The Efficacy of Early Start Denver Model Intervention in Young Children with Autism Spectrum Disorder Within Japan: A Preliminary Study

Objectives

Among the many intervention programs for children with autism spectrum disorder (ASD), the Early Start Denver Model (ESDM) is one of the few approaches that has succeeded in demonstrating clinical efficacy in randomized control trials. Here, we investigate the clinical efficacy of ESDM intervention in young children with ASD in a community setting within Japan.

Methods

All subjects were children with ASD who received ESDM intervention during the study period. Each ESDM session lasted 75 min and occurred once per week for at least 12 weeks. The outcome measures consisted of the Kyoto Scale of Psychological Development (K-test), Aberrant Behavior Checklist-Japanese version (ABC-J), and the Clinical Global Impression-Severity scale (CGI-S).

Results

Twenty-seven subjects (29.4±6.4 months old) received ESDM intervention that lasted for 8.0±2.6 months on average. The score on Language and Social developmental quotient on the K-test increased significantly after the intervention. The total scores on the ABC-J and CGI-S significantly decreased after completion of the ESDM intervention.

Conclusion

Our results suggest that ESDM intervention could reduce the severity of distinct clinical features of ASD, such as impairments in social interaction and communication assessed by the K-test, and maladaptive behavior rated by the ABC-J and CGI-S. We believe that the ESDM adapted to each institution might become one of the standard options for children with ASD in Japan.

[Autism spectrum disorder in childhood and adults: diagnosis and differential diagnoses]

Autistic disorders are summarized in DSM‑5 under the term autism spectrum disorder (ASD) and are severe, lifelong, pervasive neurodevelopmental disorders. Core features manifested even in childhood are impairments in social interaction and communication as well as restricted and repetitive behavior. The intensity of symptoms, language and cognitive impairments vary but the majority of affected individuals have below average intelligence and 80% have at least one comorbid disorder. The diverse pathology and heterogeneity in phenotypes are caused by a complex genetic etiology, which is associated with a reduced synaptic plasticity of neural networks. The disorder is associated with a clearly reduced quality of life as well as a high familial burden. The differential diagnostics have a high relevance and the diagnosis should be carried out by specialized institutions. Behavioral therapeutic interventions are indicated.

Alterations in volumes and MRI features of amygdala in Chinese autistic preschoolers associated with social and behavioral deficits

To examine the amygdala volume in 2–5-year-old preschool children with autism and explore the relationship between amygdala volumes based on MRI findings and clinical features. A total of 39 cases with clinically diagnosed autism were collected. The oblique coronal T1 weighted image (T1WI) sequence was used to measure the volume of amygdala and the MRI signals were measured and analyzed. The data were compared to that of 24 age-matched healthy children and correlated to the clinical manifestations. The autism and the control groups were subject to brain scanning in 1 week after Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) review. The 39 cases, diagnosed with autism, were associated with social and behavioral deficits through clinical observation, physical and neurological examination, and assessments according to DSM IV, and the range of ABC scores in the autism group was 47–124, with an average score of 84.7 ± 24.1. Abnormal MRI signals were found in 19/78 (24.4%) amygdala in the autism group, the amygdala lesions showed punctuate or flaky low signal, slightly low signal, low to iso-signal, slightly high signal, or iso to high-signal intensity on T1 weighted three-dimendional fast low angle shot(T1FL3D) images. The right amygdala volume average was 1.088 ± 0.38 cm³, while that of the left amygdala was 1.04 ± 0.41 cm³, without any statistically significant difference (t = 0.533, p = 0.596) in the autism group. Among the 24 cases in the control group, the right amygdala volume average was 0.754 ± 0.194 cm³, while that of the left amygdala was 0.666 ± 0.252 cm³; the autism group had a significantly larger right and left amygdala volumes as compared to the age-matched typically developing group with a significant positive correlation between age and right amygdala volume (r = 0.406, p = 0.01). The preschool children with autism had significantly larger bilateral amygdala volumes as compared to age-matched typically developing children, the amygdala lesions may show abnormal signal. A relationship between age and right amygdala volume in the preschool children with autism was established.

Process Evaluation of the BOOST-A™ Transition Planning Program for Adolescents on the Autism Spectrum: A Strengths-Based Approach

A process evaluation was conducted to determine the effectiveness, usability, and barriers and facilitators related to the Better OutcOmes & Successful Transitions for Autism (BOOST-A™), an online transition planning program. Adolescents on the autism spectrum (n = 33) and their parents (n = 39) provided feedback via an online questionnaire. Of these, 13 participants were interviewed to gain in-depth information about their experiences. Data were analyzed using descriptive statistics and thematic analysis. Four themes were identified: (i) taking action to overcome inertia, (ii) new insights that led to clear plans for the future, (iii) adolescent empowerment through strengths focus, and (iv) having a champion to guide the way. The process evaluation revealed why BOOST-A™ was beneficial to some participants more than others. Trial registration #ACTRN12615000119594.

Mercury-associated diagnoses among children diagnosed with pervasive development disorders

Nelson and Bauman (Pediatrics 111:674-679, 2003) previously hypothesized that pervasive developmental disorder (PDD) was not associated with mercury (Hg) exposure because the medical conditions associated with Hg exposure were not associated with PDD. A hypothesis-testing longitudinal case-control study evaluated the frequency of medically diagnosed conditions previously associated with Hg poisoning, including: epilepsy, dysarthria, failure to thrive, cerebral palsy, or contact dermatitis and other eczema among children preceding their eventual PDD diagnosis (cases) compared to controls. A retrospective examination of medical records within the Vaccine Safety Datalink (VSD) was undertaken. Cases diagnosed with PDD (n = 534) were born from 1991 to 2000 and continuously enrolled until their PDD diagnosis. Controls (n = 26,367) were born from 1991 to 1993 and continuously enrolled from birth for 7.22 years. Within the first 5 years of life, cases compared to controls were significantly (p < 0.0001) more likely to be assigned a diagnosis of contact dermatitis and other eczema (odds ratio (OR) = 2.033), dysarthria (OR = 23.992), epilepsy (OR = 5.351), failure to thrive (OR = 25.3), and cerebral palsy (OR = 4.464). Similar results were observed when the data were separated by gender. Overall, the results of the present study and recently published studies provide direct evidence supporting a link in twelve of twelve categories (100%) of Hg poisoning associated symptoms as defined by Nelson and Bauman (Pediatrics 111:674-679, 2003) and symptoms observed in those with a PDD diagnosis. The results of this study support the biological plausibility of Hg poisoning to induce PDD diagnoses and rejection of the Nelson and Bauman (Pediatrics 111:674-679, 2003) hypothesis because those with a PDD diagnosis have an increased frequency of conditions previously associated with Hg poisoning.

Autism Spectrum Disorder: Classification, diagnosis and therapy

Autism Spectrum Disorder (ASD) refers to a group of neurodevelopmental disorders including autism, Asperger's syndrome (AS) and pervasive developmental disorder-not otherwise specified (PDD-NOS). The new diagnostic criteria of ASD focuses on two core domains: social communication impairment and restricted interests/repetitive behaviors. The prevalence of ASD has been steadily increasing over the past two decades, with current estimates reaching up to 1 in 36 children. Hereditary factors, parental history of psychiatric disorders, pre-term births, and fetal exposure to psychotropic drugs or insecticides have all been linked to higher risk of ASD. Several scales such as the Childhood Autism Rating Scale (CARS), The Autism Spectrum Disorder-Observation for Children (ASD-OC), The Developmental, Dimensional, and Diagnostic Interview (3di), are available to aid in better assessing the behaviors and symptoms associated with ASD. Nearly 75% of ASD patients suffer from comorbid psychiatric illnesses or conditions, which may include attention-deficit hyperactivity disorder (ADHD), anxiety, bipolar disorder, depression, Tourette syndrome, and others. Both pharmacological and non-pharmacological interventions are available for ASD. Pharmacological treatments include psychostimulants, atypical antipsychotics, antidepressants, and alpha-2 adrenergic receptor agonists. These medications provide partial symptomatic relief of core symptoms of ASD or manage the symptoms of comorbid conditions. Non-pharmacological interventions, which show promising evidence in improving social interaction and verbal communication of ASD patients, include music therapy, cognitive behavioral therapy and social behavioral therapy. Hormonal therapies with oxytocyin or vasopressin receptor antagonists have also shown some promise in improving core ASD symptoms. The use of vitamins, herbal remedies and nutritional supplements in conjunction with pharmacological and behavioral treatment appear to have some effect in symptomatic improvement in ASD, though additional studies are needed to confirm these benefits. Developing novel disease-modifying therapies may prove to be the ultimate intervention for sustained improvement of symptoms in ASD.

Cyber Victimization and Depression among Adolescents with Autism Spectrum Disorder: The Buffering Effects of Parental Mediation and Social Support

The purpose of the present study was to examine the buffering effect of parental mediation of technology use and social support from parents on the association between cyber victimization and depression, assessed over one year. Participants were 113 7th through 9th graders from the Midwestern United States (age ranged from 12 to 17 years old; 86% were male) who were diagnosed with autism spectrum disorder. They completed questionnaires on their perceptions of parental mediation of technology use, perceived social support from parents, and self-reported face-to-face and cyber victimization and depression at Wave 1. One year later, at Wave 2, they completed a questionnaire on their depression. Results indicated that the associations between cyber victimization and depression were more negative at higher levels of perceived parental technology mediation and social support, while these associations were more negative at lower levels of these variables, after controlling for face-to-face victimization and Wave 1 depression.

A Comparison of DSM-IV-TR and DSM-5 Diagnostic Classifications in the Clinical Diagnosis of Autistic Spectrum Disorder

Aim of this study was to compare children diagnosed with Pervasive Developmental Disorder (PDD) according to DSM-IV-TR and DSM-5 diagnostic systems. One hundred fifty children aged between 3 and 15 years diagnosed with PDD by DSM-IV-TR were included. PDD symptoms were reviewed through psychiatric assessment based on DSM-IV-TR and DSM-5 criteria. Clinical severity was determined using Childhood Autism Rating Scale (CARS) and Autism Behavior Checklist (ABC). A statistically significant decrease (19.3 %) was detected in the diagnostic ratio with DSM-5. Age and symptom severity differed significantly between those who were and were not diagnosed with PDD using DSM-5. B4 criteria in DSM-5 was most common criterion. Results indicate that individuals diagnosed with PDD by DSM-IV-TR criteria may not be diagnosed using DSM-5 criteria.

Phenotypic continuum between autism and schizophrenia: Evidence from the Movie for the Assessment of Social Cognition (MASC)

Schizophrenic (SCZ) and autism (ASD) spectrum disorders share several features including social cognition impairments. In SCZ, the link between symptomatic dimensions and social cognition deficits remains unclear. The Movie for the Assessment of Social Cognition (MASC) test, available in several languages including English, investigates mental state attribution capabilities in complex interpersonal situations. After its translation into French, we used MASC to direct compare social cognition in 36 young participants with SCZ to 19 with ASD and 20 healthy controls (HC) matched for gender, age (18-25y.o.) and level of education. The MASC discriminated each group from the others, patients with SCZ exhibiting difficulties compared to ASD (MASC total score 28.1 (4) and 24.2 (6.6), respectively; p<.001). In the whole sample, MASC scores were inversely correlated with autistic traits, evaluated by autism quotient, and with disorganization symptoms. Finally, in SCZ, over-mentalizing difficulties were correlated with age at disease onset. Our results demonstrate the validity of the French version of the MASC and bring direct evidence supporting the hypothesis of a phenotypic continuum between autism and schizophrenia.

Reconsideration of the diagnosis and treatment of childhood migraine: A practical review of clinical experiences

OBJECTIVE

To provide insight into the wide spectrum of migraine during childhood to establish practical and comprehensive treatment strategies.

BACKGROUND

Although recent studies have confirmed the effect of anti-migraine agents in childhood headaches fulfilling the criteria of migraine without aura, there have been no studies regarding the efficacy of these drugs in childhood migraine without aura not filling the diagnostic criteria.

METHODS

In total, 154 patients with a clinical diagnosis of migraine, with onset of repetitive headaches at the age of ⩽15years, were retrospectively included from clinics in seven tertiary medical centers.

RESULTS

Patients' diagnoses included migraine with aura (n=49), migraine without aura (n=65), clinical migraine without aura not fulfilling International Classification of Headache Disorders-3 beta criteria (suspected migraine without aura; n=38), and hemiplegic migraine (n=2). Abortive medicine was effective in 74 of 97 patients, and preventive medicine was effective in 61 of 84 patients. Drugs with high efficacy were acetaminophen and ibuprofen for abortive therapy and cyproheptadine, amitriptyline, and propranolol for preventive therapy. Psychosocial problems were less common, and abnormalities on electroencephalography were more common in the suspected migraine without aura group. Otherwise, clinical features and drug responsibility were comparable among the migraine with aura, migraine without aura, and suspected migraine without aura groups. Retrospectively, experts clinically diagnosed childhood migraine without aura when the headache met at least one of the three criteria B, C, and D in International Classification of Headache Disorders-3 beta in addition to A and E. Abortive and preventive medication including paroxetine (n=2) benefited 10 and 15 of the 33 patients with daily headache, respectively. Psychotherapy/counseling (n=4), treatment for orthostatic dysregulation (n=4), and elimination of stressors (n=3) markedly alleviated headache in this group.

CONCLUSION

Our results indicated that those with suspected migraine without aura not filling International Classification of Headache Disorders diagnostic criteria should be included in the treatment for migraine. Treatment should also be targeted to comorbid developmental disorders, orthostatic dysregulation, and psychosocial problems in patients with refractory daily headaches.

Autism Spectrum Disorders - Diagnosis and Management

Autism Spectrum Disorder (ASD) is a neuro-developmental disorder commonly seen in children. It is characterized by age inappropriate, impaired social communication and the presence of stereotypic behavior. This disorder is hypothesized to result from cerebral dysfunction arising from a complex interaction between genetic, epigenetic and environmental factors. ASD should be suspected in children failing ASD specific screening tests, in the presence of red flags in social, language and/or play domains, in children with developmental or language delay, abnormal behavior, poor school performance or in those who are at high risk. Comprehensive assessment comprises of a step-wise approach that includes taking a detailed history, performing a holistic examination and observing the child closely in relation to play, social interaction and behavior. Diagnosis is established by application of the diagnostic criteria for ASD of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM V). The degree of severity, intellectual and language impairment and presence of other illnesses should be specified. Functional assessment identifies an individual's strengths and weaknesses. All these are important to formulate a customized intervention plan along with the family. The goal is to build up skills enabling optimal and as far as possible normal functioning while simultaneously reducing maladaptive behavior. This is achieved by a multi-disciplinary team comprising of various personnel experienced in tackling issues in ASD related to their respective areas of expertise. Intervention is primarily non-pharmacological, based on behavioral modification strategies. Drugs are only indicated in the reduction of target symptoms refractory to behavioral intervention. Although there is no cure, timely and appropriate intervention can improve the quality of life significantly.

Hemispheric Processing of Idioms and Irony in Adults With and Without Pervasive Developmental Disorder

Previous studies on individuals with pervasive developmental disorders (PDD) have pointed to difficulties in comprehension of figurative language. Using the divided visual field paradigm, the present study examined hemispheric processing of idioms and irony in 23 adults with PDD and in 24 typically developing (TD) adults. The results show that adults with PDD were relatively unimpaired in understanding figurative language. While the TD group demonstrated a right hemisphere advantage in processing the non-salient meanings of idioms as well as the ironic endings of paragraphs, the PDD group processed these stimuli bilaterally. Our findings suggest that brain lateralization is atypical in adults with PDD. Successful performance along with bilateral brain activation suggests that the PDD group uses a compensation mechanism.

Identifying features of 'pathological demand avoidance' using the Diagnostic Interview for Social and Communication Disorders (DISCO)

The term 'pathological demand avoidance' (PDA) was coined by Elizabeth Newson to describe children within the autism spectrum who exhibit obsessive resistance to everyday demands and requests (Newson et al., Arch Dis Child 88:595-600, 2003). Clinical accounts describe avoidance strategies including apparently strategic use of distraction or socially shocking behaviour, and obsessive need for control, reflected in domineering behaviour to peers and adults. Educational and management approaches effective for PDA reportedly differ from those for 'typical' autism spectrum disorders (ASD), and include novelty, humour and flexibility. Identification of PDA in individuals with ASD may have important implications for management (Eaton and Banting, J Learn Disabil Offending Behav 3:150-157, 2012). Despite increasing interest, no clinician-rated instrument for PDA has been developed. Here, items relevant to PDA were identified from the Diagnostic Interview for Social and Communication Disorder (DISCO) (Wing et al., J Child Psychol Psychiatry 43:307-325, 2002). The most PDA-specific subset of relevant DISCO items was selected, based on low endorsement in general across a sample of 153 individuals assessed for possible ASD using the DISCO. Having selected 11 DISCO PDA items for the measure, a subset of individuals with a high number of these features was identified (N = 27). Consistent with Newson's descriptions, this high scoring group was characterised by lack of co-operation, use of apparently manipulative behaviour, socially shocking behaviour, difficulties with other people, anxiety and sudden behavioural changes from loving to aggression. All but one case met criteria for an ASD. This study brings the field a step closer to a clinician-rated measure of PDA features and highlights the need for further elucidation of the PDA phenotype.

Comorbidity in pediatric bipolar disorder: prevalence, clinical impact, etiology and treatment

BACKGROUND

Research on pediatric bipolar disorder (PBD) is providing a plethora of empirical findings regarding its comorbidity. We addressed this question through a systematic review concerning the prevalence, clinical impact, etiology and treatment of main comorbid disorders involved.

METHOD

A comprehensive database search was performed from 1990 to August 2014. Overall, 167 studies fulfilled the inclusion criteria.

RESULTS

Bipolar youth tend to suffer from comorbid disorders, with highest weighted mean prevalence rate arising from anxiety disorders (54%), followed by attention deficit hyperactivity disorder (ADHD) (48%), disruptive behavior disorders (31%), and substance use disorders (SUD) (31%). Furthermore, evidence indicates that ADHD and anxiety disorders negatively affect the symptomatology, neurocognitive profile, clinical course and the global functioning of PBD. Likewise, several theories have been posited to explain comorbidity rates in PBD, specifically common risk factors, one disorder being a risk factor for the other and nosological artefacts. Lastly, randomized controlled trials highlight a stronger therapeutic response to stimulants and atomoxetine (vs. placebo) as adjunctive interventions for comorbid ADHD symptoms. In addition, research focused on the treatment of other comorbid disorders postulates some benefits from mood stabilizers and/or SGA.

LIMITATIONS

Epidemiologic follow-up studies are needed to avoid the risk of nosological artefacts. Likewise, more research is needed on pervasive developmental disorders and anxiety disorders, especially regarding their etiology and treatment.

CONCLUSIONS

Psychiatric comorbidity is highly prevalent and is associated with a deleterious clinical effect on pediatric bipolarity. Different etiological pathways may explain the presence of these comorbid disorders among bipolar youth. Standardized treatments are providing ongoing data regarding their effectiveness for these comorbidities among bipolar youth.

Mitochondrial Aspartate/Glutamate Carrier SLC25A12 and Autism Spectrum Disorder: a Meta-Analysis

Mitochondrial dysfunction has been reported to be involved in the pathophysiology of autism spectrum disorder (ASD). Studies investigating the possible association between ASD and polymorphism in SLC25A12, which encodes the mitochondrial aspartate/glutamate carrier, have yielded inconsistent results. We conducted a systematic review and meta-analysis of such studies to elucidate if and which SLC25A12 single nucleotide polymorphisms (SNPs) are associated with ASD. We searched PubMed, Ovid, Web of Science, and ERIC databases through September 20th, 2014. Odds ratios (ORs) were aggregated using random effect models. Sensitivity analyses were conducted based on study design (family-based or case-control). Fifteen out of 79 non-duplicate records were retained for qualitative synthesis. We pooled 10 datasets from 9 studies with 2001 families, 735 individuals with ASD and 632 typically developing (TD) individuals for the meta-analysis of rs2292813, as well as 11 datasets from 10 studies with 2016 families, 852 individuals with ASD and 1058 TD individuals for the meta-analysis of rs2056202. We found a statistically significant association between ASD and variant in rs2292813 (OR = 1.190, 95% CI 1.052-1.346, P = 0.006) as well as in rs2056202 (OR = 1.206, 95% CI 1.035-1.405, P = 0.016). Sensitivity analyses including only studies with family-based design demonstrated significant association between ASD and polymorphism in rs2292813 (OR = 1.216, 95% CI 1.075-1.376, P = 0.002) and rs2056202 (OR = 1.267, 95% CI 1.041-1.542, P = 0.018). In contrast, sensitivity analyses including case-control design studies only failed to find a significant association. Further research on the role of SLC25A12 and ASD may pave the way for potential innovative therapeutic interventions.

Catatonic features in adolescents with schizophrenia with and without a comorbid pervasive developmental disorder

BACKGROUND

Catatonia has been associated with both schizophrenia and pervasive developmental disorders. The aim of this study was to evaluate catatonic features among adolescents suffering from schizophrenia. Further, we compared these features between adolescents with a comorbid pervasive developmental disorder and those without one. Finally, we wanted to compare the profile of catatonia-like features of our schizophrenia patients to that described earlier among persons with autism spectrum disorders.

METHODS

The study comprised a consecutive sample of 18 adolescents with schizophrenia (mean age 15.6 years, SD 1.4) and their families. Diagnosis of schizophrenia was assessed with the Schedule for Affective Disorders and Schizophrenia for School-Aged Children - Present and Life-Time (K-SADS-PL) for the DSM-IV. The Diagnostic Interview for Social and Communication Disorders version 11 was used to assess catatonic features.

RESULTS

All adolescents with schizophrenia had showed some lifetime catatonic features. Approximately 78% of them had already expressed these features before the age of 10. The number of catatonic features before the age of 10 was significantly higher among the adolescents with a comorbid pervasive developmental disorder compared to those without one. The numbers of catatonic features after the age of 10 did not significantly differ between the two groups. Over three-quarters of schizophrenia patients shared four lifetime catatonic features: "lacks facial expression", "odd intonation", "poor eye contact" and "lack of cooperation".

CONCLUSIONS

Adolescent schizophrenia patients with a comorbid pervasive developmental disorder show many catatonic features in childhood whereas those without one seem to develop these features first in adolescence. Catatonic features exhibited by adolescents with schizophrenia resemble those described among persons with pervasive developmental disorders without schizophrenia.

Autism Spectrum Disorder: Defining Dimensions and Subgroups

Autism spectrum disorder (ASD) is a behaviorally defined neurodevelopmental disorder associated with the presence of social-communication deficits and restricted and repetitive behaviors. In the latest conceptualization of ASD, these two behavioral dimensions represent the core defining features of ASD, whereas associated dimensions, such as intellectual and language ability, provide a means for describing the ASD heterogeneity. In addition, the characterization of ASD subgroups, defined by the presence of known medical, genetic, or other psychiatric disorders, furthers our understanding of ASD heterogeneity. This paper reviews the history of autism, describes its core defining features, and provides an overview of the clinically and etiologically relevant subgroups that add to the complexity of this condition.

Obstetric risk factors and autism spectrum disorders in Finland

OBJECTIVE

To examine the relationship between obstetric risk factors and childhood autism, Asperger syndrome, and other pervasive developmental disorders (PDDs).

STUDY DESIGN

Registry-based case-control study from all singleton births in Finland from 1990-2005. Cases with childhood autism, Asperger syndrome, or PDD (n = 4713) were identified from the Finnish Hospital Discharge Register. Each case was matched to 4 controls on sex, date of birth, and place of birth. Information on obstetric risk factors was from the Finnish Medical Birth Register. Conditional logistic regression models were used for statistical analyses.

RESULTS

When adjusted with confounders, childhood autism was associated with maternal high blood pressure (OR 1.49, 95% CI 1.1-2.1, P = .018), Apgar scores less than 7 (1 minute, OR 1.46, 95% CI 1.1-2.0, P = .021), and neonatal treatment with monitoring (OR 1.40, 95% CI 1.02-1.9, P = .038). PDD was associated with induced labor (OR 1.25 95% CI 1.1-1.5, P = .007), planned cesarean delivery (OR 1.34, 95% CI 1.1-1.7, P = .009), 1-minute Apgar scores 7-8 ( OR 1.22, 95% CI 1.1-1.4, P = .008) and less than 7 (OR 1.34, 95% CI 1.03-1.8, P = .032), and neonatal intensive care unit treatment (OR 1.52, 95% CI 1.2-2.0, P = .003). Asperger syndrome was associated only with 1-minute Apgar scores 7-8 (OR 1.19, 95% CI 1.03-1.4, P = .018).

CONCLUSIONS

Low Apgar scores as well as conditions requiring neonatal special follow-up are important risk factors for childhood autism and PDD. These findings suggest that fetal distress is a potential risk factor for these disorders, but not for Asperger syndrome.

High incidence of sleep problems in children with developmental disorders: results of a questionnaire survey in a Japanese elementary school

OBJECTIVE

The aim of the present school-based questionnaire was to analyze the sleep problems of children with developmental disorders, such as pervasive developmental disorder and attention deficit hyperactivity disorder.

METHODS

The sleep problems of 43 children with developmental disorders were compared with those of 372 healthy children (control group). All children attended one public elementary school in Kurume, Japan; thus, the study avoided the potential bias associated with hospital-based surveys (i.e. a high prevalence of sleep disturbance) and provided a more complete picture of the children's academic performance and family situation compared with a control group under identical conditions. Children's sleep problems were measured with the Japanese version of the Children's Sleep Habits Questionnaire (CSHQ).

RESULTS

Children with developmental disorders had significantly higher total CSHQ scores, as well as mean scores on the parasomnias and sleep breathing subscales, than children in the control group. The total CSHQ score, bedtime resistance, sleep onset delay, and daytime sleepiness worsened with increasing age in children with developmental disorders; in contrast, these parameters were unchanged or became better with age in the control group. In children with developmental disorders, there was a significant association between a higher total CSHQ score and lower academic performance, but no such association was found in the control group. For both groups, children's sleep problems affected their parents' quality of sleep. There were no significant differences in physical, lifestyle, and sleep environmental factors, or in sleep/wake patterns, between the two groups.

CONCLUSIONS

Children with developmental disorders have poor sleep quality, which may affect academic performance. It is important for physicians to be aware of age-related differences in sleep problems in children with developmental disorders. Further studies are needed to identify the association between sleep quality and school behavioral performance.

Retrospective case series of aripiprazole augmentation in pervasive developmental disorders

Due to co-morbidities and treatment resistant nature of pervasive developmental disorder (PDD), diverse combinations of regimens have been tried. This retrospective study aimed to explore adjunctive use of aripiprazole in children with PDD. Changes in illness severity were measured by Clinical Global Impression of Severity (CGI-S) and Clinical Global Impression of Improvement (CGI-I) in 14 aripiprazole-treated patients with PDD. Improvement of illness severity was observed after aripiprazole add-on (5.8±0.8 to 4.9±1.0, Z=-2.75, p=0.001). Mean dosage was 7.7 mg/day [standard deviation (SD) 3.3, range 5-15]. A higher mean dosage was observed in group with improvement in symptoms (t=-2.33, df =12, p=0.004). The target symptoms most effectively improved after using aripiprazole were positive psychotic symptoms (mean CGI-I: 2.0±1.4, 3 responders/4 patients, 75% response) followed by aggressive behavior (2.5±1.7, 3/4, 75%), self-injurious behavior (2.0±1.0, 2/3, 67%), stereotypic behavior (2.7±1.2, 2/3, 67%), tic (2.8±1.0, 2/4, 50%), irritability (3.5±2.1, 1/2, 50%), obsessive behavior (2.5±2.1, 1/3, 33%), hyperactivity (3.4±1.6, 3/7, 43%) and mood fluctuation (3, 0/1, no response). Five patients (35%) discontinued aripiprazole due to treatment-emergent adverse effects (akathisia, insomnia, withdrawal). The results of this study suggest that aripiprazole augmentation may be used safely in maladaptive behaviors of some populations of PDD. However, future studies are required to confirm these preliminary findings.