Advances in drug treatments for children and adolescents with autism and other pervasive developmental disorders

The Role of the Gut Microbiota and the Immune System in the Development of Autism

Autism‌ ‌spectrum‌ ‌disorders‌ ‌(ASDs)‌ ‌are‌ ‌neurodevelopmental‌ ‌disorders‌ ‌that‌ ‌present‌ ‌with‌ ‌social‌ skills‌ ‌and‌ ‌communication‌ ‌challenges,‌ ‌restricted‌ ‌interest,‌ ‌and‌ ‌repetitive‌ ‌behavior.‌ ‌The‌ ‌specific‌ cause ‌of‌ ‌autism‌ ‌is‌ ‌not‌ ‌well‌ ‌understood‌ ‌yet.‌ ‌However,‌ ‌numerous‌ ‌studies‌ ‌indicated‌ ‌that‌ ‌environmental‌ ‌and‌ ‌genetic‌ ‌factors,‌ ‌dysregulated‌ ‌immune‌ ‌response,‌ ‌and‌ ‌alterations‌ ‌to‌ ‌the‌ ‌balance‌ ‌and‌ ‌content‌ ‌of‌ ‌the‌ ‌gut‌ ‌microbiota‌ ‌are‌ ‌implemented‌ ‌in‌ ‌the‌ ‌development‌ ‌of‌ ‌autism.‌ ‌Many‌ ‌non-pharmacological‌ ‌interventions‌ ‌are‌ ‌nominated‌ ‌to‌ ‌manage ‌autism,‌ ‌including‌ ‌family‌ ‌support‌ ‌services‌ ‌and‌ ‌psychoeducational‌ ‌methods‌. Moreover,‌ ‌different‌ ‌pharmacological‌ ‌therapy‌ ‌modalities‌ ‌are‌ ‌recommended‌ ‌for‌ ‌children‌ ‌with‌ ‌ASD.‌ ‌Learning‌ ‌more‌ ‌about‌ ‌the‌ ‌brain,‌ ‌immune‌ ‌system, ‌and‌ ‌gut‌ ‌connections‌ ‌could‌ ‌assist‌ ‌in early‌ ‌diagnosis‌ ‌and‌ ‌treatment‌ ‌of‌ ‌this‌ ‌devastating‌ ‌neurodevelopmental‌ ‌disorders‌ ‌as‌ ‌an‌ ‌early‌ ‌intervention‌ ‌in‌ ‌ASD‌ ‌could‌ ‌improve‌ ‌a‌ ‌child's‌ ‌overall‌ ‌development.‌ We‌ ‌gathered‌ ‌data‌ ‌from‌ ‌relevant‌ ‌previously‌ ‌published‌ ‌articles‌ ‌on‌ ‌PubMed‌ ‌to‌ ‌evaluate ‌the‌ ‌role‌ ‌of‌ ‌the‌ ‌gut‌ ‌microbiota‌ ‌and‌ ‌the‌ ‌immune‌ ‌system‌ ‌on‌ ‌the‌ ‌development‌ ‌of‌ ‌autism.‌.

The Potential Role of Gut Peptide Hormones in Autism Spectrum Disorder

Gut peptide hormones are one group of secretory factors produced from gastrointestinal endocrine cells with potent functions in modulating digestive functions. In recent decades, they have been found across different brain regions, many of which are involved in autism-related social, emotional and cognitive deficits. Clinical studies have revealed possible correlation between those hormones and autism spectrum disorder pathogenesis. In animal models, gut peptide hormones modulate neurodevelopment, synaptic transmission and neural plasticity, explaining their behavioral relevance. This review article will summarize major findings from both clinical and basic research showing the role of gut peptide hormones in mediating autism-related neurological functions, and their potential implications in autism pathogenesis. The pharmaceutical value of gut hormones in alleviating autism-associated behavioral syndromes will be discussed to provide new insights for future drug development.

Systematic review and meta-analysis of reported adverse events of long-term intranasal oxytocin treatment for autism spectrum disorder

Recent studies have suggested oxytocin as a possible drug to treat social deficits caused by autism spectrum disorder (ASD), but the safety of intranasal oxytocin in autistic patients has not been established. The aim of this review was to characterize the side-effect profile of long-term intranasal oxytocin in treatment of ASD compared to placebo. All randomized controlled trials of intranasal oxytocin in the treatment of ASD published before 1 January 2017 that reported safety data were identified from databases, including PubMed, Embase, Cochrane Library, and International Pharmaceutical Abstract. Relevant data from the selected studies were then extracted for meta-analysis to estimate the pooled risk ratio for the most common adverse events. Descriptive analysis of severe adverse events was also conducted. Of the 223 participants in the five included studies, 123 were given oxytocin and 100 were given placebos. Nasal discomfort (14.3%), tiredness (7.2%), irritability (9.0%), diarrhea (4.5%), and skin irritation (4.5%) were the most common adverse events. None of these common adverse events was statistically associated with treatment allocation according to meta-analysis using pooled data (all P-values > 0.1). Five severe adverse events were reported, namely aggression (one in placebo, two in oxytocin) and seizures (one in placebo, one in oxytocin). Results from this systematic review support intranasal oxytocin as well tolerated and safe for use in the ASD population. Larger clinical trials should be conducted to establish the efficacy of intranasal oxytocin as a treatment of ASD.

Altered intrinsic functional connectivity of the cingulate cortex in children with severe temper outbursts

Severe temper outbursts (STO) in children are associated with impaired school and family functioning and may contribute to negative outcomes. These outbursts can be conceptualized as excessive frustration responses reflecting reduced emotion regulation capacity. The anterior cingulate cortex (ACC) has been implicated in negative affect as well as emotional control, and exhibits disrupted function in children with elevated irritability and outbursts. This study examined the intrinsic functional connectivity (iFC) of a region of the ACC, the anterior midcingulate cortex (aMCC), in 5- to 9-year-old children with STO (n = 20), comparing them to children with attention-deficit/hyperactivity disorder (ADHD) without outbursts (ADHD; n = 18). Additional analyses compared results to a sample of healthy children (HC; n = 18) and examined specific associations with behavioral and emotional dysregulation. Compared to the ADHD group, STO children exhibited reduced iFC between the aMCC and surrounding regions of the ACC, and increased iFC between the aMCC and precuneus. These differences were also seen between the STO and HC groups; ADHD and HC groups did not differ. Specificity analyses found associations between aMCC-ACC connectivity and hyperactivity, and between aMCC-precuneus iFC and emotion dysregulation. Disruption in aMCC networks may underlie the behavioral and emotional dysregulation characteristic of children with STO.

A Guide to Medications Inducing Salivary Gland Dysfunction, Xerostomia, and Subjective Sialorrhea: A Systematic Review Sponsored by the World Workshop on Oral Medicine VI

BACKGROUND

Medication-induced salivary gland dysfunction (MISGD), xerostomia (sensation of oral dryness), and subjective sialorrhea cause significant morbidity and impair quality of life. However, no evidence-based lists of the medications that cause these disorders exist.

OBJECTIVE

Our objective was to compile a list of medications affecting salivary gland function and inducing xerostomia or subjective sialorrhea.

DATA SOURCES

Electronic databases were searched for relevant articles published until June 2013. Of 3867 screened records, 269 had an acceptable degree of relevance, quality of methodology, and strength of evidence. We found 56 chemical substances with a higher level of evidence and 50 with a moderate level of evidence of causing the above-mentioned disorders. At the first level of the Anatomical Therapeutic Chemical (ATC) classification system, 9 of 14 anatomical groups were represented, mainly the alimentary, cardiovascular, genitourinary, nervous, and respiratory systems. Management strategies include substitution or discontinuation of medications whenever possible, oral or systemic therapy with sialogogues, administration of saliva substitutes, and use of electro-stimulating devices.

LIMITATIONS

While xerostomia was a commonly reported outcome, objectively measured salivary flow rate was rarely reported. Moreover, xerostomia was mostly assessed as an adverse effect rather than the primary outcome of medication use. This study may not include some medications that could cause xerostomia when administered in conjunction with others or for which xerostomia as an adverse reaction has not been reported in the literature or was not detected in our search.

CONCLUSIONS

We compiled a comprehensive list of medications with documented effects on salivary gland function or symptoms that may assist practitioners in assessing patients who complain of dry mouth while taking medications. The list may also prove useful in helping practitioners anticipate adverse effects and consider alternative medications.

Effects associated with on- and off-label stimulant treatment of core autism and ADHD symptoms exhibited by children with autism spectrum disorder

OBJECTIVE

Families of children with autism spectrum disorder are barraged by different treatment options. Some of these options have the support of empirical evidence while others do not. Stimulant treatments are typically utilized to treat symptoms of ADHD indicating an on-label use of such treatment.

METHODS

This study examines the association of stimulant treatment with the on- (symptoms of ADHD) and off- (symptoms of ASD) label symptoms among children with ASD via a non-clinical, population-based sample.

RESULTS

Results indicate no significant association of stimulant treatment with a reduction of on- or off-label symptoms among children with ASD.

CONCLUSION

Stimulant medications utilized in the treatment of DSM core symptoms of autism spectrum disorder would be considered an off-label use because there is limited evidence to support that stimulants are effective in treating core symptoms of ASD, which is supported by the results of the current study.

Integrative gene network analysis provides novel regulatory relationships, genetic contributions and susceptible targets in autism spectrum disorders

Autism spectrum disorders (ASDs) are a group of diseases exhibiting impairment in social drive, communication/language skills and stereotyped behaviors. Though an increased number of candidate genes and molecular interactions have been identified by various approaches, the pathogenesis remains elusive. Based on clinical observations, data from accessible GWAS and expression datasets we identified ASDs gene candidates. Integrative gene network and a novel CNV-centric Node Network (CNN) analysis method highlighted ASDs-associated key elements and biological processes. Functional analysis identified neurological functions including synaptic cholinergic receptor (CHRNA) families, dopamine receptor (DRD2), and correlations between social behavior and oxytocin related pathways. CNN analysis of genome-wide genetic and expression data identified inheritance-related clusters related to PTEN/TSC1/FMR1 and mTor/PI3K regulation. Integrative analysis identified potential regulators of networks, specifically TNF and beta-estradiol, suggesting a potential central role in ASDs. Our data provide information on potential disease mechanisms, and key regulators that may generate novel postulations, and diagnostic molecular biomarkers.

Long-Term Aripiprazole in Youth With Developmental Disabilities Including Autism

We retrospectively reviewed clinic charts of 21 children and adolescents with developmental disabilities including autism spectrum disorders (ASD) treated consecutively with aripiprazole (ARI) for irritability and severe challenging behaviors. Data extracted include age, sex, and race; level of intellectual disability (ID); Diagnostic and Statistical Manual-IV diagnoses including comorbidity, ARI dosage, and treatment duration; other psychoactive medications and Clinical Global Impressions-Improvement (CGI-I) at baseline and end point; weight; height; and side effects. Body mass index (BMI) z scores are compared with Centers for Disease Control norms. Eleven boys and 10 girls with ID and/or ASD ages 8 to 18 years (mean age 13.4 years) received ARI; mean dose was 8.4 mg/day (range 2.5 to 15); average duration was 60.6 weeks (7 to 132). Eleven of 21 patients (52%) met CGI-I response of ≤ 2. ARI was well tolerated, including together with stimulants, divalproex, or less commonly other medications. Mean BMI was 23.8 ± 5.9 at baseline and 24.2 ± 5.2 at end. Mean BMI z score increase was 0.06 ± 0.67. Four individuals (19%) manifested early intolerable weight gain. In this long-term clinical sample, ARI was effective in 52% and well tolerated. ARI was mostly weight neutral; early weight gain was intolerable in 19%. Larger long-term outcome studies are warranted in this population.

Psychopharmacology of autistic spectrum disorders in children and adolescents

This article provides an overview of the psychopharmacologic management of irritability, hyperactivity, and repetitive behaviors in children and adolescents with autism spectrum disorder. A review of the current literature on medications used to treat these conditions with emphasis on randomized controlled trials is presented.

Effectiveness of medication combined with intensive behavioral intervention for reducing aggression in youth with autism spectrum disorder

BACKGROUND

The use of antipsychotic medications to treat aggression in youths with autism spectrum disorders (ASD) is based on open-label trials and efficacy studies. There are no studies examining the combined effectiveness of antipsychotic medications and intensive behavioral intervention (IBI) to treat aggression in ASD.

METHODS

Youths with ASD and aggressive behavior received IBI. Medication use remained stable during the study period and was coded into antipsychotic, mood-stabilizing, and nonstimulant attention-deficit/hyperactivity disorder (ADHD)/sleep medication classes. Analysis of covariance (ANCOVA) and survival analyses examined the effects of medication classes on the average number of aggressive behaviors and time to behavior plan success.

RESULTS

Thirty-two youths (mean age = 11.16, standard deviation [SD] = 3.31, range = 4-16 years, 75% male) with ASD received aggression reduction plans. Of these, 25 youths were taking at least one psychiatric medication (antipsychotic n = 18, mood stabilizing n = 10, and nonstimulant ADHD/sleep n = 12). Aggression dropped substantially following implementation of IBI (p < 0.001; d = 1.70). Antipsychotic medication use predicted significantly fewer sessions to achieve behavior plan success (chi(2)(1) = 5.67, p = 0.017; d = 0.93). No other medication classes influenced aggressive behavior (largest chi(2)(1) = 0.16, p = 0.694).

CONCLUSIONS

Behavioral treatment combined with antipsychotic medication was the most effective approach to reducing aggressive behaviors in youths with ASD. Mood-stabilizing and nonstimulant ADHD/sleep medications did not contribute to aggression reduction.

Secretin: Should we revisit its metabolic outcomes?

Metabolic pathologies such as Type 2 Diabetes have become a major health problem for worldwide populations. Unfortunately, efforts to cure and especially to prevent these significant global problems have so far been met with disappointment. Recently, the involvement of the gut-derived hormonal dysregulation in the development of obesity-related disturbances has been intensively studied. For instance, studies of gut-derived peptides such as peptide YY 3-36, glucagon-like peptide-1, oxyntomodulin and, more recently, ghrelin have significantly improved our understanding of mechanisms underlying weight and metabolic regulation. Even though early reports of the existence of secretin, the first peptide hormone to be described, date back as far as 1825, so much and yet so little is still known about its physiological role in mammals, including humans. However, recent years have provided a better understanding of how the release of secretin is regulated by enteral secretagogues. On the other hand, most basic questions about its role in the post-prandial regulation of metabolic functions in normal and pathophysiological conditions remain to be elucidated. The present work intends to review the physiology of secretin along with its central and peripheral outcomes on metabolic functions.

Presenting the self: negotiating a label of autism

BACKGROUND

An important element in the experiences of people with autism is the key role played by therapeutic interventions. This paper examines the role of therapeutic intervention and the construction of individuals with autism in the therapeutic relationship.

METHOD

The contributions to four online asynchronous discussion lists were analysed using discourse analysis over a 3-month period.

FINDINGS

Two key themes identified in the data are presented. These comprise issues concerning therapeutic intervention and issues related to the employment opportunities of adults with autism.

CONCLUSIONS

In this paper the notion that people with autism must change in order to accommodate the non-autistic world is discussed. The author seeks to present an alternative construction of autism as a difference rather than a deficit or deviance and to examine the negotiation of a place for a person with autism within a neurologically typical dominated society.

Examination of association to autism of common genetic variationin genes related to dopamine

Autism is a severe neurodevelopmental disorder characterized by a triad of complications. Autistic individuals display significant disturbances in language and reciprocal social interactions, combined with repetitive and stereotypic behaviors. Prevalence studies suggest that autism is more common than originally believed, with recent estimates citing a rate of one in 150. Although multiple genetic linkage and association studies have yielded multiple suggestive genes or chromosomal regions, a specific risk locus has yet to be identified and widely confirmed. Because many etiologies have been suggested for this complex syndrome, we hypothesize that one of the difficulties in identifying autism genes is that multiple genetic variants may be required to significantly increase the risk of developing autism. Thus, we took the alternative approach of examining 14 prominent dopamine pathway candidate genes for detailed study by genotyping 28 single nucleotide polymorphisms. Although we did observe a nominally significant association for rs2239535 (P=0.008) on chromosome 20, single-locus analysis did not reveal any results as significant after correction for multiple comparisons. No significant interaction was identified when Multifactor Dimensionality Reduction was employed to test specifically for multilocus effects. Although genome-wide linkage scans in autism have provided support for linkage to various loci along the dopamine pathway, our study does not provide strong evidence of linkage or association to any specific gene or combination of genes within the pathway. These results demonstrate that common genetic variation within the tested genes located within this pathway at most play a minor to moderate role in overall autism pathogenesis.

The role of antipsychotics in the management of behavioural symptoms in children and adolescents with autism

Autistic disorder or autism is a serious childhood-onset disorder that affects all areas of development, particularly in the areas of language, communication and reciprocal social interaction. Patients with autistic disorder typically demonstrate repetitiveness and a restricted repertoire of behaviour. Additionally, they also have a number of disruptive symptoms that may be reduced by drug treatment, including severe tantrums, hyperactivity and lability. Antipsychotic drugs are the agents that are the most critically studied as treatments for reducing symptoms. Both first- and second-generation antipsychotics have shown safety and efficacy in short- and long-term studies in autism. The most studied antipsychotic drugs include haloperidol and risperidone, although studies of other antipsychotic drugs are underway. Safety concerns associated with treatment include the risk of drug-related dyskinesias, which is greater with the first-generation drugs, and the risk of weight gain and associated metabolic problems (i.e. increases in glucose and lipids), which is greater with second-generation agents. Prescription of antipsychotic drugs requires careful monitoring because of these safety risks and the likelihood of long-term use. Drug administration should be initiated at low dosages and subsequent dosage changes should be based on tolerability and clinical response.

Risperidone alters food intake, core body temperature, and locomotor activity in mice

Risperidone induces significant weight gain in female mice; however, the underlying mechanisms related to this effect are unknown. We investigated the effects of risperidone on locomotor activity, core body temperature, and uncoupling protein (UCP) and hypothalamic orexin mRNA expression. Female C57BL/6J mice were acclimated to individual housing and randomly assigned to either risperidone (4 mg/kg BW day) or placebo (PLA). Activity and body temperature were measured over 48-hour periods twice a week for 3 weeks. Food intake and body weights were measured weekly. UCP1 (BAT), UCP3 (gastrocnemius), and orexin (hypothalamus) mRNA expressions were measured using RT-PCR. Risperidone-treated mice consumed more food (p=0.050) and gained more weight (p=0.0001) than PLA-treated mice after 3 weeks. During the initial 2 days of treatment, there was an acute effect of treatment on activity (p=0.046), but not body temperature (p=0.290). During 3 weeks of treatment, average core body temperatures were higher in risperidone-treated mice compared to controls during the light phase (p=0.0001), and tended to be higher during the dark phase (p=0.057). Risperidone-treated mice exhibited lower activity levels than controls during the dark phase (p=0.006); there were no differences in activity during the light phase (p=0.47). UCP1 (p<0.01) and UCP3 (p<0.05) mRNA expressions were greater in risperidone-treated mice compared to controls, whereas, orexin mRNA expression was lower in risperidone-treated mice (p<0.01). These results suggest that risperidone-induced weight gain in mice is a consequence of increased energy intake and reduced activity, while the elevation in body temperature may be a result of thermogenic effect of food intake and elevated UCP1, UCP3, and a reduced hypothalamic orexin expression.

Treatment models for treating patients with combined mental illness and developmental disability

The presence of co-occurring psychiatric disorders among individuals with developmental disability (DD) requires clinicians to adjust and modify standard mental health assessment and treatment planning. In particular, assessment includes input from a multi-disciplinary team and as a result, diagnosis is frequently a synthesis of data from many different points of view. Treatment planning and implementation commonly include a collection of highly specialized, individualized programs that focus on the long term management of both disorders. Crises and recurrence of mental disorders are commonplace in part due to the presence of ongoing risk and vulnerability factors for mental disorders. As a result, the need for emergency interventions, specialized respite services, hospitalization and other transition services is extensive. The quality, availability and access to these services vary considerably. Many programs are concentrated in metropolitan or university-based centers and pose hardships based on geographic distance. The availability and utilization of services is affected by political, economic, socio-cultural and psychological forces that impact both the willingness to use services and the distribution of professionals trained and qualified to manage individuals with dual diagnoses. The complex interaction between each of these factors determines the structure, function, and capacity for innovation built into current service models.

Pharmacological treatment options for autism spectrum disorders in children and adolescents

Autism and other pervasive developmental disorders (PDDs) are frequently associated with dysfunctional behaviors and are characterized by deficits in socialization, communication, and behavioral rigidity. Despite the absence of a pharmacological cure for PDDs, many of the dysfunctional, coinciding behaviors may be treated pharmacologically. This article reviews what is known about the efficacy and tolerability of pharmacological interventions for the treatment of children and adolescents suffering from autistic spectrum disorders.

Psychopharmacology of aggression in children and adolescents with autism: a critical review of efficacy and tolerability

BACKGROUND

Autism is characterized by a clinical triad of symptoms that affect social, language, and behavioral domains. Aggression and self-injury may be associated symptoms of autism and can result in significant harm to those affected as well as marked distress for their families. The precise nature of the relationship between aggressive or self-injurious behavior (SIB) and autism remains unclear and as a result, these symptoms are treated with a broad range of pharmacological approaches. This review seeks to systematically and critically examine the evidence for the pharmacological management of aggression and SIB in children with autism spectrum disorders.

METHOD

The entire PubMed database was searched for English language biomedical articles on clinical trials with medication in autism spectrum disorders. Studies were selected based on the following inclusion criteria: (1) randomized placebo-controlled trials; (2) a sample population that included children and adolescents; (3) at least one standardized assessment of aggression as a primary outcome measure of the study.

RESULTS

Twenty one trials with 12 medications were identified. Five medications produced significant improvement as compared to placebo, including tianeptine, methylphenidate, risperidone, clonidine, and naltrexone. Only risperidone and methylphenidate demonstrate results that have been replicated across at least two studies.

CONCLUSIONS

Although many medications have been studied under placebo-controlled conditions, few produce significant improvement. Additional placebo-controlled trials are needed to increase the number of therapeutic options available in the treatment of aggression in autism.

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

OBJECTIVE: To evaluate the efficacy of pharmacotherapy on the symptoms of psychomotor agitation and aggressive behavior in a sample of patients with autistic spectrum disorder. METHOD: The charts of all patients with a diagnosis of autistic spectrum disorder, receiving care for psychomotor agitation and/or aggressive behavior in two psychiatric outpatient departments between 2001 and 2006, were reviewed. The Clinical Global Impression-Severity and -Improvement scales (CGI-S and CGI-I) were applied to the data retrieved from the charts. RESULTS: The majority of the 26 patients included were treated with second-generation antipsychotics. A positive, statistically significant correlation was found between the implementation of pharmacotherapy and a reduction in CGI-S scores (p<0.05). Treatment response in patients with no mental retardation was better than in those mentally retarded (p<0.05). The majority of patients in whom clinical improvement was found following implementation of treatment had participated in at least one form of intervention therapy in addition to the principal treatment (p<0.05). CONCLUSION: Second-generation antipsychotics seem to reduce psychomotor agitation and aggressive behavior in patients with autistic spectrum disorder; however, further studies are required to evaluate the side effects of these drugs in relation to their beneficial effects.