Promoting social communication in high functioning individuals with autistic spectrum disorders

This article reviews a range of social communication interventions that have been developed for students with autism at the preschool, school age, and adolescent level. Adult-mediated and peer-mediated methods that use highly structured, child-centered, and hybrid methods are examined. Programs that provide information on generalization and maintenance are identified. A set of recommendations for programs that would seem to be most appropriate for students with Asperger syndrome is presented.     

Seizures and epilepsy among children with language regression and autistic spectrum disorders

Clinical and subclinical seizures occur frequently among children with autistic spectrum disorders. Electrographic status epilepticus in sleep, or continuous spike-wave in slow-wave sleep, is a typical feature of acquired epileptic aphasia and Landau-Kleffner syndrome. Seizures and epilepsy are more common among children with autistic spectrum disorder who experience language regression, especially those who experience language regression after the age of 2 years. Although the seizures associated with Landau-Kleffner syndrome and with acquired epileptic aphasia can be easily treated, improvement in language function often does not follow successful treatment of seizures. There are no published randomized clinical trials of treatments for Landau-Kleffner syndrome or for autistic language regression. Broad-spectrum antiepileptic drugs not associated with cognitive slowing are probably the treatment of choice for epilepsy among children with autistic spectrum disorder. Large multisite trials are needed to determine treatment efficacy among children with Landau-Kleffner syndrome and acquired epileptic aphasia and to establish whether there is a cause-effect relationship between electrographic status epilepticus in sleep or continuous spike-wave in slow-wave sleep and autistic language regression.     

Intervention for autistic spectrum disorders

A comprehensive approach to the assessment of any child with autism must be matched specifically to each individual child and family. This premise holds for medical therapies and special education services as well as psychopharmacologic interventions. Behavioral, as opposed to pharmacologic, treatment is the hallmark of effective intervention for autism. Physicians involved in the care of children with autism need to become familiar with educational law and intervention recommendations. Goals should include improved functional verbal and nonverbal communication and social skills, increased engagement in developmentally appropriate activities, improved fine and gross motor skills, and the development of independent academic and organizations skills, as well as replacement of problem behaviors with developmentally appropriate behaviors. Medicating children with autism is difficult, but is often necessary for chronic behavioral difficulties. In the absence of clear and present guidelines, we have attempted to use evidence and clinical experience to suggest an algorithm based on symptom clusters. Although children with autism may be responsive to medications at lower doses and more susceptible to side effects than other children, medical intervention can produce a significant improvement in the quality of life for the child and family. Careful thought leading to correct identification of target behaviors can appropriately direct better alternatives for medication. Although these approaches are costly and time-consuming endeavors, the expenditure of such efforts is the only available pathway to improve the potential outcomes for individuals with autism as well as decrease the lifetime societal costs for each individual.     

Psychiatric disorders in the parents of autistic individuals.

Eighty-one parents of 42 autistic probands and 34 parents of 18 Down syndrome probands were examined using a semistructured, investigator-based version of the Schedule for Affective Disorders and Schizophrenia Lifetime Version to estimate the lifetime risk of psychiatric disorder. The lifetime prevalence rate of anxiety disorder was significantly greater in parents of autistic probands than in parents of Down syndrome probands. The lifetime prevalence rate of major depressive disorder, while not significantly different in cases and controls, may be high in the parents of autistic probands (27%) in comparison with populations rates.     

The role of physiological arousal in the management of challenging behaviours in individuals with autistic spectrum disorders

Challenging behaviours restrict opportunities and choices for people with autistic spectrum disorders (ASD) and frequently lead to inappropriate and costly service interventions. Managing challenging behaviours of people with autism is an important area of research. This paper examines some of the evidence for the role of physiological arousal influencing these behaviours. Evidence from the emerging literature about sensory differences is examined. It is proposed that sensory reactivity is associated with hyperarousal; catatonic type behaviours are associated with low levels of reactivity (hypoarousal). A low arousal approach is proposed as a generalised strategy to managing challenging behaviours with ASD. The use of non-contingent reinforcement and antecedent control strategies are recommended for use with challenging behaviours which have a sensory component. Examples are provided to illustrate the approach. The implications of arousal and the use of physical interventions are discussed. It is proposed that arousal is a construct which has significant heuristic value for researchers and practitioners.     

Medication treatment in subjects with autistic spectrum disorders

Autism is a pervasive developmental disorder that is aetiologically and clinically heterogeneous. Twin and family genetic studies provide evidence for strong genetic components. An international consortium using an affected sib pair strategy has found a promising linkage to a region on chromosome 7. In 10–15% of the cases autism is due to associated medical conditions that affect normal brain functioning. Post-mortem studies on small case series report cellular abnormalities in the limbic system and cerebellum. Between 10 and 20% of subjects with autism have macrocephalia, which is in accordance with MRI findings of an increased total brain tissue volume and enlargement most prominent in the occipital and parietal lobes. The most robust and well-replicated neurobiological abnormality in autism is an elevation of whole blood serotonin found in over 30% of the patients. Pharmacological interventions with serotonin reuptake blockers or with atypical neuroleptics that block both dopamine (D₂) and serotonin (5-HT₂) receptors seem to offer clinical benefit and merit further study.

     

Clinical experience with Topiramate to counteract neuroleptic induced weight gain in 10 individuals with autistic spectrum disorders

Children and adolescents with autistic spectrum disorders are treated with neuroleptics to limit behavioral disturbances such as aggression, hyperactivity and self-injury. They may experience substantial weight gain when undergoing treatment with atypical antipsychotics actually employed. Topiramate (TPM) is an antiepileptic medication that is being progressively demonstrating a wider spectrum of action, mainly as an agent for weight control and as a mood stabilizer. It was administered to a group of children and adolescents with autistic spectrum disorders with the aim of reversing weight gain. This is an open study over an observation period of 18 months of 10 children and adolescents, eight males and two females, mean age 13 years, SD+/-3.6, range 8-19 years with a diagnosis of autistic disorder or pervasive developmental disorder not otherwise specified according to DSM-IV. Starting dosage of TPM was 0.5 mg/kg followed by titration of 0.5 mg/kg on a weekly basis, up to 1-3 mg/kg/day as the maintenance dosage. Eight subjects were undergoing long-term treatment with risperidone, one with pimozide and one was temporarily not on antipsychotics. Six patients took TPM on a regular basis and four dropped out. Variable degrees of weight reduction were observed in four patients, two subjects showed weight increase. Behavioral adverse effects were observed in three patients causing rapid withdrawal of the medication. TPM should be used with caution in autistic spectrum disorders because this population has a high risk of behavioral disruption.     

The role of the medial temporal lobe in autistic spectrum disorders

The neural basis of autistic spectrum disorders (ASDs) is poorly understood. Studies of mnemonic function in ASD suggest a profile of impaired episodic memory with relative preservation of semantic memory (at least in high-functioning individuals). Such a pattern is consistent with developmental hippocampal abnormality. However, imaging evidence for abnormality of the hippocampal formation in ASD is inconsistent. These inconsistencies led us to examine the memory profile of children with ASD and the relationship to structural abnormalities. A cohort of high-functioning individuals with ASD and matched controls completed a comprehensive neuropsychological memory battery and underwent magnetic resonance imaging for the purpose of voxel-based morphometric analyses. Correlations between cognitive/behavioural test scores and quantified results of brain scans were also carried out to further examine the role of the medial temporal lobe in ASD. A selective deficit in episodic memory with relative preservation of semantic memory was found. Voxel-based morphometry revealed bilateral abnormalities in several areas implicated in ASD including the hippocampal formation. A significant correlation was found between parental ratings reflecting autistic symptomatology and the measure of grey matter density in the junction area involving the amygdala, hippocampus and entorhinal cortex. The data reveal a pattern of impaired and relatively preserved mnemonic function that is consistent with a hippocampal abnormality of developmental origin. The structural imaging data highlight abnormalities in several brain regions previously implicated in ASD, including the medial temporal lobes.     

Iron deficiency in preschool children with autistic spectrum disorders

Iron deficiency (ID) cause negative outcomes on psychomotor and behavioral development of infants and young children. Children with autistic spectrum disorders (ASD) are under risk for ID and this condition may increase the severity of psychomotor and behavioral problems, some of which already inherently exist in these children. In the present study, the frequency of ID and the association between ID and autistic symptoms, developmental level, and behavioral problems in preschool children attending a clinic for ASD (N = 31) were evaluated. No association was observed between ID and the severity of autistic symptoms, developmental level and behavioral problems. ID was detected in 32.3% (N = 10) of the children based on serum ferritin level. In this study, the negative impact of low serum ferritin in ASD has not been confirmed. On the other hand, the rate of ID was considerably high in this sample of children with ASD compared to normative data of preschool children. Further studies with larger samples are needed to clarify the relationship between ID and clinical variables associated with ASD.     

Prevalence and characteristics of autistic spectrum disorders in the ALSPAC cohort

The aim of this study was to determine the prevalence of autistic spectrum disorder (ASD) within a large representative population sample: the Avon Longitudinal Study of Parents and Children (ALSPAC). Cases of ASD were identified from the clinical notes of children in the ALSPAC with a suspected developmental disorder and from the Pupil Level Annual Schools Census (PLASC) for England in 2003. Seventy-one cases of ASD diagnosed after a multidisciplinary assessment were identified from health records. There were an additional 15 cases from PLASC data in which ASD was mentioned as a principal difficulty, thus giving a total of 86 children diagnosed by the age of 11 years. Prevalence of ASD per 10,000 population at 11 years was 51.1 for those with a multi-professional diagnosis, and 61.9 if cases from education were included, made up of 21.6 for childhood autism, 10.8 for atypical autism, 16.6 for Asperger syndrome, and 13.0 for unspecified ASD. The male:female ratio was 6.8:1. Median age at diagnosis ranged from 45 months in childhood autism to 116 months in Asperger syndrome. A comorbid developmental disorder was recorded in 33.8% of cases, including learning disability in 14.7%, epilepsy in 10.3%, and mixed developmental disorder in 4.4%. We conclude that the prevalence of ASD diagnosed at 11 years in a UK representative population-based sample is at least 51.1/10,000.     

5-HTTLPR variants not associated with autistic spectrum disorders

To determine whether there is an association of polymorphic variants of the serotonin transporter (5-HTT) gene-linked polymorphic region (5-HTTLPR) and autistic spectrum disorders, we analyzed the 5-HTTLPR genotypes of 72 autistic subjects, 11 fragile X syndrome patients with autistic behavior, 43 normal subjects, and 49 fragile X syndrome non-autistic subjects. The distribution frequency of 5-HTTLPR long allele (L) and the short allele (S) variants showed no differences between subjects. Our findings do not support the hypothesis that polymorphic 5-HTTLPR variants are a susceptibility factor for autistic disorders. Received: August 5, 1998 / Accepted: December 22, 1998 / Published online: March 11, 1999     

The inclusion of fathers in investigations of autistic spectrum disorders

Recent reviews indicate an underrepresentation of fathers in empirical investigations of child development and psychopathology (Cassano et al., 2006, Phares et al., 2005). The purpose of the current study was to examine the nature of parental involvement in research on children with autistic spectrum disorders (ASD). Articles published over the last decade from journals with the highest impact factors in disciplines relevant to the study of ASD were reviewed, including areas of psychiatry, developmental psychopathology, and developmental disabilities. A total of 404 articles were included in the review and were coded to determine if parental inclusion and method of statistical analysis varied as a function of child age, journal type, year of publication, and parent gender. Results were consistent with findings from recent reviews and indicated that fathers are widely underrepresented in the literature on ASD, even more so than rates of inclusion in investigations of developmental and child clinical psychology. In contrast to findings from broad reviews of parental inclusion in studies of child psychopathology, fathers’ involvement was not higher in older versus younger age of child participant. Clinical implications and recommendations to improve inclusion rates of fathers in research on children with ASDs are discussed.     

Comorbidity of autistic spectrum disorders in children with Down syndrome

The aim of the study was to identify the comorbidity of autistic spectrum disorders in a population of children with Down syndrome (DS). All children with DS within a defined population of South Birmingham were identified. The Asperger Syndrome Screening Questionnaire and the Child Autism Rating Scale were completed and diagnosis made according to ICD-10 criteria following interview and observation. Thirty-three of 58 identified children completed the measures, four of whom received a diagnosis of an autistic spectrum disorder. This is equivalent to a minimum comorbid rate of 7%. The questionnaire items concerning social withdrawal, restricted or repetitive interests, clumsiness, and unusual eye contact were associated with an autistic disorder. Of the remaining 29 participating children, 11 also displayed marked obsessional and ritualistic behaviours. The comorbid occurrence of autism and DS is at least 7%. It is important that these children are identified and receive appropriate education and support. A full assessment of social, language, and communication skills and behaviour is crucial, particularly in children with DS who appear different from other children with DS. Potential mechanisms accounting for this comorbidity are discussed.     

Impairment in movement skills of children with autistic spectrum disorders

Aim  We undertook this study to explore the degree of impairment in movement skills in children with autistic spectrum disorders (ASD) and a wide IQ range.
Method  Movement skills were measured using the Movement Assessment Battery for Children (M-ABC) in a large, well defined, population-derived group of children ( n =101: 89 males,12 females; mean age 11y 4mo, SD 10mo; range 10y–14y 3mo) with childhood autism and broader ASD and a wide range of IQ scores. Additionally, we tested whether a parent-completed questionnaire, the Developmental Coordination Disorder Questionnaire (DCDQ), was useful in identifying children who met criteria for movement impairments after assessment ( n =97 with complete M-ABCs and DCDQs).
Results  Of the children with ASD, 79% had definite movement impairments on the M-ABC; a further 10% had borderline problems. Children with childhood autism were more impaired than children with broader ASD, and children with an IQ less than 70 were more impaired than those with IQ more than 70. This is consistent with the view that movement impairments may arise from a more severe neurological impairment that also contributes to intellectual disability and more severe autism. Movement impairment was not associated with everyday adaptive behaviour once the effect of IQ was controlled for. The DCDQ performed moderately well as a screen for possible motor difficulties.
Interpretation  Movement impairments are common in children with ASD. Systematic assessment of movement abilities should be considered a routine investigation.     

Neural correlates of executive function in autistic spectrum disorders.

BACKGROUND: Some clinical characteristics of high-functioning individuals with autistic spectrum disorder (ASD) such as repetitive stereotyped behaviors, perseveration, and obsessionality have been related to executive function (EF) deficits, more specifically to deficits in inhibitory control and set shifting and mediating frontostriatal neural pathways. However, to date, no functional imaging study on ASD has investigated inhibition and cognitive flexibility and no one has related EF brain activation to brain structure. METHODS: We compared brain activation (using functional magnetic resonance imaging) in 10 normal intelligence adults with ASD and 12 healthy control subjects during three different EF tasks: 1) motor-inhibition (GO/NO-GO); 2) cognitive interference-inhibition (spatial STROOP); and 3) set shifting (SWITCH). Using voxel-based morphometry, we investigated if cortical areas which were functionally different in people with ASD were also anatomically abnormal. RESULTS: Compared with control subjects, ASD individuals showed significantly increased brain activation in 1) left inferior and orbital frontal gyrus (motor-inhibition); 2) left insula (interference-inhibition); and 3) parietal lobes (set shifting). Moreover, in individuals with ASD, increased frontal gray matter density and increased functional activation shared the same anatomical location. CONCLUSIONS: Our findings suggest an association between successful completion of EF tasks and increased brain activation in people with ASD, which partially may be explained by differences in brain anatomy.     

The validity of autistic spectrum disorders: A literature review

The objective of this literature review is to assess the validity of autistic spectrum disorders (ASD). Twenty papers were identified that adequately investigated the internal or external validity of various subtypes of ASD. At least three groups can be distinguished from autism on clinical grounds; an Asperger syndrome subtype, and two atypical subtypes characterized by low IQ and high IQ. However, the evidence that these clinical distinctions carry inferences with respect to etiology, clinical course, and treatment is only suggestive. Nevertheless, the specification of several ASD subtypes might promote further research and resolve many of the nosologic issues with respect to the classification of pervasive developmental disorders (PDDs).The literature review was prepared for the APA DSM-IV Advisory Group on Pervasive Developmental Disorders. The opinions expressed in the paper are solely those of the author, and not those of the APA or the Advisory Group. The author thanks members of the committee for their helpful comments and the reviewers who commented on an earlier version of this paper. The author was supported in the preparation of this paper by grants from the Ontario Mental Health Foundation and National Health and Welfare, Canada.