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Yılmaz Z, Al-Taie A. A cross-sectional study of community pharmacists' self-reported disease knowledge and competence in the treatment of childhood autism spectrum disorder. Int J Clin Pharm 2023; 45:1088-1097. [PMID: 36547799 DOI: 10.1007/s11096-022-01530-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Autism spectrum disorder (ASD) is a neurodevelopmental disease that can cause significant social, communication, and behavioural challenges. Given the rising prevalence of autism and multiple medication use, healthcare professionals, including community pharmacists, are required to have sufficient ASD knowledge to affect positively the disease prognosis and related comorbidities. AIM To assess community pharmacists' knowledge of disease and pharmacotherapy of ASD, along with the provision of patient education and counselling provided by, community pharmacists in Turkey. METHOD This was a descriptive, cross-sectional study conducted among community pharmacists in Turkey using a structured, validated questionnaire to assess ASD knowledge, awareness, and the provision of patient education and counselling by community pharmacists. RESULTS 486 community pharmacists were included, with a mean age of 39.69 ± 13.10 years, and most (n = 151, 31.1%) in the age range between 20 and 29 years. 96.3% of community pharmacists never had training about ASD. 32.9% of the participants were aware of the medicines for ASD treatment, and 25.7% were aware of the drugs' side effects. The mean overall knowledge about childhood autism among health workers questionnaire (KCAHW) score was 11.83 ± 3.91, and there was a statistically significant KCAHW score difference between other pharmacists and those with ASD training (p = 0.006). CONCLUSION There is a lack of disease and pharmacotherapy knowledge about childhood ASD among Turkish community pharmacists, particularly about communication impairment, type, onset, and comorbidities, as well as poor knowledge about drug pharmacotherapy and patient counselling services. This potentially creates a barrier to the adequate provision of healthcare to autistic patients.
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Affiliation(s)
- Zekiye Yılmaz
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Acıbadem Mehmet Ali Aydınlar, Kayışdağı Cad. No: 32, Ataşehir, 34758, Istanbul, Turkey.
| | - Anmar Al-Taie
- Department of Clinical Pharmacy, Faculty of Pharmacy, Istinye University, Istanbul, Turkey
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Cervantes PE, Conlon GR, Shalev RA, Castellanos FX. Trends in ASD Pharmacological Research: An Analysis of ClinicalTrials.gov. REVIEW JOURNAL OF AUTISM AND DEVELOPMENTAL DISORDERS 2022. [DOI: 10.1007/s40489-021-00297-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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3
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Blázquez Hinojosa A, Lázaro Garcia L, Puig Navarro O, Varela Bondelle E, Calvo Escalona R. Sensitivity and specificity of DSM-5 diagnostic criteria for autism spectrum disorder in a child and adolescent sample. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2021; 14:202-211. [PMID: 34802987 DOI: 10.1016/j.rpsmen.2019.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 10/16/2019] [Indexed: 10/19/2022]
Abstract
BACKGROUND Controversy exists regarding the DSM-5 criteria for autism spectrum disorders (ASD). Given the mixed results that have been reported, our main aim was to determine DSM-5 sensitivity and specificity in a child and adolescent Spanish sample. As secondary goals, we assessed the diagnostic stability of DSM-IV-TR in DSM-5, and clinical differences between children diagnosed with an ASD or a social (pragmatic) communication disorder (SPCD). METHODS This study was carried out in 2017, reviewing the medical records of patients evaluated in our service. Items from a parent report measure of ASD symptoms (Autism Diagnostic Interview-Revised) were matched to DSM-5 criteria and used to assess the sensitivity and specificity of the DSM-5 criteria and current DSM-IV criteria when compared with clinical diagnoses. RESULTS DSM-5 sensitivity ranged from .69 to 1.00, and was higher in females. By age, the DSM-5 and DSM-IV-TR criteria showed similar sensitivity. In the case of intellectual quotient, DSM-5 criteria sensitivity was lower for those in the "low-functioning" category. DSM-5 specificity ranged from .64 to .73, while DSM-5 specificity was similar for all phenotypic subgroups. With respect to stability, 83.3% of autism disorder cases retained a diagnosis of ASD using the DSM-5 criteria. With regard to differences between ASD and SPCD, we found that patients diagnosed with ASD received more pharmacological treatment than those diagnosed with SPCD. CONCLUSIONS Further research is required to confirm our results. Studies focusing on the SPCD phenotype will be necessary to determine outcome differences with ASD and the most effective diagnostic and therapeutic tools.
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Affiliation(s)
- Ana Blázquez Hinojosa
- Servicio de Psiquiatría y Psicología Infantil y Juvenil, Instituto de Neurociencias, Hospital Clínico Universitario, Barcelona, Spain.
| | - Luisa Lázaro Garcia
- Servicio de Psiquiatría y Psicología Infantil y Juvenil, Instituto de Neurociencias, Hospital Clínico Universitario, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain; Departamento de Psiquiatría y Psicobiología Clínica, Universidad de Barcelona, Barcelona, Spain
| | - Olga Puig Navarro
- Servicio de Psiquiatría y Psicología Infantil y Juvenil, Instituto de Neurociencias, Hospital Clínico Universitario, Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain
| | - Eva Varela Bondelle
- Servicio de Psiquiatría y Psicología Infantil y Juvenil, Instituto de Neurociencias, Hospital Clínico Universitario, Barcelona, Spain
| | - Rosa Calvo Escalona
- Servicio de Psiquiatría y Psicología Infantil y Juvenil, Instituto de Neurociencias, Hospital Clínico Universitario, Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain
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Wiggins LD, Nadler C, Rosenberg S, Moody E, Reyes N, Reynolds A, Alexander A, Daniels J, Thomas K, Giarelli E, Levy SE. Many Young Children with Autism Who Use Psychotropic Medication Do Not Receive Behavior Therapy: A Multisite Case-Control Study. J Pediatr 2021; 232:264-271. [PMID: 33493493 PMCID: PMC8174527 DOI: 10.1016/j.jpeds.2021.01.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 01/17/2021] [Accepted: 01/19/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To explore how many pre-school aged children with autism spectrum disorder (ASD) used psychotropic medication, child and geographic factors associated with psychotropic medication use, and how many children who used psychotropic medication did or did not ever receive behavior therapy. STUDY DESIGN Children 2-5 years of age were enrolled from 2012 to 2016 in a multisite case-control study designed to investigate the development and risk factors of ASD. Children with a positive ASD screen or ASD diagnosis upon enrollment were asked to complete a comprehensive evaluation to determine ASD status and developmental level. Caregivers completed a Services and Treatments Questionnaire and multiple self-administered questionnaires to determine child use of psychotropic medication, ever receipt of behavior therapy, and presence of co-occurring symptoms. RESULTS There were 763 children who were classified as ASD and had data collected on the Services and Treatments Questionnaire. Of those, 62 (8.1%) used psychotropic medication to treat behavioral symptoms and 28 (3.7%) were ≤3 years of age when medication was first started. Attention problems (aOR, 7.65; 95% CI, 3.41-16.1; P < .001) and study site (aOR, 2.62; 95% CI, 1.04-6.56; P = .04) were significantly associated with psychotropic medication use after controlling for maternal race/ethnicity. More than one-half (59.7%) of those who used psychotropic medication did not ever receive behavior therapy. CONCLUSIONS Many preschool-aged children with ASD who use psychotropic medication do not receive behavior therapy. Pediatricians are an important resource for children and families and can help facilitate behavioral treatment for children with ASD and other disorders.
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Affiliation(s)
- Lisa D Wiggins
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA.
| | - Cy Nadler
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO
| | - Steven Rosenberg
- School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO
| | - Eric Moody
- Institute for Disabilities, University of Wyoming, Laramie, WY
| | - Nuri Reyes
- School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO
| | - Ann Reynolds
- School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO
| | - Aimee Alexander
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Julie Daniels
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC
| | - Kathleen Thomas
- Center for Health Services Research, University of North Carolina, Chapel Hill, NC
| | - Ellen Giarelli
- College of Nursing and Health Professions, Drexel University, Philadelphia, PA
| | - Susan E Levy
- Center for Autism Research, Children's Hospital of Philadelphia, Philadelphia, PA
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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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Blázquez Hinojosa A, Lázaro Garcia L, Puig Navarro O, Varela Bondelle E, Calvo Escalona R. Sensitivity and specificity of DSM-5 diagnostic criteria for autism spectrum disorder in a child and adolescent sample. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2019; 14:S1888-9891(19)30099-0. [PMID: 31864965 DOI: 10.1016/j.rpsm.2019.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 10/15/2019] [Accepted: 10/16/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Controversy exists regarding the DSM-5 criteria for autism spectrum disorders (ASD). Given the mixed results that have been reported, our main aim was to determine DSM-5 sensitivity and specificity in a child and adolescent Spanish sample. As secondary goals, we assessed the diagnostic stability of DSM-IV-TR in DSM-5, and clinical differences between children diagnosed with an ASD or a social (pragmatic) communication disorder (SPCD). METHODS This study was carried out in 2017, reviewing the medical records of patients evaluated in our service. Items from a parent report measure of ASD symptoms (Autism Diagnostic Interview-Revised) were matched to DSM-5 criteria and used to assess the sensitivity and specificity of the DSM-5 criteria and current DSM-IV criteria when compared with clinical diagnoses. RESULTS DSM-5 sensitivity ranged from 0.69 to 1.00, and was higher in females. By age, the DSM-5 and DSM-IV-TR criteria showed similar sensitivity. In the case of intellectual quotient, DSM-5 criteria sensitivity was lower for those in the "low-functioning" category. DSM-5 specificity ranged from 0.64 to 0.73, while DSM-5 specificity was similar for all phenotypic subgroups. With respect to stability, 83.3% of autism disorder cases retained a diagnosis of ASD using the DSM-5 criteria. With regard to differences between ASD and SPCD, we found that patients diagnosed with ASD received more pharmacological treatment than those diagnosed with SPCD. CONCLUSIONS Further research is required to confirm our results. Studies focusing on the SPCD phenotype will be necessary to determine outcome differences with ASD and the most effective diagnostic and therapeutic tools.
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Affiliation(s)
- Ana Blázquez Hinojosa
- Servicio de Psiquiatría y Psicología Infantil y Juvenil, Instituto de Neurociencias, Hospital Clínico Universitario, Barcelona, España.
| | - Luisa Lázaro Garcia
- Servicio de Psiquiatría y Psicología Infantil y Juvenil, Instituto de Neurociencias, Hospital Clínico Universitario, Barcelona, España; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, España; Departamento de Psiquiatría y Psicobiología Clínica, Universidad de Barcelona, Barcelona, España
| | - Olga Puig Navarro
- Servicio de Psiquiatría y Psicología Infantil y Juvenil, Instituto de Neurociencias, Hospital Clínico Universitario, Barcelona, España; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, España
| | - Eva Varela Bondelle
- Servicio de Psiquiatría y Psicología Infantil y Juvenil, Instituto de Neurociencias, Hospital Clínico Universitario, Barcelona, España
| | - Rosa Calvo Escalona
- Servicio de Psiquiatría y Psicología Infantil y Juvenil, Instituto de Neurociencias, Hospital Clínico Universitario, Barcelona, España; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, España
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Rezaei M, Moradi A, Tehrani-Doost M, Hassanabadi H, Khosroabadi R. Effects of Combining Medication and Pivotal Response Treatment on Aberrant Behavior in Children with Autism Spectrum Disorder. CHILDREN (BASEL, SWITZERLAND) 2018; 5:E19. [PMID: 29385740 PMCID: PMC5835988 DOI: 10.3390/children5020019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/08/2018] [Accepted: 01/23/2018] [Indexed: 11/24/2022]
Abstract
Abstract: The purpose of this study was to investigate the effects of combined risperidone (RIS) and pivotal response treatment (PRT) on children with autism spectrum disorder (ASD). A total of 34 children diagnosed with ASD according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) (mean age of 12.36 years) were randomly assigned to either of two groups; the first group (n = 17) received combined PRT-RIS while the second group (n = 17) received RIS only. Behavioral problems were evaluated with the Aberrant Behavior Checklist (ABC), whereas global improvement (GI) was measured with the Clinical Global Impressions (CGI). Assessment of ABC was performed before intervention, after intervention (12 weeks), and following 3 months of the intervention (follow-up). Total ABC scores were seen to decrease in both groups after 3 months, as compared with the scores prior to the interventions. Also, in both groups, mean scores of behavioral problems after the intervention were not significantly different from those prior to the intervention, in all subscales but the inappropriate speech (p < 0.001). However, both groups showed significant differences in mean scores of ABC subscales in both of the post-intervention evaluation stages. It was concluded that the combination of behavioral and drug interventions can further improve behavioral problems, ultimately improving patient's communication and social skills.
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Affiliation(s)
- Mohammad Rezaei
- Institute for Cognitive Science Studies (ICSS), 16516-56717 Tehran, Iran.
- Pediatric Developmental Disorder Research Center, Hamadan University of Medical Sciences, 65178-38695 Hamadan, Iran.
| | - AliReza Moradi
- Institute for Cognitive Science Studies (ICSS), 16516-56717 Tehran, Iran.
- Department of Clinical Psychology, Kharazmi University, 37551-31979 Tehran, Iran.
| | | | - HamidReza Hassanabadi
- Department of Educational Psychology, Kharazmi University, 37551-31979 Tehran, Iran.
| | - Reza Khosroabadi
- Institute for Cognitive and Brain Sciences, Shahid Beheshti University GC, 19839-69411 Tehran, Iran.
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Elvins R, Green J. Pharmacological management of core and comorbid symptoms in autism-spectrum disorder. ACTA ACUST UNITED AC 2018. [DOI: 10.1192/apt.bp.108.005538] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SummaryIn this article we review the evidence base and practical experience supporting the use of psychopharmacological treatments for autism-spectrum disorders across the lifespan. Recent advances in knowledge are highlighted, as are the shortcomings of published data in this field. Psychosocial and educational interventions remain the core of treatment, but there is now evidence that medication management is a good option for certain domains of behaviour. We discuss the evidence in terms of symptom clusters, including the underlying social deficit of autism and common psychiatric comorbidities.
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Medical Conditions and Demographic, Service and Clinical Factors Associated with Atypical Antipsychotic Medication Use Among Children with An Autism Spectrum Disorder. J Autism Dev Disord 2017; 47:1391-1402. [PMID: 28210827 DOI: 10.1007/s10803-017-3058-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
This study aimed to describe rates of antipsychotic medication use and the association between their use and demographics, clinical variables, and the use of behavioral/education services among children with ASD. For children with ASD ages 2-11 (n = 4749) and those 12-17 (n = 401), 5.4 and 17.7% were prescribed at least one atypical antipsychotic medication respectively. In the multivariable model of young children, older age, use of multiple psychotropic medications, prior ASD diagnosis, non-white Hispanic race/ethnicity, and oppositional defiant problems were associated with antipsychotic use. Among older children, only older age was associated with antipsychotic use. In at least one age group, antipsychotic medication use was also related to behaviour, family and occupational therapy, public insurance, site region, externalizing problems, body mass index, and sleep and gastrointestinal problems.
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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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Gnanasekaran S, Choueiri R, Neumeyer A, Ajari O, Shui A, Kuhlthau K. Impact of employee benefits on families with children with autism spectrum disorders. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2015; 20:616-22. [DOI: 10.1177/1362361315598891] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The objectives of this study are to evaluate the employee benefits parents of children with autism spectrum disorders have, how benefits are used, work change, and job satisfaction. We conducted a cross-sectional mailed survey study of 435 families with children with autism spectrum disorders residing in the United States. We received 161 surveys for a response rate of 37%. Families reported using the following benefits: 39% paid family leave, 19% unpaid family leave, 91% flexible work arrangements, and 86% telecommuting. Of respondents, 43% reported stopping work, cutting down on hours worked, or changing jobs because of their child’s condition. Having paid family leave was a positive predictor for job satisfaction. Parents of children with autism spectrum disorders have an interest and need for alternative work arrangements.
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Affiliation(s)
| | - Roula Choueiri
- University of Massachusetts Memorial Children’s Medical Center, USA
| | - Ann Neumeyer
- MassGeneral Hospital for Children, USA
- Massachusetts General Hospital, USA
| | | | - Amy Shui
- Massachusetts General Hospital, USA
| | - Karen Kuhlthau
- MassGeneral Hospital for Children, USA
- Massachusetts General Hospital, USA
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12
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Rates and predictors of adherence to psychotropic medications in children with autism spectrum disorders. J Autism Dev Disord 2015; 44:2931-48. [PMID: 24929833 DOI: 10.1007/s10803-014-2156-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Medication adherence in children is poor, particularly among those with chronic or mental health disorders. However, adherence has not been fully assessed in autism spectrum disorders (ASDs). The validated proportion of days covered method was used to quantify adherence to psychotropic medication in Medicaid-eligible children who met diagnostic criteria for ASD between 2000 and 2008 (N = 628). Among children prescribed attention deficit hyperactivity disorder (ADHD) medications, antidepressants, or antipsychotics, 44, 40 and 52 % were adherent respectively. Aggressive behaviors and abnormalities in eating, drinking, and/or sleeping, co-occurring ADHD, and the Medication Regimen Complexity Index were the most significant predictors of adherence rather than demographics or core deficits of ASD. Identifying barriers to adherence in ASD may ultimately lead to improved treatment outcomes.
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Logan SL, Carpenter L, Leslie RS, Garrett-Mayer E, Hunt KJ, Charles J, Nicholas JS. Aberrant Behaviors and Co-occurring Conditions as Predictors of Psychotropic Polypharmacy among Children with Autism Spectrum Disorders. J Child Adolesc Psychopharmacol 2015; 25:323-36. [PMID: 25919445 PMCID: PMC4442569 DOI: 10.1089/cap.2013.0119] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES The purpose of this study was to identify rates and predictors of psychotropic medication polypharmacy among Medicaid-eligible children in South Carolina with autism spectrum disorder (ASD) from 2000 to 2008. METHODS Population-based surveillance data were linked with state Medicaid records to obtain a detailed demographic, behavioral, educational, clinical, and diagnostic data set for all Medicaid-eligible 8-year-old children (n=629) who were identified and diagnosed with ASD using standardized criteria. Polypharmacy was defined as having interclass psychotropic medication claims overlapping for ≥30 consecutive days at any time during the 2-year study period. Multivariable logistic regression was used to model predictors of any polypharmacy, and for the three most common combinations. RESULTS Overall, 60% (n=377) used any psychotropic medication, and 41% (n=153) of those had interclass polypharmacy. Common combinations were attention-deficit/hyperactivity disorder (ADHD) medications with an antidepressant (A/AD), antipsychotic (A/AP) or a mood stabilizer (A/MS). Black children had lower odds of any polypharmacy, as did those eligible for Medicaid because of income or being foster care versus those eligible because of disability. There were no significant associations between polypharmacy and social deficits in ASD for any combination, although children with communication deficits diagnostic of ASD had lower odds of any polypharmacy and A/AP polypharmacy. Children with argumentative, aggressive, hyperactive/impulsive, or self-injurious aberrant behaviors had higher odds of polypharmacy, as did children with diagnosed co-occurring ADHD, anxiety or mood disorders, or conduct/oppositional defiant disorder (ODD) in Medicaid records. CONCLUSIONS Future research is warranted to investigate how child-level factors impact combination psychotropic medication prescribing practices and outcomes in ASD.
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Affiliation(s)
- Sarah L Logan
- 1 Department of Healthcare Leadership and Management, Medical University of South Carolina , Charleston, South Carolina
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Lake JK, Weiss JA, Dergal J, Lunsky Y. Child, parent, and service predictors of psychotropic polypharmacy among adolescents and young adults with an autism spectrum disorder. J Child Adolesc Psychopharmacol 2014; 24:486-93. [PMID: 25329798 DOI: 10.1089/cap.2014.0011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE This study examined the child, parent, and service factors associated with polypharmacy in adolescents and young adults with autism spectrum disorders (ASD). METHODS As part of an online survey examining health service utilization patterns among individuals with ASD, parents provided demographic and clinical information pertaining to their child. This included information on current medication use, as well as information on clinical services received, clinical history, and parent well-being. Analyses examined the bivariate association between individual child, parent, and service variables and polypharmacy. Variables significantly associated with polypharmacy were included in a multiple variable logistic regression. RESULTS Of the 363 participants sampled, ∼25% were receiving two or more psychotropic drugs concurrently. The patient's psychiatric comorbidity, history of hurting others, therapy use, and parent burden were predictors of polypharmacy. CONCLUSIONS Adolescents and young adults with ASD are a highly medicated population with multiple factors associated with psychotropic polypharmacy. Although there may be circumstances in which polypharmacy is necessary, a richer understanding of what predicts polypharmacy may lead to targeted interventions to better support these individuals and their families. Findings also highlight the need to support families of children with ASD prescribed multiple psychotropic medications.
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Affiliation(s)
- Johanna K Lake
- 1 Centre for Addiction and Mental Health , Dual Diagnosis Service, Toronto, Ontario, Canada
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Mental health services for individuals with high functioning autism spectrum disorder. AUTISM RESEARCH AND TREATMENT 2014; 2014:502420. [PMID: 25276425 PMCID: PMC4168143 DOI: 10.1155/2014/502420] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 08/09/2014] [Indexed: 11/17/2022]
Abstract
Adolescents and adults with an autism spectrum disorder (ASD) who do not have an intellectual impairment or disability (ID), described here as individuals with high-functioning autism spectrum disorder (HFASD), represent a complex and underserved psychiatric population. While there is an emerging literature on the mental health needs of children with ASD with normal intelligence, we know less about these issues in adults. Of the few studies of adolescents and adults with HFASD completed to date, findings suggest that they face a multitude of cooccurring psychiatric (e.g., anxiety, depression), psychosocial, and functional issues, all of which occur in addition to their ASD symptomatology. Despite this, traditional mental health services and supports are falling short of meeting the needs of these adults. This review highlights the service needs and the corresponding gaps in care for this population. It also provides an overview of the literature on psychiatric risk factors, identifies areas requiring further study, and makes recommendations for how existing mental health services could include adults with HFASD.
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Effectiveness and tolerability of switching to aripiprazole from risperidone in subjects with autism spectrum disorders: a prospective open-label study. Clin Neuropharmacol 2014; 36:151-6. [PMID: 24045605 DOI: 10.1097/wnf.0b013e3182a31ec0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Subjects with autism spectrum disorders (ASDs) often exhibit behavioral symptoms such as aggressiveness and irritability. The purpose of this study was to examine the efficacy and the tolerability of aripiprazole switched from risperidone in children and adolescents with ASD. METHODS This prospective, 12-week, open-label study included 9 male subjects with ASD (age range, 9-22 years; mean ± SD age, 14.8 ± 4.0 years) followed up for 12 weeks after switching to aripiprazole from risperidone. The primary outcome measures were the Clinical Global Impression-Improvement scales and the irritability subscale of the Aberrant Behavior Checklist. RESULTS The mean ± SD maintenance dosages of risperidone and aripiprazole were 0.6 ± 0.4 mg/d and 4.8 ± 4.0 mg/d, respectively. The mean ± SD scores of the irritability subscale of the Aberrant Behavior Checklist before switching to aripiprazole (baseline) and 12 weeks after switching to aripiprazole (end point) were 14.8 ± 7.6 and 13.1 ± 8.0, respectively. The mean ± SD Clinical Global Impression-Improvement score, a comparison from baseline to end point, was 2.4 ± 0.7. Mild somnolence was observed only in 1 subject. No significant changes in vital signs, weight, electrocardiogram, or laboratory measures occurred during switching to aripiprazole. Serum prolactin levels decreased significantly from 17.3 ± 9.4 ng/mL (baseline) to 2.3 ± 1.7 ng/mL (end point). CONCLUSIONS The results show that aripiprazole might be generally well tolerated and might constitute an alternative treatment of subjects with ASD who experience poor efficacy or tolerability issues with risperidone treatment. Additional long-term controlled studies are needed to evaluate the efficacy and the safety of switching to aripiprazole from other antipsychotics in subjects with ASD.
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Stewart AM, Nguyen M, Wong K, Poudel MK, Kalueff AV. Developing zebrafish models of autism spectrum disorder (ASD). Prog Neuropsychopharmacol Biol Psychiatry 2014; 50:27-36. [PMID: 24315837 DOI: 10.1016/j.pnpbp.2013.11.014] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 11/22/2013] [Accepted: 11/28/2013] [Indexed: 01/07/2023]
Abstract
Autism spectrum disorder (ASD) is a serious neurodevelopmental disorder with complex symptoms and unclear, multi-factorial pathogenesis. Animal (rodent) models of ASD-like behavior are extensively used to study genetics, circuitry and molecular mechanisms of ASD. The evolutionarily conserved nature of social behavior and its molecular pathways suggests that alternative experimental models can be developed to complement and enhance the existing rodent ASD paradigms. The zebrafish (Danio rerio) is rapidly becoming a popular model organism in neuroscience and biological psychiatry to study brain function, model human brain disorders and explore their genetic or pharmacological modulation. Representing highly social animals, zebrafish emerge as a strong potential model organism to study normal and pathological social phenotypes, as well as several other ASD-like symptoms. Here, we discuss the developing utility of zebrafish in modeling ASD as a new emerging field in translational neuroscience and drug discovery.
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Affiliation(s)
- Adam Michael Stewart
- ZENEREI Institute and Zebrafish Neuroscience Research Consortium (ZNRC), 309 Palmer Court, Slidell, LA 70458, USA; Department of Neuroscience, University of Pittsburgh, A210 Langley Hall, Pittsburgh, PA 15260, USA
| | - Michael Nguyen
- Department of Biomedical Engineering, University of Virginia, 415 Lane Road, Charlottesville, VA 22908, USA
| | - Keith Wong
- University of California San Diego (UCSD) School of Medicine, 9500 Gilman Dr, La Jolla, CA 92093, USA
| | - Manoj K Poudel
- ZENEREI Institute and Zebrafish Neuroscience Research Consortium (ZNRC), 309 Palmer Court, Slidell, LA 70458, USA
| | - Allan V Kalueff
- ZENEREI Institute and Zebrafish Neuroscience Research Consortium (ZNRC), 309 Palmer Court, Slidell, LA 70458, USA.
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Memarzia J, Tracy D, Giaroli G. The use of antipsychotics in preschoolers: a veto or a sensible last option? J Psychopharmacol 2014; 28:303-19. [PMID: 24451556 DOI: 10.1177/0269881113519506] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Recent reports have illustrated a dramatic rise in the use of antipsychotics in preschool children, medications originally designed and licensed for the treatment of adult psychotic disorders. Within this context, the current usage and the associated diagnoses are reviewed and compared with official guidelines and licensing for such use, highlighting a controversial challenge for clinicians. A review of the evidence base of the relative efficacy of such medications for a range of disorders is given. Associated safety and side effects are discussed, with compelling evidence for increased adverse events associated with use of antipsychotics in preschoolers, and neurodevelopmental hypotheses are used to guide predictions of long-term risk. An apparent gap in the literature and evidence base supporting such use and elucidating the risks and benefits leaves a challenge for clinicians and researchers and hinders the development of appropriate guidelines. Pragmatism in clinical practice, mindful of the limited evidence base that does exist and the propensity for harm, is necessary; far more research is required in this important area.
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Affiliation(s)
- Jessica Memarzia
- 1Department of Psychosis Studies, Institute of Psychiatry, King's College London, UK
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Abstract
OBJECTIVE This study systematically reviews the current literature on the administration of atomoxetine for treating children and adolescents with comorbidity on autism spectrum disorder (ASD) and ADHD. METHOD PubMed/Medline and Google Scholar databases were electronically searched to find the published trials on atomoxetine and ASD. RESULTS Six articles reported the clinical trials of atomoxetine for treatment of ADHD symptoms in patients with autism or pervasive development disorders. Only one study that was placebo-controlled crossover pilot trial reported that it is effective. Atomoxetine may be effective in high-functioning patients with autism or patients with low severity. Those with high severity of ASD may be more vulnerable to the adverse effects of atomoxetine. CONCLUSION There are not enough controlled clinical trials for showing the efficacy of atomoxetine for treatment of ADHD symptoms in autism. Although evidence suggests potential efficacy of atomoxetine, the current evidences are not conclusive.
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Affiliation(s)
- Ahmad Ghanizadeh
- 1Shiraz University of Medical Sciences, School of Medicine, Hafez hospital, Iran
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20
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Wang X, Bey AL, Chung L, Krystal AD, Jiang YH. Therapeutic approaches for shankopathies. Dev Neurobiol 2013; 74:123-35. [PMID: 23536326 DOI: 10.1002/dneu.22084] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 03/21/2013] [Indexed: 12/13/2022]
Abstract
Despite recent advances in understanding the molecular mechanisms of autism spectrum disorders (ASD), the current treatments for these disorders are mostly focused on behavioral and educational approaches. The considerable clinical and molecular heterogeneity of ASD present a significant challenge to the development of an effective treatment targeting underlying molecular defects. Deficiency of SHANK family genes causing ASD represent an exciting opportunity for developing molecular therapies because of strong genetic evidence for SHANK as causative genes in ASD and the availability of a panel of Shank mutant mouse models. In this article, we review the literature suggesting the potential for developing therapies based on molecular characteristics and discuss several exciting themes that are emerging from studying Shank mutant mice at the molecular level and in terms of synaptic function.
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Affiliation(s)
- Xiaoming Wang
- Department of Pediatrics, Duke University School of Medicine Durham, North Carolina, 27710
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21
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Fernández-Jaén A, Fernández-Mayoralas DM, Calleja-Pérez B, Muñoz-Jareño N, Campos Díaz MDR, López-Arribas S. Efficacy of atomoxetine for the treatment of ADHD symptoms in patients with pervasive developmental disorders: a prospective, open-label study. J Atten Disord 2013; 17:497-505. [PMID: 22366240 DOI: 10.1177/1087054711423626] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Atomoxetine's tolerance and efficacy were studied in 24 patients with pervasive developmental disorder and symptoms of ADHD. METHOD Prospective, open-label, 16-week study was performed, using the variables of the Clinical Global Impression Scale and the Conners' Scale, among others. RESULTS A significant difference was found between pre- and posttreatment scores as well as a significant reduction was found on the scales used. Only five patients presented adverse events. CONCLUSION Atomoxetine therefore appears to be a useful drug, pointing to the need for larger, randomized, controlled, double-blind studies to confirm its efficacy versus placebo and in comparison with other treatment options.
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22
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Woods AG, Ngounou Wetie AG, Sokolowska I, Russell S, Ryan JP, Michel TM, Thome J, Darie CC. Mass spectrometry as a tool for studying autism spectrum disorder. J Mol Psychiatry 2013; 1:6. [PMID: 25408899 PMCID: PMC4223881 DOI: 10.1186/2049-9256-1-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 11/13/2012] [Indexed: 12/04/2022] Open
Abstract
Autism spectrum disorders (ASDs) are increasing in incidence but have an incompletely understood etiology. Tools for uncovering clues to the cause of ASDs and means for diagnoses are valuable to the field. Mass Spectrometry (MS) has been a useful method for evaluating differences between individuals with ASDs versus matched controls. Different biological substances can be evaluated using MS, including urine, blood, saliva, and hair. This technique has been used to evaluate relatively unsupported hypotheses based on introduction of exogenous factors, such as opiate and heavy metal excretion theories of ASDs. MS has also been used to support disturbances in serotonin-related molecules, which have been more consistently observed in ASDs. Serotonergic system markers, markers for oxidative stress, cholesterol system disturbances, peptide hypo-phosphorylation and methylation have been measured using MS in ASDs, although further analyses with larger numbers of subjects are needed (as well as consideration of behavioral data). Refinements in MS and data analysis are ongoing, allowing for the possibility that future studies examining body fluids and specimens from ASD subjects could continue to yield novel insights. This review summarizes MS investigations that have been conducted to study ASD to date and provides insight into future promising applications for this technique, with focus on proteomic studies.
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Affiliation(s)
- Alisa G Woods
- Biochemistry and Proteomics Group Department of Chemistry and Biomolecular Science, Clarkson University, 8 Clarkson Avenue, Potsdam, NY 13699-5810 USA
| | - Armand G Ngounou Wetie
- Biochemistry and Proteomics Group Department of Chemistry and Biomolecular Science, Clarkson University, 8 Clarkson Avenue, Potsdam, NY 13699-5810 USA
| | - Izabela Sokolowska
- Biochemistry and Proteomics Group Department of Chemistry and Biomolecular Science, Clarkson University, 8 Clarkson Avenue, Potsdam, NY 13699-5810 USA
| | - Stefanie Russell
- Department of Psychology, State University of New York at Plattsburgh, 101 Broad Street, Plattsburgh, NY 12901 USA
| | - Jeanne P Ryan
- Department of Psychology, State University of New York at Plattsburgh, 101 Broad Street, Plattsburgh, NY 12901 USA
| | - Tanja Maria Michel
- Department of Psychiatry, University of Rostock, Gehlsheimer Straße 20, D-18147 Rostock, Germany
| | - Johannes Thome
- Department of Psychiatry, University of Rostock, Gehlsheimer Straße 20, D-18147 Rostock, Germany ; College of Medicine, Swansea University, Singleton Park, Swansea, SA2 8PP UK
| | - Costel C Darie
- Biochemistry and Proteomics Group Department of Chemistry and Biomolecular Science, Clarkson University, 8 Clarkson Avenue, Potsdam, NY 13699-5810 USA
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Gardner DM, Murphy AL, Kutcher S, Beaulieu S, Carandang C, Labelle A, Lalonde P, Malla A, Milliken H, O’Donovan C, Schaffer A, Soni J, Taylor VH, Williams R. Evidence review and clinical guidance for the use of ziprasidone in Canada. Ann Gen Psychiatry 2013; 12:1. [PMID: 23347694 PMCID: PMC3564821 DOI: 10.1186/1744-859x-12-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 01/14/2013] [Indexed: 12/17/2022] Open
Abstract
While indicated for schizophrenia and acute mania, ziprasidone's evidence base and use in clinical practice extends beyond these regulatory approvals. We, an invited panel of experts led by a working group of 3, critically examined the evidence and our collective experience regarding the effectiveness, tolerability and safety of ziprasidone across its clinical uses. There was no opportunity for manufacturer input into the content of the review. As anticipated, ziprasidone was found to be effective for its indicated uses, although its utility in mania and mixed states lacked comparative data. Beyond these uses, the available data were either unimpressive or were lacking. An attractive characteristic is its neutral effect on weight thereby providing patients with a non-obesogenic long-term treatment option. Key challenges in practice include the need for dosing on a full stomach and managing its early onset adverse effect of restlessness. Addressing these issues are critical to its long-term success.
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Affiliation(s)
- David M Gardner
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Andrea L Murphy
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Stan Kutcher
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Serge Beaulieu
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Carlo Carandang
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Alain Labelle
- Department of Psychiatry, University of Ottawa, Ottawa, ON, Canada
| | - Pierre Lalonde
- Centre de recherche Fernand-Seguin de l’Hôpital Louis-H. Lafontaine, Montreal, QC, Canada
| | - Ashok Malla
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Heather Milliken
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Claire O’Donovan
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Ayal Schaffer
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Jorge Soni
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Valerie H Taylor
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Richard Williams
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
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Frustaci A, Neri M, Cesario A, Adams JB, Domenici E, Dalla Bernardina B, Bonassi S. Oxidative stress-related biomarkers in autism: systematic review and meta-analyses. Free Radic Biol Med 2012; 52:2128-41. [PMID: 22542447 DOI: 10.1016/j.freeradbiomed.2012.03.011] [Citation(s) in RCA: 225] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 03/02/2012] [Accepted: 03/02/2012] [Indexed: 01/08/2023]
Abstract
Autism spectrum disorders (ASDs) are rarely diagnosed in children younger than 2 years, because diagnosis is based entirely on behavioral tests. Oxidative damage may play a central role in this pathogenesis, together with the interconnected transmethylation cycle and transsulfuration pathway. In an attempt to clarify and quantify the relationship between oxidative stress-related blood biomarkers and ASDs, a systematic literature review was carried out. For each identified study, mean biomarker levels were compared in cases and controls providing a point estimate, the mean ratio, for each biomarker. After meta-analysis, the ASD patients showed decreased blood levels of reduced glutathione (27%), glutathione peroxidase (18%), methionine (13%), and cysteine (14%) and increased concentrations of oxidized glutathione (45%) relative to controls, whereas superoxide dismutase, homocysteine, and cystathionine showed no association with ASDs. For the C677T allele in the methylene tetrahydrofolate reductase gene (MTHFR), homozygous mutant subjects (TT) showed a meta-OR of 2.26 (95% CI 1.30-3.91) of being affected by ASD with respect to the homozygous nonmutant (CC). Case-control studies on blood levels of vitamins suggest a lack of association (folic acid and vitamin B12) or rare association (vitamins A, B6, C, D, E). Sparse results were available for other biomarkers (ceruloplasmin, catalase, cysteinylglycine, thiobarbituric acid-reactive substances, nitric oxide) and for polymorphisms in other genes. Existing evidence is heterogeneous and many studies are limited by small sample size and effects. In conclusion, existing evidence suggests a role for glutathione metabolism, the transmethylation cycle, and the transsulfuration pathway, although these findings should be interpreted with caution, and larger, more standardized studies are warranted.
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Affiliation(s)
- Alessandra Frustaci
- Unit of Clinical and Molecular Epidemiology, IRCCS San Raffaele Pisana, 00166 Roma, Italy
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Ishitobi M, Hiratani M, Kosaka H, Takahashi T, Mizuno T, Asano M, Murata T, Tomoda A, Wada Y. Switching to aripiprazole in subjects with pervasive developmental disorders showing tolerability issues with risperidone. Prog Neuropsychopharmacol Biol Psychiatry 2012; 37:128-31. [PMID: 22245026 DOI: 10.1016/j.pnpbp.2011.12.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 12/12/2011] [Accepted: 12/29/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND Subjects with Pervasive Developmental Disorders (PDD) often exhibit behavioral symptoms such as aggressiveness and irritability, which are targets of psychopharmacologic intervention. This retrospective study was designed to examine children and adolescents with PDD experiencing tolerability issues with risperidone treatment, and thereby assess the efficacy and tolerability of switching to aripiprazole. METHODS This naturalistic study included 23 subjects with PDD (16 males, 7 females, age range 9-24 years, mean age 15.1±3.9 years) diagnosed according to DSM-IV criteria and followed up for 14.9±8.4 weeks after switching to aripiprazole from risperidone. Outcome measures were the Clinical Global Impression-Severity (CGI-S) and CGI Improvement (CGI-I) scales. RESULTS The mean CGI-S scores of pre-aripiprazole treatment and post-aripiprazole treatment were, respectively 4.7±1.4 and 4.6±1.3. Mean maintenance dosages of risperidone and aripiprazole were, respectively, 0.7±0.5mg/day and 2.8±1.3mg/day. The mean CGI-I score, which shows the difference induced by switching from risperidone to aripiprazole, was 3.4±0.8 for the whole sample, suggesting that the efficacy of risperidone for treating behavioral problems of PDD was maintained by aripiprazole. Some improvement of safety/tolerability issues such as increased appetite, somnolence, hyperprolactinemia, and amenorrhea occurred after switching to aripiprazole. CONCLUSION Results show that switching to aripiprazole might be generally well tolerated and might constitute an alternative treatment for subjects with PDD who experience tolerability issues with risperidone treatment. Additional long-term controlled studies of PDD subjects should be undertaken to evaluate the efficacy and safety of switching to aripiprazole from other antipsychotics.
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Affiliation(s)
- Makoto Ishitobi
- Department of Neuropsychiatry, University of Fukui, 23-3 Matsuokashimoaizuki, Eiheiji-Cho, Yoshida-Gun, Fukui 910-1193, Japan.
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Gerber F, Bessero S, Robbiani B, Courvoisier DS, Baud MA, Traoré MC, Blanco P, Giroud M, Galli Carminati G. Comparing residential programmes for adults with autism spectrum disorders and intellectual disability: outcomes of challenging behaviour and quality of life. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2011; 55:918-932. [PMID: 21806693 DOI: 10.1111/j.1365-2788.2011.01455.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Owing to methodological issues, little research has been conducted to examine quality of life (QoL) as a treatment outcome in autism spectrum disorders (ASD) and intellectual disabilities (ID). This study was conducted to combine QoL measures and objective observations of challenging behaviours (CB) in order to evaluate changes over time in adults with ASD and ID who were treated in two different residential programmes; we hypothesised that a decrease in CB would be related to an improved QoL. METHOD In a longitudinal study (45 months), we followed 31 adults with ASD and ID who had been integrated into two residential programmes [Autism Programme with a Structured Method (PAMS) vs. traditional programme for ID (No-PAMS)] for 2-19 years. QoL [Quality of Life Inventory in a Residential Environment (IQVMR)] and severity of autistic features (Childhood Autism Rating Scales) were evaluated annually. CB, as measured by the Aberrant Behaviour Checklist (ABC), including stereotypic behaviour and inappropriate speech, were repeatedly assessed every 3 months. RESULTS Observed separately, the groups' results were different. In the PAMS programme, stereotypic behaviour and inappropriate speech (ABC scores) significantly decreased, and the IQVMR total score increased; in contrast, in the comparison group, ABC scores did not change and the IQVMR total score decreased. In all, three mixed-effect ANCOVAs partially confirmed that the PAMS programme had an effect on CB and that QoL improvement did not directly depend on the type of programme but on reducing CB as measured by the ABC. CONCLUSION The PAMS programme has a positive and indirect influence on QoL by reducing CB.
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Affiliation(s)
- F Gerber
- Psychiatric Unit of Mental Development (UPDM), Department of Psychiatry, University Hospitals of Geneva (HUG) - University of Geneva, Geneva, Switzerland.
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Management of symptoms in children with autism spectrum disorders: a comprehensive review of pharmacologic and complementary-alternative medicine treatments. J Dev Behav Pediatr 2011; 32:56-68. [PMID: 21160435 DOI: 10.1097/dbp.0b013e3182040acf] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
In the care of children with autism spectrum disorders (ASD), medical treatment is typically considered an adjunct to educational and behavioral interventions. Nonetheless, large proportions of children with ASD are managed medically and receive both pharmacologic and complementary-alternative medicine (CAM) treatments. Although many medical treatments have been studied in children with ASD, studies vary widely in terms of the sample, sample size, research design, purposes of treatment, and measurements of change. Surprisingly, comprehensive reviews of the options for medical management in ASD are lacking, particularly reviews that address both pharmacologic and CAM treatments. Furthermore, reviews to date tend to emphasize general effects of medication; this perspective contradicts medical practice, which targets particular symptoms during treatment selection and monitoring. This review of 115 studies adds to the ASD treatment literature by (1) including studies of individuals 0 to 22 years of age; (2) aggregating studies of pharmacologic treatments and CAM treatments; and importantly, (3) organizing treatment response by ASD symptoms, differentiating core and associated symptoms.
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Villagonzalo KA, Dodd S, Dean O, Gray K, Tonge B, Berk M. Oxidative pathways as a drug target for the treatment of autism. Expert Opin Ther Targets 2010; 14:1301-10. [PMID: 20954799 DOI: 10.1517/14728222.2010.528394] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD Autism is a severe, pervasive developmental disorder, the aetiology of which is poorly understood. Current pharmacological treatment options for autism are often focused on addressing comorbid behavioural problems, rather than core features of the disorder. Investigation of a new treatment approach is needed. AREAS COVERED IN THIS REVIEW Recent research has indicated a possible role of abnormalities in oxidative homeostasis in the pathophysiology of autism, based on reports that a range of oxidative biomarkers are significantly altered in people with autism. This article reviews the current findings on oxidative stress in autism, including genetic links to oxidative pathways, changes in antioxidant levels and other oxidative stress markers. We conducted a search of the literature up to June 2010, using Medline, Pubmed, PsycINFO, CINAHL PLUS and BIOSIS Previews. WHAT THE READER WILL GAIN This review provides an overview of the current understanding of the role of oxidative stress in autism. This will assist in highlighting areas of future therapeutic targets and potential underlying pathophysiology of this disorder. TAKE HOME MESSAGE Abnormalities in oxidative homeostasis may play a role in the pathophysiology of autism. Antioxidant treatment may form a potential therapeutic pathway for this complex disorder.
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Affiliation(s)
- Kristi-Ann Villagonzalo
- University of Melbourne, Department of Clinical and Biomedical Sciences, Victoria 3220, Australia.
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Rezaei V, Mohammadi MR, Ghanizadeh A, Sahraian A, Tabrizi M, Rezazadeh SA, Akhondzadeh S. Double-blind, placebo-controlled trial of risperidone plus topiramate in children with autistic disorder. Prog Neuropsychopharmacol Biol Psychiatry 2010; 34:1269-72. [PMID: 20637249 DOI: 10.1016/j.pnpbp.2010.07.005] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Revised: 07/06/2010] [Accepted: 07/07/2010] [Indexed: 11/27/2022]
Abstract
BACKGROUND Autism is a complex neurodevelopmental disorder that forms part of a spectrum of related disorders referred to as Autism Spectrum Disorders. The present study assessed the effects of topiramate plus risperidone in the treatment of autistic disorder. METHOD Forty children between the ages of 4 and 12 years with a DSM IV clinical diagnosis of autism who were outpatients from a specialty clinic for children were recruited. The children presented with a chief complaint of severely disruptive symptoms related to autistic disorder. Patients were randomly allocated to topiramate+risperidone (Group A) or placebo+risperidone (Group B) for an 8-week, double-blind, placebo-controlled study. The dose of risperidone was titrated up to 2 mg/day for children between 10 and 40 kg and 3 mg/day for children weighting above 40 kg. The dose of topiramate was titrated up to 200 mg/day depending on weight (100 mg/day for <30 kg and 200 mg/day for >30 kg). Patients were assessed at baseline and after 2, 4, 6 and 8 weeks after starting medication. Measure of outcome was the Aberrant Behavior Checklist-Community (ABC-C) Rating Scale. RESULTS Difference between the two protocols was significant as the group that received topiramate had a greater reduction in ABC-C subscale scores for irritability, stereotypic behavior and hyperactivity/noncompliance. CONCLUSION The results suggest that the combination of topiramate with risperidone may be superior to risperidone monotherapy for children with autistic disorder. However the results need to be further confirmed by a larger randomized controlled trial.
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Affiliation(s)
- Vala Rezaei
- Research Center for Psychiatry and Behavioral Sciences, Shiraz University of Medical Sciences, Hafez Hospital, Shiraz, Iran
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Double-blind placebo-controlled trial of pentoxifylline added to risperidone: effects on aberrant behavior in children with autism. Prog Neuropsychopharmacol Biol Psychiatry 2010; 34:32-6. [PMID: 19772883 DOI: 10.1016/j.pnpbp.2009.09.012] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2009] [Revised: 09/12/2009] [Accepted: 09/12/2009] [Indexed: 11/23/2022]
Abstract
BACKGROUND There are several lines of evidence to indicate that the immune system plays an important role in the pathophysiology of autism. The objective of this study was to access the effects of pentoxifylline plus risperidone in the treatment of autistic disorder. METHODS Forty children between the ages 4 and 12 years with a DSM IV-TR clinical diagnosis of autism were recruited. The children presented with a chief complaint of severely disruptive symptoms related to autistic disorder. Patients were randomly allocated to pentoxifylline+risperidone or placebo+risperidone for a 10-week, double-blind, placebo-controlled study. The dose of risperidone was titrated up to 3 mg/day, pentoxifylline was titrated to 600 mg/day. Patients were assessed at baseline and after 2, 4, 6, 8 and 10 weeks of starting medication. The measure of the outcome was the Aberrant Behavior Checklist-Community (ABC-C). RESULTS The difference between the two protocols was significant as the group that received pentoxifylline had greater reduction in ABC-C subscale scores for Irritability, Lethargy/Social Withdrawal, Stereotypic Behavior, Hyperactivity/Noncompliance and Inappropriate Speech. CONCLUSION The results suggest that combination of atypical antipsychotic medications and pentoxifylline might have synergistic effects in treatment of behavioral problems of children with autism.
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Bacher I, Wu B, Shytle DR, George TP. Mecamylamine - a nicotinic acetylcholine receptor antagonist with potential for the treatment of neuropsychiatric disorders. Expert Opin Pharmacother 2010; 10:2709-21. [PMID: 19874251 DOI: 10.1517/14656560903329102] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Mecamylamine (Inversine), the first orally available antihypertensive agent launched in the 1950s, is rarely used today for hypertension because of its widespread ganglionic side effects at antihypertensive doses (25 - 90 mg/day). However, more recent clinical studies suggest that mecamylamine is effective at much lower doses for blocking the central and peripheral effects of nicotine. Pharmacologically, mecamylamine has been well characterized as a nonselective and noncompetitive antagonist of nicotinic acetylcholine receptors (nAChRs). Because mecamylamine easily crosses the blood - brain barrier at relatively low doses (2.5 - 10 mg), it has been used by several research groups over the past two decades investigating the role of central nAChRs in the etiology and treatment of various neuropsychiatric disorders, including addiction disorders, Tourette's syndrome, schizophrenia and various cognitive and mood disorders. Two independent Phase II clinical trials recently confirmed mecamylamine's hypothesized antidepressant activity and suggest that it may be effective as an augmentation pharmacotherapy for SSRI treatment resistant major depression. These areas of investigation for mecamylamine are reviewed and recommendations for future research directions are proposed.
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Affiliation(s)
- Ingrid Bacher
- University of Toronto, Department of Psychiatry, Faculty of Medicine, Toronto, Canada.
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Weeden M, Ehrhardt K, Poling A. Psychotropic drug treatments for people with autism and other developmental disorders: a primer for practicing behavior analysts. Behav Anal Pract 2010; 3:4-12. [PMID: 22479667 PMCID: PMC3004683 DOI: 10.1007/bf03391753] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Many people with developmental disabilities receive medications prescribed to improve behavior. This manuscript overviews the psychopharmacology of developmental disabilities and considers how practitioners can assist in improving the quality of the pharmacological treatments that their clients receive.
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Affiliation(s)
- Marc Weeden
- Department of Psychology, Western Michigan University, Kalamazoo, MI 49008 USA
| | - Kristal Ehrhardt
- Department of Psychology, Western Michigan University, Kalamazoo, MI 49008 USA
| | - Alan Poling
- Department of Psychology, Western Michigan University, Kalamazoo, MI 49008 USA
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Noggle CA, Dean RS. Atypical and typical antipsychotics in the schools. PSYCHOLOGY IN THE SCHOOLS 2009. [DOI: 10.1002/pits.20427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Theoharides TC, Kempuraj D, Redwood L. Autism: an emerging 'neuroimmune disorder' in search of therapy. Expert Opin Pharmacother 2009; 10:2127-43. [PMID: 19640207 DOI: 10.1517/14656560903107789] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Autism spectrum disorders (ASDs) are neurodevelopmental disorders characterized by difficulties in communication and by repetitive and stereotypic behaviors, as well as by social impairment, attention, cognitive, and learning defects. ASDs present in early childhood and their prevalence has increased significantly to 1/150 children. Despite a number of theories, the actual reasons for this increase are still not clear. There is no reliable screening test, and no definite pathogenesis or curative therapy. Consequently, there is a major gap hampering development of effective treatments. OBJECTIVE To review recent publications on ASDs pathogenesis and treatment with emphasis on neuroimmune processes and new therapeutic approaches. METHODS Mostly original papers (450) on epidemiology, possible pathogenesis or treatment of ASDs in Medline from 1990 to May 2009 were reviewed. All authors contributed to this review. RESULTS/CONCLUSION Increased oxidative stress and immune dysregulation are present in ASDs. Mast-cell activation may contribute to gut-blood-brain barrier disruption and brain inflammation. No effective treatments have emerged. Well-designed clinical trials with nonpsychotropic drugs were few and ASD characteristics varied considerably, making conclusions difficult. Psychotropic drugs are often used for stereotypic and aggressive behaviors. Unique combinations with antioxidant and anti-inflammatory flavonoids hold promise. New potential translational research areas and possible treatments are suggested.
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Affiliation(s)
- Theoharis C Theoharides
- Molecular Immunopharmacology and Drug Discovery Laboratory, Tufts University School of Medicine, Tufts Medical Center, Department of Pharmacology, Boston, MA 02111, USA.
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A longitudinal investigation of psychotropic and non-psychotropic medication use among adolescents and adults with autism spectrum disorders. J Autism Dev Disord 2009; 39:1339-49. [PMID: 19434487 DOI: 10.1007/s10803-009-0750-3] [Citation(s) in RCA: 124] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2008] [Accepted: 04/23/2009] [Indexed: 10/20/2022]
Abstract
Medication use was examined in 286 adolescents and adults with ASD over a 4.5 year period. A total of 70% were taking a psychotropic or non-psychotropic medication at the beginning of the study. Both the number of psychotropic and non-psychotropic medications taken, and the proportion of individuals taking these medications, increased significantly over the study period, with 81% taking at least one medication 4.5 years later. Our findings suggested a high likelihood of staying medicated over time. Thus, adolescents and adults with ASD are a highly and increasingly medicated population.
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Affiliation(s)
- Scott M Myers
- Geisinger Health System, Danville, Pennsylvania 17822-13391, USA.
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Hughes JR. A review of recent reports on autism: 1000 studies published in 2007. Epilepsy Behav 2008; 13:425-37. [PMID: 18627794 DOI: 10.1016/j.yebeh.2008.06.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2008] [Revised: 06/24/2008] [Accepted: 06/27/2008] [Indexed: 01/28/2023]
Abstract
From 1000 studies published in 2007 on all aspects of autism, those that reached clear conclusions or included quantitative data were selected for this review. Possible etiologies include elemental metals, especially the inconsistent evidence regarding mercury from the vaccine preservative thimerosal, not used after 2001, and chromosomes and genes with the conclusion that autism has a complex genetic architecture. Also, various parental conditions are considered, as are many different abnormalities in the central nervous system, especially underconnectivity within the cortex. Furthermore, deficiencies in mirror neurons have been proposed, leading to the "theory of mind" explanation that autistic children tend to disregard others. In addition, various global deficiencies, like an increase in inhibitory synaptic transmission, are proposed. Characteristics of these children include selective (inward) attention; underresponsiveness; stereotyped repetitive motor behavior; increased head size, weight, and height; various cognitive and communicative disorders; and also epilepsy. Therapy has emphasized risperidone, but some atypical antipsychotic medications have been helpful, as have robotic aids, massage, hyperbaric oxygen, and music. Nearly every conceivable problem that a child could have can be observed in these unfortunate children.
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Affiliation(s)
- John R Hughes
- Department of Neurology, University of Illinois Medical Center (M/C 796), 912 South Wood Street, Chicago, IL 60612, USA
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Ivanov I, Charney A. Treating pediatric patients with antipsychotic drugs: balancing benefits and safety. ACTA ACUST UNITED AC 2008; 75:276-86. [DOI: 10.1002/msj.20051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Reiersen AM, Todd RD. Co-occurrence of ADHD and autism spectrum disorders: phenomenology and treatment. Expert Rev Neurother 2008; 8:657-69. [PMID: 18416666 DOI: 10.1586/14737175.8.4.657] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The Diagnostic and Statistical Manual of Mental Disorders (4th Edition) prohibits the co-diagnosis of attention-deficit/hyperactivity disorder (ADHD) and an autism spectrum disorder (ASD). However, recent studies indicate that co-occurrence of clinically significant ADHD and autistic symptoms is common, and that some genes may influence both disorders. Children with the combination of ADHD and motor coordination problems are particularly likely to have an ASD. These co-occurrences of symptoms are important since children with ASD in addition to ADHD symptoms may respond poorly to standard ADHD treatments or have increased side effects. Such children may benefit from additional classes of pharmacologic agents (i.e., alpha-agonists, selective serotonin reuptake inhibitors and neuroleptics). They may also benefit from social skills therapy, individual and family psychotherapy, behavioral therapy and other nonpharmacologic interventions.
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Affiliation(s)
- Angela M Reiersen
- Department of Psychiatry, Washington University in St. Louis School of Medicine, St. Louis, MO 63110-1093, USA.
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Abstract
Pediatricians have an important role not only in early recognition and evaluation of autism spectrum disorders but also in chronic management of these disorders. The primary goals of treatment are to maximize the child's ultimate functional independence and quality of life by minimizing the core autism spectrum disorder features, facilitating development and learning, promoting socialization, reducing maladaptive behaviors, and educating and supporting families. To assist pediatricians in educating families and guiding them toward empirically supported interventions for their children, this report reviews the educational strategies and associated therapies that are the primary treatments for children with autism spectrum disorders. Optimization of health care is likely to have a positive effect on habilitative progress, functional outcome, and quality of life; therefore, important issues, such as management of associated medical problems, pharmacologic and nonpharmacologic intervention for challenging behaviors or coexisting mental health conditions, and use of complementary and alternative medical treatments, are also addressed.
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