Pharmacotherapy for severe aggression in a child with autism: "open label" evaluation of multiple medications on response frequency and intensity of behavioral intervention

Propranolol for treating emotional, behavioural, autonomic dysregulation in children and adolescents with autism spectrum disorders

OBJECTIVES

To date, there is no single medication prescribed to alleviate all the core symptoms of Autism Spectrum Disorder (ASD; National Institute of Health and Care Excellence, 2016). Both serotonin reuptake inhibitors and drugs for psychosis possess therapeutic drawbacks when managing anxiety and aggression in ASD. This review sought to appraise the use of propranolol as a pharmacological alternative when managing emotional, behavioural and autonomic dysregulation (EBAD) and other symptoms.

MATERIALS AND METHODS

Sixteen reports examined the administration of propranolol in the context of ASD.

RESULTS

Sixteen reports broadly covered cognitive domains, neural correlates, and behavioural domains. From the eight single-dose clinical trials, propranolol led to significant improvements in cognitive performance - verbal problem solving, social skills, mouth fixation, and conversation reciprocity; and changes in neural correlates - improvement in semantic networks and functional connectivity. The remaining eight case series and single case reports showed improvements in EBAD, anxiety, aggressive, self-injurious and hypersexual behaviours. Additionally, propranolol significantly improved similar behavioural domains (aggression and self-injury) for those with acquired brain injury.

CONCLUSION

This review indicates that propranolol holds promise for EBAD and cognitive performance in ASD. Given the lack of good quality clinical trials, randomised controlled trials are warranted to explore the efficacy of propranolol in managing EBAD in ASD.

Reliability and Validity of a New Comprehensive Tool for Assessing Challenging Behaviors in Autism Spectrum Disorder

OBJECTIVE

The purpose of this study was to examine the validity and reliability of the Korean Comprehensive Scale for the Assessment of Challenging Behavior in Developmental Disorders (K-CSCB).

METHODS

In total, the parents of 189 patients with autism spectrum disorder (ASD) and 168 controls completed the K-CSCB, the Behavior Problems Inventory (BPI) and Child Behavior Checklist (CBCL). The reliability and validity of the K-CSCB was investigated.

RESULTS

The K-CSCB was found to be a reliable instrument (Cronbach's α=0.97). There was a significant difference between the ASD and control groups in all subscale scores. Scores on the K-CSCB subscales were significantly correlated with those on the BPI and CBCL. The diagnostic validity was 97.7%, and the cut-off score with the highest sensitivity and specificity was 12.5 points.

CONCLUSION

The K-CSCB is the first tool in Korean to assess problematic behavior in individuals with ASD, and this study shows that it is a valid and reliable instrument. We expect the K-CSCB to be widely used in clinical and research settings.

Thyroid dysfunction in children with autism spectrum disorder is associated with folate receptor α autoimmune disorder

Folate receptor α (FRα) autoantibodies (FRAAs) are prevalent in autism spectrum disorder (ASD). FRAAs disrupt folate transport across the blood-brain barrier by binding to the FRα. Thyroid dysfunction is frequently found in children with ASD. We measured blocking and binding FRAAs and thyroid-stimulating hormone (TSH), free thyroxine (T4) (FT4), total triiodothyronine (T3) (TT3), reverse T3 (rT3), thyroid-releasing hormone (TRH) and other metabolites in 87 children with ASD, 84 of whom also underwent behaviour and cognition testing and in 42 of whom FRAAs, TSH and FT4 were measured at two time points. To better understand the significance of the FRα in relation to thyroid development, we examined FRα expression on prenatal and postnatal thyroid. TSH, TT3 and rT3 were above the normal range in 7%, 33% and 51% of the participants and TRH was below the normal range in 13% of the participants. FT4 was rarely outside the normal range. TSH concentration was positively and the FT4/TSH, TT3/TSH and rT3/TSH ratios were inversely related to blocking FRAA titres. On repeated measurements, changes in TSH and FT4/TSH ratio were found to correspond to changes in blocking FRAA titres. TSH and the FT4/TSH, TT3/TSH and rT3/TSH ratios were related to irritability on the Aberrant Behavior Checklist and several scales of the Social Responsiveness Scale (SRS), whereas TT3 was associated with SRS subscales and TRH was related to Vineland Adaptive Behavior Scale subscales. The thyroid showed significant FRα expression during the early prenatal period, although expression decreased significantly in later gestation and postnatal thyroid tissue. The results of the present study suggest that thyroid dysfunction in ASD may be related to blocking FRAA. The high expression of FRα in the early foetal thyroid suggests that foetal and neonatal exposure to maternal FRAAs could affect the development of the thyroid and may contribute to the pathology in ASD.

Treating aggression in persons with autism spectrum disorders: a review

Aggression is one of the most frequent and debilitating problems observed among persons with autism spectrum disorders (ASD). It is common and can be more problematic than many core symptoms of ASD. Thus, treating the behavior is a high priority. A surprisingly limited number of studies have addressed treatment when taken in the context of the vast ASD literature. This paper reviews many of these papers and describes the types of interventions that have been used and the characteristics of the people who have been studied.

The relationship between race and challenging behaviours in infants and toddlers with autistic disorder and pervasive developmental disorder-not otherwise specified

OBJECTIVE

To examine the contributions of race and diagnostic category to endorsement rates of challenging behaviours in infants and toddlers with autism, PDD-NOS and atypical development without ASD, using the Baby and Infant Screen for Children with aUtIsm Traits, Part-3 (BISCUIT Part-3).

DESIGN

Multivariate analyses of variance (MANOVAs) on each sub-scale of the BISCUIT Part-3. Follow-up univariate analyses and post-hoc tests as needed.

METHODS

Scores on the BISCUIT Part-3 were compared for 453 Caucasian and 409 African-American infants and toddlers, grouped by race and diagnosis.

RESULTS

Significant differences between races were found on five out of 10 aggressive behaviours, while no significant differences were found on self-injurious or stereotypic behaviours. Significant differences between diagnostic groups were found on all behaviours.

CONCLUSION

Cultural factors should be taken into account when examining challenging behaviours in infants and toddlers with ASD.

Managing irritability and aggression in autism spectrum disorders in children and adolescents

Children with autism and autism spectrum disorders have a high rate of irritability and aggressive symptoms. In one study up to 20% of children with autism have symptoms of irritability and aggression including aggression, severe tantrums, and deliberate self injurious behavior (Lecavalier [2006] J. Autism Dev. Disord. 36:1101-1114.). These symptoms can lead to impairment and distress in both home and school settings. Medications to treat the irritability will be discussed across categories of antipsychotics, antidepressants, antihypertensive agents, and others. Emphasis will be placed on medications with the most safety and efficacy and FDA approval.

Aggression in low functioning children and adolescents with autistic disorder

BACKGROUND

Parents, caregivers and mental health professionals have often reported violence and aggression in children or adolescents with autistic disorder. However, most of these observations derived from anecdotal reports, and studies on frequency and characterization of aggression in autism remain limited. Our objective was to better characterize and understand the different types of aggressive behaviors displayed by a large group of individuals with autism in different observational situations.

METHODOLOGY/FINDINGS

The study was conducted on 74 children and adolescents with autism and 115 typically developing control individuals matched for sex, age and pubertal stage. Other-Injurious Behaviors (OIB) were assessed in three observational situations (parents at home, two caregivers at day-care, a nurse and a child psychiatrist during blood drawing) using validated scales. The frequency of OIB was significantly higher in individuals with autism compared to typically developing control individuals during the blood drawing (23% vs. 0%, P<0 .01). The parents observed significantly less OIB in their children than caregivers (34% vs. 58%, P<0.05). In addition, the most frequent concurrent behaviors occurring just before the appearance of OIB in individuals with autism were anxiety-related behaviors and excitation according to the parental as well as the caregiver observation.

CONCLUSIONS/SIGNIFICANCE

The results suggest that in a stressful situation, such as the blood drawing, individuals with autism release their stress through behaviors such as OIB, whereas typically developing individuals regulate and express their stress through cognitive skills such as mental coping strategies, symbolization skills with representation and anticipation of the stressful situation, social interaction and verbal or non-verbal communication. The findings underline also the key role of the environment in assessing OIB and developing therapeutic perspectives, with an individual who modulates his/her behavior according to the environment, and an environment that perceives this behavior and reacts to it with different tolerance thresholds according to the observers.

The relation of social behaviours and challenging behaviours in infants and toddlers with Autism Spectrum Disorders

PURPOSE

Challenging behaviours are a commonly co-occuring problem in children with ASD and are often present during the toddler years. The relationship that these challenging behaviours have with core features of ASD, specifically social behaviours, was examined in this study.

METHOD

This study analysed the relationship between socialization and challenging behaviours among 153 toddlers with autism spectrum disorder. Social behaviour was evaluated using the Battelle Developmental Inventory, 2nd Edition and challenging behaviours were assessed using Baby and Infant Screen for Children with aUtIsm Traits, Part 3.

RESULT

Lower levels of adult interaction and peer interaction were associated with higher levels of stereotypic behaviour, aggressive/destructive behaviour and to a lesser extent self-injury.

CONCLUSIONS

The nature of the relationships between socialization and challenging behaviours likely interact in several ways. A better understanding of these relationships is essential to early identification and treatment of children with ASD.

Assessing challenging behaviors in children with autism spectrum disorders: a review

A common covarying group of behaviors with ASD are self-injury, aggression, noncompliance, and stereotypies. These problems and related challenging behaviors are problematic in that they are physically dangerous and can impede learning and access to normal activities. Additionally, they require a considerable amount of resources, and compound the difficulty in treating core ASD symptoms. Despite the high profile challenging behaviors present in this population, there has not been a great deal of research regarding assessment, identification, and monitoring of such difficulties. This review covers available empirical based methods for assessing these behaviors. A discussion is provided of potential avenues for future research and clinical practice which is urgently needed for ASD children at this time.

Utilization of Lymphoblastoid Cell Lines as a System for the Molecular Modeling of Autism

In order to provide an alternative approach for understanding the biology and genetics of autism, we performed statistical analysis of gene expression profiles of lymphoblastoid cell lines derived from children with autism and their families. The goal was to assess the feasibility of using this model in identifying autism-associated genes. Replicate microarray experiments demonstrated that expression data from the cell lines were consistent and highly reproducible. Further analyses identified differentially expressed genes between cell lines derived from children with autism and those derived from their normally developing siblings. These genes were then used to identify biochemical pathways potentially involved in autism. This study suggests that lymphoblastoid cell lines may be a viable tool for identifying genes associated with autism.