Treatment of Aggression in Adults with Autism Spectrum Disorder: A Review

Prevalence of Psychotropic Medication Use and Psychotropic Polypharmacy in Autistic Adults With or Without Intellectual Disability

The aim of this study was to compare the rates of psychotropic medication use and psychotropic polypharmacy between autistic adults with and without intellectual disability (ID) and to examine factors associated with psychotropic medication use and psychotropic polypharmacy in autistic adults, stratified by the presence of ID. We conducted a retrospective medical chart review of outpatients with an autism diagnosis aged 18 years and older. The rates of psychotropic medication use and psychotropic polypharmacy were compared between autistic adults with and without ID. Subsequently, logistic regression analyses were performed to identify factors associated with psychotropic medication use and psychotropic polypharmacy in autistic adults with ID and those without ID, respectively. The rates of prevalence of psychotropic medication use and polypharmacy were significantly higher in participants with ID than those without ID (78.6% vs. 58.8% and 49.3% vs. 31.2%; p-values < 0.05). Age, gender, race, residence, presence of mood disorders, presence of schizophrenia, absence of anxiety disorder, number of psychiatric comorbidities, and presence of behaviors that challenge were significantly associated with these outcomes, depending on the presence/absence of ID. The need to optimize pharmacotherapy in autistic adults, stratifying by the presence of ID, is highlighted.

Clozapine for Treatment-Resistant Disruptive Behaviors in Youths With Autism Spectrum Disorder Aged 10-17 Years: Protocol for an Open-Label Trial

BACKGROUND

Autism Spectrum Disorder (ASD) is a complex neurodevelopmental condition emerging in early childhood, characterized by core features such as sociocommunicative deficits and repetitive, rigid behaviors, interests, and activities. In addition to these, disruptive behaviors (DB), including aggression, self-injury, and severe tantrums, are frequently observed in pediatric patients with ASD. The atypical antipsychotics risperidone and aripiprazole, currently the only Food and Drug Administration-approved treatments for severe DB in patients with ASD, often encounter therapeutic failure or intolerance. Given this, exploring pharmacological alternatives for more effective management of DB associated with ASD is essential. Clozapine, noted for its unique antiaggressive effects in schizophrenia and in various treatment-resistant neuropsychiatric disorders, independent from its antipsychotic efficacy, remains underexplored in youths with ASD facing severe and persistent DB.

OBJECTIVE

This study aimed to evaluate the efficacy, tolerability, and safety of clozapine for treatment-resistant DB in youths with ASD.

METHODS

This is a prospective, single-center, noncontrolled, open-label trial. After a cross-titration phase, 31 patients with ASD aged 10-17 years and with treatment-resistant DB received a flexible dosage regimen of clozapine (up to 600 mg/day) for 12 weeks. Standardized instruments were applied before, during, and after the treatment, and rigorous clinical monitoring was performed weekly. The primary outcome was assessed using the Irritability Subscale of the Aberrant Behavior Checklist. Other efficacy measures include the Clinical Global Impression Severity and Improvement, the Swanson, Nolan, and Pelham questionnaire-IV, the Childhood Autism Rating Scale, and the Vineland Adaptive Behavior Scale. Safety and tolerability measures comprised adverse events, vital signs, electrocardiography, laboratory tests, physical measurements, and extrapyramidal symptoms with the Simpsons-Angus Scale. Statistical analysis will include chi-square tests with Monte Carlo simulation for categorical variables, paired t tests or Wilcoxon tests for continuous variables, and multivariate linear mixed models to evaluate the primary outcome, adjusting for confounders.

RESULTS

Recruitment commenced in February 2023. Data collection was concluded by April 2024, with analysis ongoing. This article presents the protocol of the initially planned study to provide a detailed methodological description. The results of this trial will be published in a future paper.

CONCLUSIONS

The urgent need for effective pharmacological therapies in mitigating treatment-resistant DB in pediatric patients with ASD underscores the importance of this research. Our study represents the first open-label trial to explore the anti-aggressive effects of clozapine in this specific demographic, marking a pioneering step in clinical investigation. Adopting a pragmatic approach, this trial protocol aims to mirror real-world clinical settings, thereby enhancing the applicability and relevance of our findings. The preliminary nature of future results from this research has the potential to pave the way for more robust studies and emphasize the need for continued innovation in ASD treatment.

TRIAL REGISTRATION

Brazilian Clinical Trials Registry RBR-54j3726; https://ensaiosclinicos.gov.br/rg/RBR-54j3726.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/58031.

Pharmacological treatment in autism: a proposal for guidelines on common co-occurring psychiatric symptoms

BACKGROUND

The prevalence of autism spectrum disorder (ASD) has surged, with an estimated 1 in 36 eight-year-olds in the United States meeting criteria for ASD in 2020. Autistic individuals face elevated rates of co-occurring medical, psychiatric, and behavioral conditions compared to non-autistic individuals. The rising ASD-patient demand is increasingly outpacing the capacity of ASD-specialty clinics, resulting in urgent need for autism-competent providers in general practice settings. This work aims to empower healthcare providers, especially primary care providers (PCPs), with guidelines for the recognition and safe pharmacologic management of common co-occurring psychiatric and behavioral conditions in ASD.

METHODS

Lurie Center for Autism medical providers, who have extensive experience in ASD care, delineated approaches for recognition and pharmacological treatment of sleep disturbances, attention-deficit/hyperactivity disorder (ADHD), anxiety, depression, and irritability tailored to ASD patients. Pharmacological guidelines were iteratively refined until consensus was reached. Treatment differences relative to standard of care (SOC) of non-autistic individuals are noted. Key literature and clinical trial results were reviewed to supplement clinical experience.

RESULTS

The pharmacological treatment pathways reflect how appropriate medication options for ASD patients can depend on many factors unique to the patient and can differ from established non-autistic SOC. Key takeaways include: For sleep disturbances in ASD, initial strategies align with non-autistic SOC, emphasizing sleep hygiene and melatonin use. First-line recommendations for treating ADHD, anxiety, and depression in ASD differ from non-autistic SOC; α2-adrenergic agonists are more suitable than stimulants for some ASD-ADHD patients, buspirone and mirtazapine are preferred to selective serotonin reuptake inhibitors (SSRIs) for anxiety, and duloxetine, mirtazapine, bupropion, and vortioxetine are recommended ahead of SSRIs for depression. Addressing irritability in ASD requires interdisciplinary evaluation of contributing factors, and guanfacine, risperidone, or aripiprazole may be appropriate, depending on severity.

CONCLUSIONS

Recognition and treatment of co-occurring psychiatric and behavioral conditions in autistic patients must account for differences in clinical presentation and medication effectiveness and tolerability. Drawing on evidence-based clinical insights, these guidelines seek to support PCPs in making informed decisions when prescribing medications for ASD patients with co-occurring psychiatric and behavioral conditions, ultimately enhancing access to timely, comprehensive care for all individuals with ASD.

Managing Aggressive Behavior in Adolescents With Autism Spectrum Disorder: Pharmacological and Non-Pharmacological Approaches

Adolescents diagnosed with autism spectrum disorder (ASD) often encounter significant challenges, particularly aggressive behaviors that persist into adulthood and profoundly affect their daily functioning and quality of life. These behaviors not only pose hurdles for affected individuals but also present considerable challenges for caregivers and families. Managing aggression in adolescents with ASD requires comprehensive treatment approaches encompassing both non-pharmacological and pharmacological interventions. This paper reviews current interventions that have proven to be effective through empirical studies in managing aggression among adolescents with ASD. By synthesizing evidence-based practices, this study underscores the importance of a multidisciplinary approach involving medical, psychological, and educational interventions to effectively manage aggression among adolescents with ASD. It aimed to inform clinicians, educators, and caregivers of practical strategies and evidence-based interventions to address aggression in this population.

Nursing strategies for enhancing calm in older Arabs with dementia: integrating Snoezelen methods, aromatherapy, and personal items to reduce agitation

BACKGROUND

Agitation significantly impacts Arab elders with dementia. Multisensory stimulation, such as Snoezelen, shows promise but lacks exploration in Arab contexts.

OBJECTIVE

Evaluate a culturally adapted multisensory intervention-combining Snoezelen, aromatherapy, and personal items-on agitation in Arab elders with dementia.

METHODS

A quasi-experimental design assessed 31 patients receiving the intervention against 31 controls. Agitation, quality of life, and neuropsychiatric symptoms were measured using the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory (NPI).

RESULTS

The intervention group exhibited notable reductions in CMAI scores for aggression and agitation behaviors (p < 0.001) and improvements in quality of life and NPI scores for agitation/aggression and depression/dysphoria (p < 0.001).

CONCLUSION

This culturally tailored multisensory approach effectively reduced agitation and improved well-being in Arab dementia patients. The findings advocate for further research and suggest such interventions can be beneficial in culturally diverse dementia care settings.

TRIAL REGISTRATION

ClinicalTrials.gov, ID NCT06216275.

Alcohol use, civilian interference, and other possible risk factors for death during restraint

Physical restraint is usually used when trying to control and terminate a violent episode. Many causes are possible behind aggressive, agitated, and violent behavior. Some of these are such factors that can either be detected in forensic autopsies or can be evident from the person's medical records. Various causes for deaths during physical restraint have been suggested. In this study, we wanted to review all incidents in which physical restraint was employed, ending in death of the restrained person, whether the restraint was applied by police officers, security guards, police custody personnel, health care personnel or ordinary civilians. The main aim was to see if this new kind of study design would increase our knowledge in circumstances and causes leading to death in restraint situations. Data was collected retrospectively from all forensic autopsies performed in the Southern Finland area during 2010-2015. We went through 21,036 forensic autopsy cases and found 12 cases (0.06 %) in which a physical restraint was employed before death. Police officers were involved in the physical restraint in 7/12 of the cases: in two of these cases, police alone; in three cases, police and guards; and in two cases, police and health care personnel. Civilians carried out the restraint in 5/12 cases. With civilians responsible for the restraint, the cause of death was more likely considered to be a result of the restraint itself than in cases where police and other authorities were responsible for the restraint. This could be because civilians aren't educated about safe restraint methods, and they might themselves be intoxicated. Alcohol was the most common psychoactive substance found in this study and could be a risk factor for not only aggressive behavior but also death, since alcohol use can provoke cardiac arrhythmias and even sudden death. Based on this study, and previously published studies, we see restraint deaths as a varying spectrum of deaths, in which the death is often possibly a result of many factors, including the effects of agitation and restraint, intoxication, and cardiac and other illnesses.

Identification of hippocampal area CA2 in hamster and vole brain

Prairie voles (Microtus ochrogaster) and Syrian, or golden, hamsters (Mesocricetus auratus) are closely related to mice (Mus musculus) and are commonly used in studies of social behavior including social interaction, social memory, and aggression. Hippocampal area CA2 is known to play a key role in these behaviors in mice and responds to social stimuli in rats, but CA2 has yet to be characterized in hamsters or voles, which are also used in studies of social behaviors. Here, we used immunofluorescence to determine whether CA2 could be molecularly identified in tissue from voles and hamsters. We found that  staining for many CA2 markers was similar in these three species, with labeling seen in neurons at the distal end of the mossy fibers . In contrast, although perineuronal nets (PNNs) surround CA2 cells in mice, PNN staining differed across species. In voles, both CA2 and CA3 were labeled, whereas in hamsters, labeling was seen primarily in CA3. These results demonstrate that CA2 can be molecularly distinguished from neighboring CA1 and CA3 areas in voles and hamsters with several antibodies commonly used in mice. However, PNN staining is not useful for identifying CA2 in voles or hamsters, suggestive of differing roles for either PNNs or for the hippocampal subregions in social behavior. These findings reveal commonalities across species in the molecular profile of CA2 and should facilitate future studies of CA2 in these species.

Identification of hippocampal area CA2 in hamster and vole brain

Prairie voles (Microtus ochrogaster) and Syrian, or golden, hamsters (Mesocricetus auratus) are closely related to mice (Mus musculus) and rats (Rattus norvegicus, for example) and are commonly used in studies of social behavior including social interaction, social memory, and aggression. The CA2 region of the hippocampus is known to play a key role in social memory and aggression in mice and responds to social stimuli in rats, likely owing to its high expression of oxytocin and vasopressin 1b receptors. However, CA2 has yet to be identified and characterized in hamsters or voles. In this study, we sought to determine whether CA2 could be identified molecularly in vole and hamster. To do this, we used immunofluorescence with primary antibodies raised against known molecular markers of CA2 in mice and rats to stain hippocampal sections from voles and hamsters in parallel with those from mice. Here, we report that, like in mouse and rat, staining for many CA2 proteins in vole and hamster hippocampus reveals a population of neurons that express regulator of G protein signaling 14 (RGS14), Purkinje cell protein 4 (PCP4) and striatal-enriched protein tyrosine phosphatase (STEP), which together delineate the borders with CA3 and CA1. These cells were located at the distal end of the mossy fiber projections, marked by the presence of Zinc Transporter 3 (ZnT-3) and calbindin in all three species. In addition to staining the mossy fibers, calbindin also labeled a layer of CA1 pyramidal cells in mouse and hamster but not in vole. However, Wolframin ER transmembrane glycoprotein (WFS1) immunofluorescence, which marks all CA1 neurons, was present in all three species and abutted the distal end of CA2, marked by RGS14 immunofluorescence. Staining for two stress hormone receptors-the glucocorticoid (GR) and mineralocorticoid (MR) receptors-was also similar in all three species, with GR staining found primarily in CA1 and MR staining enriched in CA2. Interestingly, although perineuronal nets (PNNs) are known to surround CA2 cells in mouse and rat, we found that staining for PNNs differed across species in that both CA2 and CA3 showed staining in voles and primarily CA3 in hamsters with only some neurons in proximal CA2 showing staining. These results demonstrate that, like in mouse, CA2 in voles and hamsters can be molecularly distinguished from neighboring CA1 and CA3 areas, but PNN staining is less useful for identifying CA2 in the latter two species. These findings reveal commonalities across species in molecular profile of CA2, which will facilitate future studies of CA2 in these species. Yet to be determined is how differences in PNNs might relate to differences in social behavior across species.

Changes in Challenging Behaviors Accompanying Transition to a New Facility in Individuals with Intellectual Disabilities

Challenging behavior (CB), the most common example being extreme self-injurious or aggressive/destructive behavior, is often observed as a major behavior issue in individuals with severe intellectual disabilities. This study investigated how CB changed among residents of a facility for people with disabilities before and after it was restructured from a traditional format single room shared by two to three individuals with approximately 20 residents lived together to a format featuring private areas with two rooms per resident and a unitcare system. Twenty-one residents of Care Home A, which was rebuilt in the new care format, were selected. Care staff completed a questionnaire one month before, one month after, and six months after residents moved to the new facility. Scores were compared among each time point. The results revealed significant reductions in residents' aggressive, stereotyped, and targeted behaviors, such as hitting their own head and fecal smearing. The major features of the restructured facility were a living space consisting of two private rooms per resident and a shift to unit care for the entire ward. These new features enabled residents to reduce destructive stimuli and made it easier to understand what to do in each private room.

National screening for Egyptian children aged 1 year up to 12 years at high risk of Autism and its determinants: a step for determining what ASD surveillance needs

This study aimed to provide a national estimate of the prevalence of the high risk of autism spectrum disorder (ASD) and their determinants. A national screening survey was conducted for 41,640 Egyptian children aged 1 to 12 years in two phases. Tools used were Vineland's Adaptive Behavior Scales, Modified Checklist for Autism in Toddlers, Gilliam Autism Rating scale, and Denver II Developmental screening test. The overall prevalence of children at high risk of ASD was 3.3% (95% CI:3.1%-3.5%). Children living without mothers in homes, suffered from convulsions (AOR = 3.67; 95%CI:2.8-4.8), a history of cyanosis after birth (AOR = 1.87; 95% CI:1.35-2.59) or history of LBW babies (AOR = 1.53; 95% CI:1.23-1.89) carried higher odds of being at high risk of ASD.

National screening for Egyptian children aged 1 year up to 12 years at high risk of Autism and its determinants: a step for determining what ASD surveillance needs

This study aimed to provide a national estimate of the prevalence of the high risk of autism spectrum disorder (ASD) and their determinants. A national screening survey was conducted for 41,640 Egyptian children aged 1 to 12 years in two phases. Tools used were Vineland's Adaptive Behavior Scales, Modified Checklist for Autism in Toddlers, Gilliam Autism Rating scale, and Denver II Developmental screening test. The overall prevalence of children at high risk of ASD was 3.3% (95% CI:3.1%–3.5%). Children living without mothers in homes, suffered from convulsions (AOR = 3.67; 95%CI:2.8–4.8), a history of cyanosis after birth (AOR = 1.87; 95% CI:1.35–2.59) or history of LBW babies (AOR = 1.53; 95% CI:1.23–1.89) carried higher odds of being at high risk of ASD.

Traditional uses, chemical compounds, pharmacological activities and clinical studies on the traditional Chinese prescription Yi-Gan San

ETHNOPHARMACOLOGICAL RELEVANCE

A widely used traditional prescription, Yi-Gan San (YGS) is a remedy for neurodegenerative disorders. The formulation consists of seven Chinese medicinal materials in specific proportions, namely Uncariae Ramulus cum Uncis (Uncaria rhynchophylla (Miq.) Miq. ex Havil.), Bupleuri Radix (Bupleurum chinense DC.), Angelicae Sinensis Radix (Angelica sinensis (Oliv.) Diels), Chuanxiong Rhizoma (Ligusticum wallichii Franch.), Poria (Poria cocos (Schw.) Wolf), Atractylodis Macrocephalae Rhizoma (Atractylodes macrocephala Koidz.) and Glycyrrhizae Radix et Rhizoma (Glycyrrhiza uralensis Fisch.). Using YGS has been shown to alleviate various behavioural and psychological symptoms of dementia (BPSD).

AIM OF THIS REVIEW

The goal of this review is to give up-to-date information about the traditional uses, chemistry, pharmacology and clinical efficacy of YGS based on the scientific literature and to learn the current focus and provide references in the next step.

MATERIALS AND METHODS

The database search room was accessed using the search terms "Yi-Gan San" and "Yokukansan" to obtain results from resources such as Web of Science, PubMed, Google Scholar and Sci Finder Scholar. We not only consulted the literature of fellow authors for this review but also explored classical medical books.

RESULTS

YGS has been used to cure neurosis, sleeplessness, night weeping and restlessness in infants. Its chemical components primarily consist of triterpenes, flavonoids, phenolics, lactones, alkaloids and other types of compounds. These active ingredients displayed diverse pharmacological activities to ameliorate BPSD by regulating serotonergic, glutamatergic, cholinergic, dopaminergic, adrenergic, and GABAergic neurotransmission. In addition, YGS showed neuroprotective, antistress, and anti-inflammatory effects. The majority of cases of neurodegenerative disorders are treated with YGS, including Alzheimer's disease and dementia with Lewy bodies.

CONCLUSIONS

Based on previous studies, YGS has been used as a traditional prescription in East Asia, such as Japan, Korea and China, and it has diverse chemical compounds and multiple pharmacological activities. Nevertheless, few experimental studies have focused on chemical and quantitative YGS studies, suggesting that further comprehensive research on its chemicals and quality assessments is critical for future evaluations of drug efficacy.

Clinical Safety and Treatment of Severe Aggression: Behavioral-Pharmacological Intervention Evaluation in a Young Adult With Autism Spectrum Disorder

This case study concerned clinical safety and behavioral-pharmacological intervention with an 18-year-old man who had autism spectrum disorder and high-frequency aggression toward care providers at a specialized school. A multicomponent behavior support plan included antecedent, differential reinforcement, environmental modification, and physical management procedures subsequently combined with psychotropic medication (aripiprazole). Clinical safety components emphasized comprehensive care provider training, continuous supervision, function-based treatment, and prevention-focused strategies. The behavioral-pharmacological intervention eliminated implementation of aggression-contingent physical restraint and was associated with increased transition compliance during the school day. Throughout the 7.5 months duration of the study, there were no injuries to the participant or other students and a single injury was sustained by one care provider. Intervention effects were long-standing, and care providers rated their training, implementation fidelity, and therapeutic outcome favorably.

Self-management interventions for reducing challenging behaviors among school-age students: A systematic review

Background

Challenging classroom behaviors can interfere with student social and academic functioning and may be harmful to everyone in schools. Self-management interventions within schools can address these concerns by helping students develop necessary social, emotional, and behavioral skills. Thus, the current systematic review synthesized and analyzed school-based self-management interventions used to address challenging classroom behaviors.

Objectives

The current study aimed to inform practice and policy by (a) evaluating the effectiveness of self-management interventions at improving classroom behaviors and academic outcomes and (b) examining the state of research for self-management interventions based on existing literature.

Search Methods

Comprehensive search procedures included electronically searching online databases (e.g., EBSCO Academic Search Premier, MEDLINE, ERIC, PsycINFO), hand-searching 19 relevant journals (e.g., School Mental Health, Journal of School Psychology), reference-list searching 21 relevant reviews, and searching gray literature (e.g., contacting authors, searching online dissertation/theses databases and national government clearinghouses/websites). Searches were completed through December of 2020.

Selection Criteria

Included studies employed either a multiple group-design (i.e., experimental or quasi-experimental) or single-case experimental research design and met the following criteria: (a) utilized a self-management intervention, (b) conducted in a school setting, (c) included school-aged students, and (d) assessed classroom behaviors.

Data Collection and Analysis

Standard data collection procedures expected by the Campbell Collaboration were used in the current study. Analyses for single-case design studies incorporated three-level hierarchical models to synthesize main effects, and meta-regression for moderation. Further, robust variance estimation was applied to both single-case design and group-design studies to account for dependency issues.

Main Results

Our final single-case design sample included 75 studies, 236 participants, and 456 effects (i.e., 351 behavioral outcomes and 105 academic outcomes). Our final group-design sample included 4 studies, 422 participants, and 11 total behavioral effects. Most studies occurred in the United States, in urban communities, in public schools, and in elementary settings. Single-case design results indicated that self-management interventions significantly and positively impacted both student classroom behaviors (LRRi = 0.69, 95% confidence interval [CI] [0.59, 0.78]) and academic outcomes (LRRi = 0.58, 95% CI [0.41, 0.76]). Single-case results were found to be moderated by student race and special education status, whereas intervention effects were more pronounced for African American students (F = 5.56, p = 0.02) and students receiving special education services (F = 6.87, p = 0.01). Single-case results were not found to be moderated by intervention characteristics (i.e., intervention duration, fidelity assessment, fidelity method, or training). Despite positive findings for single-case design studies, risk of bias assessment indicated methodological shortcomings that should be considered when interpreting findings. A significant main effect of self-management interventions for improving classroom behaviors was also revealed for group-design studies (g = 0.63, 95% CI [0.08, 1.17]). However, these results should be interpreted with caution given the small number of included group-design studies.

Implications for Policy Practice and Research

The current study, conducted using comprehensive search/screening procedures and advanced meta-analytic techniques, adds to the large amount of evidence indicating that self-management interventions can be successfully used to address student behaviors and academic outcomes. In particular, the use specific self-management elements (i.e., self-determining a performance goal, self-observing and recording progress, reflecting on a target behavior, and administering primary reinforcers) should be considered within current interventions as well as in the development of future interventions. Future research should aim to assess the implementation and effects of self-management at the group or classroom-level within randomized controlled trials.

Non-pharmacological interventions for autism spectrum disorder in children: an overview of systematic reviews

OBJECTIVE

To assess the effectiveness of non-pharmacological interventions for the treatment of autism spectrum disorder (ASD) in children.

DESIGN

Overview of systematic reviews (SRs).

PARTICIPANTS

Children aged 12 years and under with ASD.

SEARCH METHODS

In October 2021, we searched Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO and Epistemonikos placing no restrictions on language or date of publication.

INTERVENTIONS

17 non-pharmacological interventions compared with placebo, no-treatment (including waiting list) or other interventions (ie, usual care, as defined by the authors of each study).

DATA COLLECTION AND ANALYSIS

We rated the methodological quality of the included SRs using A Measurement Tool to Assess Systematic Reviews (AMSTAR 2). We reported the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) certainty of the evidence (CoE) according to the analysis conducted by the authors of the included SRs.

MAIN OUTCOME MEASURES

A multidisciplinary group of experts agreed on analysing nine critical outcomes evolving core and non-core ASD symptoms.

PUBLIC AND PATIENT INVOLVEMENT STATEMENT

Organisations of parents of children with ASD participated in external revision of the final version of the report.

RESULTS

We identified 52 reports that were within our scope, of which 48 were excluded for various reasons. After excluding less reliable SRs, we included four SRs. Non-pharmacological interventions (ie, Early Intensive Behavioural Intervention, Applied Behaviour Analysis, Picture Exchange Communication System and Naturalistic Developmental Behavioural Interventions) may have favourable effects on some core outcomes including language, social and functioning, play or daily living skills in children with ASD (with either no GRADE assessment, very low or low CoE). In addition, we identified a lack of report for other key outcomes in the included SRs (ie, restricted, repetitive behaviour; play and sensory processing).

CONCLUSIONS

Synthesised evidence regarding the efficacy of non-pharmacological interventions for children with ASD is scarce. High-quality SRs addressing the variety of both non-pharmacological interventions and relevant outcomes are needed.

PROSPERO REGISTRATION NUMBER

CRD42020206535.

Symptomatic, Genetic, and Mechanistic Overlaps between Autism and Alzheimer's Disease

Autism spectrum disorder (ASD) and Alzheimer's disease (AD) are neurodevelopmental and neurodegenerative disorders affecting two opposite ends of life span, i.e., childhood and old age. Both disorders pose a cumulative threat to human health, with the rate of incidences increasing considerably worldwide. In the context of recent developments, we aimed to review correlated symptoms and genetics, and overlapping aspects in the mechanisms of the pathogenesis of ASD and AD. Dementia, insomnia, and weak neuromuscular interaction, as well as communicative and cognitive impairments, are shared symptoms. A number of genes and proteins linked with both disorders have been tabulated, including MECP2, ADNP, SCN2A, NLGN, SHANK, PTEN, RELN, and FMR1. Theories about the role of neuron development, processing, connectivity, and levels of neurotransmitters in both disorders have been discussed. Based on the recent literature, the roles of FMRP (Fragile X mental retardation protein), hnRNPC (heterogeneous ribonucleoprotein-C), IRP (Iron regulatory proteins), miRNAs (MicroRNAs), and α-, β0, and γ-secretases in the posttranscriptional regulation of cellular synthesis and processing of APP (amyloid-β precursor protein) have been elaborated to describe the parallel and overlapping routes and mechanisms of ASD and AD pathogenesis. However, the interactive role of genetic and environmental factors, oxidative and metal ion stress, mutations in the associated genes, and alterations in the related cellular pathways in the development of ASD and AD needs further investigation.