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PubMed2002

Children with disruptive behaviours II: clinical and community service needs.

OBJECTIVE: To assist in health service planning by determining the perceived clinical and community service needs of families resident in the Hunter region who care for a child manifesting disruptive behaviour. METHODOLOGY: Families were eligible to participate in the survey if they had at least one child known to have one of the DSM-IV disruptive behaviour disorders, autistic spectrum disorders, behaviour problems associated with rarer forms of brain disease, brain injury or mild intellectual disability or were identified by school personnel as having significant behaviour problems. Families were recruited to the survey via schools, early education centres and clinical services. Parents completed a questionnaire, mailed to them by educational and/or clinical services. Parents were asked to prioritize options for improving or expanding clinical services and for reducing their treatment costs. RESULTS: A total of 1412 families responded to the survey. The highest-ranked clinical service options involved the expansion of mainstream community treatment services for children with disruptive behaviour problems and their families, with a particular emphasis on counselling services. Respite care and in-patient services were given relatively low priority. Subgroup analyses showed that disadvantaged and stressed families gave higher rankings to out of home options, such as respite care, in-patient care and subsidised holiday camps, than the aggregate sample. CONCLUSIONS: Enhancement of community based counselling services would meet the needs of the greatest number of participating families. Resource-intense residential services are required by a small but important group of families who experience disadvantage and high levels of stress.

Adolescent↗
PubMed2005

The presentation of anxiety in children with pervasive developmental disorders.

OBJECTIVE: Although the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) diagnostic criteria generally discourage the diagnosis of other Axis I disorders in children with pervasive developmental disorder (PDD), anxiety symptoms are often observed in this clinical population. Moreover, there are some albeit limited data that suggest an association between anxiety and psychotic symptoms in children. Because co-occurring psychiatric symptoms have important clinical implications, this study examined anxiety and psychotic symptoms in children with and without PDD. METHOD: Parents and teachers completed the Early Childhood Inventory-4 (ECI-4) or the Child Symptom Inventory (CSI-4) for children evaluated in a developmental disabilities clinic (PDD) or a child psychiatry outpatient clinic (non-PDD). Children were divided into four groups: 3-5- year-olds with (n = 182) and without (n = 135) PDD, and 6-12-year-olds with (n = 301) and without (n = 191) PDD. The 6-12-year-olds were further divided into high-anxious and low-anxious subgroups based on CSI-4 ratings and compared with regard to severity of psychotic symptoms. RESULTS: Teachers rated preschoolers with PDD as exhibiting more severe anxiety symptoms than the non-PDD group; however, the converse was true for parent ratings. For 6-12- year-olds, both parents and teachers rated children with PDD as significantly more anxious than non-PDD clinic referrals. In general, the severity of anxiety symptoms varied by PDD subtype (Asperger's disorder > PDDNOS > Autistic disorder) and IQ (high > low). Furthermore, highly anxious 6-12-year-olds with PDD received significantly higher parent and teacher ratings of psychotic symptom severity (strange behaviors, hearing voices, illogical thinking, inappropriate affect, and odd thoughts) than our low-anxious group, even when controlling for PDD symptom severity. Moreover, the relation between anxiety level and psychotic symptom severity was similar for both PDD and non-PDD children. Parent and teachers differed in their perceptions of the severity of specific anxiety symptoms. In addition, parent- versus teacher-defined anxiety level groups varied with regard to the differential severity of psychotic symptoms. This finding highlights the importance of continued investigation of source-specific syndromes in children with PDD. Two case vignettes are presented. CONCLUSION: Anxiety appears to be a clinically important concern in many children with PDD. Similarities in anxiety symptom presentation and their association with psychotic symptoms in both children with and without PDD support the possibility of: (1) psychiatric comorbidity in the former; (2) at least some overlap in causal mechanisms for anxiety and psychotic symptoms in both PDD and non-PDD children; and (3) a unique diagnostic entity comprised of PDD, anxiety, and psychotic symptoms. Lastly, clinicians should seriously consider dual diagnoses in children with PDD.

Anxiety Disorders↗
PubMed1998

DNA diagnosis of FRAXA and FRAXE in Chinese children with neurodevelopmental disorders and fragile X syndrome.

Fragile X (FraX) syndrome is the most common cause of inherited mental retardation. To see whether FRAXA or FRAXE can account for the etiology of some unexplained neurodevelopmental disorders in children, we screened for trinucleotide repeat expansion in a consecutive cohort of 73 Chinese children and their mothers seen in 1995 (group 1) referred for developmental assessment due to developmental delay, language delay, attention deficit hyperactivity disorder, autistic spectrum disorder, mental retardation and/or learning disability. We also screened DNA samples of all five previously diagnosed cytogenetically-positive FraX boys, their mothers and sisters (group 2). A control group of unrelated teenagers and adults were recruited from the community (group 3). In group 1, 3 families (2 mothers and a mother and her son) were found to carry a small premutation allele at FRAXA (premutation frequency = 2%, 3/153 independent X chromosomes), but none had any expansion at FRAXE. In group 2, all 5 FraX boys had full mutation at FRAXA and normal repeat length at FRAXE. In group 3, 1 male has a premutation allele out of 18 males and 59 females tested (premutation frequency of control = 0.7%, 1 out of 136 X chromosomes). For FRAXE screening in group 3, 2 females were carriers (1.5%, 2 out of 136 X chromosomes). Thus, FRAXA and FRAXE cannot account for the etiology of neurodevelopmental disorders in our cohort of Chinese children, and the prevalence of FRAXE mutation in normal Chinese population appears to be higher than reported in the Caucasians.

Adult↗
PubMedDate not supplied

Mutually exclusive versus co-occurring diagnostic categories: the challenge of diagnostic comorbidity.

Diagnostic comorbidity is the rule rather than the exception in both DSM-IV and ICD-10. Three types of comorbidity include true comorbidity (clinically distinct entities), artifactual comorbidity (a byproduct of the DSM/ICD strategy to split categorical diagnoses) and spurious comorbidity. DSM has established 'mutually exclusive' relationships between disorders to reduce such spurious comorbidity. Four types of mutually exclusive relationships are identified: (1) between disorders that are on different levels of the Kraepelinian-defined hierarchy (e.g., schizophrenia and major depressive disorder); (2) between categories with identical features that are split according to age or duration (schizophrenia and schizophreniform disorder); (3) between categories in which the defining features of one disorder are contained in the definition of more broadly-defined disorder (Asperger's disorder and autistic disorder), and (4) between categories in which the defining features of one disorder are an associated feature of another disorder (e.g., dysthymic disorder and schizophrenia). Although less comorbidity may be desirable to reduce diagnostic complexity, in the absence of knowledge about underlying pathophysiology, the trend in successive editions of the DSM has been to reduce diagnostic hierarchies and increase comorbidity (e.g., elimination of exclusion between panic disorder and major depression in DSM-III-R because of evidence of independence). It is important to understand that comorbidity in psychiatry does not imply the presence of multiple diseases or dysfunctions but rather reflects our current inability to apply Occam's razor (i.e., a single diagnosis to account for all symptoms).

Comorbidity↗
PubMed2000

Fluvoxamine. An updated review of its use in the management of adults with anxiety disorders.

UNLABELLED: Fluvoxamine is a potent and selective serotonin reuptake inhibitor (SSRI) that has little or no effect on other monoamine reuptake mechanisms. Relative to other SSRIs, fluvoxamine is a weak inhibitor of cytochrome P450 (CYP) 2D6, a moderate inhibitor of CYP2C19 and CYP3A4 and a potent inhibitor of CYP1A2. In randomised, double-blind trials. fluvoxamine 100 to 300 mg/day for 6 to 10 weeks significantly reduced symptoms of obsessive-compulsive disorder (OCD) compared with placebo. Response rates of 38 to 52% have been reported with fluvoxamine, compared with response rates of 0 to 18% with placebo. In patients with OCD, fluvoxamine had similar efficacy to that of clomipramine and, in smaller trials, the SSRIs paroxetine and citalopram and was significantly more effective than desipramine. Maintenance therapy with fluvoxamine may reduce the likelihood of relapses in up to 67% of patients with OCD. Fluvoxamine < or = 300 mg/day for 6 to 8 weeks was as effective as imipramine in patients with panic disorder, and significantly more effective than placebo. In addition, treatment with fluvoxamine < or = 300 mg/day for > or = 8 weeks improved symptoms of social phobia (social anxiety disorder), post-traumatic stress disorder (PTSD), pathological gambling, compulsive buying, trichotillomania, kleptomania, body dysmorphic disorder, eating disorders and autistic disorder. Large trials comparing the efficacy of fluvoxamine and other SSRIs in patients with anxiety disorders are warranted. Fluvoxamine is generally well tolerated; in postmarketing studies, nausea was the only adverse event occurring in >10% of patients with less commonly reported events including somnolence, asthenia, headache, dry mouth and insomnia. Fluvoxamine is associated with a low risk of suicidal behaviour, sexual dysfunction and withdrawal syndrome. Fewer anticholinergic or cardiovascular events are associated with fluvoxamine than tricyclic antidepressants. Although comparative data are lacking, the tolerability profile of fluvoxamine appears to be broadly similar to those of other SSRIs. CONCLUSION: Fluvoxamine has demonstrated short term efficacy in the treatment of OCD, panic disorder, social phobia, PTSD and in a range of obsessive-compulsive spectrum disorders. The drug is as effective as clomipramine in patients with OCD but appears to have a better tolerability profile. On the basis of current treatment guidelines, fluvoxamine, like other SSRIs, is recommended as first-line treatment for a number of anxiety disorders. It appears to offer some pharmacokinetic advantages and a different drug interaction profile to the other SSRIs with a broadly similar spectrum of adverse events. However, direct comparisons are required to assess the relative efficacy and tolerability of the different agents of this drug class.

Adult↗
PubMed2005

Do adolescents with autistic spectrum disorders adhere to social conventions in virtual environments?

The potential for using virtual environments (VEs) in educational contexts for people with autistic spectrum disorders (ASDs) has been recognized. However, very little is known about how people with ASDs interpret and understand VEs. This study aimed to investigate this directly with a group of 12 adolescents with ASDs, each individually matched with comparison participants. Participants were presented with VEs to assess whether they adhered to particular social conventions, such as not walking across grass and flowerbeds en route to a café, or not walking between two people (ostensibly involved in conversation) en route to the bar. Whilst a significant minority of the ASD group adhered to the social conventions, others displayed substantial 'off-task' behaviour and a limited understanding of the VE. It is suggested that some individuals with an ASD, low verbal IQ and weak executive ability require the most support to complete tasks successfully in the VE.

Adolescent↗
PubMed2003

Social play and autistic spectrum disorders: a perspective on theory, implications and educational approaches.

The article considers the nature of the presumed social play deficit in autistic spectrum disorders (ASDs). The nature of play and its typical development is outlined and discussed in relation to play development in ASDs. It is suggested that social play is a confluence of two strands of development that are affected in autism: social and emotional development, and the cognitive development of play. It is shown that social play develops in a transactional way and in ASDs initial social difficulties prevent the development of social interaction, with its role in eliciting and enriching spontaneous play. At the same time, cognitive and affective difficulties prevent the play of children with autism developing to the extent of attracting other children and being of a complexity from which social play might develop. This cycle of impoverished play opportunities for children with ASDs may be broken through direct teaching and there are encouraging models of teaching social play with some success.

Autistic Disorder↗
PubMed2004

EEG spectral analysis of wakefulness and REM sleep in high functioning autistic spectrum disorders.

OBJECTIVE: The aim of this study was to investigate the involvement of temporo-occipital regions in the pathophysiology of autistic spectrum disorders (ASD) by using REM sleep and waking EEG. METHODS: The EEG recordings of 9 persons with ASD and 8 control participants were recorded using a 12-electrode montage. Spectral analysis (0.75-19.75 Hz) was performed on EEG activity recorded upon two activated states: REM sleep and wakefulness. RESULTS: During REM sleep, persons with ASD showed a selective, significantly lower absolute beta (13.0-19.75 Hz) spectral amplitude over the primary (O(1), O(2)) and associative (T(5), T(6)) cortical visual areas compared to controls. Persons with ASD showed significantly higher absolute theta (4.0-7.75 Hz) spectral amplitude over the left frontal pole region (Fp1) compared to controls during evening wakefulness, but not during morning wakefulness. SIGNIFICANCE: The results of waking EEG are consistent with previously reported observations of neuropsychological signs of frontal atypicalities in ASD; results from REM sleep are the first EEG evidence to support the hypothesis of abnormal visuoperceptual functioning in ASD. Altogether, these results point toward atypical thalamo-cortical mechanisms subserving the neural processing of information in ASD.

Adolescent↗
PubMed2005

Novel treatments for autistic spectrum disorders.

In no area of developmental pediatric practice is there more controversy regarding the choice of treatment than related to children with autistic spectrum disorders (ASD). Complementary and alternative medical therapies (CAM) are often elected because they are perceived as treating the cause of symptoms rather than the symptoms themselves. CAM used for autism can be divided by proposed mechanism: immune modulation, gastrointestinal, supplements that affect neurotransmitter function, and nonbiologic intervention. Secretin as a therapy for autism is discussed as an example of how a clinical observation rapidly grew to a widespread treatment before well-designed studies demonstrated absence of effect. The plausibility for behavioral effect was not substantiated by clinical studies. CAM used for treatment of autism is examined in terms of rationale, evidence of efficacy, side effects, and additional commentary. Families and clinicians need access to well-designed clinical evidence to assist them in choice of therapies.

Anti-Bacterial Agents↗
PubMed2006

Etiologic yield of autistic spectrum disorders: a prospective study.

Studies addressing etiologic yield in childhood developmental disabilities have mainly looked at individuals with developmental delay/mental retardation. The few studies addressing the question of etiologic yield in patients with pervasive developmental disorders (PDDs) had a major drawback, in that the enrolled subjects were diagnosed as having the autistic spectrum disorders based only on history and clinical examination, and/or on unspecified instruments. In addition, only some of these patients underwent a complete laboratory evaluation. To investigate the etiologic yield of PDDs, we undertook a large prospective study on subjects selected according to very strict criteria and diagnosed as having PDD based on the present "gold standard" (ADI-R and ADOS-G), and a clinical diagnosis made by a child psychiatrist. Eighty-five (85) patients with PDD and their first degree relatives participated in this study. These patients were selected from a sample of 236 subjects who had received a clinical diagnosis of PDD at the Stella Maris Institute between March 2002 and 2005. Selection criteria for entering the study were: (1) a diagnosis of PDD (with exclusion of the Rett syndrome) confirmed after the administration of the ADI-R (autism diagnostic interview-revised) and the ADOS-G (autism diagnostic observation schedule-generic). In addition, a clinical diagnosis was made by the child psychiatrist, on the basis of presence or absence of DSM-IV symptoms of autism; (2) chronological age between 4 and 18 years; (3) IQ>30; (4) availability of both biologic parents. Patients, 65/85 (76.5%), had autism, 18/85 (21.2%) had PDD-NOS, and the remaining 2/85 (2.3%) had Asperger syndrome. Ages varied between 4 years 2 months and 12 years 5 months (mean 7.6 years), and there was a marked male preponderance (68/85). All subjects underwent various laboratory studies and neuroimaging. With respect to possible etiologic determination, a detailed history and physical examination in this group of patients with PDD was informative in 10.5% (9/85). HRB karyotype was diagnostic in one, and molecular fragile X studies in one child. Brain MRI was informative in two children (2.3%) with relative macrocrania but no neurological features; and EEG was helpful in one child, identifying a Landau-Kleffner disorder. Audiometry and brainstem auditory evoked potentials (BAEPs) showed a bilateral sensorineural loss in another child. Metabolic evaluation gave normal results in all subjects. The results suggest an evaluation paradigm with reference to etiologic determination for individuals with PDDs that does not presently justify metabolic or neuroimaging on a screening basis. Recurrence risk, treatment implications, and significant and long-lasting emotional relief for the parents suggest that serious consideration be given to clinical genetic examination, genetic testing, EEG study (during wakefulness and sleep), and audiometry, despite a relatively low yield.

Adolescent↗
PubMed2006

Autonomic and neuroendocrine responses to a psychosocial stressor in adults with autistic spectrum disorder.

Objective of the study was to replicate in adults our previous findings of decreased heart rate and normal endocrine responses to stress in autistic children and to elucidate the discrepancy between autonomic and endocrine stress responses by including epinephrine, norepinephrine, oxytocin and vasopressin measurements. Ten autistic spectrum disorder (ASD) adults were compared to 14 healthy controls in their response to a psychosocial stressor (public speaking). ASD patients showed decreased heart rate, but normal cortisol responses, consistent with our prior findings in children. No differences in norepinephrine, epinephrine, oxytocin or vasopressin responses to stress were found. However, in contrast to previous findings in low functioning autistic children, ASD adults showed increased basal oxytocin levels, which may be related to developmental factors.

Adrenocorticotropic Hormone↗
PubMed2007

Quantitative electroencephalographic profiles for children with autistic spectrum disorder.

The present study examined quantitative electroencephalographic (QEEG) profile for children with autistic spectrum disorder (ASD). Five-minute QEEG data were obtained from 90 normal controls (NCs) and 66 children with ASD. Spectrum analyses revealed that ASD children showed significantly less relative alpha and more relative delta than NC. Specifically, 26% of ASD children and 2% of NCs showed 1.5 SDs of relative alpha below the normative mean. Children with this QEEG profile had 17 times the risk of having ASD than those without such a profile. Sensitivity and specificity of relative alpha were 91% and 73%, respectively. Split-half cross-validation yielded a sensitivity of 76%.

Adolescent↗
PubMed2002

Acquired epileptiform aphasia: a dimensional view of Landau-Kleffner syndrome and the relation to regressive autistic spectrum disorders.

Acquired epileptiform aphasia (AEA) is characterized by deterioration in language in childhood associated with seizures or epileptiform electroencephalographic abnormalities. Despite an extensive literature, discrepancies and contradictions surround its definition and nosological boundaries. This paper reviews current conceptions of AEA and highlights variations in the aphasic disturbance, age of onset, epileptiform EEG abnormalities, temporal course, and long-term outcome. We suggest that AEA, rather than being a discrete entity, is comprised of multiple variants that have in common the features of language regression and epileptiform changes on EEG. Viewed this way, we argue that AEA can be conceptualized on a spectrum with other epileptiform neurocognitive disorders that may share pathophysiological features. The implications of this viewpoint are discussed, with emphasis on parallels between the AEA variants and regressive autistic spectrum disorders.

Adolescent↗
PubMed2003

Prevalence of chronic gastrointestinal symptoms in children with autism and autistic spectrum disorders.

The purpose of this study was to estimate the prevalence of chronic gastrointestinal symptoms in a general population of children with autism or autistic spectrum disorder (ASD). The study site was a clinic specializing in ASD in a large pediatric medical center serving a 10 county area in the midwestern USA. In a sample of 137 children, age 24-96 months, classified as having autism or ASD by the Autism Diagnostic Observation Schedule-Generic, 24 percent had a history of at least one chronic gastrointestinal symptom. The most common symptom was diarrhea, which occurred in 17 percent. There was no association between chronic gastrointestinal symptoms and a history of developmental regression. The potential phenotypic association between autism and gastrointestinal symptoms is discussed.

Abdominal Pain↗
PubMed2006

Objective investigation of the sleep-wake cycle in adults with intellectual disabilities and autistic spectrum disorders.

BACKGROUND: Disturbances in circadian rhythm functioning, as manifest in abnormal sleep-wake cycles, have been postulated to be present in people with autistic spectrum disorders (ASDs). To date, research into the sleep-wake cycle in people with ASDs has been primarily dependant on third-party data collection. METHOD: The utilization of non-invasive objective recording technologies such as actigraphy permits investigation of both sleep and circadian rhythm functioning in people with ASDs, together with the collection of data on daytime activity. RESULTS: Data were collected from 31 participants with intellectual disabilities living in supported community-based residential provision aged between 20 and 58 years, of whom 14 had an ASD. Analysis indicated that there were no significant differences in sleep patterns and circadian rhythm function between those participants with an ASD and those without. CONCLUSIONS: The mean scores of the participants as a whole indicated abnormalities in the two key circadian rhythm parameters of interdaily stability and intradaily variability. The implications of these findings for both clinical practice and theory are discussed.

Adult↗
PubMed2004

Regression and word loss in autistic spectrum disorders.

BACKGROUND: For many years, researchers and clinicians have described parent reports of an unusual developmental phenomenon in a substantial minority of children with Autistic Spectrum Disorders (ASD), the acquisition and then loss of communication skills during the second year of life. METHODS: As part of a longitudinal study of 110 children referred for assessments of possible autism at age 2 years or younger, 21 developmentally delayed children and 33 typically developing controls, 19 children were described by their parents at age 2 as having gained and lost spontaneous, meaningful words, and 12 children as having a history of less specific loss of imitated words or nonword vocalizations. A battery of diagnostic and cognitive tasks was administered to all children at study entrance, at ages 3 (for the referral children only) and 4 or 5 (for referral and developmentally delayed children). RESULTS: Results indicated that the acquisition of a small number of spontaneous words used meaningfully and consistently followed by loss of all words, often associated with other social changes, was unique to children diagnosed at 5 years with ASD. Few differences, besides those that defined the pattern of word loss, emerged between children with ASD with and without word loss. Loss of less specific, nonword vocalizations was associated with cognitive delay, with or without autism. CONCLUSIONS: Word loss is a reliably identifiable phenomenon in early childhood that appears to be unique, but not universal to, ASD. Histories and outcome of children with word loss were not in keeping with a sudden change from normal to abnormal functioning, but did suggest that this type of loss in the second year of life may be a useful 'red flag' for ASD in a significant minority of cases.

Autistic Disorder↗