Meera Roy

Are opioid antagonists effective in attenuating the core symptoms of autism spectrum conditions in children: a systematic review

BACKGROUND ASC (autism spectrum conditions) may result from a failure of striatal beta endorphins to diminish with maturation. Many symptoms of ASC resemble behaviours induced in animals or humans by opiate administration, including decreased socialisation, diminished crying, repetitive stereotypies, insensitivity to pain and motor hyperactivity. Naltrexone, an opioid antagonist, has been used in the management of children with ASC and can produce a clinically significant reduction in the serious and life-threatening behaviour of self-injury for individuals who have not been responsive to any other type of treatment and is important for this reason. It was therefore appropriate to reconsider the available evidence and a systematic review was undertaken. METHODS Four electronic databases were searched for relevant journal articles. In addition, cross-referencing of pertinent reviews and a hand search for articles in major international intellectual disability (ID) journals between the years 2010 and 2012 was carried out to ensure that all relevant articles were identified. We also searched databases for unpublished clinical trials to overcome publication bias. Each database was searched up to present (February 2013) with no restrictions on the date of publication. The search terms consisted of broad expressions used to describe ID and autistic spectrum disorder as well as terms relating to opioid antagonists and specific drugs. All studies identified by the electronic database search and hand search were examined on the basis of title alone for relevance and duplication. The abstracts of the remaining papers were then scrutinised against the inclusion criteria. Where abstracts failed to provide adequate information, the full texts for these papers were obtained. All the full texts were then evaluated against the inclusion proforma. Two reviewers carried out all the stages of the process independently. The reviewers met to discuss their selections and where disagreements arose, these were settled by discussion with a member of the study group. Data from each study meeting the inclusion criteria were extracted on a pre-piloted data extraction form. The quality of each study was further assessed using the Jadad scale, a tool developed to assess the quality of randomised controlled trials. RESULTS 155 children participated in 10 studies; 27 received placebo. Of the 128 that received naltrexone 98 (77%) showed statistically significant improvement in symptoms of irritability and hyperactivity. Side effects were mild and the drug was generally well tolerated. CONCLUSIONS Naltrexone may improve hyperactivity and restlessness in children with autism but there was not sufficient evidence that it had an impact on core features of autism in majority of the participants. It is likely that a subgroup of children with autism and abnormal endorphin levels may respond to naltrexone and identifying the characteristics of these children must become a priority.

The effectiveness of aripiprazole in the management of problem behaviour in people with intellectual disabilities, developmental disabilities and/or autistic spectrum disorder--a systematic review.

The management of problem behaviours (PB) in individuals with intellectual disabilities (ID), developmental disabilities (DD) and/or autistic spectrum disorders (ASD) can be challenging. Antipsychotic medications are commonly prescribed where other strategies have failed. A systematic review (SR) was conducted to establish the research evidence for the efficacy of aripiprazole in the management of PB in adults and children with ID, DD and/or ASD. Although included studies supported the efficacy of aripiprazole for this indication, the overall quality of studies was poor. Of the 20 studies included in this systematic review there were only two randomised controlled trials (RCTs) on children with ASD and/or ID/DD, both of which were conducted by the pharmaceutical company that manufactures aripiprazole, and it is not clear whether a number of same participants were included in both RCTs. One of the RCTs was extended into an open label long term follow up, which showed that aripiprazoles efficacy lasted over 52 weeks and the adverse effects were tolerable. Four studies were open label prospective studies, 11 were retrospective case reports which included four single case reports, and two were prospective case series. Most studies reported adverse effects from aripiprazole in the form of weight gain, increased appetite, sedation, tiredness, drooling and tremor. However, aripiprazole improved serum prolactin level in some participants and overall did not show any adverse effect on QTc interval. There is a need for more carefully designed RCTs into the use of aripiprazole in the management of PB in people with ID/DD and/or ASD, which should be carried out independent of pharmaceutical companies.

Missed diagnosis of autism in an Australian Indigenous psychiatric population

Objective: The aim of this paper is to review the diagnosis among adult Indigenous patients from the Kimberley region of Western Australia who had an existing diagnosis of schizophrenia. A visit from a psychiatrist specializing in intellectual disability provided the opportunity for conducting psychiatric assessments from a developmental perspective. Method: Selected patients with schizophrenia were assessed from an intellectual disability perspective from an active case load of 215 patients. Result: Thirteen out of 14 selected patients were considered to have a diagnosis of autism when a developmental history was undertaken. Case studies are presented to illustrate the overlap in symptoms and potential for the diagnosis of autism to be missed. Conclusions: Autism spectrum disorders may be missed in Indigenous population groups. This has implications for treatment and service provision. Clinicians need to be mindful of the diagnostic possibility that an autism spectrum disorder might be masquerading as schizophrenia in the context of intellectual disability and atypical presentation.

The human rights of women with intellectual disability

The universal human rights ‘to marry and found a family’ and to not be ‘subjected to torture or degrading treatment or punishment’ as affirmed by the United Nations Universal Declaration of Human Rights are breached when people with intellectual disability lacking capacity to consent are sterilized. In this paper the authors review the practices of contraceptive sterilization for people with intellectual disability in different countries including the United Kingdom United States Canada Australia Germany Belgium Scandinavia South Africa Japan China India and Taiwan. After conducting an extensive literature review the authors found that hysterectomies continue to be performed for menstrual management in several countries. In a few notable cases the rights of the person with intellectual disability can be superseded by interests of caregivers. It appears that worldwide there is a slow but definite move to uphold the rights of people with intellectual disability in line with Universal Human Rights with consideration of their capacity to consent and their best interest. It is important that gynecologists and psychiatrists are aware of these issues and the practice of using the least restrictive contraceptive option when dealing with women with intellectual disabilities.

Improving recording of capacity to consent and explanation of medication side effects in a psychiatric service for people with learning disability: audit findings.

This study aimed to examine the practice of psychiatrists in a large learning disability service in recording capacity to consent to treatment and side effect discussion, and the impact of measures aimed at improving this. Three audit cycles were completed between 2007 and 2009, each examining 26 case notes selected at random. Information was gathered on recording of capacity and documentation of explanation of potential side effects. Changes in practice following the introduction of a rubber stamp in 2008, as a visual prompt for clinicians, were examined. Rates of recording of capacity rose from 30% in 2007 to 51% in 2009 (P = 0.000006). Capacity was more likely to have been recorded if the stamp was present (odds ratio 13.5, p < 0.0001). Recording of side effect discussion was consistently higher than that of capacity and showed little change between cycles. We conclude that the use of a rubber stamp in case notes was associated with improvements in the recording of capacity assessments.

Efficacy of beta blockers in the management of problem behaviours in people with intellectual disabilities: a systematic review.

Both medication and non-medication based strategies are used in the management of problem behaviours in individuals with intellectual disabilities. Beta-adrenoceptor blocking medications are one group of drugs used for this purpose. However, despite its regular use, the evidence for the efficacy of these drugs for in this context is lacking. A systematic review was conducted to establish the research evidence for the efficacy of beta blockers in problem behaviours in adults and children with intellectual disabilities. Although the research identified supported the efficacy of beta blockers for this indication the overall quality of studies identified was poor and no randomised controlled trials were identified. There is a need for more robust research into the use of beta blockers for people with intellectual disabilities who show problem behaviours.

A case note follow-up of women with intellectual disability referred for sterilization:

A case note audit was carried out to follow up women with intellectual disabilities referred for contraceptive sterilization 20 years ago. None of the women had been sexually active or become pregnant. Two had hysterectomies for medical indications at a younger age. Women with intellectual disability may use reversible and less invasive methods of contraception before considering contraceptive sterilization. Although the assessments predated the Mental Capacity Act 2005, they were largely compliant with it.

Use of melatonin for sleep disturbance in a large intellectual disability psychiatry service

Abstract Aims and methods: A retrospective case note analysis was undertaken to evaluate prescribing practices, tolerability and perceived effectiveness in patients treated with melatonin for sleep disturbance in a psychiatry service caring for people with intellectual disability in a city with a population of 1·1 million.Two authors scrutinized notes to extract information on to a previously agreed proforma on degree of intellectual disability, comorbid conditions and medication, type of sleep disturbance, dose of melatonin, response to treatment and side effects. Results: One hundred and nineteen patients of whom 103(86·5%) had Autism Spectrum Disorder or traits, had been prescribed melatonin; Eighty eight (73·9%) of these had documented improvements in their sleep pattern. There was variation in prescribing practice regarding doses used and titration regime. No serious adverse effects were associated with its use in the short term; those which did occur probably do not represent a rise above events that would be seen by chance in this population. Patients with autistic spectrum disorder (ASD) or autistic traits were more likely to show a positive response to melatonin than those with learning disability and no ASD/autistic traits (P = 0·0229.). Some subjects showed a loss of efficacy after initial response, some of who responded to a higher dose. Clinical implications: Melatonin appears to represent an effective treatment for sleep disorders in children and adults with intellectual disability (ID), patients with ASD are likely to be responders. It is associated with few serious side effects. There is a need for large-scale studies to further evaluate short and long-term side effects and to determine optimal dosing regimes.

Intellectual disability and indigenous Australians: An overview

The review summarizes important literature in the emerging field of intellectual disability (ID) in indigenous Australians. Search of various electronic databases revealed 19 papers that provide information regarding prevalence, sociodemographic factors, and issues in assessment and management. Overall, there is limited information regarding ID in indigenous Australians, which is reported to be more prevalent compared with nonindigenous Australians. Sociocultural constructs affect what is considered to be ID in indigenous communities and this may be at odds with western notions. Other difficulties include lack of validated psychometric instruments to effectively measure cognitive functioning in indigenous Australians. Prenatal, perinatal, and postnatal factors are significant factors that impair brain development and contribute to ID in indigenous communities. Comorbid physical and psychiatric disorders need to be assessed and managed. This paper provides an overview of current knowledge regarding this important area that requires further research, appropriate training, and resourcing.The review summarizes important literature in the emerging field of intellectual disability (ID) in indigenous Australians. Search of various electronic databases revealed 19 papers that provide information regarding prevalence, sociodemographic factors, and issues in assessment and management. Overall, there is limited information regarding ID in indigenous Australians, which is reported to be more prevalent compared with nonindigenous Australians. Sociocultural constructs affect what is considered to be ID in indigenous communities and this may be at odds with western notions. Other difficulties include lack of validated psychometric instruments to effectively measure cognitive functioning in indigenous Australians. Prenatal, perinatal, and postnatal factors are significant factors that impair brain development and contribute to ID in indigenous communities. Comorbid physical and psychiatric disorders need to be assessed and managed. This paper provides an overview of current knowledge regarding this important area that requires further research, appropriate training, and resourcing.

The effectiveness of methylphenidate in the management of Attention Deficit Hyperactivity Disorder (ADHD) in people with intellectual disabilities: A systematic review

BACKGROUND The effectiveness of psychostimulants, primarily methylphenidate (MPH), in the treatment of Attention Deficit Hyperactivity Disorder (ADHD) in the general population of typically growing children and adolescents is well established through many Randomised Controlled Trials (RCTs). AIMS AND METHODS We carried out a systematic review of all the RCTs in people with intellectual disabilities (ID) that assessed effectiveness of MPH on the core ADHD symptoms. OUTCOMES AND RESULTS We included 15 papers from 13 studies that were all on children and adolescents with ID (315 participants were on MPH and placebo respectively), 12 of which used a cross over design, and one used a parallel design. On average around 40-50% responded to MPH in the ID group whereas around 70-80% response rate is reported among the non-ID children. Because of the heterogeneity of the outcome data it was not possible to carry out a meta-analysis. Significant adverse events included sleep difficulties and poor appetite along with weight loss and also irritability, social withdrawal and increased motor activities including tic. CONCLUSIONS AND IMPLEMENTATION On the basis of the poor quality evidence that is available, it seems that MPH may be effective in some but not all children and adolescents with ID and ADHD.