The Use of N-acetylcysteine Supplementation to Decrease Irritability in Four Youths With Autism Spectrum Disorders.

Children and adolescents with autism spectrum disorder (ASD) often experience high levels of irritability, which adversely affects their functioning and behaviors. N-acetylcysteine (NAC), an antioxidant precursor to glutathione, has recently been studied for a variety of neuropsychiatric disorders. There is growing evidence to support its use to decrease irritability and self-injurious behaviors in youth with ASD. However, previous studies were limited to outpatient youth with mild symptoms of irritability, maintained on stable medication regimens, who do not meet criteria for higher levels of care. We describe the use of NAC among 4 youths (14-17 years) with ASD who had Aberrant Behavior Checklist-Irritability (ABC-I) scores of ≥ 20 and other psychotropic medication trials prior to treatment with NAC. In all of the cases, NAC appeared to be well tolerated. There was a reduction of symptoms of irritability and/or antipsychotic medication dosages in these cases; despite this, the authors cannot know whether use of NAC or other medication or behavioral strategies were responsible for such changes because this study was not a controlled trial.

Sleep Problems and Their Relationship to Maladaptive Behavior Severity in Psychiatrically Hospitalized Children with Autism Spectrum Disorder (ASD).

We examined the relationship between sleep duration and awakenings to Aberrant Behavior Checklist-Community (ABC-C) and Autism Diagnostic Observation Schedule (ADOS-2) scores in hospitalized youth with ASD and behavioral disturbance. Participants included 106 patients with a stay of at least 10 nights. Sleep in the hospital was recorded by staff observation. Higher scores on the ABC-C (irritability, stereotypy, and hyperactivity subscales) at admission were significantly associated with fewer minutes slept during the last five nights of hospitalization. There was no association between total awakenings and ABC-C scores or ADOS-2 comparison scores. Improved understanding of the relationship between sleep quality and maladaptive behavior in this challenging cohort of patients with ASD is vital to the definition and design of future effective interventions.

Interventions for paediatric surgery patients with comorbid autism spectrum disorder: a systematic literature review.

AIMS: To survey perioperative management practices for paediatric patients diagnosed with autism spectrum disorder (ASD). METHODS: A systematic review was carried out of empirical studies and case reports published in peer-reviewed journals of current best practices and behavioural interventions for paediatric patients with ASD who had undergone surgery. RESULTS: The final sample included 11 articles published between 1997 and 2016 that met broad inclusion criteria of surveying perioperative interventions for the ASD population. There is broad endorsement across the scant publications on this topic of the following practices: increased attention to individual patient needs, rehearsal and other desensitisation efforts, departure from a sole focus on sedation or restraint of the combative or uncooperative patient and engaging caregivers in tuning perioperative management to individual needs. CONCLUSIONS: This review supports the need for an individualised structure and approach to the perioperative care of these unique patients.

Preliminary investigation of lithium for mood disorder symptoms in children and adolescents with autism spectrum disorder.

OBJECTIVE: Children with autism spectrum disorder (ASD) have higher rates of comorbid psychiatric disorders, including mood disorders, than the general child population. Although children with ASD may experience irritability (aggression, self-injury, and tantrums), a portion also experience symptoms that are typical of a mood disorder, such as euphoria/elevated mood, mania, hypersexuality, paranoia, or decreased need for sleep. Despite lithium's established efficacy in controlling mood disorder symptoms in the neurotypical population, lithium has been rarely studied in children with ASD. METHODS: We performed a retrospective chart review of 30 children and adolescents diagnosed with ASD by the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV-TR) criteria who were prescribed lithium in order to assess target symptoms, safety, and tolerability. Clinical Global Impressions - Improvement (CGI-I) ratings were performed by two board-certified child psychiatrists with expertise in ASD. CGI-I scores were dichotomized into "improved" (CGI-I score of 1 or 2) or "not improved" (CGI-I score ≥3). RESULTS: Forty-three percent of patients who received lithium were rated as "improved" on the CGI-I. Seventy-one percent of patients who had two or more pretreatment mood disorder symptoms were rated as "improved." The presence of mania (p=0.033) or euphoria/elevated mood (p=0.041) were the pretreatment symptoms significantly associated with an "improved" rating. The mean lithium blood level was 0.70 mEq/L (SD=0.26), and the average length of lithium treatment was 29.7 days (SD=23.9). Forty-seven percent of patients were reported to have at least one side effect, most commonly vomiting (13%), tremor (10%), fatigue (10%), irritability (7%), and enuresis (7%). CONCLUSIONS: This preliminary assessment of lithium in children and adolescents with ASD suggests that lithium may be a medication of interest for those who exhibit two or more mood disorder symptoms, particularly mania or euphoria/elevated mood. A relatively high side effect rate merits caution, and these results are limited by the retrospective, uncontrolled study design. Future study of lithium in a prospective trial with treatment-sensitive outcome measures may be indicated.

Management of agitation in individuals with autism spectrum disorders in the emergency department.

Individuals with autism spectrum disorder (ASD) presenting with acute agitation in emergency departments (ED) during a crisis situation present both diagnostic and treatment challenges for ED personnel, families, caregivers, and patients seeking treatment. This article describes the challenges that individuals with ASD face when receiving treatment in crisis and emergency settings. Additionally, this article provides information for emergency physicians, ED personnel, and crisis response teams on a systematic, minimally restrictive approach when assessing and providing treatment to patients with ASD presenting with acute agitation in ED settings.

Improving psychiatric hospital care for pediatric patients with autism spectrum disorders and intellectual disabilities.

Pediatric patients with autism spectrum disorders (ASD) and/or intellectual disabilities (ID) are at greater risk for psychiatric hospitalization compared to children with other disorders. However, general psychiatric hospital environments are not adapted for the unique learning styles, needs, and abilities of this population, and there are few specialized hospital-based psychiatric care programs in the United States. This paper compares patient outcomes from a specialized psychiatric hospital program developed for pediatric patients with an ASD and/or ID to prior outcomes of this patient population in a general psychiatric program at a children's hospital. Record review data indicate improved outcomes for patients in the specialized program of reduced recidivism rates (12% versus 33%) and decreased average lengths of inpatient stay (as short as 26 days versus 45 days). Available data from a subset of patients (n = 43) in the specialized program showed a decrease in irritability and hyperactivity behaviors from admission to discharge and that 35 previously undetected ASD diagnoses were made. Results from this preliminary study support specialized psychiatric care practices with this population to positively impact their health care outcomes.

Assessing disordered thoughts in preschoolers with dysregulated mood.

There is rising interest in identifying precursors to bipolar disorder symptoms, including thought disorder. Thought disorder is identified in adults through self-report and in school-aged children through parent report and child story-telling. This study is an exploration to determine if preschoolers with mood dysregulation have evidence of disordered thoughts using a story-stem completion method. Participants included two groups of 3.5-6 year-old children: 20 with mood dysregulation including manic symptoms and 11 typically developing comparison children. Children were administered story completion narratives including one story where the child character accidentally cuts him/herself while pretending to cook. The children were asked to complete the stories and their responses were analyzed for atypical themes consistent with disordered thoughts such as violence or bizarreness outside of the story or props coming to life. Thirty-five percentage of symptomatic preschoolers versus 0% of typically developing preschoolers ascribed independent actions to inanimate props (p = 0.03). Eighty percentage of symptomatic preschoolers versus 9% of typically developing preschoolers utilized props in a violent or bizarre manner outside the central story (p < 0.001). Preschool children with symptoms of dysregulated mood express themes related to the unusual use of story props which may indicate disordered thoughts. This preschool expression of dysregulated mood appears similar to and possibly continuous with school-age and adult versions of bipolar disorder.

Family-focused treatment for adolescents with bipolar disorder: results of a 2-year randomized trial.

CONTEXT: Family interventions have been found to hasten episode recovery and delay recurrences among adults with bipolar disorder. OBJECTIVE: To examine the benefits of family-focused treatment for adolescents (FFT-A) and pharmacotherapy in the 2-year course of adolescent bipolar disorder. DESIGN: Two-site outpatient randomized controlled trial with 2-year follow-up. PATIENTS: A referred sample of 58 adolescents (mean [SD] age, 14.5 [1.6] years) with bipolar I (n = 38), II (n = 6), or not otherwise specified disorder (n = 14) with a mood episode in the prior 3 months. INTERVENTIONS: Patients were randomly assigned to FFT-A and protocol pharmacotherapy (n = 30) or enhanced care (EC) and protocol pharmacotherapy (n = 28). The FFT-A consisted of 21 sessions in 9 months of psychoeducation, communication training, and problem-solving skills training. The EC consisted of 3 family sessions focused on relapse prevention. MAIN OUTCOME MEASURES: Independent "blind" evaluators assessed patients every 3 to 6 months for 2 years. Outcomes included time to recovery from the index episode, time to recurrence, weeks in episode or remission, and mood symptom severity scores. RESULTS: Analyses were by intent to treat. Rates of 2-year study completion did not differ across the FFT-A (60.0%) and EC conditions (64.3%). Although there were no group differences in rates of recovery from the index episode, patients in FFT-A recovered from their baseline depressive symptoms faster than patients in EC (hazard ratio, 1.85; 95% confidence interval, 1.04-3.29; P = .04). The groups did not differ in time to recurrence of depression or mania, but patients in FFT-A spent fewer weeks in depressive episodes and had a more favorable trajectory of depression symptoms for 2 years. CONCLUSIONS: Family-focused therapy is effective in combination with pharmacotherapy in stabilizing bipolar depressive symptoms among adolescents. To establish full recovery, FFT-A may need to be supplemented with systematic care interventions effective for mania symptoms.

Story stem responses of preschoolers with mood disturbances.

Observing the young child's affect regulation and thought processes during a clinic assessment visit is of critical importance although challenging for children referred for mood disturbance. In this study, parents reported symptoms using standardized clinical interviews and story stems narratives were administered to 20 referred and 12 typically developing preschool age children. Comparison of the referred and typically developing children in our sample showed that specific story contexts varied in eliciting responses reflecting disorganization and thought disturbance from the referred children. The experience of using story stem narratives in the clinical assessment process suggests it provides a valuable complement to parent report for children referred for mood disturbance and mania symptoms but additional development and study of the method is necessary.

Family-focused treatment for adolescents with bipolar disorder.

BACKGROUND: Research has begun to elucidate the optimal pharmacological treatments for pediatric-onset bipolar patients, but few studies have examined the role of psychosocial interventions as adjuncts to pharmacotherapy in maintenance treatment. This article describes an adjunctive family-focused psychoeducational treatment for bipolar adolescents (FFT-A). The adult version of FFT has been shown to be effective in forestalling relapses in two randomized clinical trials involving bipolar adults. METHODS: FFT-A is administered to adolescents who have had an exacerbation of manic, depressed, or mixed symptoms within the last 3 months. It is given in 21 outpatient sessions of psychoeducation, communication enhancement training, and problem solving skills training. We describe modifications to the adult FFT model to address the developmental issues and unique clinical presentations of pediatric-onset patients. RESULTS: An open treatment trial involving 20 bipolar adolescents (11 boys, 9 girls; mean age 14.8+/-1.6) found that the combination of FFT-A and mood stabilizing medications was associated with improvements in depression symptoms, mania symptoms, and behavior problems over 1 year. LIMITATIONS: These early results are based on a small-scale open trial. CONCLUSIONS: Results from an ongoing randomized controlled trial will clarify whether combining FFT-A with pharmacotherapy improves the 2-year course of adolescent bipolar disorder. If the results are positive, then a structured manual-based psychosocial approach will be available for clinicians who treat adolescent bipolar patients in the community.

Creating school-age versions of semistructured interviews for the prodrome to schizophrenia: lessons from case reviews.

There is an increasing emphasis on identifying individuals with schizophrenia earlier and earlier in their disease process, with the assumption that earlier identification translates into earlier treatment, which translates into improved outcome. Unfortunately, one age cohort, children under 13 years of age, have been excluded from this critical alteration in clinical intervention strategy, and its associated improved clinical outcome. One of the barriers to inclusion of younger children is the lack of knowledge about diagnostic issues related to attenuated psychotic symptoms in this age sample. This report focuses on our experience with evaluating attenuated psychotic symptoms in young children, in particular subthreshold hallucinations and delusions, using semistructured interviews. The inclusion of both Caregiver and Child report sections and the addition of concrete, detailed examples of clear-conscience, non-stress-related subthreshold psychotic symptoms are likely to be necessary.