Lynne C. Huffman

Dyadic distress management predicts subsequent security of attachment

The purpose of this study was to examine methodologically independent infant, maternal, and dyadic variables to predict security of attachment. The subjects were 52 mothers and their firstborn infants from middle- to upper-middle-class backgrounds. Prenatal assessment of maternal characteristics included measures of depression, anxiety, and self-efficacy. Infant characteristics were assessed via a standardized laboratory procedure at 3 months of age. Dyadic behaviors were observed in the home also at 3 months of age. At 12 months of age, security of attachment was assessed in the Strange Situation procedure. Results indicate that prenatal maternal anxiety and dyadic behaviors involving distress management were the best predictors of security of attachment. This study provides support for the role of maternal characteristics measured in the prenatal period as well as mother-infant dyadic patterns involving distress management in determining subsequent security of attachment.

MANAGEMENT OF SYMPTOMS IN CHILDREN WITH AUTISM SPECTRUM DISORDERS: A COMPREHENSIVE REVIEW OF PHARMACOLOGIC AND COMPLEMENTARY-ALTERNATIVE MEDICINE TREATMENTS

In the care of children with autism spectrum disorders (ASD), medical treatment is typically considered an adjunct to educational and behavioral interventions. Nonetheless, large proportions of children with ASD are managed medically and receive both pharmacologic and complementary-alternative medicine (CAM) treatments. Although many medical treatments have been studied in children with ASD, studies vary widely in terms of the sample, sample size, research design, purposes of treatment, and measurements of change. Surprisingly, comprehensive reviews of the options for medical management in ASD are lacking, particularly reviews that address both pharmacologic and CAM treatments. Furthermore, reviews to date tend to emphasize general effects of medication; this perspective contradicts medical practice, which targets particular symptoms during treatment selection and monitoring. This review of 115 studies adds to the ASD treatment literature by (1) including studies of individuals 0 to 22 years of age; (2) aggregating studies of pharmacologic treatments and CAM treatments; and importantly, (3) organizing treatment response by ASD symptoms, differentiating core and associated symptoms.

Cortisol and social stressors in children with fragile X: a pilot study.

Evidence of neuroendocrine dysfunction, behavioral features of social anxiety and avoidance, and neuroanatomical abnormalities suggest that abnormal hypothalamic-pituitary-adrenal (HPA) function may be a component of the fragile X (fra X) syndrome. In this preliminary study, salivary cortisol levels of males (n = 8, mean age = 13.5 yr) and females (n = 7, mean age = 13.9 yr) with the fra X full mutation were studied for 3 days. Day 1 was an experimental day, during which subjects experienced a Social Stressor task midmorning. Days 2 and 3 were routine days, during which the subjects were engaged in their typical activities. Saliva samples were collected before breakfast, lunch, dinner, and bedtime. On the experimental day, the prelunch sample collection occurred 30 and 90 minutes after the Social Stressor task. Compared with childrens norms, the combined group of males and females with fra X had significantly higher cortisol levels in the prelunch and the prebedtime samples for the routine days. Comparisons between the two fra X groups for the experimental day revealed similar diurnal patterns for cortisol level. However, compared with females with fra X, males with fra X had significantly higher cortisol levels at two points during the day: 30 minutes after the social stressor and at bedtime. These preliminary data suggest that individuals with fra X have abnormal HPA function. Understanding the relations among HPA dysfunction, abnormalities in brain structure and/or function, and maladaptive behavior and cognition in fra X could inform the design of early interventions using pharmacological or environmental measures designed to normalize neuroendocrine function.

Tetrahydrobiopterin as a novel therapeutic intervention for autism

SummaryTetrahydrobiopterin (BH4) is an essential cofactor for several critical metabolic pathways that have been reported to be abnormal in autism spectrum disorder (ASD). In addition, the cerebrospinal fluid concentration of BH4 is reported to be depressed in children with ASD. Over the past 25 years, several clinical trials have suggested that treatment with BH4 improves ASD symptomatology in some individuals. Two ongoing clinical protocols may help further define the efficacy of BH4 treatment in children with ASD. First, children with ASD who had low concentrations of cerebrospinal fluid or urine pterins were treated in an open-label manner with 20 mg/kg per day of BH4. The majority of children (63%) responded positively to treatment, with minimal adverse events (AEs). Second, a double-blind placebo-controlled study examining the efficacy of 20 mg/kg per day of BH4 treatment in children with ASD is currently underway. Safety studies from the commercially available forms of BH4 document the low incidence of AEs, particularly serious AEs. Studies have also documented the ability of BH4 to cross the blood-brain barrier. Based on the importance of BH4 in neurodevelopmental metabolic pathways, the safety of BH4 treatment, and the evidence for a therapeutic benefit of BH4 treatment in children with ASD, we conclude that BH4 represents a novel therapy for ASD, one that may gain wider use after further clinical studies have established efficacy and treatment guidelines.

Learning Culture and Outcomes Measurement Practices in Community Agencies.

The present study is a first step in examining learning culture and outcomes measurement practices as indicators of community agencies’ readiness for the implementation of research-based evaluation. Representatives from Northern California community agencies serving children and youth (n=25) completed surveys, which included questions about agency demographics, outcomes measurement practices, and learning culture. Results indicate that, although there is an awareness of the importance of outcomes evaluation, most agencies lack the resources for its systematic implementation. They express interest in learning more about outcomes measurement techniques and program evaluation, and they report needing help in building internal capacity for evaluation. The newly developed Assessing Learning Culture Scale revealed that an underlying set of beliefs, norms, and behaviors characterizes the learning culture of community agencies. These attitudes and beliefs are positively related to systematic data collection efforts and external funding, while attitudes and beliefs that indicate absence of a learning culture are correlated with sporadic data collection efforts and less external funding. Findings indicate that learning culture is an important factor for both the implementation of systematic evaluation efforts and the successful procurement of external funding. They also suggest that systematic evaluation efforts can serve as a change agent for creating a culture that values learning within the organization.

Children with Special Health Care Needs: How Immigrant Status is Related to Health Care Access, Health Care Utilization, and Health Status

To compare health care access, utilization, and perceived health status for children with SHCN in immigrant and nonimmigrant families. This cross-sectional study used data from the 2003 California Health Interview Survey to identify 1404 children (ages 0–11) with a special health care need. Chi-square and logistic regression analyses were used to examine relations between immigrant status and health access, utilization, and health status variables. Compared to children with special health care needs (CSHCN) in nonimmigrant families, CSHCN in immigrant families are more likely to be uninsured (10.4 vs. 4.8%), lack a usual source of care (5.9 vs. 1.9%), report a delay in medical care (13.0 vs. 8.1%), and report no visit to the doctor in the past year (6.8 vs. 2.6%). They are less likely to report an emergency room visit in the past year (30.0 vs. 44.0%), yet more likely to report fair or poor perceived health status (33.0 vs. 16.0%). Multivariate analyses suggested that the bivariate findings for children with SHCN in immigrant families largely reflected differences in family socioeconomic status, parent’s language, parental education, ethnicity, and children’s insurance status. Limited resources, non-English language, and limited health-care use are some of the barriers to staying healthy for CSHCN in immigrant families. Public policies that improve access to existing insurance programs and provide culturally and linguistically appropriate care will likely decrease health and health care disparities for this population.

Folic acid in neurodevelopment and child psychiatry

1. Folic acid deficiency has been associated with diverse neuropsychiatric symptoms. 2. This paper discusses the impact of folate on brain development, maturation and function and reviews the role of folate in psychiatric disorders, particularly childhood disorders. 3. A brief case report examines the use of folate in the treatment of attentional problems in a child with fragile X syndrome.

Missed Opportunities in the Referral of High-Risk Infants to Early Intervention

OBJECTIVE: Using a statewide population-based data source, we describe current neonatal follow-up referral practices for high-risk infants with developmental delays throughout California. METHODS: From a cohort analysis of quality improvement data from 66 neonatal follow-up programs in the California Children’s Services and California Perinatal Quality Care Collaborative High-Risk Infant Follow-Up Quality of Care Initiative, 5129 high-risk infants were evaluated at the first visit between 4 and 8 months of age in neonatal follow-up. A total of 1737 high-risk infants were evaluated at the second visit between 12 and 16 months of age. We calculated referral rates in relation to developmental status (high versus low concern) based on standardized developmental testing or screening. RESULTS: Among infants with low concerns (standard score >70 or passed screen) at the first visit, 6% were referred to early intervention; among infants with high concerns, 28% of infants were referred to early intervention. Even after including referrals to other (private) therapies, 34% infants with high concerns did not receive any referrals. These rates were similar for the second visit. CONCLUSIONS: In spite of the specialization of neonatal follow-up programs to identify high-risk infants with developmental delays, a large proportion of potentially eligible infants were not referred to early intervention.

Tetrahydrobiopterin as a Treatment for Autism Spectrum Disorders: A Double-Blind, Placebo-Controlled Trial

OBJECTIVE The purpose of this study was to determine if tetrahydrobiopterin (BH4) reduced core symptoms of autism spectrum disorder (ASD). METHOD In this study, 46 children, 3-7 years of age diagnosed with an ASD were randomly assigned to double-blind treatment with 20 mg/kg/day BH4 or placebo for 16 weeks. The primary outcome measure was the Clinical Global Impressions Improvement and Severity Scales (CGI-I and CGI-S); secondary outcomes were the Preschool Language Scale-4 (PLS-4), Social Responsiveness Scale (SRS), Aberrant Behavior Checklist (ABC), and Vineland Adaptive Behavior Scales (Vineland). RESULTS Overall, no differences were found on global improvement as measured with the CGI-I or CGI-S. Secondary measures indicated significant improvements for BH4 relative to placebo with regard to social awareness, autism mannerisms, hyperactivity, and inappropriate speech. Side effects were minimal and similar between both active medication and placebo. CONCLUSIONS These results indicate that BH4 offers promise in reducing symptoms of ASD. Clinical Trials.gov Identifier: NCT00850070.

Variation in specialty care hospitalization for children with chronic conditions in California.

OBJECTIVE: Despite the documented utility of regionalized systems of pediatric specialty care, little is known about the actual use of such systems in total populations of chronically ill children. The objective of this study was to evaluate variations and trends in regional patterns of specialty care hospitalization for children with chronic illness in California. METHODS: Using Californias Office of Statewide Health Planning and Development unmasked discharge data set between 1999 and 2007, we performed a retrospective, total-population analysis of variations in specialty care hospitalization for children with chronic illness in California. The main outcome measure was the use of pediatric specialty care centers for hospitalization of children with a chronic condition in California. RESULTS: Analysis of 2 170 102 pediatric discharges revealed that 41% had a chronic condition, and 44% of these were discharged from specialty care centers. Specialty care hospitalization varied by county and type of condition. Multivariate analyses associated increased specialty care center use with public insurance and high pediatric specialty care bed supply. Decreased use of regionalized care was seen for adolescent patients, black, non-Hispanic children, and children who resided in zip codes of low income or were located farther from a regional center of care. CONCLUSIONS: Significant variation exists in specialty care hospitalization among chronically ill children in California. These findings suggest a need for greater scrutiny of clinical practices and child health policies that shape patterns of hospitalization of children with serious chronic disease.