insight into the phenotypic and molecular heterogeneity of neurodevelopmental disease and suggests how study of these disorders can be helpful in understanding disease mechanisms implicated in nonsyndromic autism.
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Affiliation(s)
- Catherine A Ziats
- Greenwood Genetic Center, J.C. Self Research Institute, Greenwood, South Carolina.
| | - Wesley G Patterson
- Greenwood Genetic Center, J.C. Self Research Institute, Greenwood, South Carolina
| | - Michael Friez
- Greenwood Genetic Center, J.C. Self Research Institute, Greenwood, South Carolina
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16
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Gergoudis K, Weinberg A, Templin J, Farmer C, Durkin A, Weissman J, Siper P, Foss-Feig J, Del Pilar Trelles M, Bernstein JA, Buxbaum JD, Berry-Kravis E, Powell CM, Sahin M, Soorya L, Thurm A, Kolevzon A. Psychometric Study of the Social Responsiveness Scale in Phelan-McDermid Syndrome. Autism Res 2020; 13:1383-1396. [PMID: 32406614 DOI: 10.1002/aur.2299] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 02/05/2020] [Accepted: 03/05/2020] [Indexed: 12/17/2022]
Abstract
The Social Responsiveness Scale-2 (SRS-2) is a quantitative measure used to characterize symptoms of autism spectrum disorder (ASD). However, research suggests that SRS-2 scores are significantly influenced by language ability and intellectual disability (ID). Efforts to refine the SRS-2 by Sturm, Kuhfeld, Kasari, and Mccracken [Journal of Child Psychology and Psychiatry, 58(9), 1053-1061] yielded a shortened form, yet its psychometric properties in populations with severe ID remain unknown. This study aims to examine the psychometric properties of the SRS-2 in Phelan-McDermid syndrome (PMS), a genetic condition associated with ASD and ID, thereby guiding score interpretation in this population and future development of targeted scales. Analyses, including Item Response Theory (IRT), were conducted on a sample of individuals with PMS (n = 91) recruited at six sites nationally. Psychometric properties evaluated include measures of reliability (internal consistency, test-retest reliability) and validity (structural, construct, content). While both SRS-2 forms are reliable, the shortened SRS-2 shows superior validity to the full SRS-2 for measuring ASD symptoms in PMS. On IRT analysis, the shortened SRS-2 shows excellent discrimination and precisely evaluates respondents across a wide range of ASD symptomatology but interpretation is limited by uncertain content validity and small sample size. The shortened SRS-2 shows some promise for use in PMS, but future refinements and additions are needed to develop items that are tailored to identify ASD in children with severe ID and specifically PMS. LAY SUMMARY: This study determined that a shortened form of the Social Responsiveness Scale, Second Edition (SRS-2) shows both promise and limitations for the characterization of autism symptomatology in individuals with Phelan-McDermid syndrome (PMS), a population characterized by intellectual disability (ID). Caution should be used when interpreting SRS-2 scores in individuals with ID and future research should modify existing items and develop new items to improve the SRS-2's ability to accurately characterize autism symptomatology in PMS. Autism Res 2020, 13: 1383-1396. © 2020 International Society for Autism Research, Wiley Periodicals, Inc.
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Affiliation(s)
- Kellie Gergoudis
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alan Weinberg
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan Templin
- Department of Psychology and Research in Education, University of Kansas, Lawrence, Kansas, USA
| | - Cristan Farmer
- Pediatrics and Developmental Neuroscience Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, USA
| | - Alison Durkin
- Seaver Autism Center, Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jordana Weissman
- Seaver Autism Center, Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Paige Siper
- Seaver Autism Center, Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jennifer Foss-Feig
- Seaver Autism Center, Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Maria Del Pilar Trelles
- Seaver Autism Center, Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan A Bernstein
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Joseph D Buxbaum
- Seaver Autism Center, Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Elizabeth Berry-Kravis
- Department of Pediatrics, Rush University Medical Center, Chicago, Illinois, USA.,Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA.,Department of Biochemistry, Rush University Medical Center, Chicago, Illinois, USA
| | - Craig M Powell
- Department of Neurobiology, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Civitan International Research Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mustafa Sahin
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Latha Soorya
- Department of Psychiatry, Rush University Medical Center, Chicago, Illinois, USA
| | - Audrey Thurm
- Pediatrics and Developmental Neuroscience Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, USA
| | - Alexander Kolevzon
- Seaver Autism Center, Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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17
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Kohlenberg TM, Trelles MP, McLarney B, Betancur C, Thurm A, Kolevzon A. Psychiatric illness and regression in individuals with Phelan-McDermid syndrome. J Neurodev Disord 2020; 12:7. [PMID: 32050889 PMCID: PMC7014655 DOI: 10.1186/s11689-020-9309-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 01/23/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Phelan-McDermid syndrome (PMS) is a genetic condition characterized by intellectual disability, speech and language deficits, hypotonia, autism spectrum disorder, and epilepsy. PMS is caused by 22q13.33 deletions or mutations affecting SHANK3, which codes for a critical scaffolding protein in excitatory synapses. SHANK3 variants are also known to be associated with an increased risk for regression, as well as for psychiatric disorders, including bipolar disorder and catatonia. This study aimed to further describe these phenomena in PMS and to explore any relationship between psychiatric illness and regression after early childhood. METHODS Thirty-eight people with PMS were recruited to this study through the Phelan-McDermid Syndrome Foundation based on caregiver report of distinct development of psychiatric symptoms. Caregivers completed a clinician-administered semi-structured interview focused on eliciting psychiatric symptomatology. Data from the PMS International Registry were used to confirm genetic diagnoses of participants and to provide a larger sample for comparison. RESULTS The mean age of the 38 participants was 24.7 years (range = 13 to 50; SD = 10.06). Females (31 of 38 cases; 82%) and sequence variants (15 of 38 cases; 39%) were over-represented in this sample, compared to base rates in the PMS International Registry. Onset of psychiatric symptoms occurred at a mean age of 15.4 years (range = 7 to 32), with presentations marked by prominent disturbances of mood. Enduring substantial loss of functional skills after onset of psychiatric changes was seen in 25 cases (66%). Symptomst indicative of catatonia occurred in 20 cases (53%). Triggers included infections, changes in hormonal status, and stressful life events. CONCLUSIONS This study confirms that individuals with PMS are at risk of developing severe neuropsychiatric illness in adolescence or early adulthood, including bipolar disorder, catatonia, and lasting regression of skills. These findings should increase the awareness of these phenotypes and lead to earlier diagnosis and the implementation of appropriate interventions. Our findings also highlight the importance of genetic testing in the work-up of individuals with intellectual disability and acute psychiatric illness or regression. Future research is needed to clarify the prevalence and nature of psychiatric disorders and regression among larger unbiased samples of individuals with PMS.
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Affiliation(s)
- Teresa M Kohlenberg
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA.
| | - M Pilar Trelles
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Catalina Betancur
- Sorbonne Université, INSERM, CNRS, Neuroscience Paris Seine, Institut de Biologie Paris Seine, Paris, France
| | - Audrey Thurm
- Neurodevelopmental and Behavioral Phenotyping Service, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Alexander Kolevzon
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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18
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Wester Oxelgren U, Åberg M, Myrelid Å, Annerén G, Westerlund J, Gustafsson J, Fernell E. Autism needs to be considered in children with Down Syndrome. Acta Paediatr 2019; 108:2019-2026. [PMID: 31090964 DOI: 10.1111/apa.14850] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 05/08/2019] [Accepted: 05/13/2019] [Indexed: 02/01/2023]
Abstract
AIM To analyse levels and profiles of autism symptoms in children with Down Syndrome (DS) with and without diagnosed autism spectrum disorder (ASD) and to specifically study the groups with severe Intellectual Disability (ID). METHODS From a population-based cohort of 60 children with DS (age 5-17 years) with 41 participating children, scores obtained from the Autism Diagnostic Observation Schedule (ADOS) Module-1 algorithm were compared between those with and without diagnosed ASD. Children with DS and ASD were also compared to a cohort of children with idiopathic ASD, presented in the ADOS manual. RESULTS Children with DS and ASD had significantly higher ADOS scores in all domains compared to those without ASD. When the groups with DS, with and without ASD, were restricted to those with severe ID, the difference remained. When the children with DS and ASD and the idiopathic autism group were compared, the ADOS profiles were similar. CONCLUSION A considerable proportion of children with DS has ASD, but there is also a group of children with DS and severe ID without autism. There is a need to increase awareness of the high prevalence of autism in children with DS to ensure that appropriate measures and care are provided.
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Affiliation(s)
| | - Marie Åberg
- Department of Health and Habilitation Kungsgärdet Center Uppsala Sweden
| | - Åsa Myrelid
- Department of Women’s and Children´s Health Uppsala University Uppsala Sweden
| | - Göran Annerén
- Department of Immunology, Genetics, and Pathology, Science for Life Laboratory Uppsala University Uppsala Sweden
| | - Joakim Westerlund
- Department of Psychology Stockholm University Stockholm Sweden
- Gillberg Neuropsychiatry Centre, Department of Neuroscience and Physiology Gothenburg University Gothenburg Sweden
| | - Jan Gustafsson
- Department of Women’s and Children´s Health Uppsala University Uppsala Sweden
| | - Elisabeth Fernell
- Gillberg Neuropsychiatry Centre, Department of Neuroscience and Physiology Gothenburg University Gothenburg Sweden
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19
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Watkins A, Bissell S, Moss J, Oliver C, Clayton-Smith J, Haye L, Heald M, Welham A. Behavioural and psychological characteristics in Pitt-Hopkins syndrome: a comparison with Angelman and Cornelia de Lange syndromes. J Neurodev Disord 2019; 11:24. [PMID: 31586495 PMCID: PMC6778364 DOI: 10.1186/s11689-019-9282-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 08/28/2019] [Indexed: 12/23/2022] Open
Abstract
Background Pitt-Hopkins syndrome (PTHS) is a genetic neurodevelopmental disorder associated with intellectual disability. Although the genetic mechanisms underlying the disorder have been identified, description of its behavioural phenotype is in its infancy. In this study, reported behavioural and psychological characteristics of individuals with PTHS were investigated in comparison with the reported behaviour of age-matched individuals with Angelman syndrome (AS) and Cornelia de Lange syndrome (CdLS). Methods Questionnaire data were collected from parents/caregivers of individuals with PTHS (n = 24), assessing behaviours associated with autism spectrum disorder (ASD), sociability, mood, repetitive behaviour, sensory processing, challenging behaviours and overactivity and impulsivity. For most measures, data were compared to data for people with AS (n = 24) and CdLS (n = 24) individually matched by adaptive ability, age and sex. Results Individuals with PTHS evidenced significantly higher levels of difficulties with social communication and reciprocal social interaction than individuals with AS, with 21 of 22 participants with PTHS meeting criteria indicative of ASD on a screening instrument. Individuals with PTHS were reported to be less sociable with familiar and unfamiliar people than individuals with AS, but more sociable with unfamiliar people than individuals with CdLS. Data also suggested areas of atypicality in sensory experiences. Challenging behaviours were reported frequently in PTHS, with self-injury (70.8%) occurring at significantly higher rates than in AS (41.7%) and aggression (54.2%) occurring at significantly higher rates than in CdLS (25%). Individuals with PTHS also evidenced lower reported mood than individuals with AS. Conclusions Behaviours which may be characteristic of PTHS include those associated with ASD, including deficits in social communication and reciprocal social interaction. High rates of aggression and self-injurious behaviour compared to other genetic syndrome groups are of potential clinical significance and warrant further investigation. An atypical sensory profile may also be evident in PTHS. The specific aetiology of and relationships between different behavioural and psychological atypicalities in PTHS, and effective clinical management of these, present potential topics for future research.
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Affiliation(s)
- Alice Watkins
- Cerebra Centre for Neurodevelopmental Disorders, School of Psychology, University of Birmingham, Birmingham, UK. .,Great Ormond Street Institute of Child Health, University College London, London, UK.
| | - Stacey Bissell
- Cerebra Centre for Neurodevelopmental Disorders, School of Psychology, University of Birmingham, Birmingham, UK
| | - Jo Moss
- Cerebra Centre for Neurodevelopmental Disorders, School of Psychology, University of Birmingham, Birmingham, UK.,Institute of Cognitive Neuroscience, University College London, London, UK
| | - Chris Oliver
- Cerebra Centre for Neurodevelopmental Disorders, School of Psychology, University of Birmingham, Birmingham, UK
| | - Jill Clayton-Smith
- Division of Evolution & Genomic Sciences, St Mary's Hospital, Manchester, UK
| | - Lorraine Haye
- Cerebra Centre for Neurodevelopmental Disorders, School of Psychology, University of Birmingham, Birmingham, UK
| | - Mary Heald
- Cerebra Centre for Neurodevelopmental Disorders, School of Psychology, University of Birmingham, Birmingham, UK
| | - Alice Welham
- Cerebra Centre for Neurodevelopmental Disorders, School of Psychology, University of Birmingham, Birmingham, UK.,Department of Psychology, University of Leicester, Leicester, UK
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O'Brien S, Ng-Cordell E, Astle DE, Scerif G, Baker K. STXBP1-associated neurodevelopmental disorder: a comparative study of behavioural characteristics. J Neurodev Disord 2019; 11:17. [PMID: 31387522 PMCID: PMC6683428 DOI: 10.1186/s11689-019-9278-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 07/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND De novo loss of function mutations in STXBP1 are a relatively common cause of epilepsy and intellectual disability (ID). However, little is known about the types and severities of behavioural features associated with this genetic diagnosis. METHODS To address this, we collected systematic phenotyping data encompassing neurological, developmental, and behavioural characteristics. Participants were 14 individuals with STXBP1-associated neurodevelopmental disorder, ascertained from clinical genetics and neurology services UK-wide. Data was collected via standardised questionnaires administered to parents at home, supplemented by researcher observations. To isolate discriminating phenotypes, the STXBP1 group was compared to 33 individuals with pathogenic mutations in other ID-associated genes (ID group). To account for the potential impact of global cognitive impairment, a secondary comparison was made to an ability-matched subset of the ID group (low-ability ID group). RESULTS The STXBP1 group demonstrated impairments across all assessed domains. In comparison to the ID group, the STXBP1 group had more severe global adaptive impairments, fine motor difficulties, and hyperactivity. In comparison to the low-ability ID group, severity of receptive language and social impairments discriminated the STXBP1 group. A striking feature of the STXBP1 group, with reference to both comparison groups, was preservation of social motivation. CONCLUSIONS De novo mutations in STXBP1 are associated with complex and variable neurodevelopmental impairments. Consistent features, which discriminate this disorder from other monogenic causes of ID, are severe language impairment and difficulties managing social interactions, despite strong social motivation. Future work could explore the physiological mechanisms linking motor, speech, and social development in this disorder. Understanding the developmental emergence of behavioural characteristics can help to focus clinical assessment and management after genetic diagnosis, with the long-term aim of improving outcomes for patients and families.
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Affiliation(s)
- Sinéad O'Brien
- MRC Cognition and Brain Sciences Unit, University of Cambridge, 15 Chaucer Road, Cambridge, CB2 7EF, UK
| | - Elise Ng-Cordell
- MRC Cognition and Brain Sciences Unit, University of Cambridge, 15 Chaucer Road, Cambridge, CB2 7EF, UK.,Department of Experimental Psychology, University of Oxford, Anna Watts Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | | | - Duncan E Astle
- MRC Cognition and Brain Sciences Unit, University of Cambridge, 15 Chaucer Road, Cambridge, CB2 7EF, UK
| | - Gaia Scerif
- Department of Experimental Psychology, University of Oxford, Anna Watts Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Kate Baker
- MRC Cognition and Brain Sciences Unit, University of Cambridge, 15 Chaucer Road, Cambridge, CB2 7EF, UK. .,Department of Medical Genetics, University of Cambridge, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0XY, UK.
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21
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Bakke KA, Howlin P, Retterstøl L, Kanavin ØJ, Heiberg A, Nærland T. Effect of epilepsy on autism symptoms in Angelman syndrome. Mol Autism 2018; 9:2. [PMID: 29340132 PMCID: PMC5759870 DOI: 10.1186/s13229-017-0185-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 12/25/2017] [Indexed: 12/02/2022] Open
Abstract
Background Autism spectrum disorder and epilepsy often co-occur; however, the extent to which the association between autism symptoms and epilepsy is due to shared aetiology or to the direct effects of seizures is a topic of ongoing debate. Angelman syndrome (AS) is presented as a suitable disease model to explore this association. Methods Data from medical records and questionnaires were used to examine the association between age of epilepsy onset, autism symptoms, genetic aberration and communication level. Forty-eight participants had genetically verified AS (median age 14.5 years; range 1–57 years). A measure of autism symptoms (the Social Communication Questionnaire; SCQ) was completed for 38 individuals aged ≥ 4 years. Genetic cause was subgrouped into deletion and other genetic aberrations of the 15q11-q13 area. The number of signs used to communicate (< 20 sign and ≥ 20 signs) was used as a measure of nonverbal communication. Results Mean age of epilepsy onset was 3.0 years (range 3 months–7.8 years). Mean SCQ score for individuals without epilepsy was 13.6 (SD = 6.7) and with epilepsy 17.0 (SD = 5.6; p = 0.17); 58% used fewer than 20 signs to communicate. There were no age differences between groups according to presence of epilepsy, level of nonverbal communication or type of genetic aberration. SCQ scores were higher in individuals with the deletion than in those with other genetic aberrations (18.7 vs 10.8 p = 0.008) and higher in the group who used < 20 signs to communicate (19.4 vs 14.1 p = 0.007). Age of epilepsy onset was correlated with SCQ (r = − 0.61, p < 0.001). Multiple regression showed that age of seizure onset was significantly related to SCQ score (β = − 0.90; p = 0.006), even when the type of genetic abnormality was controlled (R2 = 0.53; F = 10.7; p = 0.001). Conclusions The study provides support for the notion that seizures themselves contribute more to autism symptoms than expected from the underlying genetic pathology alone. The study demonstrates how a rare genetic syndrome such as Angelman syndrome may be used to study the relation between epilepsy and autism symptomatology.
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Affiliation(s)
- Kristin A Bakke
- NevSom, Department of Rare Disorders, Oslo University Hospital, Oslo, Norway
| | - Patricia Howlin
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Faculty of Health Sciences, University of Sydney, Sydney, NSW Australia
| | - Lars Retterstøl
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - Øivind J Kanavin
- Frambu National Resource Center for Rare Disorders, Siggerud, Norway
| | - Arvid Heiberg
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - Terje Nærland
- NevSom, Department of Rare Disorders, Oslo University Hospital, Oslo, Norway.,NORMENT, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Garg S, Green J. Studying child development in genetic models of ASD. PROGRESS IN BRAIN RESEARCH 2018; 241:159-192. [DOI: 10.1016/bs.pbr.2018.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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23
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Alexandrov PN, Zhao Y, Jaber V, Cong L, Lukiw WJ. Deficits in the Proline-Rich Synapse-Associated Shank3 Protein in Multiple Neuropsychiatric Disorders. Front Neurol 2017; 8:670. [PMID: 29321759 PMCID: PMC5732231 DOI: 10.3389/fneur.2017.00670] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 11/27/2017] [Indexed: 12/18/2022] Open
Abstract
Signaling between neurons in the human central nervous system (CNS) is accomplished through a highly interconnected network of presynaptic and postsynaptic elements essential in the conveyance of electrical and neurochemical information. One recently characterized core postsynaptic element essential to the efficient operation of this complex network is a relatively abundant ~184.7 kDa proline-rich synapse-associated cytoskeletal protein known as Shank3 (SH3-ankyrin repeat domain; encoded at human chr 22q13.33). In this “Perspectives” article, we review and comment on current advances in Shank3 research and include some original data that show common Shank3 deficits in a number of seemingly unrelated human neurological disorders that include sporadic Alzheimer’s disease (AD), autism spectrum disorder (ASD), bipolar disorder (BD), Phelan–McDermid syndrome (PMS; 22q13.3 deletion syndrome), and schizophrenia (SZ). Shank3 was also found to be downregulated in the CNS of the transgenic AD (TgAD) 5x familial Alzheimer’s disease murine model engineered to overexpress the 42 amino acid amyloid-beta (Aβ42) peptide. Interestingly, the application of known pro-inflammatory stressors, such as the Aβ42 peptide and the metal-neurotoxin aluminum sulfate, to human neuronal–glial cells in primary culture resulted in a significant decrease in the expression of Shank3. These data indicate that deficits in Shank3-expression may be one common denominator linking a wide-range of human neurological disorders that exhibit a progressive or developmental synaptic disorganization that is temporally associated with cognitive decline.
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Affiliation(s)
| | - Yuhai Zhao
- LSU Neuroscience Center, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA, United States.,Department of Anatomy and Cell Biology, Louisiana State University Health Sciences Center, New Orleans, LA, United States
| | - Vivian Jaber
- LSU Neuroscience Center, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA, United States
| | - Lin Cong
- LSU Neuroscience Center, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA, United States.,Department of Neurology, Shengjing Hospital, China Medical University, Shenyang, China
| | - Walter J Lukiw
- Russian Academy of Medical Sciences, Moscow, Russia.,LSU Neuroscience Center, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA, United States.,Department of Neurology, Shengjing Hospital, China Medical University, Shenyang, China.,Department of Ophthalmology, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA, United States.,Department of Neurology, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA, United States
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