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PubMed2006

Blueprints for the assessment, treatment, and future study of catatonia in autism spectrum disorders.

The blueprints for the assessment, treatment, and future study of catatonia in autism spectrum disorders (ASDs), which are submitted in this chapter aim to increase early recognition and treatment of catatonia in ASDs, show the urgency of controlled treatment trials, and increase collaborative and interdisciplinary research into the co-occurrence of these two enigmatic disorders. Catatonia should be assessed in any patient with ASDs when there is an obvious and marked deterioration in movement, pattern of activities, self-care, and practical skills, compared with previous levels, through a comprehensive diagnostic evaluation of medical and psychiatric symptoms. A formal diagnosis should be ascertained using ASD specific criteria for catatonia that takes into account baseline symptoms like muteness, echophenomena, stereotypy, negativism, or other psychomotor abnormalities. Any underlying medical and neurological conditions should be treated, and culprit medications or other substances that may cause catatonia should be eliminated. Separate treatment blueprints are presented for mild, moderate, and severe catatonia, featuring combinations of a psychological approach developed by Shah and Wing and medical treatments that have shown efficacy in catatonia: lorazepam challenge, lorazepam trial, lorazepam continuation, and bilateral electroconvulsive therapy (ECT). These treatment modalities in themselves are well established. Side effects and complications are known and manageable. Legal, ethical, and practice guidelines governing all treatment aspects should be followed. The treatment blueprints should be viewed as best estimates pending future controlled studies. The blueprint for the future study of catatonia in ASDs describes promising clinical and preclinical research avenues. Longitudinal studies need to assess the possible effect of early recognition and adequate treatment of catatonia in ASDs in order to avoid the impairment associated with chronicity. Effects of current and new anticatatonic treatments should be examined in experimental models of autism and catatonia. Finally, the role of gamma-aminobutyric acid (GABA) dysfunction in autism, catatonia, and abnormal stress responses in these disorders should be further assessed.

Adult↗

PubMed2006

Histological and magnetic resonance imaging assessment of cortical layering and thickness in autism spectrum disorders.

BACKGROUND: Qualitative reports of the cerebral cortex in a small number of autism spectrum disorder (ASD) cases have suggested an increase in thickness and disruptions in migration and lamination patterns. METHODS: We examined postmortem ASD individuals and age-matched controls using magnetic resonance imaging (MRI) to evaluate total cortical thickness, and histological samples to evaluate the pattern of cortical layering. RESULTS: Overall, thickness measures from ASD subjects were equivalent to control cases. Individual regions showed marginal but nonsignificant thickness differences in the temporal lobes. Cortical thickness values in ASD subjects decreased significantly with age. Quantitative examination of proportional layer thickness in histological sections indicated that the pattern of cortical layering was largely undisturbed, while qualitative examination of these same samples revealed evidence of cell clustering and supernumerary cells in layer I and the subplate. These features were not severe and were never found in a majority of cases. CONCLUSIONS: These findings support limited disturbances in cortical cell patterning, but do not indicate a major deficit in the orderly migration of cortical neuroblasts during development, or their subsequent aggregation into the laminar pattern found in typically developing individuals.

Adolescent↗

PubMed2004

Management of hyperactivity and other acting-out problems in patients with autism spectrum disorder.

Hyperactivity/impulsivity, aggression, self injury, and irritability are disruptive behaviors that frequently accompany autism spectrum disorders (ASD). The psychostimulants and atypical antipsychotics have been used with some success to manage hyperactivity, but neither drug group is fully satisfactory and clinical response to the stimulants varies. For other disruptive symptoms (irritability, aggression, self injury), both older antipsychotics and newer atypical antipsychotics have been shown to have helpful effects. Because of potential side effects, atypical antipsychotics should ordinarily be preferred over older agents. A small group of studies suggests that selective serotonin reuptake inhibitors may be helpful in managing symptoms related to aggression, self injury, and the like. A small and largely imperfect literature suggests that beta blockers, mood stabilizers, and alpha-2 agonists may also have some role for treating such symptoms. More research is needed on the management of all of these target symptoms, both for new agents (e.g., atomoxetine) and for established psychoactive medicines.

Aggression↗

PubMed2007

Referral trends in mental health services for adults with intellectual disability and autism spectrum disorders.

Researchers have paid increasing attention to mental health issues in adults with autism spectrum disorders (ASDs) over the last decades. However, little is known about how rates of clinical referrals, types of mental health diagnoses and treatment in adults with ASDs and intellectual disability have changed. We examined patterns of change in referral trends to specialist mental health services in south London from 1983 to 2000 (N = 137). The majority of the cases (58.4%) did not have a diagnosable psychiatric disorder. Schizophrenia was the most frequent psychiatric diagnosis followed by depression, adjustment reaction and anxiety. There was a significant change in the rate of referrals, an increase in the diagnosable psychiatric disorders over time and a significant reduction of medication at time of referral. There were no significant changes in the use of other therapeutic interventions. The proportion of participants living independently increased. Implications for services and future research are discussed.

Adult↗

PubMed2005

The functional neuroanatomy of spatial attention in autism spectrum disorder.

This study investigated the functional neuroanatomical correlates of spatial attention impairments in autism spectrum disorders (ASD) using an event-related functional magnetic resonance imaging (FMRI) design. Eight ASD participants and 8 normal comparison (NC) participants were tested with a task that required stimulus discrimination following a spatial cue that preceded target presentation by 100 msec (short interstimulus interval [ISI]) or 800 msec (long ISI). The ASD group showed significant behavioral spatial attention impairment in the short ISI condition. The FMRI results showed a reduction in activity within frontal, parietal, and occipital regions in ASD relative to the NC group, most notably within the inferior parietal lobule. ASD behavioral performance improved in the long ISI condition but was still impaired relative to the NC group. ASD FMRI activity in the long ISI condition suggested that the rudimentary framework of normal attention networks were engaged in ASD including bilateral activation within the frontal, parietal, and occipital lobes. Notable activation increases were observed in the superior parietal lobule and extrastriate cortex. No reliable activation was observed in the posterior cerebellar vermis in ASD participants during either long or short ISI conditions. In addition, no frontal activation during short ISI and severely reduced frontal activation during long ISI was observed in the ASD group. Taken together, these findings suggest a dysfunctional cerebello-frontal spatial attention system in ASD. The pattern of findings suggests that ASD is associated with a profound deficit in automatic spatial attention abilities and abnormal voluntary spatial attention abilities. This article also describes a method for reducing the contribution of physical eye movements to the blood-oxygenation level dependent activity in studies of ASD.

Adolescent↗

PubMed2007

Sexual behavior in high-functioning male adolescents and young adults with autism spectrum disorder.

Group home caregivers of 24 institutionalized, male, high-functioning adolescents and young adults with Autism Spectrum Disorder, were interviewed with the Interview Sexuality Autism. Most subjects were reported to express sexual interest and to display some kind of sexual behavior. Knowledge of socio-sexual skills existed, but practical use was moderate. Masturbation was common. Many subjects were seeking physical contact with others. Half of the sample had experienced a relationship, while three were reported to have had sexual intercourse. The number of bisexual orientations appeared high. Ritual-sexual use of objects and sensory fascination with a sexual connotation were sometimes present. A paraphilia was present in two subjects. About one third of the group needed intervention regarding sexual development or behavior.

Adolescent↗

PubMed2007

Response to joint attention in toddlers at risk for autism spectrum disorder: a prospective study.

Response to joint attention (RJA) is impaired in preschoolers with autism spectrum disorder (ASD) and is pivotal to social and communication development. Response to joint attention was examined at 14 and 24 months in 51 children at high risk for autism (siblings of children with autism). Outcome groups at age 3 years included ASD (n = 16), broader autism phenotype (n = 8), and non-broader autism phenotype (n = 27). The ASD group made minimal improvement in RJA between 14 and 24 months, but stability of RJA across tasks increased for all three groups. Significantly, lower RJA was observed for the ASD group at 24 months. Response to joint attention performance at 14 months predicted ASD outcome. Response to joint attention is an important screening and early intervention target.

Attention↗

PubMed2006

Sleep disturbances and correlates of children with autism spectrum disorders.

This study examined sleep patterns, sleep problems, and their correlates in children with autism spectrum disorders (ASD). Subjects consisted of 167 ASD children, including 108 with autistic disorder, 27 with Asperger's syndrome, and 32 with other diagnoses of ASD. Mean age was 8.8 years (SD = 4.2), 86% were boys. Parents completed a self-administered child sleep questionnaire. Results showed that average night sleep duration was 8.9 h (SD = 1.8), 16% of children shared a bed with parent. About 86% of children had at least one sleep problem almost every day, including 54% with bedtime resistance, 56% with insomnia, 53% with parasomnias, 25% with sleep disordered breathing, 45% with morning rise problems, and 31% with daytime sleepiness. Multivariate logistic regression analyses indicated that younger age, hypersensitivity, co-sleeping, epilepsy, attention-deficit/hyperactivity disorder (ADHD), asthma, bedtime ritual, medication use, and family history of sleep problems were related to sleep problems. Comorbid epilepsy, insomnia, and parasomnias were associated with increased risk for daytime sleepiness. Results suggest that both dyssomnias and parasomnias are very prevalent in children with ASD. Although multiple child and family factors are associated with sleep problems, other comorbid disorders of autism may play a major role.

Asperger Syndrome↗

PubMed2006

Screening for autism spectrum disorders with the social communication questionnaire.

The Social Communication Questionnaire (SCQ) is a parent report screening measure for autism spectrum disorders (ASDs) based on the Autism Diagnostic Interview-Revised (ADI-R). To examine its validity in a young sample, the SCQ was given to parents of 151 children at a mean age of 5 years, before assessment in tertiary autism or preschool clinics. Overall sensitivity was .71, the same for both clinics, but specificity was better for the preschool clinic (.62) than for the autism clinic (.53) reflecting fewer false-positives in the former. The "hit rate" was 65% with 28% of the children with autism missed by the SCQ at a cutoff score of 15 (false-negatives) and 38% of the nonautistic misidentified as having an ASD (false-positives). Item validity analysis, contrary to what was previously published, indicated that only 15 or 46% of the items distinguished between children with and without ASD in this much younger sample. False-negatives were somewhat higher functioning. The SCQ would seem to be a useful tool for identifying young children in need of further assessment and assisting in routing them to the appropriate clinic, especially if used in conjunction with a screening by a community professional. There remain questions about the "best" cutoff score to use and whether a shorter version, based on the items that distinguished autistic from nonautistic, would be more reliable and valid with younger children. Furthermore, it may be that an adjusted score is required when parents omit items or with nonverbal children who cannot be scored on some of the items.

Adaptation, Psychological↗

PubMed2004

Measuring progress in children with autism spectrum disorder who have cochlear implants.

OBJECTIVE: To quantify progress after cochlear implantation for children with autism spectrum disorder (ASD). STUDY DESIGN: Retrospective review of speech and language and speech perception test scores of children with autism who have received a cochlear implant at our center. SETTING: University of Michigan Medical Center, Cochlear Implant Program. PATIENTS: Six children, ages 3 to 16 years, who received cochlear implants at the our center. All children were diagnosed as having ASD by a neuropsychologist, either before or after receiving a cochlear implant. MAIN OUTCOME MEASURES: Children participated in preoperative and postoperative speech and language and speech perception testing. A survey was administered to parents to evaluate subjective impressions of cochlear implant benefit and quality of life before and after implantation. RESULTS: Improved scores were recorded for children on whom standardized expressive and receptive vocabulary testing was possible. Children who could not complete standardized tests demonstrated improvement in raw scores. Improvement on the Meaningful Auditory Integration Scale was noted for the 4 of 7 children who completed the scale preoperatively and postoperatively. Survey results suggested changes in responsiveness to sound, interest in music, vocalization, and eye contact following implantation. Five of the 6 families indicated that they would recommend a cochlear implant to another family in a similar situation. CONCLUSIONS: Gains made by children in our study were small compared with the general implant population; however, when compared with themselves preoperatively, these children did demonstrate progress. Improvements in behaviors and interaction point to a quality of life benefit following implantation that is difficult to quantify.

Autistic Disorder↗

PubMed2005

The role of culture in families' treatment decisions for children with autism spectrum disorders.

There is little information available about how and why parents of children with autism spectrum disorders (ASD) make decisions regarding which of the many available treatments to implement with their children. Given the lack of available information regarding treatment efficacy, it is likely that parents' beliefs about child development, interpretation of the symptoms of ASD, its etiology and course, and their experiences with the health system influence treatment decisions. This article addresses these issues within the context of cultural influences. We review the small body of existing literature regarding cultural influences on decisions regarding ASD and draw implications for the study and treatment of ASD from the larger body of literature on culture and other health conditions of childhood. In addition to examining the potential for differences in clinical presentation by culture and different experiences with the healthcare system, we use Kleinman's framework of questions for understanding the role of culture in the interpretation and treatment of ASD. These questions address interpretation of symptoms and beliefs about their cause, course, and treatment. Finally, we present specific language for clinicians to use in discussion with families with different cultural beliefs about the use of less traditional treatment strategies.

Attitude to Health↗

PubMed2006

Story recall and narrative coherence of high-functioning children with autism spectrum disorders.

Previous research has found few quantitative differences between children with high-functioning autism spectrum disorders (ASDs) and well-matched controls in the length, complexity, and structure of their narratives. Researchers have noted, however, that narratives of children with ASDs have an unusual and idiosyncratic nature. This study provides an analysis of narratives in 17 children with high-functioning ASDs and 17 typically developing children matched on age, gender, language abilities, and cognitive abilities. We examined story recall and narrative coherence. The study revealed no group differences in story length or syntactic complexity. Children with ASDs also did not differ from controls in their use of the gist of a story to aid recall, or in their sensitivity to the importance of story events. Children with ASDs did, however, produce narratives that were significantly less coherent than the narratives of controls. Children with ASDs appeared less likely to use the gist of the story to organize their narratives coherently. These findings are discussed with regard to their relationship to other cognitive and linguistic difficulties of children with ASDs.

Adolescent↗

PubMed2006

Brain activation during semantic processing in autism spectrum disorders via functional magnetic resonance imaging.

Language and communication deficits are core features of autism spectrum disorders (ASD), even in high-functioning adults with ASD. This study investigated brain activation patterns using functional magnetic resonance imaging in right-handed adult males with ASD and a control group, matched on age, handedness, and verbal IQ. Semantic processing in the controls produced robust activation in Broca's area (left inferior frontal gyrus) and in superior medial frontal gyrus and right cerebellum. The ASD group had substantially reduced Broca's activation, but increased left temporal (Wernicke's) activation. Furthermore, the ASD group showed diminished activation differences between concrete and abstract words, consistent with behavioral studies. The current study suggests Broca's area is a region of abnormal neurodevelopment in ASD, which may be linked with semantic and related language deficits frequently observed in ASD.

Adult↗

PubMed2005

A controlled trial of a training course for parents of children with suspected autism spectrum disorder.

OBJECTIVE: To evaluate a training course for parents, designed to help them understand autism spectrum disorder and to facilitate social communication with their young child. STUDY DESIGN: Controlled trial for 51 children aged 24 to 48 months, whose parents received either immediate intervention or delayed access to the course. Outcome was measured 7 months after recruitment in parents' use of facilitative strategies, stress, adaptation to the child; and in children's vocabulary size, behavior problems, and social communication skills. RESULTS: Taking into account scores at recruitment, child's level of ability, diagnostic grouping, and the interval between assessments, a significant advantage was found for the intervention group in parents' observed use of facilitative strategies and in children's vocabulary size. CONCLUSIONS: The training course is well received by parents and has a measurable effect on both parents' and children's communication skills.

Aptitude↗

PubMed2004

Matching preschool children with autism spectrum disorders and comparison children for language ability: methodological challenges.

Earlier identification of children with autism spectrum disorders (ASDs) is welcome, but presents a number of challenges to the clinical and the research enterprises (see Charman & Baird [2002] for a review). In the research enterprise, one critical methodological challenge is the use of appropriate measures on which to match groups of preschoolers with ASDs to comparison groups with other neurodevelopmental conditions. Language and communication impairments are central to the diagnosis of ASD and, therefore, critical variables to consider in group-matched research designs. In the domain of language function the challenges include the very poor language competence of many preschoolers with ASDs, the fact that some early language competencies form part of the formal diagnostic criteria of ASD and diagnostic algorithms on research diagnostic instruments, the uneven profile of language competency in children with ASDs, and the difference between performance on measures of formal language competency in the testing situation and everyday language use. The current paper will review these challenges and suggest some possible approaches to overcome them, including using more than one measure of language ability and adopting a pragmatic approach to group composition and statistical analysis.

Autistic Disorder↗

PubMed2005

Treatment incidence and patterns in children and adolescents with autism spectrum disorders.

This study examined the treatment rates and patterns in children and adolescents with autism spectrum disorders (ASDs). Data were collected on 353 nonreferred children and adolescents (mean age 9.5 +/- 3.9 years; range 3-21 years) with ASDs from public schools across Ohio. Parents provided information on the use of psychotropic medicines, vitamins, supplements, and modified diets. They also completed measures of social competence, problem behavior, and adaptive behavior. Results indicated that 46.7% of subjects had taken at least one psychotropic medication in the past year. In addition, 17.3% of subjects had taken some type of specially formulated vitamin or supplement, 15.5% were on a modified diet, 11.9% had some combination of psychotropic medication and an alternative treatment, and 4.8% had taken an anticonvulsant. Logistic regressions indicated that greater age, lower adaptive skills and social competence, and higher levels of problem behavior were associated with greater medication use. This was the first study to focus exclusively on a younger population, to survey patterns of modified diets, and to obtain standardized ratings of social competence, problem behaviors, and adaptive behavior in relation to medication use. The results of this study highlight the need for more research on psychotropic medication in children and adolescents with ASDs.

Adolescent↗

PubMed2001

Quantifying the phenotype in autism spectrum disorders.

Twin and family studies suggest that familial transmission in autism extends to a spectrum of social and behavioral deficits that characterize individuals who have significant impairments within the autism spectrum, but do not meet formal criteria for autistic disorder. Standardized diagnostic instruments, including the Autism Diagnostic Interview-Revised (ADI-R) and the Autism Diagnostic Observation Schedule (ADOS-WPS Edition), offer the opportunity to quantify deficits across the autism spectrum, controlling effects of language and cognitive delay, in individuals with significant impairments. It is suggested that quantitative measures of social reciprocity and repetitive behaviors and interests, with separate quantification of expressive language level and nonverbal intelligence, most accurately reflect the range of behavioral phenotypes in autism spectrum disorders.

Autistic Disorder↗

PubMed2005

Spatial cognition in autism spectrum disorders: superior, impaired, or just intact?

The profile of spatial ability is of interest across autism spectrum disorders (ASD) because of reported spatial strengths in ASD and due to the recent association of Asperger's syndrome with Nonverbal Learning Disability. Spatial functions were examined in relation to two cognitive theories in autism: the central coherence and executive function (EF) theories. Performance on spatial tasks, EFs, and global/local processing was compared in children with ASD and controls. While the ASD group had faster reaction times on the Embedded Figures task, spatial performance was intact, but not superior, on other tasks. There was no evidence for impairments in EF or in processing global/local information, therefore contradicting these two theories. The implications of these results for these two theories are discussed.

Adolescent↗