A Prediction Model of Autism Spectrum Diagnosis from Well-Baby Electronic Data Using Machine Learning

Early detection of autism spectrum disorder (ASD) is crucial for timely intervention, yet diagnosis typically occurs after age three. This study aimed to develop a machine learning model to predict ASD diagnosis using infants' electronic health records obtained through a national screening program and evaluate its accuracy. A retrospective cohort study analyzed health records of 780,610 children, including 1163 with ASD diagnoses. Data encompassed birth parameters, growth metrics, developmental milestones, and familial and post-natal variables from routine wellness visits within the first two years. Using a gradient boosting model with 3-fold cross-validation, 100 parameters predicted ASD diagnosis with an average area under the ROC curve of 0.86 (SD < 0.002). Feature importance was quantified using the Shapley Additive explanation tool. The model identified a high-risk group with a 4.3-fold higher ASD incidence (0.006) compared to the cohort (0.001). Key predictors included failing six milestones in language, social, and fine motor domains during the second year, male gender, parental developmental concerns, non-nursing, older maternal age, lower gestational age, and atypical growth percentiles. Machine learning algorithms capitalizing on preventative care electronic health records can facilitate ASD screening considering complex relations between familial and birth factors, post-natal growth, developmental parameters, and parent concern.

Fetal brain growth and infant autistic traits

BACKGROUND

Structural differences exist in the brains of autistic individuals. To date only a few studies have explored the relationship between fetal brain growth and later infant autistic traits, and some have used fetal head circumference (HC) as a proxy for brain development. These findings have been inconsistent. Here we investigate whether fetal subregional brain measurements correlate with autistic traits in toddlers.

METHODS

A total of 219 singleton pregnancies (104 males and 115 females) were recruited at the Rosie Hospital, Cambridge, UK. 2D ultrasound was performed at 12-, 20- and between 26 and 30 weeks of pregnancy, measuring head circumference (HC), ventricular atrium (VA) and transcerebellar diameter (TCD). A total of 179 infants were followed up at 18-20 months of age and completed the quantitative checklist for autism in toddlers (Q-CHAT) to measure autistic traits.

RESULTS

Q-CHAT scores at 18-20 months of age were positively associated with TCD size at 20 weeks and with HC at 28 weeks, in univariate analyses, and in multiple regression models which controlled for sex, maternal age and birth weight.

LIMITATIONS

Due to the nature and location of the study, ascertainment bias could also have contributed to the recruitment of volunteer mothers with a higher than typical range of autistic traits and/or with a significant interest in the neurodevelopment of their children.

CONCLUSION

Prenatal brain growth is associated with toddler autistic traits and this can be ascertained via ultrasound starting at 20 weeks gestation.

Insight and Recommendations for Fragile X-Premutation-Associated Conditions from the Fifth International Conference on FMR1 Premutation

The premutation of the fragile X messenger ribonucleoprotein 1 (FMR1) gene is characterized by an expansion of the CGG trinucleotide repeats (55 to 200 CGGs) in the 5' untranslated region and increased levels of FMR1 mRNA. Molecular mechanisms leading to fragile X-premutation-associated conditions (FXPAC) include cotranscriptional R-loop formations, FMR1 mRNA toxicity through both RNA gelation into nuclear foci and sequestration of various CGG-repeat-binding proteins, and the repeat-associated non-AUG (RAN)-initiated translation of potentially toxic proteins. Such molecular mechanisms contribute to subsequent consequences, including mitochondrial dysfunction and neuronal death. Clinically, premutation carriers may exhibit a wide range of symptoms and phenotypes. Any of the problems associated with the premutation can appropriately be called FXPAC. Fragile X-associated tremor/ataxia syndrome (FXTAS), fragile X-associated primary ovarian insufficiency (FXPOI), and fragile X-associated neuropsychiatric disorders (FXAND) can fall under FXPAC. Understanding the molecular and clinical aspects of the premutation of the FMR1 gene is crucial for the accurate diagnosis, genetic counseling, and appropriate management of affected individuals and families. This paper summarizes all the known problems associated with the premutation and documents the presentations and discussions that occurred at the International Premutation Conference, which took place in New Zealand in 2023.

Executive Function and Working Memory Deficits in Females with Fragile X Premutation

The Fragile X premutation is a genetic instability of the FMR1 gene caused by 55–199 recurrences of the CGG sequence, whereas there are only 7–54 repeats of the CGG sequence in the normal condition. While males with the premutation of Fragile X were found to have difficulties in executive functions and working memory, little data have been collected on females. This study is among the first to address executive functions and phonological memory in females with the Fragile X premutation. Twenty-three female carriers aged 20–55 years and twelve non carrier females matched in age and levels of education (in years) participated in this study. Executive functions and phonological memory were assessed using the self-report questionnaire The Behavior Rating Inventory of Executive Function (BRIEF) and behavioral measures (nonword repetitions, forward and backward digit span). Females who were carriers of the premutation of the FMR1 gene reported less efficient executive functions in the BRIEF questionnaire compared to the control group. In addition, a relationship was found between the number of repetitions on the CGG sequence of nucleotides, nonword repetitions, and forward digit span. The findings suggest that the premutation of Fragile X in females affects their performance of executive functions and may have impact on everyday functioning.

An escalating continuum of learning and attention difficulties from premutation to full mutation in female carriers of FMR1 expansion

Objective

Carriers of Fragile X premutation may have associated medical comorbidities, such as Fragile X-associated tremor and ataxia (FXTAS) and Fragile X-associated premature ovarian insufficiency (FXPOI). We examined the Fragile X premutation effect on cognition, and we assumed that there is a direct correlation between the continuous spectrum of specific learning and attention deficits to the number of CGG repeats on the FMR1 gene.

Methods

A total of 108 women were referred to our center due to a related Fragile X syndrome (FXS) patient, 79 women carried a premutation of 56-199 repeats, and 19 women carried a full mutation of more than 200 CGG repeats on FMR1 gene. Genetic results of CGG repeats, demographic information, structured questionnaires for ADHD, learning disabilities of language and mathematics, and independence level were analyzed in women carrying the FMR1 premutation and compared to the group carrying the full mutation. Women with FXS and FXTAS were excluded.

Results

When analyzed as a continuum, there was a significant increase in the following complaints which were associated with a higher number of repeats: specific daily function skills such as driving a car, writing checks, disorientation in directions, and also specific learning difficulties such as spelling and math difficulties. Additionally, when tested as a categorical independent variable, we observe that women with the full mutation were more likely to have ADHD or other learning disability diagnoses in the past than during premutation (<200 CGG repetitions).

Conclusion

Specific learning and attention difficulties and resulting daily function difficulties correlate with an increased number of CGG repeats and are more likely to be associated as a common feature of premutation and full mutation in a female premutation carrier. Despite evidence of learning and attention difficulties, it is encouraging that most female carriers of the premutation and full mutation function well in most areas. Nevertheless, they face significant difficulties in specific areas of functioning such as driving, and confusion in times and schedules. Those daily function skills are mostly impacted by dyscalculia, right and left disorientation, and attention difficulties. This may aid to design specific interventions to address specific learning deficits in order to improve daily function skills and quality of life.

Missed initial appointments at Israeli child development centres: Rate, reasons, and associated characteristics

INTRODUCTION

Missed appointments (MAs) at child development centres (ChDCs) cause multiple problems: they preclude timely diagnosis and treatment of both the invited child and children whose appointment was delayed due to overbooking, as well as disrupting efficient organisational management. The aim of this study was to assess the rate and describe the reasons for missed appointments at Israeli ChDCs, and to evaluate the association of socio-demographic, clinical, and administrative variables with MA rates.

METHODS

This nested case-control study included all children scheduled for initial appointments (N = 1143) at three centres during 1 year. Parents of children who missed their appointment and a sample of those who attended were interviewed by telephone.

RESULTS

The rate of missed appointments was 26.6%, and the most frequent reasons were unexpected events (26.0%) and lack of insurance coverage (23.4%). Variables associated with lower MA rates were: having had ≥3 types of rehabilitative interventions (odds ratios (OR) = 0.26; 95% confidence interval [CI] 0.16-0.44), detailed referral letter (OR = 0.48; 95%CI 0.30-0.75), telephone reminder (OR = 0.37; 95%CI 0.24-0.57) and health maintenance organisations or private insurance coverage (OR = 0.12; 95%CI 0.06-0.17 and OR = 0.56; 95% CI 0.38-0.89, respectively).

CONCLUSION

Encouraging physician's referral letters and personal-contact reminders can reduce missed appointments. Understanding the family's and the child's personal characteristics, and the organisational/administrative aspects of missed appointments may guide efforts to ensure timely care for every child.

Home-quarantine during the initial Covid-19 outbreak in Israel: parent perceived impact on children with ASD

Background

Studies have reported that Covid-19 home-quarantine periods have had mostly negative psychological impact on children with ASD and their families. Here we examined parent perceived impact of a 6-week quarantine period imposed in Israel at the beginning of the Covid-19 outbreak, in mid-March 2020.

Methods

An anonymous online questionnaire was completed by parents of 268 children with ASD. Parents rated deterioration/improvement in their child's behaviors, abilities, mood, sleep, and anxiety along with changes in their own mood, sleep, parenting skills, and family relationships. We performed t-tests and ANOVA analyses to assess the significance of perceived impact on each domain and potential differences in the impact across families with children of different ages, genders, and levels of required support as well as families that experienced different magnitudes of economic hardships.

Results

Parents reported significant deterioration in their mood and sleep along with significant improvements in relationships with their spouse and child with ASD, and in their parenting skills. Parents also reported significant increases in the severity of tantrums, anxiety, and restricted and repetitive behavior symptoms along with significant improvements in social and communication abilities of their child with ASD. Ratings were significantly lower in families of ASD children who regularly require more support and in families that experienced economic hardships.

Conclusions

While periods of home-quarantine create numerous hardships for families of children with ASD, they may also offer an opportunity for improving parenting skills, family relationships, and children's social communication abilities with potential relevance for improving remote services.

The myth of vaccination and autism spectrum

BACKGROUND

Among all of the studied potential causes of autism, vaccines have received some of the most scrutiny and have been the topic of many evidence-based studies. These efforts have led the great majority of scientists, physicians, and public health researchers to refute causation between vaccines and autism.

RATIONALE

This presumed association and concern has been a major contributor to parents' refusal to immunize their children and has become a major threat to public health in secluded populations over the last two decades, even prior to the COVID-19 pandemic. With the emergence of COVID-19 immunizations, sentiments towards this topic were addressed as a public health concern that may influence the ability to overcome the Corona virus worldwide.

SCIENTIFIC REVIEW OF DATA

Despite the overwhelming data demonstrating that there is no link between vaccines and autism, many parents are hesitant to immunize their children because of the alleged association. Other contributing factors to the myths and conspiracy theories surrounding the association between vaccines and autism include the fact that the diagnosis of autism is typically made after the age of receiving the main childhood immunizations, as well as the occasional occurrence of regression after the age of first year vaccinations. In spite of vast evidence that the main contribution to the increase in incidence is from improvement of the diagnostic process, this rapid and publicized rise in autism diagnoses feeds parental concerns regarding any medical intervention that may be associated with the health of their children.

RECOMMENDATIONS

It is plausible that with more evidence-based studies linking autism to specific etiologies the myth will diminish and disappear eventually. In an era where conspiracy theories are prevalent on social media, it is critical that evidence-based studies relating autism to specific etiologies be made public, and that information concerning autism diagnosis and causes be made more readily available through social media and parental organizations.

Gaboxadol in Fragile X Syndrome: A 12-Week Randomized, Double-Blind, Parallel-Group, Phase 2a Study

Background: Fragile X syndrome (FXS), the most common single-gene cause of intellectual disability and autism spectrum disorder (ASD), is caused by a >200-trinucleotide repeat expansion in the 5' untranslated region of the fragile X mental retardation 1 (FMR1) gene. Individuals with FXS can present with a range of neurobehavioral impairments including, but not limited to: cognitive, language, and adaptive deficits; ASD; anxiety; social withdrawal and avoidance; and aggression. Decreased expression of the γ-aminobutyric acid type A (GABA_A) receptor δ subunit and deficient GABAergic tonic inhibition could be associated with symptoms of FXS. Gaboxadol (OV101) is a δ-subunit-selective, extrasynaptic GABA_A receptor agonist that enhances GABAergic tonic inhibition, providing the rationale for assessment of OV101 as a potential targeted treatment of FXS. No drug is approved in the United States for the treatment of FXS. Methods: This 12-weeks, randomized (1:1:1), double-blind, parallel-group, phase 2a study was designed to assess the safety, tolerability, efficacy, and optimal daily dose of OV101 5 mg [once (QD), twice (BID), or three-times daily (TID)] when administered for 12 weeks to adolescent and adult men with FXS. Safety was the primary study objective, with key assessments including treatment-emergent adverse events (TEAEs), treatment-related adverse events leading to study discontinuation, and serious adverse events (SAEs). The secondary study objective was to evaluate the effect of OV101 on a variety of problem behaviors. Results: A total of 23 participants with FXS (13 adolescents, 10 adults) with moderate-to-severe neurobehavioral phenotypes (Full Scale Intelligence Quotient, 41.5 ± 3.29; ASD, 82.6%) were randomized to OV101 5 mg QD (n = 8), 5 mg BID (n = 8), or 5 mg TID (n = 7) for 12 weeks. OV101 was well tolerated across all 3 treatment regimens. The most common TEAEs were upper respiratory tract infection (n = 4), headache (n = 3), diarrhea (n = 2), and irritability (n = 2). No SAEs were reported. Improvements from baseline to end-of-treatment were observed on several efficacy endpoints, and 60% of participants were identified as treatment responders based on Clinical Global Impressions-Improvement. Conclusions: Overall, OV101 was safe and well tolerated. Efficacy results demonstrate an initial signal for OV101 in individuals with FXS. These results need to be confirmed in a larger, randomized, placebo-controlled study with optimal outcomes and in the most appropriate age group. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03697161.

A single center experience with publicly funded clinical exome sequencing for neurodevelopmental disorders or multiple congenital anomalies

Exome sequencing (ES) is an important diagnostic tool for individuals with neurodevelopmental disorders (NDD) and/or multiple congenital anomalies (MCA). However, the cost of ES limits the test's accessibility for many patients. We evaluated the yield of publicly funded clinical ES, performed at a tertiary center in Israel, over a 3-year period (2018–2020). Probands presented with (1) moderate-to-profound global developmental delay (GDD)/intellectual disability (ID); or (2) mild GDD/ID with epilepsy or congenital anomaly; and/or (3) MCA. Subjects with normal chromosomal microarray analysis who met inclusion criteria were included, totaling 280 consecutive cases. Trio ES (proband and parents) was the default option. In 252 cases (90.0%), indication of NDD was noted. Most probands were males (62.9%), and their mean age at ES submission was 9.3 years (range 1 month to 51 years). Molecular diagnosis was reached in 109 probands (38.9%), mainly due to de novo variants (91/109, 83.5%). Disease-causing variants were identified in 92 genes, 15 of which were implicated in more than a single case. Male sex, families with multiple-affected members and premature birth were significantly associated with lower ES yield (p < 0.05). Other factors, including MCA and coexistence of epilepsy, autism spectrum disorder, microcephaly or abnormal brain magnetic resonance imaging findings, were not associated with the yield. To conclude, our findings support the utility of clinical ES in a real-world setting, as part of a publicly funded genetic workup for individuals with GDD/ID and/or MCA.

How Are They Doing? Neurodevelopmental Outcomes at School Age of Children Born Following Assisted Reproductive Treatments

OBJECTIVE

The purpose of this study was to assess major neurodevelopmental aspects of children conceived by assisted reproductive treatments compared to spontaneously conceived children during the early school years.

MATERIAL & METHODS

In this follow-up study, mothers of 358 children born following assisted reproductive treatments and 401 spontaneously-conceived children were interviewed by telephone regarding their children's health and development, when the children were 7-8 years old. The main outcomes were maternal responses to 4 questionnaires: Developmental Coordination Disorder Questionnaire, Short Sensory Profile, Autism Spectrum Screening Questionnaire, and the Attention-deficit hyperactive disorder (ADHD) Child Symptom Inventory-4 subscale. Mothers reported diagnoses of ADHD and autism spectrum disorder.

RESULTS

No significant differences were found between the groups in Developmental Coordination Disorder Questionnaire or Short Sensory Profile scores upon univariate or multivariable analyses. There was a slightly higher but nonsignificant rate of diagnosed ADHD among children in the assisted reproductive treatment group (9.6% vs 5.5%; P = .18); on multivariable analysis, a nonsignificant increase in ADHD was also found for assisted reproductive treatment children (hazard ratio 1.45, 95% confidence interval 0.81-2.61). Regarding the Child Symptom Inventory-4 criteria for ADHD among the children who had never been diagnosed, there was also a slightly higher but nonsignificant rate among the assisted reproductive treatments compared to spontaneously-conceived children on univariate (2.4% vs 1.8%; P = .50) and multivariable analysis (odds ratio 0.88, 95% confidence interval 0.27-2.86). Autism spectrum disorder diagnosis or Autism Spectrum Screening Questionnaire scores were not significantly different; however, 5 of the 6 children with autism spectrum disorder diagnoses were in the assisted reproductive treatment group.

CONCLUSIONS

Neurodevelopmental measures were similar in both groups, although nonconclusive regarding ADHD and autism spectrum disorder risk. These findings contribute to the knowledge regarding long-term assisted reproductive treatment outcomes.

The Weak Link: Hypotonia in Infancy and Autism Early Identification

Background: Presenting symptoms and age specific differential diagnosis of Autism Spectrum Disorder (ASD), determine the age of initial assessment and the age of a definite diagnosis. The AAP recommends screening all children for ASD at 18 and 24 months followed by a comprehensive evaluation for children with developmental concerns. More recently it has been recommended that the evaluation should be performed at a younger age, with a diagnosis being made as early as the beginning of the second year of life resulting in earlier intensive intervention. Objective: To assess early developmental milestones in a cohort of children diagnosed with Autism Spectrum Disorder (ASD) in order to find an objective and reliable early marker. We suggest that low muscle tone- hypotonia, is a sign that meets the above criteria of consistency and reliability and may be related to early diagnosis. Methods: We compared age distributions of ASD diagnosis in the presence of hypotonia in a dataset of 5,205 children diagnosed at Keshet Center. One thousand, one hundred eighty-two children (953 males) were diagnosed with ASD and compared to other developmental diagnoses. Within the ASD cohort we further analyzed for gender and pre-maturity differences. Results: In the presence of hypotonia, the mean age for ASD diagnosis was significantly lower (by 1.5 years for males and females) and this effect increased in children born at term as compared to pre-maturity. Conclusions: Hypotonia is a recognizable marker of ASD and may serve as a "red flag" to prompt earlier recognition and neurodevelopmental evaluation toward an autism diagnosis.

Motor delay - An early and more common "red flag" in girls rather than boys with autism spectrum disorder

BACKGROUND

Autism and intellectual disability may coincide and be preceded by global developmental delay or by motor delay.

HYPOTHESIS

Motor delay in the context of global developmental delay is an initial "red flag" for ASD, with added risk in girls.

OBJECTIVE

To assess early developmental milestones in girls with ASD as compared to diagnosed boys, considering prematurity risk.

METHOD

Developmental milestones in a cohort of 467 children with ASD - diagnosed at mean age of 3.4 years (SD = 2.2) - were analyzed according to gender and prematurity risk.

RESULTS

111 girls (24 %), 356 boys (76 %), presented with motor milestones acquisition grossly within the normal range. However, there was a shift towards acquisition of walking being at the later end of the norm range, with this shift being more prominent in girls. 60 % of girls and 47 % of boys with ASD had motor delay and 49 % of girls and 36 % of boys had global developmental delay. The extent of the delays was greater in the prematurity subgroup.

CONCLUSION

Global delay of early milestones occurred in half of children with ASD and in 60 % of girls with ASD. Delayed acquisition of independent walking is relatively more common in girls subsequently diagnosed with ASD.

Autism risk linked to prematurity is more accentuated in girls

INTRODUCTION

Prematurity has been identified as a risk factor for Autism Spectrum Disorder (ASD). The link between Autism Spectrum Disorder (ASD) and birth-week has not been strongly evidenced. We evaluated the correlation between the degree of prematurity and the incidence of autism in a cohort of 871 children born prematurely and followed from birth. The cohort was reduced to 416 premature infants born between 2011-2017 who were followed for 2-14 years, and analyzed according to birth week (degree of prematurity), and according to gender.

RESULTS

43 children (10.3%) received a definite diagnosis of ASD. There was a significant correlation between birth week and the risk of ASD, with 22.6% of children diagnosed with ASD when born at 25 weeks, versus 6% of ASD diagnoses at 31 weeks of prematurity. For children born after 32 weeks, the incidence decreased to 8-12.5%. A strong link was found between earlier birth week and increased autism risk; the risk remained elevated during near-term prematurity in boys. A correlation between early birth week and an elevated risk for ASD was seen in all children, but accentuated in females, gradually decreasing as birth week progresses; in males the risk for ASD remains elevated for any birth week.

CONCLUSION

A statistically significant increase in rates of autism was found with each additional week of prematurity. Females drove this direct risk related to degree of prematurity, while males had an elevated risk throughout prematurity weeks, even at near-term. We recommend including ASD screening in follow up of infants born prematurely, at all levels of prematurity.

Content Words in Child-Directed Speech of Mothers Toward Children With Autism Spectrum Disorder

Purpose Our study aimed to analyze the characteristics of content word usage in mother's child-directed speech ( CDS) toward children with autism spectrum disorder compared to mother's CDS toward typically developing children. Method We analyzed the lexical characteristics of CDS of mothers of children with autism (16 dyads) and compared them from a language developmental perspective to mothers of 20 typical children at the same level of expressive language development. Results Results suggest that mothers of children with autism use equal amounts of content words at the same language level, but the content consists of significantly more concrete nouns and active verbs and rarely the use of abstract nouns, stative verbs, adjectives, and adverbs. Conclusion This study suggests that professionals and parents of children with autism should be aware of the importance of varying their language use of content words.

Prolonged Time Lag to Final Diagnosis of Fragile X Syndrome

OBJECTIVE

To evaluate the diagnostic process in children ultimately diagnosed with fragile X syndrome (FXS), with an emphasis on the time lag between initial presentation and on diagnosis in female vs male children.

STUDY DESIGN

Interviews were conducted with 89 families of children with a final diagnosis of FXS and assessment of time intervals between initial presentation and confirmed molecular diagnosis.

RESULTS

Screening of 117 patients (25 female patients) from the 89 families revealed that less than 20% of patients obtained a diagnosis within the first year of seeking medical attention. Mean age at the time of initial presentation was 12.3 months in male patients and 23 months in female patients, while definitive diagnosis of FXS was made at a mean of 4 and 9 years, respectively. Presenting symptoms of developmental delays were recognized by 72% of parents, and 84% had another child with FXS before the index case diagnosis. Average age of diagnosis for children with FXS born since 2007 was significantly lower at 31.9 months, compared with 69.5 months for children born before 2007.

CONCLUSIONS

Although FXS is a significant and prevalent cause of disability in children, it is underdiagnosed and diagnosed late, especially in female patients. In every male and female patient presenting with developmental delay or autism, FXS should be considered. Dysmorphic physical features may not be present in infancy, and the absence of those features cannot exclude a diagnosis of FXS.

When the Ideal Meets the Feasible: Constructing a Protocol for Developmental Assessment at Early School-Age

Objective: To describe development of a methodology for an outcome study of children born following in-vitro fertilization or spontaneously-conceived, as a model for defining normal and below-normal development of school-age children for research purposes. Study Design: The main issues addressed were defining the major health and developmental domains to be investigated, selection of age-appropriate validated instruments, considering time constraints to maximize compliance, and budgetary limitations. The final protocol included a half-hour structured telephone interview with mothers of all 759 children and a 2-h developmental assessment of 294 of them. Each of the instruments and recruiting methods are described in terms of the abovementioned considerations. Results: Almost all of the mothers who agreed to be interviewed completed it within the half-hour allotted; however only about half of those who agreed to bring the child for the developmental assessment actually did so. The entire examination battery, assessing cognitive ability, executive functions, attention, and learning skills, was completed by almost all 294 children. There was a significant degree of agreement between the maternal report of the child's reading, writing and arithmetic skills and the in-person examination, as well as regarding the child's weight and height measurements. Conclusion: The findings lend support for a low-budget study, relying on telephone interviews. However, limitations such as the validity of maternal report and recall bias must be taken into consideration.

Meal time behavior difficulties but not nutritional deficiencies correlate with sensory processing in children with autism spectrum disorder

BACKGROUND

Food aversion and nutritional difficulties are common in children with autism spectrum disorder.

AIM

To compare meal time behavior of children with autism to their typically developing siblings and to typical controls and to examine if sensory profiles can predict meal time behavior or nutritional deficiencies in the autism group.

Fragile X Premutation Carrier Epidemiology and Symptomatology in Israel-Results from a Tertiary Child Developmental Center

Fragile X syndrome (FXS) is the most prevalent known genetically inherited cause for autism and intellectual disability. Premutation state can cause several clinical disorders as well. We aimed to perform a nesting approach to acquire data with regard to first degree relatives of index fragile X cases at the largest child development center in Israel in order to map characteristics of Israeli FXS permutation women carriers. Seventy-nine women were referred due to a related fragile X syndrome patient, mainly an offspring or sibling. General information regarding demographics, ethnicity, and associated medical conditions were collected using interviews and structured questionnaires. Thirteen (17 %) of the women who were referred as "carrier" were proven to be actually full mutation. The mean years of education were 14 (±1.51, range 12-17). Twenty-one women (27 %) originated from Tunisia (mainly from the island of Djerba). Ten women (13 %) reported delivery of their affected offspring beyond 41 gestational weeks. Twenty-two percent of women with premutation reported symptoms consistent with learning difficulties, mainly dyscalculia, and 14 % reported ADHD symptoms. Awareness about clinical disorders of the carriers was existent only in 25 % of the patients. Increased awareness and knowledge dissemination concerning premutation symptomatology and associated medical conditions are warranted. We suggest a national registry to be installed in different countries in order to identify fragile X premutation carriers at increased risk for various medical complications.

Fetal cerebral ventricular atria width of 8-10mm: A possible prenatal risk factor for adolescent treated Attention Deficit Hyperactivity Disorder (ADHD)

The purpose of our research was to study the in-utero and long term post-natal outcome of fetal isolated cerebral ventricular atria width between 8 and 10mm. We conducted a retrospective, observational, case-control study, of low risk pregnant women, between 1993 and 2001. One hundred and forty one fetuses with isolated cerebral ventricular atria width between 8 and 10mm, corresponding to 2-4 standard deviations above the mean, and 309 controls, with atrial width below this level, were included for the analysis. Clinical data concerning pre and post-natal outcome was retrieved from computerized medical records. Matching of cases with controls was based on age, with a ratio of 2-3 controls per case. Statistical analysis included: T-test, Chi-Square, and Multiple Logistic Regression analysis. The study group was characterized by a predominance of male gender, left side involvement, and higher birth weight, compared to the control group. Long term post-natal follow-up at a mean age of 12.7 years (±1.9) demonstrated an adjusted odds ratio of 2.589 (95% CI 1.415-4.737, p=0.001), being diagnosed as Attention Deficit Hyperactivity Disorder (ADHD), and treated by Methylphenidate (Ritalin(®)), during childhood, compared to the control group (23.6% and 10.0% respectively) (p=0.001). Cerebral atria width was an independent factor, controlled for the only two significant variants between groups, gender and weight over 90th centile. In conclusions, our preliminary results show that fetuses with prenatal finding of isolated cerebral ventricular atria width between 8 and 10mm are more likely of being diagnosed and treated as ADHD during childhood.

Prolonged auditory brainstem responses in infants with autism

Numerous studies have attempted to identify early physiological abnormalities in infants and toddlers who later develop autism spectrum disorder (ASD). One potential measure of early neurophysiology is the auditory brainstem response (ABR), which has been reported to exhibit prolonged latencies in children with ASD. We examined whether prolonged ABR latencies appear in infancy, before the onset of ASD symptoms, and irrespective of hearing thresholds. To determine how early in development these differences appear, we retrospectively examined clinical ABR recordings of infants who were later diagnosed with ASD. Of the 118 children in the participant pool, 48 were excluded due to elevated ABR thresholds, genetic aberrations, or old testing age, leaving a sample of 70 children: 30 of which were tested at 0–3 months, and 40 were tested at toddlerhood (1.5–3.5 years). In the infant group, the ABR wave‐V was significantly prolonged in those who later developed ASD as compared with case‐matched controls (n = 30). Classification of infants who later developed ASD and case‐matched controls using this measure enabled accurate identification of ASD infants with 80% specificity and 70% sensitivity. In the group of toddlers with ASD, absolute and interpeak latencies were prolonged compared to clinical norms. Findings indicate that ABR latencies are significantly prolonged in infants who are later diagnosed with ASD irrespective of their hearing thresholds; suggesting that abnormal responses might be detected soon after birth. Further research is needed to determine if ABR might be a valid marker for ASD risk. Autism Res2016, 9: 689–695. © 2015 The Authors Autism Research published by Wiley Periodicals, Inc. on behalf of International Society for Autism Research

Assessment of Abilities and Comorbidities in Children With Cerebral Palsy

This study examines major comorbidities in children with severe cerebral palsy and the feasibility of psychological tests for measuring abilities in a more impaired population. Eighty psychological evaluations of children with cerebral palsy aged 1.8 to 15.4 years (mean = 5.6) were analyzed. Major comorbid disorders were correlated with severity of motor disability. More than half of the cohort were diagnosed with severe cerebral palsy according to the Gross Motor Function Classification System. Multiple subtests were combined in order to assess the intellectual level. Normal intelligence was found in 22.5%, and 41.3% had moderate or severe intellectual impairment. Epilepsy occurred in 32.5% and attention-deficit hyperactivity disorder (ADHD) in 22.5%. Intellectual disability correlated with motor ability and with epilepsy. In a logistic regression model, epilepsy and motor ability score predicted 29.9% of IQ score variance. Intellectual impairment and epilepsy are common comorbidities. Subtests from different scales should be applied and interpreted with caution.

The influence of a multisensory intervention for preterm infants provided by parents, on developmental abilities and on parental stress levels

Evaluation of a multisensory intervention based on the developmental approach provided by parents, during neonatal intensive care unit hospitalization of their preterm infants. After guidance of parents and implementation of intervention program, children were followed up to 2 to 3 years using scales for evaluation of parental stress levels and child's development. Our 2 to 3 years' follow-up study included 41 infants (20 controls and 21 who received parental-guided intervention) as part of a group of 95 preterm infants who participated in a short-term study. The intervention group showed significantly higher scores in receptive language and fine-motor domains of the Bayley Scale of Infant and Toddler Development-3rd Edition. Boys showed superior improvements in language skills. No differences were found in the cognitive and adaptive domains. There were no differences in parental stress levels. A multisensory intervention program for preterm infants provided by trained and supervised parents may improve language and motor outcomes at 2 to 3 years.

CYP2D6 genotyping in paediatric patients with autism treated with risperidone: a preliminary cohort study

AIM

To evaluate the association between cytochrome P450 2D6 (CYP2D6) phenotypes in paediatric patients with autistic spectrum disorders (ASD) treated with risperidone, adverse drug reactions (ADRs), and drug efficacy.

METHOD

An observational cohort study of 40 children (34 males, six females; median age 7y range 3-18y) with autistic disorder, pervasive developmental disorder not otherwise specified, or Asperger syndrome diagnosed using the Autism Diagnostic Interview-Revised and treated with risperidone for at least 3 months. Charts were reviewed for demographic and clinical information, response to treatment was assessed by parents and the treating neurologist on a three-point scale, and information about ADRs was collected. Trough plasma levels of risperidone and its metabolites were determined and CYP2D6 genotyping was performed.

RESULTS

Twenty-six patients responded to therapy and 11 patients exhibited ADRs. CYP2D6 genotyping showed two patients to be poor metabolizers, two ultra-rapid metabolizers, seven intermediate metabolizers, and 29 extensive metabolizers. Both ultra-rapid metabolizer patients were non-responders and had no ADRs. In contrast, both poor metabolizer patients were responders but experienced ADRs. No correlation was found between risperidone dosage and either risperidone or drug metabolite plasma levels. There was no difference in risperidone or metabolite plasma levels when comparing responders to non-responders, or when comparing patients with or without ADRs.

INTERPRETATION

In patients with ASD treated with risperidone, a CYP2D6 phenotype may be associated with response to treatment and development of ADRs.

An etiologic classification of autism spectrum disorders

BACKGROUND

Autism spectrum disorders (ASD) represent a common phenotype related to multiple etiologies, such as genetic, brain injury (e.g., prematurity), environmental (e.g., viral, toxic), multiple or unknown causes.

OBJECTIVES

To devise a clinical classification of children diagnosed with ASD according to etiologic workup.

METHODS

Children diagnosed with ASD (n = 436) from two databases were divided into groups of symptomatic cryptogenic or idiopathic, and variables within each database and diagnostic category were compared.

RESULTS

By analyzing the two separate databases, 5.4% of the children were classified as symptomatic, 27% as cryptogenic and 67.75% as idiopathic. Among other findings, the entire symptomatic group demonstrated language delays, but almost none showed evidence for regression. Our results indicate similarities between the idiopathic and cryptogenic subgroups in most of the examined variables, and mutual differences from the symptomatic subgroup. The similarities between the first two subgroups support prior evidence that most perinatal factors and minor physical anomalies do not contribute to the development of core symptoms of autism.

CONCLUSIONS

Differences in gender and clinical and diagnostic features were found when etiology was used to create subtypes of ASD. This classification could have heuristic importance in the search for an autism gene(s).

Cognitive and developmental outcome of conservatively treated children with congenital hyperinsulinism

BACKGROUND

Congenital hyperinsulinism (CHI) is the most common cause of persistent hypoglycemia in infants. Its management can be extremely complicated, and may involve medical therapy and surgery. The mainstay of the treatment is to maintain normoglycemia, since hypoglycemia during infancy can have severe neurological consequences.

OBJECTIVE

To assess the cognitive and developmental levels and the adaptive skills achieved by children with CHI who were treated medically over the past decade.

SUBJECTS AND METHODS

Fourteen children with CHI, under the age of 10 years, who received medical treatment only, underwent a physical and neurological examination and standardized assessments that included the Bayley Scale of Infant and Toddler Development, 3rd Edition, or Kaufman Assessment Battery for Children, the Vineland Adaptive Behavior Scales and the Achenbach Child Behavior Checklist (CBCL) parent questionnaire form.

RESULTS

Twelve children (86%) achieved normal range scores in the cognitive and development assessments (Bayley Scale of Infant and Toddler Development or Kaufman Assessment Battery for Children). Only two showed cognitive achievements below the normal range. The Vineland questionnaire, which was based on parental report, showed below normal adaptive skills in eight patients (57%).

CONCLUSIONS

In contrast to previous studies showing a high prevalence of neurodevelopmental difficulties in children with congenital hyperinsulinism, our study showed normal cognitive achievements in most children. This may be attributed to the earlier recognition and better management of the disease in the past decade.

[Preschool diagnostic process and changes in diagnosis of autism spectrum disorder]

BACKGROUND

Autism spectrum disorders [ASD] are characterized by a wide range of neuropsychiatric comorbid disorders which change during early development. Coordinated collaboration between therapists from various disciplines and integrating measurements, may Lead to a comprehensive diagnosis of ASD. A diagnostic kindergarten set-up for children with a preliminary diagnosis of ASD or communication disorder can facilitate a multidisciplinary diagnosis, as an integral part of the child and parental intervention process.

GOALS

To examine the changes in the diagnosis of children after one year of observation and treatment in a special education set-up, including aspects such as common neuropsychiatric comorbidity, differential diagnosis and subsequent placement recommendations.

METHODS

Changes in the frequencies of ASD diagnoses were calculated prior to and following participation in the kindergarten for 76 children, who studied in the diagnostic kindergarten for ASD at the Weinberg Child Development Center during the last decade. Frequencies of neuropsychiatric comorbid disorders and differential diagnosis were calculated.

RESULTS

It was found that: half (44.7%) of the preliminary diagnoses changed after a year of treatment; 14.2% of the children admitted with other developmental diagnoses, were subsequently diagnosed with ASD and in the cases of 25% of the children with ASD, their diagnosis was removed. Neuropsychiatric comorbid disorders appeared in 66% of cases. The most common differential diagnosis was Language disability, which appeared in 76% of the cases.

CONCLUSIONS

This study reinforces the importance of a thorough assessment process conducted by a multidisciplinary team during and after treatment. A quarter of the children diagnosed with ASD in early childhood may have a different diagnosis later, usually milder, probably as a consequence of developmental changes combined with intensive treatment.

Prediction of participation and sensory modulation of late preterm infants at 12 months: a prospective study

The aim of the study was to prospectively assess the differences in participation and sensory modulation between late preterm infants (LPI) and term babies, and to predict it by LPI characteristics. The study population includes 124 late preterm infants at gestational age between 34 and 35 6/7 weeks who were born at the same medical center. The control group comprised of 33 term babies (18 boys, 15 girls), born during the same period and location (mean age 12.47, SD = 0.73). Sensory modulation was assessed by the test of sensory functions in infants and the infant/toddler sensory profile and for assessment of participation and parents' satisfaction we used questionnaires. Term infants had better sensory modulation than LPI. Approximately 10% of the sensory modulation of participants in the study was explained by gestational age and head circumference. LPI participation and parental satisfaction decreased in the LPI group. Among all the explanatory variables only multiple gestations and head circumference contributed to the explained variance of participation (16%), and parents' satisfaction (13%). At age of 1 year, children born as late preterm are at increased risk of developing sensory modulation disorder, showing less participation, and resulting in less parental satisfaction.

Psychiatric and autistic comorbidity in fragile X syndrome across ages

Fragile X syndrome is caused by CGG trinucleotide repeat expansion within the fragile X mental retardation 1 gene, when repeat number exceeds 200. The typical psychiatric profile of fragile X syndrome patients includes cognitive and behavioral deficits, psychiatric comorbidity, and autistic characteristics. Specific psychiatric features have not yet been clarified, specifically in relationship to age and genetic characteristics. The objective of this study was to characterize psychiatric comorbidities in subjects with fragile X syndrome at different ages. Subjects with fragile X syndrome and their unaffected siblings were recruited and their parents filled out functional-behavioral and psychiatric comorbidities questionnaires. Adolescents with fragile X syndrome showed decreased prevalence of functional-behavioral deficits. Incidence and severity of most psychiatric comorbidities were lower in older subjects. Incidence of generalized anxiety disorder increased with age in the fragile X syndrome group. The typical profile of patients with fragile X syndrome changes with age. Unaffected siblings exhibit anxiety and motor tics.

[Gastrointestinal symptoms in pediatric patients with attention deficit and hyperactivity disorders]

BACKGROUND

Only a few studies have addressed the subject of physical manifestations in children with attention deficit hyperactivity disorder (ADHD) and gastrointestinal (GI) complaints, although pharmacological treatments for ADHD may have GI symptoms as a main side effect.

AIM

The goal of this study was to assess whether children with ADHD have a higher frequency of GI symptoms compared with healthy children in the general population.

METHOD

The study group included 62 children with ADHD and 57 healthy children as a control group. The childrens' parents were asked to report on abdominal pain, diarrhea, constipation, encopresis, food intolerance or allergy. Height, weight and the medical data of the two groups were compared.

RESULTS

A higher frequency of food allergies was found in the ADHD group, but the relationship was at near significant levels only (p = 0.06), and open to criticism.

CONCLUSION

This study showed no obvious correlation between GI symptoms and ADHD in Israeli children.

Acute disseminated encephalomyelitis: an MRI/MRS longitudinal study

A clinical and radiologic diagnosis of acute disseminated encephalomyelitis was made in two children: a 6-month-old female who presented with focal seizures and thalamic and cerebral white matter lesions, and a 4.5-year-old male who presented with tremor and dystonia and had bilateral basal ganglia lesions, without evidence of active brain infection. Serial clinical and laboratory evaluations were supplemented by neuroimaging including routine magnetic resonance imaging and (1)H magnetic resonance spectroscopy. They were treated symptomatically, without using steroids or intravenous immunoglobulin, and both children recovered. Single voxel (1)H magnetic resonance spectroscopy data were acquired from the involved areas and from normal-appearing white matter. Abnormalities in N-acetyl-aspartate, choline, and lactate peaks were evident during the symptomatic phase, and persistence of low N-acetyl-aspartate was observed during recovery. These spectroscopic findings are consistent with neuropathologic findings of neuronal dysfunction, cellular membrane turnover, cellular infiltration, and metabolic stress in the acute phase, and with neuronal loss in the chronic phase.

Time lag to diagnosis of stroke in children

OBJECTIVE

Strokes occur rarely in children, and the causes are different from those in adults. Frequently, more than 1 cause is found. The consequences are lifelong significant disability in a majority of cases. Children who are younger than 18 years have not been included in therapeutic trials of thrombolytic or neuroprotective agents. We evaluated whether children who receive a diagnosis of stroke meet a major inclusion criterion for such trials, namely time to diagnosis of <3 to 6 hours.

METHODS

Prospective documentation and retrospective chart review was conducted of children who were 0 to 18 years and carried a diagnosis of stroke during the last 2 years in the hospital database, including children who presented with either ischemic or hemorrhagic strokes.

RESULTS

Forty-seven events were encountered in 41 children. Twelve neonates with stroke, diagnosed in the neonatal period, were excluded from the subsequent analysis. In the remaining 29 children, the mean age at presentation was 8.67 years. Accurate time records were available in 24 children. In this group, 28 events were recorded. Time from clinical onset to first medical contact averaged 28.5 hours, and the time to diagnosis of stroke averaged 35.7 hours. We subsequently separated between children with ischemic (21 documented events) and hemorrhagic strokes (7 documented events), because the presentation and the intervention options are different.

CONCLUSIONS

Stroke in children is rarely diagnosed in the time frame of 3 to 6 hours. Given the causes and outcome of stroke in children, this age group might benefit from thrombolysis and from neuroprotective therapy, yet the long delay in diagnosis in this age group excludes most cases from being considered for such treatments. This situation should encourage attempts to increase public and professional awareness of stroke in children and of the potential value of early diagnosis and treatment, preferably by broadening current educational efforts to all age groups.