Disruption at the PTCHD1 Locus on Xp22.11 in Autism spectrum disorder and intellectual disability

Autism is a common neurodevelopmental disorder with a complex mode of inheritance. It is one of the most highly heritable of the complex disorders, although the underlying genetic factors remain largely unknown. Here, we report mutations in the X-chromosome PTCHD1 (patched-related) gene in seven families with autism spectrum disorder (ASD) and in three families with intellectual disability. A 167-kilobase microdeletion spanning exon 1 was found in two brothers, one with ASD and the other with a learning disability and ASD features; a 90-kilobase microdeletion spanning the entire gene was found in three males with intellectual disability in a second family. In 900 probands with ASD and 208 male probands with intellectual disability, we identified seven different missense changes (in eight male probands) that were inherited from unaffected mothers and not found in controls. Two of the ASD individuals with missense changes also carried a de novo deletion at another ASD susceptibility locus (DPYD and DPP6), suggesting complex genetic contributions. In additional males with ASD, we identified deletions in the 5' flanking region of PTCHD1 that disrupted a complex noncoding RNA and potential regulatory elements; equivalent changes were not found in male control individuals. Thus, our systematic screen of PTCHD1 and its 5' flanking regions suggests that this locus is involved in ~1% of individuals with ASD and intellectual disability.

Ascertaining the prevalence of childhood disability

OBJECTIVES

To reapply 1985 Office of Population Census and Surveys (OPCS) disability survey methods, modified as necessary, to a sample of children to ascertain presence of disability. To compare OPCS-based prevalence with prevalence based on carer's views and medical records.

DESIGN

Analytical study. Setting Community Child Health Department in UK.

PARTICIPANTS

Principal carers of 100 children aged 5-15, selected from a district special needs register. Main outcome measures Comparable information about disability from three sources and diagnosis from carers and medical records.

RESULTS

Medical records of 46% contained a diagnosis. Carers were always aware of this, although a single question did not always elicit their knowledge. OPCS-derived threshold disability criteria in categories of Hand function, Personal care, Consciousness and Continence gave prevalence results similar to medical records and carers. OPCS criteria yielded higher prevalence of disability in the areas of Locomotion (8%), Communication (14%) and Hearing (18%). Carers, OPCS and medical records disagreed markedly about prevalence of disabilities of Vision, probably because of the use of differing definitions. OPCS learning criteria were judged unsuitable and standard attainment targets (SATs) were substituted. These provided similar prevalence figures to carers and medical records. OPCS behaviour criteria were also unsuitable and were replaced by the General Health and Behaviour Questionnaire (GHBQ). This found an increased prevalence of problems compared with carers and doctors.

CONCLUSIONS

Diagnostic labels have limited use when collecting data about disabled children. Doubt is cast on the validity of some of the 1985 OPCS threshold criteria, and reassessment is suggested before their future use. Further work is needed on the use of SATs and GHBQ in the benchmarking of disability. To collect population data it would be easier and at least equally effective (with caution in the case of Vision) to ask carers directly rather than applying descriptive thresholds and external judgements. Similar information could be obtained from medical records, however, they are likely to be out of date.

Using simulated patients in a multiprofessional communications skills programme: reflections from the programme facilitators

This paper discusses a multiprofessional, 4-day communication skills programme in which participants explore the challenges of communicating with cancer patients and their families. Effective communication and skilled emotional support are essential prerequisites for high quality care in oncology and palliative care settings. This aspect of care presents major challenges to nurses and other health care professionals. It is acknowledged that health professionals often lack the requisite skills to communicate meaningfully with this patient group and that tangible benefits accrue from training in this area. Using simulated patients, structured feedback and small group discussions, this multiprofessional programme seeks to provide a forum that enables participants to acquire confidence and competence in a safe, comfortable and non-threatening environment. The programme structure presents several challenges in terms of providing a learning experience that addresses the diverse educational of a heterogeneous learning group. Participants' comments and programme facilitators reflections suggest that the programme is successful in addressing these challenges and providing a meaningful learning experience.

Survey of UK computerised special needs registers

A postal survey of all computerised children's disability registers in the UK was undertaken in 1996. Information was returned from 155 of 166 districts (93%). The implementation of computerised special needs registers is a continuing nationwide trend. Although there is evidence of successful use of registers both as an individual and as a population service planning tool, a high percentage of existing registers are functioning in a way which is far short of their potential for research, audit, and planning. Registers which work well have been set up with expertise, have staff enthusiastic about data entry, and are well supported for data output and software modification. There should be continued cooperative work towards a national consensus on the categories of disability and definition of severity of disability used in these registers.

Development and satisfaction with individual programme planning in a disability service

A consumer survey of a preschool disability service identified parents who did not feel their concerns were fully understood by professionals, nor felt involved or in agreement with treatment decisions, nor that services were provided in a coordinated way. A system of individual programme planning (IPP) was introduced in order to address these issues and other shortfalls of the existing service. Information was obtained from 96% of parents and 87% of professionals who attended IPP meetings over a four month period. Overall satisfaction was high (92% of parents: 96% of professionals). Parents now felt fully involved in decision making, 80% felt their views were understood and 100% agreed with treatment goals. Dissatisfaction was expressed with meeting attendance, the marginalisation of parents, and the timing and chairing of meetings. Consumer satisfaction surveys are recommended for use in highlighting areas of service shortfall, to direct and evaluate service change, and to monitor quality.

Improved primary care does not prevent the admission of children to hospital

In Nottingham Health District a study has been carried out whose aims were: (1) to compare acute paediatric medical admissions in 1985 with those in 1975 and to relate any differences to changes in services; (2) to measure the numbers of preventable admissions, working on the hypothesis that this would give an indication of the performance of community services. A structured questionnaire was completed with parents, and information obtained from notes of all children admitted with acute medical problems during October 1985. Results were compared with a similar study undertaken in 1975 by Wynne and Hull1 on children from the same catchment area. Further information for all health districts in Trent Region was obtained from Hospital Activity Analysis data relating to these 10 years. There has been a 100% increase in children's admissions in Nottingham, with similar increases throughout Trent Region. Apart from ingestions, there are increases in every diagnostic category, with a 6-fold increase in the admission rate for lower respiratory tract problems, mostly asthma and wheeze. Only 9% were classified as 'social admissions'. The idea of certain admissions being preventable is not a useful concept. Improvements in primary care have not been accompanied by a fall in hospital admissions.

Dermatologic lesions in a transplant population

Many authors have reported an increase in the incidence of skin neoplasia in renal transplant patients. Two hundred and twenty-three patients, who received a renal transplants between 1965 and 1984, were examined for the presence of skin lesions. There was a high incidence of simple warts (24%) and hyperkeratoses (21%). Frank malignancy had developed in 9 patients; this is more than 4 times the expected incidence for the population of Northern Ireland.

Developmental screening and surveillance

This article reviews the practice of and state of knowledge concerning developmental screening and surveillance of preschool children in the UK. It includes testing for defects of hearing and vision but does not constitute a "how-to-do-it" guide. This is available elsewhere (Egan et al, 1969; Sheridan, 1975).

A training procedure for immunization

A booklet on child immunization and a training procedure using a video have been developed in a health authority. The initiative has proven highly acceptable and has resulted in a demonstrable increase in professional knowledge and in vaccine uptake. Further initiatives are described.

Mutiny over Bounty?

Bounty Services Ltd advertise commercial products on postnatal wards of hospitals throughout Britain by means of free gifts. Since the " Bounty lady" is apparently well known to nursing staff but may have gone unnoticed by paediatricians and obstetricians an investigation was conducted of the quality of the gifts and the nature of the company. With two exceptions the samples and promotional leaflets were sound, and mothers apparently enjoyed receiving them. Educational pamphlets distributed with the gifts were excellent, and cine films shown to the mothers were of good quality and informative about basic parental skills. Bounty , however, operates by exerting commercial pressure on new mothers at a time when they are most vulnerable and distributes materials among them without consultation with medical staff. Most of the mothers questioned assumed that the service was being provided by the NHS. The Bounty service may or may not be perceived as a satisfactory operation but details should be known to paediatricians and obstetricians; any action to be taken might be decided locally after discussion in individual hospitals or districts.

Pain, control over treatment, and compliance in dialysis and transplant patients

Pain was surveyed via structured interview and the McGill Pain Questionnaire in 53 dialysis and 27 transplant patients. Increased patient control over the dialysis procedure was not associated with a reduction in pain though perceived control may have been. Compliance with the dialysis regimen did not predict pain and the validity of the category "dialysis headache" was questioned. Overall, transplant recipients did not report significantly less pain than dialysis patients. Self-reported depression was correlated positively with pain. The clinical implications of these findings are discussed.