IDENTIFYING AND MANAGING AUTISM SPECTRUM DISORDERS IN CHILDREN

The American Academy of Pediatrics has published two clinical reports in the November Pediatrics focusing on the early identification and management of autism spectrum disorders in children. Authored by Chris Plauché Johnson, MD, Scott M. Myers, MD, and the Council on Children With Disabilities, the reports replace the original American Academy of Pediatrics policy statement and technical report published in 2001.

“Pediatricians play an important role in early recognition of autism spectrum disorders, because they usually are the first point of contact for parents,” the authors stated. “It is important that pediatricians be able to recognize the signs and symptoms of autism spectrum disorders and have a strategy for assessing them systematically. Pediatricians also must be aware of local resources that can assist in making a definitive diagnosis of, and in managing, autism spectrum disorders.”

The first report addressed the definition, history, epidemiology, diagnostic criteria, early signs, neuropathologic aspects, and etiologic possibilities in autism spectrum disorders and provided an algorithm to aid clinicians in developing a strategy for early identification. The investigators highlighted communication deficits among the early signs of the disorder, pointing out that although lack of speech is recognized as a hallmark of autistic disorder, presence of speech in conjunction with milder symptoms and normal cognitive skills is also a feature.

“Some children with autism spectrum disorders say ‘pop-up words’ without any apparent stimulus or communicative intent,” the authors stated. “They are spontaneous and inconsistent, although sometimes they may occur during acutely stressful situations. These words are said out of context for a short period of time (days or weeks) and then, as suddenly as they might pop up for no apparent reason, they disappear.

Children with autism spectrum disorders also may develop ‘language’ in overlearned or gestalt phrases that are acquired and spoken almost as a single ‘giant-word’ (ie, Whatisit? Idontknow).”

The investigators stated that prespeech deficits that occur before classic hallmarks such as pop-up words and giant words may facilitate earlier diagnosis of autism spectrum disorders. Such earlier deficits include:

• Lack of appropriate gaze

• Lack of warm, joyful expressions with gaze

• Lack of the alternating to-and-fro pattern of vocalizations between infant and parent that usually occurs at approximately 6 months of age

• Lack of recognition of consistent caregiver’s voice

• Disregard for vocalizations, yet keen awareness for environmental sounds

• Delayed onset of babbling past 9 months of age

• Decreased or absent use of prespeech gestures, such as waving, pointing, and showing.

The second report addressed the management of autism spectrum disorders in children by reviewing the educational strategies and related therapies currently being used as primary treatments. The investigators reported “a growing consensus [for certain] important principles and components of effective early childhood intervention.” These include not waiting until a definitive diagnosis is made to allow for an intervention, but rather when an autism spectrum disorder is first seriously considered; having a provision of intensive intervention “with active engagement of the child at least 25 hours per week, 12 months per year, in systematically planned, developmentally appropriate educational activities designed to address identified objectives”; and allowing for a low student-to-teacher ratio and inclusion of a family component, among other recommendations.

“Autism spectrum disorders are chronic conditions that affect nearly one of every 150 children and require ongoing medical and nonmedical intervention,” the researchers stated. “There is a growing body of evidence that supports the efficacy of certain interventions in ameliorating symptoms and enhancing functioning, but much remains to be learned. In addition to their important roles in identifying autism spectrum disorders through screening and surveillance, establishing the diagnosis, conducting an etiologic evaluation, and providing genetic counseling after a diagnosis is made, pediatricians and other primary health care professionals are in a position to provide important longitudinal medical care and to support and educate families and guide them to empirically supported interventions for their children.”

Suggested Reading
Johnson CP, Myers SM, Council on Children With Disabilities. Identification and evaluation of children with autism spectrum disorders. Pediatrics. 2007;120(5):1183-1215.
Myers SM, Johnson CP, Council on Children With Disabilities. Management of children with autism spectrum disorders. Pediatrics. 2007;120(5):1162-1182.

ONCE-DAILY LAMOTRIGINE EFFECTIVELY TREATS PARTIAL SEIZURES IN EPILEPSY

The addition of a slow-release formulation of lamotrigine to the medication regimen of patients with epilepsy whose partial seizures are not fully controlled by their current medications may significantly reduce partial seizure frequency, reported Dean K. Naritoku, MD, and colleagues in the October 16 Neurology.

Dr. Naritoku, an Associate Professor of Neurology and Pharmacology and Director of the Clinical Neurophysiology and Epilepsy fellowship at the Southern Illinois University School of Medicine in Springfield, and colleagues randomized 243 patients 12 and older diagnosed with epilepsy with partial seizures to receive once-daily lamotrigine extended-release (XR) or placebo. All participants were taking one or two antiepileptic drugs at baseline, most often carbamazepine and/or valproate. The mean total daily dose of lamotrigine XR during the 12-week maintenance phase ranged from 230.2 to 500.3 mg/day, depending on the pretreatment regimen.

Of the 239 participants who received at least one dose of the study medication, 97 who received lamotrigine XR and 106 who received a placebo completed the entire 19-week double-blind treatment phase, reported the researchers. Participants who received lamotrigine XR experienced a median 46.1% reduction from baseline in weekly frequency of partial seizures, versus a median 24.2% reduction in the placebo group. “A similar pattern of results was observed for secondarily generalized seizures,” stated the authors: The median percentage reductions in weekly frequency were 55.2% in the lamotrigine XR group and 3.2% in the placebo group. The percentage of patients with a 50% or greater reduction in partial or secondarily generalized seizure frequency was also significantly higher in the lamotrigine XR group (42.2% and 52.2%, respectively) than in the placebo group (24.2% and 25.5%, respectively). Similarly greater efficacy with lamotrigine XR was also observed during the escalation and maintenance phases, reported the researchers.

Adverse events, such as dizziness and nausea, led to withdrawal from the study in 9% of the original lamotrigine XR group and 2% of the placebo group. Of those who completed the study, adverse events occurred in 69% of the lamotrigine XR group and in 62% of the placebo group. Headache was reported most often, with similar frequency between the treatment groups (17% for the lamotrigine group and 15% for the placebo group), and dizziness was more prevalent in the lamotrigine XR group. However, no serious rashes were reported, and “clinical laboratory results and EKG findings were unremarkable in both treatment groups,” stated the authors.           

Suggested Reading
Naritoku DK, Warnock CR, Messenheimer JA, et al. Lamotrigine extended-release as adjunctive therapy for partial seizures. Neurology. 2007;69(16):1610-1618.

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