Seizures as presentation of shunt malfunction: tertiary paediatric neurosurgery experience

AIM

Patients with a background of cerebrospinal fluid (CSF)-diverting shunts are frequently investigated for shunt malfunction when presenting with seizures. However, there is very limited evidence in the literature regarding the association of seizures and shunt malfunction. We sought to determine the incidence of shunt malfunction in our cohort of shunted paediatric patients presenting with seizures, and the utility of seizures as a marker of shunt malfunction.

METHODS

We retrospectively identified all shunted patients presenting with seizures, as well as all patients undergoing shunt revision following a presentation with seizures from our hospital database over a 14-year period from 2009 to 2023. Data gathered included demographics, de novo seizures or change in pattern of seizures, the aetiology of hydrocephalus and the segment of shunt requiring revision. Exclusion criteria included infected cases requiring shunt externalisation. A literature review of all papers discussing seizures as a presentation of shunt malfunction was also carried out.

RESULTS

Overall, over a 14-year period of study, 338 shunted patients presented with seizures and were referred as suspected shunt malfunction with 10 having confirmed shunt malfunction requiring revision (2.9%). This group represented 6.2% of 161 cases of shunt revision carried out during the 14-year period of study. Post-haemorrhagic hydrocephalus secondary to prematurity was the commonest aetiology of shunted hydrocephalus presenting with seizures. Out of 10 patients presenting with seizures with shunt malfunction, 4 presented with de novo seizures, while 6 presented with a change in seizure pattern or frequency in already known epileptic patients. Shunt revision surgeries included 5 distal catheter, 2 proximal catheter, 1 proximal catheter-valve, 1 valve only and 1 case of whole shunt change.

CONCLUSION

Our data supports that seizures are rare manifestation of shunt malfunction and can present either de novo or with a change in seizure frequency in already-known epileptic patients.

Belonolaimus longicaudatus: An Emerging Pathogen of Peanut in Florida

Sting nematode (Belonolaimus longicaudatus) is an economically important ectoparasitic nematode that is highly pathogenic on a wide range of agricultural crops in sandy soils of the southeastern United States. Although this species is commonly found in Florida in hardwood forests and as a soilborne pathogen on turfgrasses and numerous agronomic and horticultural crops, it has not been reported infecting peanut. In the summers of 2012 and 2013, sting nematode was found infecting three different peanut cultivars being grown on two separate peanut farms in Levy County, FL. The damage consisted of large irregular patches of stunted, chlorotic plants at both farms. The root systems were severely abbreviated and there were numerous punctate-like isolated lesions observed on pegs and pods of infected plants. Sting nematodes were extracted from soil collected around the roots of diseased peanut over the course of the peanut season at both farm sites. Peanut yield from one of these nematode-infested sites was 64% less than that observed in areas free from sting nematodes. The morphological characters of the nematode populations in these fields were congruous with those of the original and other published descriptions of B. longicaudatus. Moreover, the molecular analyses based on the sequences of D2/D3 expansion fragments of 28S rRNA and internal transcribed spacer (ITS) rRNA genes from the nematodes further collaborates the identification of the sting nematode isolates as B. longicaudatus. The sequences were deposited in GenBank (accession no. KF963097, KF963098 for ITS, and KF96399, KF963100 for D2-D3). The results of the phylogenetic analysis using the sequences of these isolates from peanut compared with those of other isolates from Florida suggests that the sting nematode from both peanut farms are genetically close to B. longicaudatus populations occurring in the state. Peanut plants inoculated with both nematode isolates showed punctate-like isolated lesions on pods and pegs, and an abbreviation of their root systems, whereas those symptoms were not observed on noninoculated peanut plants. To our knowledge, this is the first report of large-scale field damage caused by sting nematode infecting peanut grown under field conditions in Florida.

Epidural analgesia during labour - maternal understanding and experience - informed consent

Women obtain information on epidural analgesia from various sources. For epidural for pain relief in labour this is provided by the anaesthetist as part of the consenting process. There is much discussion about the inadequacy of this consenting process; we report on women's knowledge, experience and recall of this process at a regional hospital with a 24-h epidural service. Fifty-four women were interviewed within 72 h of a vaginal birth. 91% of the women had acquired information from friends, relatives and antenatal classes. Lack of recall of benefits of epidural analgesia accounted for 26 (38%) and 25 (26%) of the responses, respectively. Similarly in terms of amount of pain relief they could expect, 13 (21%) could not remember and 13 (21%) thought that it may not work. We suggest use of varying methods of disseminating information and wider utilisation of anaesthetists in the antenatal educational programmes.

Age-related loss of noradrenergic neurons in the brains of triple transgenic mice

Microscopic findings in Alzheimer's disease (AD) at autopsy include a wide cortical distribution of beta amyloid (Aβ)-containing plaques and diminished numbers of pyramidal neurons in CA1 of hippocampus and tyrosine hydroxylase-positive (TH+) neurons in the locus coeruleus (LC). To better understand the neuropathology underlying cognitive decline in AD, we analyzed the AD-type neuropathology in brains of triple transgenic (3×Tg) mice harboring mutations for APP(swe), PS1(M146V), and tau(P301L). Histochemical and immunohistochemical staining and computerized stereology were carried out in age-matched young, early middle age, and late middle age 3×Tg mice. The 3×Tg mice showed an intracellular Aβ deposition in subiculum and CA1 pyramidal neurons and an extracellular distribution of amyloid plaques specifically in the subiculum of hippocampal formation and in neocortical layer V. The 3×Tg mice also showed an age-related loss of TH+ neurons in LC, with a loss of 37% of these neurons at 15 months of age. There was no loss of CA1 neurons at any age examined. Reduced AD-type neuropathology in CA1 of 3×Tg mice suggests a possible neuroprotective role for high intracellular-to-extracellular ratios of insoluble Aβ deposits. Understanding the neurobiology of this apparent neuroprotection could lead to an improved understanding of age-related cognitive function in general, and the development of novel strategies for the therapeutic management of AD patients.

Designing a plan for drug discovery in rare pediatric neurodegenerative disease

There are currently no cures for neurodegenerative diseases, including Batten disease, a rare and fatal disorder affecting young children. While researchers have made headway in preventing genetic disorders through preconception carrier screenings and have found potential drug targets, the gap between basic research and clinical treatment development remains. To overcome this gap, write authors Dr. Danielle Kerkovich and Amy Drew, researchers in academia and the pharmaceutical industry, supported by government agencies and nonprofit institutions, must come together to share expertise and promote translational research.

Attentional deficits in concussion

PRIMARY OBJECTIVE

The purpose of the present study was to examine deficits in the alerting, orienting and executive components of attention in individuals who have recently suffered a concussion.

RESEARCH DESIGN

A group design was used in which the performance by individuals with concussion was compared to control subjects matched for age, height, weight and activity level.

METHODS AND PROCEDURES

Participants completed the Attentional Network Test (ANT) that breaks down attention into alerting, orienting and executive components. Reaction time and response accuracy were the dependent variables.

MAIN OUTCOMES AND RESULTS

It was found that only the orienting and executive components of attention were affected by concussion, whereas the alerting component was normal. Furthermore, participants with concussion required a significantly longer time than controls to initiate correct responses.

CONCLUSIONS

These results suggest that the orienting and executive components of attention are most susceptible to the effects of concussion.

Colonisation of native tree and shrub plantings by woodland birds in an agricultural landscape

Tree planting has become a cornerstone strategy for natural resource management in agricultural landscapes, yet its contribution as habitat for woodland birds has not been fully investigated. A case study from the Holbrook region in southern New South Wales was used to assess woodland birds in young plantings of native trees and shrubs. Ground-foraging insectivorous woodland birds were under-represented in the plantings, partly due to a lack of native forb diversity (wildflowers) and leaf litter. Of 69 woodland bird species recorded over a three-year period, 48 species (70%) occurred in planted sites, 59 species (86%) occurred in remnant woodland, and 34 species (49%) occurred in adjacent paddock sites. The greater diversity of birds in planted sites relative to paddock sites was mostly due to understorey birds. The proportion of mist-netted birds recaptured was similar in both planted (15%) and remnant woodland (16%) sites, suggesting that individual birds were staying in planted sites. The proportion of woodland birds showing breeding activity (as measured by the presence of a brood patch) was slightly lower in planted sites (24% of all woodland species) than in remnant woodland (29%). Birds such as the superb fairy-wren, red-browed finch and southern whiteface were more likely to occur in planted sites, suggesting that plantings provide unique, transitional-stage habitat within agricultural landscapes. Restoring native forbs, as part of a broader strategy of woodland management, will help to reverse the decline of ground-foraging insectivorous woodland birds in agricultural landscapes.

Muons as local probes of three-body correlations in the mixed state of type-II superconductors

The vortex glass state formed by magnetic flux lines in a type-II superconductor is shown to possess nontrivial three-body correlations. While such correlations are usually difficult to measure in glassy systems, the magnetic fields associated with the flux vortices allow us to probe these via muon-spin rotation measurements of the local field distribution. We show via numerical simulations and analytic calculations that these observations provide detailed microscopic insight into the local order of the vortex glass and more generally validate a theoretical framework for correlations in glassy systems.

Analysis of climatic and geographic factors affecting the presence of chytridiomycosis in Australia

Chytridiomycosis is an emerging fungal disease that has been implicated in the global decline of amphibian populations. Identifying climatic and geographic factors associated with its presence may be useful in control and prevention measures. Factors such as high altitude, cool temperature, and wet climate have been associated with chytridiomycosis outbreaks. Although some of these factors have been studied in a laboratory setting, there have been few studies in a natural setting. In this investigation, the relationship between altitude, average summer maximum temperature, or the amount of rainfall and the presence or absence of chytridiomycosis are statistically tested using data from 56 study sites in Australia. Currently, in Australia, 48 native species of wild amphibians have been found infected with chytridiomycosis. The 56 sites in the present study, extending along approximately 50% of the coastline of Australia, have been identified as either a chytrid site, where > or = 1 species are infected with chytridiomycosis, or a no-decline site, where none of the species present at the site are experiencing a decline or are known to be infected. The odds-ratio test and two-proportions test applied to this data indicate that the presence of chytridiomycosis in Australia is significantly related to temperature. In particular, the presence of chytridiomycosis is more likely at sites where the average summer maximum temperature is < 30 degrees C. The results of the analyses do not indicate a significant relationship between the presence of chytridiomycosis and altitude or rainfall.

Square vortex lattice at anomalously low magnetic fields in electron-doped Nd1.85Ce0.15CuO4

We report here on the first direct observations of the vortex lattice in the bulk of electron-doped Nd1.85Ce0.15CuO4 single crystals. Using small-angle neutron scattering, we have observed a square vortex lattice with the nearest neighbors oriented at 45 degrees from the Cu-O bond direction, which is consistent with theories based on the d-wave superconducting gap. However, the square symmetry persists down to unusually low magnetic fields. Moreover, the diffracted intensity from the vortex lattice is found to decrease rapidly with increasing magnetic field.

The effect of increased ground-level habitat complexity on mouse population dynamics

We investigated experimentally the influence of habitat structure on the population dynamics of house mice. Three habitat types were used. In one, dense stands of regenerating cypress pine were felled and left in situ to cover at least 40% of experimental plots, providing high complexity at ground level; in another, dense stands of regenerating pine were left intact, providing low complexity at ground level; in the third, open grassland adjacent to dense stands of regenerating pine also provided low complexity at ground level. Mouse populations occurred at higher densities in felled pine plots compared with both the standing pine and grassland plots, consistent with the hypothesis that the presence of increased habitat complexity at ground level reduced the impact of predation. Even though populations responded to the felled pine, they dropped to very low densities over winter, suggesting that the habitat was still marginal for the persistence of mice, probably due to a lack of food. The results are discussed with reference to their implications for the influence that habitat structure may have on the impact of introduced predators on native species.

Direct evidence for an intrinsic square vortex lattice in the overdoped high- T(c) superconductor La(1.83)Sr(0.17)CuO(4+delta)

We report here the first direct observations of a well ordered vortex lattice in the bulk of a La(2-x)Sr(x)CuO(4+delta) single crystal (slightly overdoped, x = 0.17). Our small angle neutron scattering investigation of the mixed phase reveals a crossover from triangular to square coordination with increasing magnetic field. The existence of an intrinsic square vortex lattice has never been observed in high-temperature superconductors and is indicative of the coupling of the vortex lattice to a source of anisotropy, such as those provided by a d-wave order parameter or the presence of stripes.

Specific monoclonal antibodies and human immunoglobulin E show that Hev b 5 is an abundant allergen in high protein powdered latex gloves

BACKGROUND

Hev b 5 is a major latex allergen recognized predominantly by latex-allergic health care workers (HCWs). Recombinant Hev b 5 (rHev b 5) was previously expressed as a fusion protein with maltose binding protein (MBP), itself an immunogenic molecule; therefore non-fusion rHev b 5 is desirable. Moreover, standardized immunological assays for the detection of Hev b 5 are currently lacking and may have important implications for both allergen avoidance and diagnosis in latex allergy.

OBJECTIVES

To generate and use Hev b 5-specific mAbs to determine the relative abundance of Hev b 5 in different latex extracts, correlating this with the IgE reactivity of latex-allergic HCWs and to produce non-fusion rHev b 5.

METHODS

For the production of mAbs, mice were immunized with rHev b 5/MBP fusion protein and mAbs selected with rHev b 5/MBP but not MBP reactivity. The mAb reactivity was compared with polyclonal IgE from latex-allergic HCWs using direct and inhibition ELISA and immunoblot assays. Recombinant Hev b 5 was expressed and purified in the pPROEX-HTa bacterial expression system.

RESULTS

Four Hev b 5-specific mAbs were produced. Immunoblotting and ELISA using the mAbs indicate abundant Hev b 5 in high protein powdered latex glove extracts as compared with crude latex sap extracts. High quality surgical gloves with no detectable protein have no detectable Hev b 5. Inhibition ELISAs using serum IgE from latex-allergic HCWs and Hev b 5-specific mAbs gave strong correlation. Non-fusion recombinant Hev b 5 was successfully expressed and purified, showing reactivity with both the Hev b 5-specific mAbs and serum IgE of latex-allergic HCWs.

CONCLUSION

Hev b 5-specific mAbs and human IgE from latex-allergic HCWs demonstrate the greater content of Hev b 5 in high protein powdered glove extracts. This may explain the observed higher frequency of sensitization to this allergen in HCWs.

Commentary: The Modified Checklist for Autism in Toddlers

The question of when it is best to screen for autism may only be answered by a series of empirical studies. These will be difficult to plan, fund, and conduct, and will by necessity take many years because of the need to systematically follow up the whole cohort screened. In our study, we identified 19 of the 50 children with autism by their profile at the 18-month screen (though note that some fell out of risk status at the repeat screen 1 month later--thus sacrificing sensitivity for improved positive predictive power). Through the subsequent surveillance methods we employed, we identified the remaining cases as follows: 5 at 42 months, 4 between 42 months and 7 years, and 25 at 7 years. We do not mean to end on a pessimistic note. Our experiences have been positive both in regard to the instrument we developed and the effects that using it have had on the health practitioners involved in the research study. In discussion, practitioners have commented on the usefulness of knowing what prelanguage and prosocial skills can reliably be looked at during the 18-month check. Training using the CHAT and eliciting its behaviors improved the skills and confidence of primary health practitioners. It is our view that this has had the effect of reducing the age at which autism is recognized and cases are referred on for a developmental assessment. The work reported by Robins er al. makes an important contribution to this ongoing research and clinical process as we attempt to accurately identify children with autism at a young age.

A screening instrument for autism at 18 months of age: a 6-year follow-up study

OBJECTIVES

A population of 16,235 children aged 18 months was screened using the Checklist for Autism in Toddlers (CHAT) to identify childhood autism (CA). Two further screening procedures were conducted at age 3 and 5 years. The population was followed up at age 7 years in order to establish the sensitivity, specificity, and positive predictive value of the instrument.

METHOD

A brief checklist assessing joint attention and pretend play behaviors was administered by primary health care practitioners when the children were 18 months old. Follow-up methods included screening through parents and health practitioners and checking medical and educational records.

RESULTS

Nineteen cases of CA were successfully identified by the CHAT at 18 months. At follow-up a total of 50 cases of CA were identified via all surveillance methods. Thus, the CHAT has a sensitivity of 38% and a specificity of 98% for identifying CA. The positive predictive value of the instrument was maximized by concentration on the highest-risk group. Repeated screening 1 month later increased the positive predictive value to 75% for identification of CA but reduced the sensitivity to 20%, although the specificity was close to 100%. The screen also identified cases of pervasive developmental disorder as well as children with language and other developmental disorders.

CONCLUSIONS

The CHAT can be used to identify cases of autism and related pervasive developmental disorders at 18 months of age. It is emphasized that the CHAT is not a diagnostic instrument but can identify potential cases of autism spectrum disorders for a full diagnostic assessment.

Floral dimorphism, pollination, and self-fertilization in gynodioecious GERANIUM RICHARDSONII (Geraniaceae)

The selective maintenance of gynodioecy depends on the relative fitness of the male-sterile (female) and hermaphroditic morphs. Females may compensate for their loss of male fitness by reallocating resources from male function (pollen production and pollinator attraction) to female function (seeds and fruits), thus increasing seed production. Females may also benefit from their inability to self-fertilize if selfing and inbreeding depression reduce seed quality in hermaphrodites. We investigated how differences in floral resource allocation (flower size) between female and hermaphroditic plants affect two measures of female reproductive success, pollinator visitation and pollen receipt, in gynodioecious populations of Geranium richardsonii in Colorado. Using emasculation treatments in natural populations, we further examined whether selfing by autogamy and geitonogamy comprises a significant proportion of pollen receipt by hermaphrodites. Flowers of female plants are significantly smaller than those of hermaphrodites. The reduction in allocation to pollinator-attracting structures (petals) is correlated with a significant reduction in pollinator visitation to female flowers in artificial arrays. The reduction in attractiveness is further manifested in significantly less pollen being deposited on the stigmas of female flowers in natural populations. Autogamy is rare in these protandrous flowers, and geitonogamy accounts for most of the difference in pollen receipt between hermaphrodites and females. Female success at receiving pollen was negatively frequency dependent on the relative frequency of females in populations. Thus, two of the prerequisites for the maintenance of females in gynodioecious populations, differences in resource allocation between floral morphs and high selfing rates in hermaphrodites, occur in G. richardsonii.

Autism spectrum disorders at 20 and 42 months of age: stability of clinical and ADI-R diagnosis

The association between, and stability of, clinical diagnosis and diagnosis derived from the Autism Diagnostic Interview-Revised (ADI-R; Lord, Rutter, & Le Couteur, 1994) was examined in a sample of prospectively identified children with childhood autism and other pervasive developmental disorders assessed at the age of 20 months and 42 months. Clinical diagnosis of autism was stable, with all children diagnosed with childhood autism at age 20 months receiving a diagnosis of childhood autism or a related pervasive developmental disorder (PDD) at age 42 months. Clinical diagnosis of childhood autism was also reasonably sensitive, with all children who went on to receive a clinical diagnosis of childhood autism at 42 months being identified as having autism or PDD at 20 months. However, clinical diagnosis for PDD and Asperger's syndrome lacked sensitivity at 20 months, with several children who subsequently received these diagnoses at 42 months receiving diagnoses of language disorder or general developmental delay, as well as in two cases being considered clinically normal, at the earlier timepoint. The ADI-R was found to have good specificity but poor sensitivity at detecting childhood autism at 20 months; however, the stability of diagnosis from 20 to 42 months was good. In addition, the ADI-R at age 20 months was not sensitive to the detection of related PDDs or Asperger's syndrome. The continuity and discontinuity between behavioural abnormalities identified at both timepoints in the three domains of impairment in autism was examined, both in children who met final clinical criteria for an autistic spectrum disorder, and for children with language disorder who did not, as well as for a small sample of typically developing children.

Regulation of cytosolic phospholipase A2 expression by cytokines in human amnion cells

The metabolism of arachidonic acid results in the production of prostaglandins (PGs), which are involved in the initiation of labour at term and preterm. The fetal membranes are a source of pro-inflammatory cytokines which promote increased PG biosynthesis via increased release of arachidonic acid and its conversion to biologically active metabolites such as PGE2 and PGF2alpha. In the amnion, the liberation of arachidonic acid from membrane glycerophospholipid stores can be catalysed by cytosolic phospholipase A2 (cPLA2). In amnion-derived WISH cells, the addition of tumour-necrosis factor alpha (TNF-alpha) (50 ng/ml) provoked a time-dependent increase in the expression of the cPLA2 mRNA which was greatest at 8 and 16 h post-treatment (3.62+/-0.52 and 3.15+/-0.45-fold of control, n=3). The increase in cPLA2 mRNA expression by TNF-alpha was unaffected by the prior addition of interleukin-4 (IL-4) (10 ng/ml), a known inhibitor of prostaglandin endoperoxide H synthase (PGHS)-2 mRNA and protein expression in WISH cells. TNF-alpha also increased the level of immunoreactive cPLA2 protein in a time-dependent manner with the highest levels evident after 8 and 16 h. As with the mRNA, cPLA2 protein levels were unaffected by pre-incubation with IL-4. The inclusion of the cPLA2-specific inhibitor arachidonyl trifluoromethyl ketone (AACOCF3) resulted in a concentration-dependent inhibition of PGE2 biosynthesis in WISH cells treated with TNF-alpha (>95 per cent at 2 microM). We conclude that TNF-alpha increases the abundance of the cPLA2 mRNA and protein in amnion epithelial cells, an effect which plays an important role in amnion PG biosynthesis in the presence of intrauterine infection.

Patellar tendon bearing orthosis--application as adjunctive treatment in healing of lower-limb tissue loss

OBJECTIVES

To assess the efficacy of the patellar tendon bearing orthosis (PTBO) as adjunctive treatment of patients with significant lower-limb ischaemia and tissue loss complicated by neuropathy.

DESIGN, MATERIALS AND METHODS

Twelve consecutive patients (14 legs) with a variety of underlying conditions causing extensive lower limb tissue loss are described. Seven patients were diabetic. Six patients (seven legs) underwent vascular reconstruction procedures.

CHIEF OUTCOME MEASURES

Wound healing and amputation rate.

RESULTS

Eight patients had ulcer healing within 5 months, one at 18 months (patient with alcoholic neuropathy who was poorly compliant with treatment), one stopped using the PTBO at 3 months and was converted to protective footwear with healing, one died of a myocardial infarct 1 month after the PTBO was fitted (the ulcer was showing signs of healing), and one has just had surgery and been fitted with a PTBO.

CONCLUSIONS

Early results from this anecdotal series are encouraging and a prospective study to determine the application of the PTBO in patients with neuropathic and neuropathic/ischaemic tissue loss is planned.

Urokinase-generated plasmin activates matrix metalloproteinases during aneurysm formation

The molecular mechanisms predisposing to atherosclerotic aneurysm formation remain undefined. Nevertheless, rupture of aortic aneurysms is a major cause of death in Western societies, with few available treatments and poor long-term prognosis. Indirect evidence suggests that matrix metalloproteinases (MMPs) and plasminogen activators (PAs) are involved in its pathogenesis. MMPs are secreted as inactive zymogens (pro-MMPs), requiring activation in the extracellular compartment. Plasmin, generated from the zymogen plasminogen by tissue-type plasminogen activator (t-PA) or urokinase-type plasminogen activator (u-PA; refs 14,15), has been proposed as a possible activator in vitro, but evidence for such a role in vivo is lacking. Analysis of atherosclerotic aorta in mice with a deficiency of apoliprotein E (Apoe-/-; ref. 18), singly or combined with a deficiency of t-PA (Apoe-/-:Plat-/-) or of u-PA (Apoe-/-:Plau-/-; ref. 19), indicated that deficiency of u-PA protected against media destruction and aneurysm formation, probably by means of reduced plasmin-dependent activation of pro-MMPs. This genetic evidence suggests that plasmin is a pathophysiologically significant activator of pro-MMPs in vivo and may have implications for the design of therapeutic strategies to prevent aortic-wall destruction by controlling Plau gene function.

Infants with autism: an investigation of empathy, pretend play, joint attention, and imitation

Systematic studies of infants with autism have not been previously carried out. Taking advantage of a new prospective screening instrument for autism in infancy (S. Baron-Cohen et al., 1996), the present study found that, compared with developmentally delayed and normally developing children, 20-month-old children with autism were specifically impaired on some aspects of empathy, joint attention, and imitation. Infants with autism failed to use social gaze in the empathy and joint attention tasks. Both the infants with autism and the infants with developmental delay demonstrated functional play, but very few participants in either group produced spontaneous pretend play. In the developmental delay group, but not the autism group, pretend play was shown following prompting. The implications of these findings for developmental accounts of autism and for the early diagnosis of the disorder are discussed.

Infants with autism: an investigation of empathy, pretend play, joint attention, and imitation

Systematic studies of infants with autism have not been previously carried out. Taking advantage of a new prospective screening instrument for autism in infancy (S. Baron-Cohen et al., 1996), the present study found that, compared with developmentally delayed and normally developing children, 20-month-old children with autism were specifically impaired on some aspects of empathy, joint attention, and imitation. Infants with autism failed to use social gaze in the empathy and joint attention tasks. Both the infants with autism and the infants with developmental delay demonstrated functional play, but very few participants in either group produced spontaneous pretend play. In the developmental delay group, but not the autism group, pretend play was shown following prompting. The implications of these findings for developmental accounts of autism and for the early diagnosis of the disorder are discussed.

Psychological markers in the detection of autism in infancy in a large population

BACKGROUND

Investigation to see if there are key psychological risk indicators for autism in a random population study of children at 18 months of age; and to assess how well these discriminate children who receive a diagnosis of autism from other forms of developmental delay.

METHOD

Sixteen thousand children in the southeast of England were screened for autism by their health visitor or GP, during their routine 18-month-old developmental check-up, using the CHAT (Checklist for Autism in Toddlers). From a previous high-risk study we predicted that children at 18 months of age who failed three items ('protodeclarative pointing', 'gaze-monitoring', and 'pretend play') would be at risk for receiving a diagnosis of autism. From other evidence, we further predicted that those 18-month-olds who failed one or two of the key items (either pretend play, or protodeclarative pointing and pretend play) would be at risk for developmental delay without autism.

RESULTS

Twelve children out of the total population of 16,000 consistently failed the three key items. Of these, 10 (83.3%) received a diagnosis of autism. Thus, the false positive rate was 16.6% (2 out of 12 cases), and even these 2 cases were not normal. When the 10 children with autism were reassessed at 3.5 years of age, their diagnosis remained the same. Thus the false positive rate among the cases diagnosed with autism was zero. In contrast, of 22 children who consistently failed either protodeclarative pointing and/or pretend play, none received a diagnosis of autism, but 15 (68.2%) received a diagnosis of language delay.

CONCLUSIONS

Consistent failure of the three key items from the CHAT at 18 months of age carries an 83.3% risk of autism; and this pattern of risk indicator is specific to autism when compared to other forms of developmental delay.