Matthew Siegel

Psychotropic Medications in Children with Autism Spectrum Disorders: A Systematic Review and Synthesis for Evidence-Based Practice

This paper presents a systematic review, rating and synthesis of the empirical evidence for the use of psychotropic medications in children with autism spectrum disorders (ASD). Thirty-three randomized controlled trials (RCTs) published in peer-reviewed journals qualified for inclusion and were coded and analyzed using a systematic evaluative method specific to autism research (Reichow et al. in Journal of Autism and Developmental Disorders 38:1311–1319, 2008). Results are presented by agent and primary target symptom(s). The findings suggest established evidence for relatively few agents, with preliminary and promising evidence for a larger group. Challenges and opportunities in the developing field of ASD psychopharmacology are identified, and recommendations for further research are provided.

Psychiatric hospital treatment of children with autism and serious behavioral disturbance.

Children with autism spectrum disorder are psychiatrically hospitalized much more frequently than children in the general population. Hospitalization occurs primarily because of externalizing behaviors and is associated with behavioral disturbance, impaired emotion regulation, and psychiatric comorbidity. Additionally, a lack of practitioner and/or administrator training and experience with this population poses risks for denial of care by third-party payers or treatment facilities, inadequate treatment, extended lengths of stay, and poor outcomes. Evidence and best practices for the inpatient psychiatric care of this population are presented. Specialized treatment programs universally rely on multidisciplinary approaches, including behaviorally informed interventions.

Psychiatric Features in Children with Genetic Syndromes: Toward Functional Phenotypes

Neurodevelopmental disorders with identified genetic etiologies present a unique opportunity to study gene-brain-behavior connections in child psychiatry. Parsing complex human behavior into dissociable components is facilitated by examining a relatively homogenous genetic population. As children with developmental delay carry a greater burden of mental illness than the general population, familiarity with the most common genetic disorders will serve practitioners seeing a general child population. In this article basic genetic testing and 11 of the most common genetic disorders are reviewed, including the evidence base for treatment. Based on their training in child development, family systems, and multimodal treatment, child psychiatrists are well positioned to integrate cognitive, behavioral, social, psychiatric, and physical phenotypes, with a focus on functional impairment.

Psychopharmacology of Autism Spectrum Disorder: Evidence and Practice

Children with autism spectrum disorder present with a high rate of maladaptive behaviors and comorbid psychopathology. Psychopharmacologic treatment is frequently used in this population and is particularly associated with comorbid mental illness and increasing age. Successful treatment of presenting problems, however, is most likely achieved through consideration of multiple potential etiologic factors, only some of which may respond to pharmacologic intervention. The evidence base for targeting specific symptoms and disorders with psychopharmacology in children with autism spectrum disorder is expanding rapidly and offers guidance for practicing clinicians. The current evidence for symptom-specific treatment is presented.

Awareness of Altitude Sickness Among a Sample of Trekkers in Nepal

Abstract Objective.—To quantify awareness of altitude sickness in a sample of trekkers in Nepal and identify strategies for increasing knowledge in that population. Methods.—Sixty-five high-altitude trekkers were surveyed. Demographic data were gathered. Respondents were asked about their experience in high-altitude environments, and they answered clinical-vignette questions designed to test their abilities to recognize and identify treatments for common symptoms of altitude sickness. An altitude-awareness score was generated by tabulating correct answers to questions. Scores were correlated with demographic data. Results.—Respondents who scored highest (n = 8) had significantly more experience in high-altitude environments, averaging 5 to 10 years (P < .05), and achieved higher average altitudes on their treks of 5171 m (P < .05) than did low scorers. Respondents with low scores (n = 17) trekked to an average altitude of 4138 m. Seventy-three percent wanted to learn more about altitude sickness, 30% said they would prefer to learn from the Internet, and 27% said they would ask a doctor. Conclusion.—This study suggests that a large population of at-risk high-altitude travelers may be relatively naïve to the dangers of altitude sickness. Overall, respondents were interested in learning more about altitude sickness. Physicians and the Internet are the most attractive sources of information for this population.

Development of the Emotion Dysregulation Inventory: A PROMIS®ing Method for Creating Sensitive and Unbiased Questionnaires for Autism Spectrum Disorder

The lack of sensitive measures suitable for use across the range of functioning in autism spectrum disorder (ASD) is a barrier to treatment development and monitoring. The Emotion Dysregulation Inventory (EDI) is a caregiver-report questionnaire designed to capture emotional distress and problems with emotion regulation in both minimally verbal and verbal individuals. The first two phases of the EDI’s development are described, including: (1) utilizing methods from the Patient-Reported Outcomes Measurement Information System (PROMIS®) project to develop the item pool and response options; and (2) assessment of the EDI in psychiatric inpatients with ASD. The results suggest that the EDI captures a wide range of emotion dysregulation, is sensitive to change, and is not biased by verbal or intellectual ability.

Psychiatric Hospitalization of Children With Autism or Intellectual Disability: Consensus Statements on Best Practices.

Psychiatric hospitalization of children with Autism Spectrum Disorder (ASD) and/or Intellectual Disability (ID), is both common and challenging. Children with ASD are six times more likely to be psychiatrically hospitalized than children without ASD.1 Due to the limited number of specialized psychiatric units for children and adolescents with ASD or ID in the United States, most admissions are to general child and adolescent psychiatric units. Staff may have limited experience with this population, and the treatment approach and therapeutic milieu may not be well adapted to children with ASD or ID. General units typically use verbal interventions (e.g., individual, family and group therapies), programming with high social demands, and general reinforcements (e.g., level systems). These interventions can be less effective in children with ASD or ID, who have impairments in social communication and cognitive abilities and may have rigid routines and preferences. Specialized units have shown improvement in the behavioral functioning of children with ASD or ID two months after discharge2, as well as decreased readmissions,3 in two uncontrolled studies with an average length of stay of 26–42 days. To identify best practices for psychiatric inpatient care of children with ASD or ID a panel of expert clinicians (child and adolescent psychiatrists, psychologists and pediatricians) from six United States specialized units convened. Due to the limited amount of research in this area, evidence-based recommendations were not feasible, and the panel undertook a consensus process based on existing literature and expert opinion gathered from a survey, a semi-structured telephone interview with the participants and regular conference calls. Although inpatient facilities can have significant resource constraints, the following consensus statements encompass trends in practices currently utilized by specialized units, and offer a vision of how to best serve this population. As such, the panel sought to strike a balance between identifying best practices and providing recommendations that may be attainable on general units.

Electroconvulsive therapy in an adolescent with autism and bipolar I disorder.

Objectives We report a positive response to electroconvulsive therapy in a severely functionally impaired adolescent with autistic disorder and classic bipolar I disorder, including an episodic pattern of decreased need for sleep, hypersexuality, expansive and agitated affect, aggression, self-injury, and property destruction. Methods After ineffective trials of mood stabilizers and antipsychotics as well as inability to sustain a positive response to lithium due to medication noncompliance, a course of acute and maintenance electroconvulsive therapy was attempted. Results A marked and sustained improvement across all symptom categories, as measured by directly observed frequency counts of target behaviors in an inpatient setting, was obtained. Conclusions Electroconvulsive therapy should be considered a potentially useful intervention in cases of children with autistic disorder and a severe comorbid affective disorder.

Talking About Death or Suicide: Prevalence and Clinical Correlates in Youth with Autism Spectrum Disorder in the Psychiatric Inpatient Setting

Little is known about suicidal ideation in youth with autism spectrum disorder (ASD), making it difficult to identify those at heightened risk. This study describes the prevalence of thoughts about death and suicide in 107 verbal youth with ASD with non-verbal IQ >55, assessed during inpatient psychiatric admission. Per parent report, 22% of youth with ASD had several day periods when they talked about death or suicide “often,” or “very often.” Clinical correlates included the presence of a comorbid mood (OR 2.71, 95% CI 1.12–6.55) or anxiety disorder (OR 2.32, 95% CI 1.10–4.93). The results suggest a need for developmentally appropriate suicide risk screening measures in ASD. Reliable detection of suicidal thoughts in this high-risk population will inform suicide prevention strategies.

Problem Behaviors in Autism Spectrum Disorder: Association with Verbal Ability and Adapting/Coping Skills

Data from the Autism Inpatient Collection was used to examine the relationship between problem behaviors and verbal ability, which have generally, though not universally, been highly associated. In a comparison of 169 minimally-verbal and 177 fluently-verbal 4 to 20-year-old psychiatric inpatients with ASD, the severity of self-injurious behavior, stereotyped behavior, and irritability (including aggression and tantrums) did not significantly differ, when controlling for age and NVIQ. Verbal ability was not strongly related to the severity of problem behaviors. However, lower adapting/coping scores were significantly associated with increasing severity of each type of problem behavior, even when accounting for verbal ability. Interventions to develop adapting/coping mechanisms may be important for mitigation of problem behaviors across the spectrum of individuals with ASD.