Control of psychomotor agitation and aggressive behavior in patients with autistic disorder: a retrospective chart review

Treatment of Aggressive Behavior and Agitation in an 11-Year-Old Boy with Co-Occurring Autism and ADHD: A Case Report and Literature Review on the Use of Intravenous Valproate in Emergency Psychiatry

Background: Autism spectrum disorder (ASD) is a persistent neurodevelopmental disorder frequently co-occurring with attention-deficit/hyperactivity disorder (ADHD) and behavior-related disorders. While behavioral therapy is the first-line option to manage the core symptoms of ASD, pharmacological therapy is sometimes needed to treat acute problems, such as agitation and aggressive behaviors. Recent guidelines recommend the use of neuroleptics to reduce psychomotor agitation in patients with ASD. However, as children with ASD are often drug-resistant, alternative treatments are often justified. Reports from the literature have indicated that intravenous valproate (IV-VPA) can be effective in reducing agitation in psychiatric patients, with a lower frequency of adverse events compared to conventional treatments. However, as the related findings are occasionally inconsistent, IV-VPA is not yet an approved option in the context of clinical psychiatry. We aim to improve knowledge of the IV-VPA treatment option for emergency psychiatric treatment in pediatric patients. Methods: We report the case of an 11-year-old boy suffering from a complex neurodevelopmental condition who experienced a psychotic episode with severe aggressive and disruptive behaviors and was successfully treated with IV-VPA. Furthermore, we provide an updated literature review on this topic. Conclusion: In our case, first-line therapies proved to be ineffective. To the contrary, IV-VPA led to safe and prompt clinical success, which is in line with other reports. Based on our literature review, IV-VPA can be highly effective and reduces the risk of adverse events that frequently occur with the use of high-dose standard medications in emergency psychiatry.

The Effect of Chronotype on Oppositional Behaviour and Psychomotor Agitation of School-Age Children: A Cross-Sectional Study

The aim of this study is to examine the relationship between chronotype, classroom behaviour and school performance in 140 healthy school-age children attending various levels of education during the 1st cycle during 2021 in Portugal. In this cross-sectional and quantitative study, the Chronotype Questionnaire for Children (to assess the chronotype) and the Conners Scale-a reduced version was presented to the teachers (to assess behaviours such as excessive movement, inattention and oppositional behaviours)-were used. The methodology of this study followed a comparative method since the independent variables were not controlled, and therefore, it was still possible to compare the differences between the morning and evening groups. Statistical methods were used such as multivariate analyses, inter-item correlations and reliability tests, and descriptive tests were used for the percentile analysis. The sample was divided into three groups based on the identification of the chronotype-morning, intermediate and evening types-to further study the relationship between these chronotypes, their academic performance and classroom behaviour were studied. A multivariate analysis of variance revealed that there was a higher rate of oppositional behaviour in the morning type and no differences in the school performance during the two semesters (covering all of the school periods) regarding the chronotype effect, even with the analysis of regression parameters and covariates. On the other hand, the morning-type children showed a greater amount of motor agitation and impulsivity after controlling for the gender covariate. Age had an effect on the chronotype, after controlling for the covariate parental education. This study highlights the need for further research on the chronotype of the morning children in order to regulate their behaviour. The data that were obtained raise questions that have not been yet considered in the literature in the area of education and infant development.

Impact of antipsychotics in children and adolescents with autism spectrum disorder: a systematic review and meta-analysis

Background

The net health benefit of using antipsychotics in children and adolescents with ASD is unclear. This review was performed to provide the evidence necessary to inform the Italian national guidelines for the management of ASD.

Methods

We performed a systematic review of randomized controlled trials (RCTs) comparing antipsychotics versus placebo for the treatment of ASD in children and adolescents. For efficacy, acceptability and safety we considered outcomes evaluated by the guideline panel critical and important for decision-making. Continuous outcomes were analyzed by using standardized mean difference (SMD), and dichotomous outcomes by calculating the risk ratio (RR), with their 95% confidence interval (95% CI). Data were analyzed using a random effects model. We used the Cochrane tool to assess risk of bias of included studies. Certainty in the evidence of effects was assessed according to the GRADE approach.

Results

We included 21 RCTs with 1,309 participants, comparing antipsychotics to placebo. Antipsychotics were found effective on “restricted and repetitive interests and behaviors” (SMD − 0.21, 95% CI − 0.35 to − 0.07, moderate certainty), “hyperactivity, inattention, oppositional, disruptive behavior” (SMD − 0.67, 95% CI − 0.92 to − 0.42, moderate certainty), “social communication, social interaction” (SMD − 0.38, 95% CI − 0.59 to − 0.16, moderate certainty), “emotional dysregulation/irritability” (SMD − 0.71, 95% CI − 0.98 to − 0.43, low certainty), “global functioning, global improvement” (SMD − 0.64, 95% CI − 0.96 to − 0.33, low certainty), “obsessions, compulsions” (SMD − 0.30, 95% CI − 0.55 to − 0.06, moderate certainty). Antipsychotics were not effective on “self-harm” (SMD − 0.14, 95% CI − 0.58 to 0.30, very low certainty), “anxiety” (SMD − 0.38, 95% CI − 0.82 to 0.07, very low certainty). Antipsychotics were more acceptable in terms of dropout due to any cause (RR 0.61, 95% CI 0.48 to 0.78, moderate certainty), but were less safe in terms of patients experiencing adverse events (RR 1.19, 95% CI 1.07 to 1.32, moderate certainty), and serious adverse events (RR 1.07, 95% CI 0.48 to 2.43, low certainty).

Conclusions

Our systematic review and meta-analysis found antipsychotics for children and adolescents with ASD more efficacious than placebo in reducing stereotypies, hyperactivity, irritability and obsessions, compulsions, and in increasing social communication and global functioning. Antipsychotics were also found to be more acceptable, but less safe than placebo.

Autism: impact of the diagnosis in the parents

ABSTRACT Objective To understand how parents react to the diagnosis of autism in their child, and the manner in which the diagnosis was revealed, as well as the method through which the researcher perceived this communication. Methods A qualitative, narrative approach was used. Semi-structured interviews were held with 21 mothers and 9 fathers of children with autism spectrum disorder (ASD) enrolled in a special needs school in Salvador, Bahia, Brazil. In another setting, a specialist university service for the diagnosis of autism located in the same city, data were collected from 11 mothers and 5 fathers receiving diagnosis using ethnographic participant observation. Analysis categories were established, and the data interpreted. Results The categories selected were: “ in search of a diagnosis ”, “ impact of receiving the diagnosis ”, “ patterns of diagnosis communication ”, and “ coping strategies ”. Conclusion The diagnosis of autism is often delayed due to doctors’ unpreparedness. Awareness of their child’s diagnosis exerts a negative emotional impact on parents, which can be softened using coping strategies and diagnosis communication that offers technical information, offers emotional support and provides hope regarding the child’s development. Parents need to be cared for in order to provide for the needs of their children at the moment of diagnosis and throughout the entire process of caring for individuals with ASD.

Parenting a child with autism

ABSTRACT Objective: This study analyzes subjective aspects associated with parents’ perception of the changes that have affected their lives since the birth of their child with autism spectrum disorder (ASD). Methods: A qualitative study, using a narrative approach. Semi-structured interviews were conducted with 7 fathers and 16 mothers of children with ASD enrolled in a special needs school in Salvador, Bahia, Brazil. The interviews were transcribed, analytical categories were defined, and data interpreted. Results: Five categories were identified: “Emotional and Health-Related Effects”, “Effects on Daily/Professional and Academic Life”, “Effects on Marital and/or Affective/Sexual Life”, “Effects on Social Life”, “Adaptation Strategies”. The analysis showed that, despite the impacts suffered, social support, professional help can facilitate parents’ adjustment to life changes following the birth of a child with ASD. Conclusion: The physical and emotional demands of living with and parenting a child with ASD are enormous, include changes in social roles and in couples’ social and affective/sexual lives, highlighting the need for parents to receive support from healthcare professionals, particularly mental health professionals. Care strategies need to be implemented for parents, in addition to the healthcare provided to their children, in order to improve the comprehensive care given to the child with ASD.

Increased sleep duration precedes the improvement of other symptom domains during the treatment of acute mania: a retrospective chart review

BACKGROUND

Understanding trajectories of symptom changes may help gauge treatment response and better identify therapeutic targets in treatment of acute mania. We examined how symptoms of sleep disturbance, mania, and psychosis resolved in a naturalistic treatment setting, hypothesizing that improvement in sleep would precede improvement in manic and psychotic symptoms.

METHODS

Charts of 100 patients with admitting diagnoses of bipolar mixed or manic episode were retrospectively reviewed. Medications and demographic variables were recorded, and the Clinician-Administered Rating Scale for Mania (CARS-M) mania and psychosis ratings and sleep hours were determined for 8 observation points. Times to minimum symptom level in each domain were compared via Wilcoxon signed-rank tests. Symptom correlations and trajectories and medication effects were explored using repeated measures ANOVA and regression models.

RESULTS

Manic and psychotic symptom resolution was linear over the time of hospitalization. In contrast, sleep showed a slow initial response, followed by rapid increase to peak, preceding peak improvement in mania and psychosis (p < 0.001). Rate of sleep restoration was a predictor of rate but not of magnitude of treatment response for symptoms mania and psychosis. Patterns of medication use did not affect symptom trajectories.

CONCLUSIONS

In acute mania, improvement in sleep with treatment is dissociable from resolution in symptoms of mania and psychosis, but there appears to be no therapeutic advantage to patient oversedation. Sleep improves first and may be both a predictor of the rate of treatment response and a useful therapeutic target.

Pervasive developmental disorder in the children of immigrant parents: comparison of different assessment instruments

The objective of this study was to describe how the Childhood Autism Rating Scale (CARS) behaves in relation to the Autism Diagnostic Observation Schedule (ADOS) and to clinical diagnosis based on the criteria defined in the Diagnostic and Statistical Manual of Mental Disorders, 4 th Edition (DSM-IV) for children of immigrant parents. Forty-nine children of parents who had immigrated to Canada were evaluated. In this sample, the ADOS and the DSM-IV showed complete agreement. Using the standard cut-off point of 30, the CARS showed high specificity and poor sensitivity. The study proposes a cut-off point for the CARS that would include pervasive developmental disorder - not otherwise specified (PDD-NOS). Reducing the cut-off point to 20/21 increased the specificity of the instrument for this group of children without significantly reducing its sensitivity.

Catechol-O-methyltransferase Val158Met polymorphism and hyperactivity symptoms in Egyptian children with autism spectrum disorder

Catechol-O-methyltransferase (COMT) plays an important role in the catabolism of brain dopamine and norepinephrine, which have been implicated in the pathogenesis of Autism spectrum disorder (ASD) as well as in other neuropsychatric disorders. We aimed to investigate the association of COMT Val158Met gene polymorphism with ASD and to examine the influence of such genotypes on hyperactivity symptoms in ASD patients. Eighty ASD patients (mean age 9 ± 1.9 years) and 100 control children (mean age 8.9 ± 1.9 years) were examined. COMT Val58Met polymorphism was genotyped using Tetra-primer ARMS-PCR method. The clinical diagnosis of ASD and ADHD were confirmed according to the DSM-IV criteria for research. We found no significant difference in genotypes or alleles' frequencies of COMT Val158Met polymorphism between ASD patients and control group. There was a significant association between COMT (Val/Val) genotype and both increasing CARS (p=0.001) and hyperactivity scores (p=0.006). Regarding Conner's Score, the DSM-IV hyperactive impulsive were significantly higher in Val/Val genotype than both Met/Val and Met/Met genotypes (p=0.03). Our data suggested an association between COMT Val58Met polymorphism and hyperactivity symptoms in Egyptian children with ASD.

Frequency of symptoms of attention deficit and hyperactivity disorder in autistic children

BACKGROUND: Both DSM-IV and the ICD-10 exclude diagnosis of attention deficit/hyperactivity disorder (ADHD) when autism diagnostic is present. Some authors suggest, however, that autism can be associated to other comorbidity amongst which the ADHD. OBJECTIVE: To estimate prevalence of ADHD in children with autism. METHOD: Children were selected from a specialized school, all of then had previous diagnosis or diagnostic suspicion of autism. The Brazilian version of the KIDDIE-SADS PL was applied to parents for diagnostic of ADHD. DSM-IV diagnostic of autism was based on parents' interview and child observation. RESULTS: 32 children were included in the study. Results show that 53.1% of the ASD child had ADHD symptoms enough to fulfill DSM-IV diagnostic criteria, whereas 56.9% did not fulfill DSM-IV criteria for ADHD. CONCLUSION: Results suggest a high frequency of ADHD symptoms in ASD patients. Elucidating if we are facing a comorbity or an autism distinct phenotype can contribute for a more adjusted pharmacotherapy approach for these children.

Update on autism: a review of 1300 reports published in 2008

This publication, by reviewing 1300 studies published on autism in 2008, represents an update on this topic. Results include possible parental influences, maternal conditions, and studies on genes and chromosomes. Possible etiological factors involve the "extreme male brain," defects in the mirror neuron system, vaccines, underconnectivity, disorders of central coherence, and many other more specific etiologies. Assessments or tests for autism are also reviewed. Characteristics of autistic individuals include repetitive behavior, language disorders, sleep disturbances, social problems, joint attention disorders, seizures, allergic reactions, and various behavioral changes. Cognitive changes involve IQ, reasoning, and verbal and language disorders. The savant syndrome is a fascinating phenomenon, at times seen in autistic individuals. Neurophysiological and neuroanatomical changes are also reviewed, as are comorbid conditions. Finally, treatment involves various medications including risperidone, ziprasidone, and antipsychotic drugs, as well as different procedures such as magnetic stimulation, acupuncture, and hyperbaric oxygen therapy. As mentioned in the 2007 survey, nearly every conceivable problem that a child can have may be found in these unfortunate children and nearly every conceivable etiology has been mentioned to account for this serious disorder.