What happens to children who move off the autism spectrum? Clinical follow-up study.

BACKGROUND: There is controversial information on outcome of school age individuals who lose the diagnosis of autism and achieve "optimal outcome" (OO). The present study assessed the autism symptoms and other psychiatric disorders in a group of children with a past history of autism. METHODS: The subjects consisted of 26 individuals who had lost the diagnosis of autism 2-8 years previously. Clinical assessment was done with both parents and children. Diagnostic and Statistical Manual of Mental Disorders (5th edn; DSM-V) criteria were used for diagnosis of autism spectrum disorder (ASD). In addition, Childhood Autism Rating Scale and Social Communication Questionnaire (current version) were used. Psychiatric disorders were assessed using the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children Present and Lifetime Version (K-SADS-PL). RESULTS: None of the participants met the criteria for ASD. Ninety-two percent had a lifetime diagnosis and 81% had a present psychiatric disorder based on the K-SADS. Attention-deficit hyperactivity disorder, specific phobia and obsessive-compulsive disorder were the most common disorders. CONCLUSIONS: Improved status with regard to autism symptomatology is maintained over time, but these individuals are vulnerable to developing other psychiatric disorders. It is crucial to maintain psychiatric follow up of children who move off the autism spectrum.

Assessment of suicidality in children and adolescents with diagnosis of high functioning autism spectrum disorder in a Turkish clinical sample.

OBJECTIVES: Considering that suicide is one of the most common reasons of adolescent death worldwide, there is a lack of clinical awareness on suicidal behaviors of children and adolescents with autism spectrum disorder (ASD). The present study aims to assess the rate of suicidality (suicidal ideation, behaviors and attempts) and associated risk factors for suicidality in high functioning ASD. METHODS: Medical records of 55 adolescents (six girls, 49 boys), aged between 7-20 years, with diagnosis of ASD were reviewed. The participants were all able to speak fluently and had no significant limitations in intellectual functioning. Clinical assessment of participants was carried out on the basis of Diagnostic and Statistical Manual of Mental Disorders 4th Edition, Text Revision criteria and Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version. Eskin's Suicide Screening Questionnaire and sociodemographic data form including detailed history of suicidal behaviors were used. The study group was also divided into suicidal and non-suicidal groups for the purpose of comparing the results. RESULTS: The rate of suicidal behaviors was 29% and suicide attempt was 12.7%. Types of suicidality were behaviors (43.7%), thoughts (37.5%), and verbal declarations (18.7%). A number of bizarre acts were recorded. Rates of comorbid psychiatric disorders such as mood disorders, anxiety disorders and disruptive behaviors were 23.6%, 43.6% and 65.4% respectively. Groups with the psychotic features, positive family history for suicidal behaviors and completed suicide showed more suicidality than the non-suicidal group. CONCLUSION: Consistent with the previous findings, rate of suicidality is higher in individuals with ASD. The type of suicidal behaviors showed some differences compared to typically developing individuals. The presence of psychotic features and positive family history for suicidality may be risk factors for suicidality in children and adolescents with ASD. To prevent suicide and implement protective health care systems, identifying the population at risk is crucial.

Effects of Atomoxetine in Individuals with Attention-Deficit/Hyperactivity Disorder and Low-Functioning Autism Spectrum Disorder.

OBJECTIVES: This naturalistic, retrospective study investigated the effects of atomoxetine (ATX) on attention-deficit/hyperactivity disorder (ADHD) symptoms and autistic features in children with autism spectrum disorders (ASDs) and intellectual disability (ID). METHODS: Participants (n = 37, age range 6-17 years, mean: 10.16 ± 3.60) were assessed at baseline, 4th and 12th weeks using Clinical Global Impressions (CGI) scales, DSM-IV-based ADHD-rating scale (ADHD-RS), and amended Turkish version of Aberrant Behavior Checklist (ABC). The primary outcome measure was a treatment response defined by a CGI-improvement score of 1 or 2 together with a decrease of at least 25% in the parent-rated ADHD-RS total score at the end of 12th week. RESULTS: Five patients (13.5%) stopped medication at 4 weeks due to ineffectivity (2) and intolerable side effects (increased motor activity and talkativeness [n = 1], irritability [n = 2], temper outbursts [n = 2], and increased blood pressure [n = 1]). Sixteen patients (43.2%) were judged to be responders according to primary outcome measure. Improvement rate on CGI scale was 48.8%. On ADHD-RS, there were significant reductions between baseline and 4th week and between baseline and 12th week in both hyperactivity and inattention, and between baseline and 12th week in impulsivity scores. Decrease was significant in hyperactivity and social withdrawal subscales of the parent-reported ABC. Responders based on primary outcome measure were not significantly different from nonresponders in terms of sociodemographic features or clinical parameters, including intellectual, language, autism symptom, and ADHD symptom levels. CONCLUSION: In this chart review, ATX appears to be safe and effective for social withdrawal and ADHD symptoms in children with ASD and ID.

Characteristics of children who lost the diagnosis of autism: a sample from istanbul, Turkey.

Aim. The aim of this study was to describe a group of children who lost a diagnosis of autism following participation in early educational programs. Method. This is a descriptive study reporting the characteristics of children (n: 39) who lost their diagnosis of autism and explaining the educational programs that these children followed. The data were collected by reviewing the participants' files and through examinations. Results. All of the children were placed at regular psychiatric follow-ups. The mean age at referral was 2.39±0.75 years, whereas the mean age at the time of optimal outcome reported was 5.11 ± 1.95 years. Two of the children were in early intensive behavioral intervention (EIBI), and the rest were in a comprehensive naturalistic behavioral program. The childhood autism rating scale (CARS) total scores at baseline and final were 32.75 ± 3.15 and 18.01 ± 1.76, respectively. The mean IQ of the group at final examination was 116.70 ± 18.88. Conclusion. It could be concluded that a group of children with an autism diagnosis could lose the diagnosis of autism upon early intervention. High IQ and the development of communicative and language skills at an early age could be the most powerful factors contributing to an optimal outcome.

Using the modified checklist for autism in toddlers in a well-child clinic in Turkey: adapting the screening method based on culture and setting.

We aimed to adapt the Modified Checklist for Autism in Toddlers to Turkish culture. The Modified Checklist for Autism in Toddlers was filled out independently by 191 parents while they were waiting for the well-child examination of their child. A high screen-positive rate was found. Because of this high false-positive rate, a second study was done in which the Modified Checklist for Autism in Toddlers was administered by health-care staff in a short interview with two groups of parents. The first group (the high-risk group) comprised 80 children aged 18-36 months, who were initially diagnosed with pervasive developmental disorders. The second group (the low-risk group) comprised 538 children of the same age, who were followed regularly by the well-child clinic. Two screen positives were found in the low-risk group. These two children, a random sample of 120 children from the low-risk group, and all the high-risk group were invited to a clinical evaluation. The diagnostic power of the Modified Checklist for Autism in Toddlers was assessed against clinical diagnosis and the Childhood Autism Rating Scale. The positive predictive value of the Modified Checklist for Autism in Toddlers was found to be 75%. Our findings led us to conclude that the Modified Checklist for Autism in Toddlers is a useful tool in Turkey for screening of pervasive developmental disorders in primary care, but in our culture, it is completed more accurately when health-care personnel ask the parents the questions. This study shows that Modified Checklist for Autism in Toddlers screening should be adapted based on culture and setting.

Positron emission tomography findings in children with infantile spasms and autism.

The purpose of this study was to evaluate positron emission tomography (PET) findings in patients diagnosed with infantile spasms and autism. This study includes 90 patients who were diagnosed with infantile spasms at the Department of Pediatric Neurology in the Istanbul University Medical Faculty between 1995 and 2007. Of the 90 patients, 15 patients who were diagnosed with autism using the Autism Behaviour Checklist and Childhood Autism Rating Scale and a control group of nine patients without autism but with infantile spasms underwent PET examination. Mean patient age (± standard error, SE) varied between 3 years and 16 years (7.8 ± 4 years), while the mean follow-up time (±SE) varied between 2 years and 16 years (average: 7.1 ± 4 years). Autism was present in 11 patients with symptomatic spasms and in four patients with cryptogenic spasms (p=0.009). On the PET scans of the 15 patients with autism, 13 (86.7%) had significantly decreased metabolic activity in the temporal lobe (p<0.001), nine (60%) had significantly decreased activity in the frontal lobe (p=0.004), and seven (46.7%) had significantly decreased activity in the parietal lobe (p=0.022). In our opinion, hypometabolism in the frontal and parietal lobes, in addition to that previously reported in the temporal lobe, plays a role in the development of autism in patients with infantile spasms.

Asperger's disorder and Williams syndrome: a case report.

Williams syndrome (WS) is a genetic disorder caused by the hemizygous microdeletion in chromosome 7q11.23. It is characterized by dysmorphic face, cardiovascular disease, idiopathic hypercalcemia, mental retardation, and an uneven profile of cognitive-linguistic abilities and deficits. The presence of autistic features in individuals with WS is a controversial issue. While there are reports that describe them as overly friendly with excessive sociability and good empathic skills, some recent studies focus more on the qualitative impairment of their social abilities. Here, we report the clinical presentation and follow-up of an eight-year-old boy with WS and clear problems in his social interaction, non-verbal communication and circumscribed interests. To our knowledge, this is the first case report on the coexistence of WS and Asperger's disorder. It also differs from previous papers on the comorbidity of WS and autism spectrum disorders, by depicting a highly verbal, nonretarded child followed for seven years through adolescence.

Catatonia in a child with autistic disorder.

Catatonia is a cluster of motor features that appears in many recognized psychiatric illnesses. It is being increasingly reported in individuals with autism, a disorder characterized by impaired reciprocal social interactions, aberrant language development and restricted behavioral repertoire. However, relatively little is known about the presentation and treatment of catatonia in children with autism. We describe herein an 11-year-old pediatric case with autism who developed catatonic symptoms and was treated effectively with lorazepam. The case reported here differs from previously reported cases in terms of age of onset and the display of all characteristics of catatonia as defined in the Diagnostic and Statistical Manual of Mental Disorders (4th ed) (DSM-IV). In addition, although it was stated that catatonia in autism is commonly associated with impaired language and social passivity, our case is an active verbal individual.

Drug induced mania in a boy with high functioning autism.

Drug induced mania is sometimes associated with drug that are primarily not used for central nervous system effects. Here we report a manic episode during the treatment of leukemia with various agents in an adolescent with diagnosis of high functioning autism. In this case, most likely candidates to induce a manic episode were dexamethazone, a corticosteroid used in the treatment of T-ALL, cyclophosphamide and cotrimoxazole. Although literature on mood disorders associated with corticosteroids exceeds that of cyclophosphamide and cotrimoxazole, an absolute causal drug cannot be stated.

Psychiatric disorders in individuals with high-functioning autism and Asperger's disorder: similarities and differences.

OBJECTIVES: To investigate and compare the rate and type of psychiatric co-morbidity in individuals with diagnosis of high functioning autism (HFA) and Asperger's disorder (AS). METHODS: This study includes 30 children and adolescents with diagnosis of HFA and 30 with diagnosis of AS. Diagnoses of HFA and AS were made using strict DSM-IV criteria. Psychiatric co-morbidity was assessed using the Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version (K-SADS-PL-T). RESULTS: The rate of comorbid psychiatric disorders was very high in both groups (93.3% in HFA and 100% in AS). The most common disorder in both groups was attention deficit hyperactivity disorder. There was no statistically significant difference between groups in the rate of associated psychiatric disorders, except for major depressive disorder (P = 0.029) and ADHD-combined type (P = 0.030). The AS group displayed greater comorbidity with depressive disorders and ADHD-CT. CONCLUSION: From a clinical perspective, it could be concluded that both disorders involve a high risk for developing psychiatric disorders, with AS patients at greater risk for depression. From a nosological perspective, the substantial similarities in terms of psychiatric comorbidity may support the idea that both disorders are on the same spectrum and differs in some aspects.

High rates of psychiatric co-morbidity in individuals with Asperger's disorder.

The present study aimed to provide clinical data regarding co-morbidity of psychiatric disorders in individuals diagnosed with Asperger's disorder (AD). This study included 37 individuals (32 male, five female, mean age: 10.9+/-4.5 years) diagnosed with AD. Psychiatric comorbidity was assessed using the Schedule for Affective Disorders and Schizophrenia for School Age Children - Present and Lifetime Version (K-SADS - PL). Ninety-four percent of participants had at least one additional psychiatric disorder. The most common were anxiety disorders (54%), disruptive behavioural disorders (48%), and mood disorders (37%). The results of this study highlight the need for detailed assessment of additional psychiatric disorders in this population.

Co-morbidity of bipolar disorder in children and adolescents with attention deficit/hyperactivity disorder (ADHD) in an outpatient Turkish sample.

This study aimed to assess the prevalence of bipolar disorder (BPD) in children and adolescents with attention deficit hyperactivity disorder (ADHD), and to compare the clinical characteristics of a group with ADHD with a group with co-morbidity of ADHD and BPD. The study includes 121 individuals, aged 6-16 years, with a diagnosis of ADHD. Co-morbidity of BPD was evaluated using the Schedule for Affective Disorders and Schizophrenia for School-age Children-Present and Lifetime version (K-SADS-PL) and the Parent-Young Mania Rating Scale (P-YMRS). The Child Behavior Checklist (CBCL) was used to assess psychopathology in two groups. Ten children (8.3%) in the ADHD sample received the additional diagnosis of BPD. The ADHD + BPD group had significantly higher scores than the ADHD group on withdrawn, anxiety/depression, social problems, thought problems, attention problems, aggression, externalization, total score items of CBCL, and on the P-YMRS. It could be concluded that BPD is not a rare co-morbid condition in children with diagnosis of ADHD and subjects with this co-morbidity show more severe psychopathology than subjects with pure ADHD. Differential diagnosis of BPD disorder in subjects with ADHD seems crucial in establishing an effective treatment program, and therefore improving mental health outcomes.

Effectiveness of mirtazapine in the treatment of inappropriate sexual behaviors in individuals with autistic disorder.

OBJECTIVE: The aim of this study was to investigate the efficacy and safety of mirtazapine in the treatment of excessive masturbation and other inappropriate sexual behaviors (ISB) in individuals with the diagnosis of autistic disorder (AD). METHOD: Subjects (n = 10; 2 females, 8 males; age range: 5.2-16.4 years) who suffered from excessive masturbation with or without other ISB were treated with mirtazapine for 8 weeks. Clinical Global Impressions-Severity (CGI-S) and Clinical Global Impressions-Improvement (CGI-I) scales were used for the evaluation of symptoms severity and effectiveness. Mirtazapine was started at 7.5-15 mg/day and titrated up to 15-30 mg/day (mean 21.6 +/- 7.9 mg/day). The data for this study were collected from reviewing medical records of all subjects that suffered from ISB and treated with mirtazapine. RESULTS: CGI scores at baseline and end point ranged from 5 to 7 (mean 6.22 +/- 0.83) and 2 to 4 (mean 3 +/- 0.7), respectively. A nonparametric t-test showed significant difference in CGI-S scores between baseline and end point assessments (Z = -2.725; p = 0.006, p < 0.01). Five subjects showed very much, 3 showed much, and 1 showed moderate improvement in excessive masturbation on the CGI-I scale. One subject dropped out from clinical follow up. Mirtazapine was generally tolerated well. The most frequently reported side effects were increased appetite, weight gain (n = 3; mean 0.78 +/- 1.20 kg), and sedation. CONCLUSIONS: Mirtazapine could be an effective treatment to ameliorate ISB in a young population with a diagnosis of AD. Well-designed, placebo-controlled studies are needed regarding this topic.

Pervasive developmental disorders in individuals with cerebral palsy.

The aim of the present study was to describe the prevalence and associated factors of pervasive developmental disorders (PDD), including autistic disorder and PDD not otherwise specified (NOS), in a clinical sample of 126 children and adolescents (75 males, 51 females; age range 4-18y, mean 8y 8mo, SD 3y 8mo) with tetraplegic, hemiplegic, diplegic, dyskinetic, or mixed types of cerebral palsy (CP); 28% could not crawl or walk even with support, 29% could move with support, and 43% walked independently. Participants were examined for PDD in two stages. In the first stage, probable participants were determined by direct observation, Autism Behavior Checklist score, and medical reports. In the second stage, those with 'probable' symptoms underwent psychiatric examination and their autistic symptoms were scored on the Childhood Autism Rating Scale. The final diagnosis of autistic disorder or PDD-NOS was given according to DSM-IV criteria. Fourteen (11%) and five (4%) of the participants met the criteria for autistic disorder and PDD-NOS respectively. Children with CP and PDD differed from those without PDD in terms of type of CP (p=0.02), presence of epilepsy (p<0.001), intellectual level (p<0.001), and level of speech (p<0.001). PDD was more common in children with tetraplegic, mixed, and hemiplegic CP, and in children with epilepsy, learning disability, and low level of speech. The findings corroborate the notion that CP is a complex disorder, often associated with additional impairments. PDD is not rare in CP and should be considered in patients with comorbid conditions such as epilepsy, learning disability, and language delay and in the presence of tetraplegic, mixed, and hemiplegic CP types.

Kleine-Levin syndrome in two subjects with diagnosis of autistic disorder.

Kleine-Levin syndrome (KLS) is a rare disease characterized by recurrent episodes of hypersomnia, cognitive and behavioural disturbances, compulsive eating and hypersexuality. The disease is predominantly described in typically developed adolescents. Here, we present two cases with the diagnosis of KLS and autistic disorder. The aim of this presentation is to illustrate the clinical expression and differential diagnosis of KLS in this group.

Mirtazapine treatment in a subject with autistic disorder and fetishism.

The presence of inappropriate sexual behaviors in individuals with autistic disorder is one of the important factors disturbing their social adaptation and distressing their families and environment. Therefore, appropriate management of these behaviors seems necessary. This case report describes a 13-year-old male with diagnosis of autistic disorder and fetishistic behavior. His fetishistic behavior was treated successfully using mirtazapine 15 mg/day. The clinical picture and efficacy of mirtazapine will be discussed.

Risperidone-induced enuresis in two children with autistic disorder.

INTRODUCTION: Risperidone appears to be effective in treating behavioral problems in children with autistic disorder. Although increased appetite, weight gain, and sedation are among the most common side effects, risperidone-induced enuresis is rarely reported. METHOD: We will present two cases with risperidone-induced enuresis, and discuss our findings in the context of current literature. RESULTS: Two children aged 11 and 10 years, diagnosed with autism and mental retardation, have developed new-onset diurnal and nocturnal enuresis respectively on their first and second weeks of risperidone monotherapy (1.5 and 1 mg/day). They did not experience sedation, and their medical history and workup were unremarkable. As enuresis did not resolve spontaneously, we decided to substitute risperidone with olanzapine. Enuresis ceased rapidly after discontinuation of risperidone with no emergence when patients were treated with olanzapine 5 mg/day for a period of 6 months and 1 year, respectively. DISCUSSION: Although the pathophysiology of antipsychotic-induced enuresis remains unclear, a number of mechanisms including alpha(1)-adrenergic blockade, dopamine blockade, and antimuscarinic effects has been proposed. Olanzapine has lower alpha(1)-adrenergic and dopaminergic blockade properties, thus changing risperidone to olanzapine may be an alternative modality in risperidone-induced enuresis when antipsychotic treatment is crucial. Clinicians should be more vigilant about screening for this side effect, especially in younger population with developmental disabilities.

Tactile sensitivity of normal and autistic children.

Many children with autistic spectrum disorders have unusual reactions to certain sensory stimuli. These reactions vary along a hyper- to hypo-responsivity continuum. For example, some children overreact to weak sensory input, but others do not respond negatively to even strong stimuli. It is typically assumed that this deviant responsivity is linked to sensitivity, although the particular stage of sensory processing affected is not known. Psychophysical vibrotactile thresholds of six male children (age: 8-12) who were diagnosed to have autistic spectrum disorders and six normal male children (age: 7-11) were measured by using a two-alternative forced-choice task. The tactile stimuli were sinusoidal displacements and they were applied on the terminal phalanx of the left middle finger of each subject. By using a forward-masking paradigm, 40- and 250-Hz thresholds of the Pacinian tactile channel and 40-Hz threshold of the Non-Pacinian I tactile channel were determined. There was no significant difference between the thresholds of autistic and normal children, and the autistic children had the same detection and masking mechanisms as the normal children. The sensory responsivity of each subject was tested by clinical questionnaires, which showed again no difference between the two subject groups. Furthermore, no significant correlations could be found between the questionnaire data and the psychophysical thresholds. However, there was a high correlation between the data from the tactile and emotional subsets of the questionnaires. These results support the hypothesis that the hyper- and hypo-responsivity to touch, which is sometimes observed in autistic spectrum disorders, is not a perceptual sensory problem, but may probably be emotional in origin.