The rise and rise of CM-AT for autism

Today's post surrounds a poster presentation delivered at INSAR 2019, the (still) premier international autism conference, albeit not without its battles. The poster was delivered by Heil and colleagues [1] and talks about a compound / preparation that has been discussed a few years back on this blog: CM-AT (see here).

CM-AT is described as a "pancreatic enzyme preparation" with chymotrypsin - a digestive enzyme - seemingly placed quite prominently in its list of ingredients. CM-AT is, from what I understand, something that is still going through the research processes with regards to its use in the context of autism. Heil and colleagues presented data on part of that research agenda, specifically pertinent to ascertaining "whether or not behavior (e.g., symptoms of irritability, hyperactivity) in preschoolers with autism could be improved with CM-AT."

Bearing in mind a conference poster presentation is not necessarily the same as a published peer-reviewed research article, the Heil data was based on the use of a "randomized, placebo-controlled, 12-week clinical trial" methodology where 92 children, aged between 3-5 years, diagnosed with an autism spectrum disorder (ASD) received CM-AT "as granules sprinkled on food" and almost a hundred boys with ASD received a placebo "which consisted of visually identical inert sprinkles." The 'Irritability' scale of the Aberrant Behavior Checklist (ABC) was the primary outcome measure.

Results: "children receiving CM-AT (relative to those receiving placebo) demonstrated significant reductions in Irritability... Hyperactivity... Inappropriate Speech... over the 12 weeks of the trial." Researchers further reported that those children with higher levels of irritability at baseline tended to show a greater positive response than when the participant sample as a whole was analysed.

I think you can perhaps see why these results - preliminary as they are - are worthy blogging material. Irritability, perhaps listed as a 'challenging behaviour' in the context of autism is something that many, many people would love to be able to effectively tackle; if not just because of the impact it can have on those with autism and those around them who have to 'cope' with such behaviours. Indeed, given the other options for managing such behaviour such as the antipsychotic risperidone (see here) and the issues which that drug and its similars can bring (see here), the idea that there may be other, less side-effect heavy options (see here) is definitely something to consider.

I'm hopeful that soon, very soon, I can talk more about CM-AT in the context of irritability and beyond in relation to autism...

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[1] Heil MF. et al. Pancreatic Replacement Therapy with CM-at Is Associated with Reduction in Maladaptive Behaviors in Preschoolers with Autism. INSAR 2019.

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Nighttime body movements and autism

I was rather interested in the findings reported by Nobushige Naito and colleagues [1] talking about how atypical body movements during the night seemed to be more frequently observed in children diagnosed with an autism spectrum disorder (ASD) compared to not-autism controls. Interested because, sleep is a long-running 'issue' in relation to autism (see here) and because, researchers relied on the use of actigraphy in their study: "a movement-based index measured by an accelerometer" rather than just second-hand observational questioning.

So: "Seventeen TD [typically developing] children and 17 children with ASD participated in this study (5 to 8 years old)." Importantly (see here) we are told that: "Considering the frequent co-occurrence of ASD and ADHD [attention-deficit hyperactivity disorder] symptoms, we did not exclude ASD patients with ADHD symptoms." Authors relied on data from a waistband accelerometer worn by participants over at least 3 nights. Using a waistband was seen as preferable to the more typical wristband. Data was collected and analysed. It included something called a movement index (MI): "the ratio of the body movement period in 20 minutes was calculated continuously for 9 hours using the sliding window method."

Results: "a higher rate of body movement 2 to 3 hours after the first onset of body stillness was more prominent in children with ASD than in TD children." Importantly authors also mention how the objective data provided by the waistband accelerometer showed a different "time course of body movements during night in young children with ASD" despite parents/carers reporting no "apparent" problems with sleeping. They also talk some of the differences in body movements seen in those children with ASD potentially *related* to some awake behaviours - "a lower social ability and more frequent maladaptive behaviour."

The Naito results represent a good start at looking at these important behaviours. I'm a little bit hesitant to go all-in with the suggestion from the authors that "atypical nocturnal body movement could be an ASD state and trait marker in young children with ASD" but can see the importance of further investigations in this area.

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[1] Naito N. et al. Atypical body movements during night in young children with autism spectrum disorder: a pilot study. Sci Rep. 2019 May 6;9(1):6999.

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Baclofen is back: "Baclofen as an adjuvant therapy for autism"

"Our data support [the] safety and efficacy of baclofen as an adjuvant to risperidone for improvement of hyperactivity symptoms in children with ASD [autism spectrum disorder]."

So said the findings reported by Seyedeh-Mahsa Mahdavinasab and colleagues [1] talking about the use of baclofen as an add-on medicine in the context of risperidone use in relation to autism. Baclofen by the way, is typically known as "a gamma-aminobutyric acid (GABA) agonist" (binds to the GABA receptors and activates them) which accounts for its use as "a skeletal muscle relaxant" given the inhibitory function of GABA and GABA receptors.

Why the 'baclofen is back' sentiment expressed in the title of this post? Well, a few years back there was some excitement about a compound called STX209 otherwise known as arbaclofen in the context of a genetic condition manifesting autistic signs and symptoms (see here) and autism itself. Arbaclofen is an enantiomer (mirror image in a chemical sense) of baclofen, but unfortunately fell by the wayside after some less than impressive results emerged from clinical trials (see here). Arbaclofen might have been kicked into the long grass for now but baclofen it seems, is still on the autism research agenda...

Researchers report results based on a "10-week randomized-controlled study aimed at evaluating the potential of baclofen as an adjuvant therapy to enhance the effect of risperidone in children with ASD." Risperidone is an antipsychotic which is indicated for selective use with children with autism (see here) specifically to treat/manage aggressive and challenging behaviours. They reported that several outcome measures saw a change - a positive change - specifically in relation to hyperactivity behaviours which can often accompany aggression. Importantly, they also noted that during and after 10 weeks of add-on baclofen use, adverse events were reported to be at a minimum.

There is more to do in this area before any sweeping generalisations are made. I personally would like to see more data on potential best- and non-responders in the context that GABA is still a topic of interest to autism research (see here). I know also that some people might be a little put-out by the idea that more medication is added to the lives of young children with autism and worries about how this might impact them in later years. We need a lot more data.

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[1] Mahdavinasab SM. et al. Baclofen as an adjuvant therapy for autism: a randomized, double-blind, placebo-controlled trial. Eur Child Adolesc Psychiatry. 2019 Apr 12.

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Lactobacillus plantarum PS128 "ameliorated opposition/defiance behaviors" in boys with autism?

There was something potentially rather special about the results published by Yen-Wenn Liu and colleagues [1] suggesting that use of a probiotic - Lactobacillus plantarum PS128 - might, under "randomized, double-blind, placebo-controlled" conditions, have some important effects with some young people diagnosed with an autism spectrum disorder. Special because, if such results are eventually replicated and borne out, some of the more 'disruptive' behaviours that can sometimes be observed alongside a diagnosis of autism - "opposition/defiance behaviors" - might be amenable to quite a simple intervention. That could be important for many, many different reasons.

The basics: PS128 containing "3 × 1010 CFU/capsule of PS128 with microcrystalline cellulose as the carrier" was the compound under investigation, pitted against a placebo that "only contained microcrystalline cellulose." Eighty participants, all boys diagnosed with an autism spectrum disorder (ASD) were recruited for study; 39 were assigned to receive PS128 and 41 receiving the placebo for a period of 4 weeks. Various different schedules and questionnaires were used to measure behaviour at baseline and week 4 between the groups. With a fairly small attrition rate - data for 36 participants in the PS128 and 35 in the placebo group were analysed - the results were pretty interesting.

Results: first and foremost we are told that no adverse events were reported during the study. That's important. Next, for the vast majority of measures used when straight comparing of PS128 and placebo, no significant difference was noted. The authors even mention how a clinician rated scale, the CGI-I, basically said that "both groups were equivalent to "minimally improved""  between baseline and study end. It was only when results were stratified for age that things started to 'happen' as various behaviours around anxiety, rule-breaking, inattention and opposition/defiance showed something like a 'nominal' reduction in the PS128 group compared with placebo, particularly for those aged between 7-12 years. As per the use of the word 'nominal' to denote a small 'change' the results were not spectacular.

Caveats? Well, this was a 4-week study of boys on the autism spectrum. Not a long time in anyone's book but longer than other studies on other interventions that did show a statistically significant effect (see here for example). The Liu study was also a study that exclusively relied on behavioural observation measures, so we can't say anything about how something like PS128 might have impacted on gut bacteria for example. Other, less methodologically sound studies have been more comprehensive (see here).

But there are strengths to the Liu study; strengths around the design and use of a placebo condition. And if there is a chance that something like Lactobacillus plantarum PS128 or other preparations (see here and see here) or related techniques (see here) *might* help improve quality of life for young and old people on the autism spectrum minus any significant side-effects, they should be explored an awful lot more...

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[1] Liu Y-W. et al. Effects of Lactobacillus plantarum PS128 on Children with Autism Spectrum Disorder in Taiwan: A Randomized, Double-Blind, Placebo-Controlled Trial. Nutrients. 2019; 11: 820.

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A puppet portrays the character of Laurence, who is described as “autistic, non-verbal and occasionally violent”

The title heading this non-sciencey post - "A puppet portrays the character of Laurence, who is described as “autistic, non-verbal and occasionally violent”" - comes from a news report discussing a play opening soon at a London theatre. The play is called 'All In A Row' and I believe centres on a family struggling to care for their son who is autistic. I believe the play specifically focuses on "the night before social services finally intervenes"...

That news item centres on the use of a puppet to depict Laurence and how writers arrived at such a decision on the reported basis that "We don’t think we could get informed consent from a non-verbal autistic actor aged 11 to play the role." Needless to say that the old tenet about not pleasing all of the people all of the time came into play, as "a backlash online" developed. Despite some initial input from the National Autistic Society (NAS) around "accuracy" and "representation" of autism in the play, they eventually decided that they couldn't support the play "particularly the use of a puppet to depict the autistic character alone."

I was a little surprised by the NAS stance on this. Surprised because when another puppet character came into being depicting autism, the NAS was a little more 'positive' on its introduction. That character was Julia "a little girl who also has autism" who appears on Sesame Street. And at the time of her introduction, the head of the NAS was reported as saying "his organisation hopes it will "inspire" other creators to include characters with autism in their work." Well it might have done, but what's the difference between Laurence and Julia, and why the different response?

I don't have any divine insight as to why the different response, but let's have a look at a few 'possibilities'.

Both puppets appear in productions that also include real-life actors, so this is not about the setting in a character-sense. The look of the puppets? Well, Julia has the typical muppet features: warm skin tone, big eyes, mouth inclined to a smile. A typical 'Anything Muppet'. Laurence is quite a bit different. More human in features, a much less warm skin tone, and eyes that can only be described as piercing. There's quite a physical difference between them. So could this be about that physical difference between the puppets?

Depiction is another factor to potentially consider. Outside of the 'autistic, non-verbal and occasionally violent' description, we are also told that "Laurence likes pizza. Laurence is about to go to school. Laurence thinks it’s okay to wee on mummy’s pillow." Allowing for the age difference in intended audiences between Sesame Street and All In A Row, I think you can see some potential differences between how autism is being depicted by Julia and Laurence. Indeed this perhaps ties into another part of the the NAS response about the use of Laurence: "we could not support the play overall due to its portrayal of autism." The question therefore is whether the depiction of autism including physical violence for example (something that has recently been enshrined in English educational law with autism in mind) is a reason for the 'backlash'? Is this more about PR than anything else?

I think what many people forget (or don't want to remember!) is that autism is a very, very heterogeneous spectrum. It describes so much human experience under one banner. There are no doubt many children who fit the Julia description of autism. Fairly quiet, wouldn't hurt a fly, thriving in some areas yet struggling in others. On the other hand, there are also children who probably better fit the Laurence description of autism: 99% of the time like Julia but also prone to aggressive outbursts (against themselves and also others) and sometimes challenging in their behaviour. The trend to show the world the Julia children over the Laurence children is quite pronounced in some quarter these days. It's also accompanied by online 'abuse' of parents and guardians who dare to show / talk about their 'challenging' children and their reality (see here). Indeed, social media is full of parents showing the good and not-so-good side of their kids, but if your child has autism / is autistic it seems some people think you're not entitled to do the same? Sounds like discrimination to me. Such sentiments have also probably partly contributed to the formation of a society that focuses on "the burgeoning population of children and adults affected by severe forms of autism or related disorders." Even that society attracted criticism (see here) despite, as far as I can see, some noble goals around healthcare and vocational options which may well benefit everyone on the autism spectrum. Like I said "not pleasing all of the people all of the time."

Finally, the word 'dehumanising' is used quite a bit in that news report: "a negative narrative of dehumanising" and "literally dehumanised the identity you sought to represent." My question: does Julia, as a puppet, also dehumanise autism? Because surely if the charge is levied against Laurence as a puppet, then Julia as a puppet also fits the bill too? And if so, perhaps the media need to come up with other ways and means of getting more characters with autism on the screen (see here) to depict the wide range of behaviour covered under the [currently] singular term of autism...

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"risperidone is efficacious in the treatment of symptoms in children and adolescents with ASD"

The heading titling this post - "risperidone is efficacious in the treatment of symptoms in children and adolescents with ASD [autism spectrum disorder]" - comes from the systematic review published by Narong Maneeton and colleagues [1]. These researchers scoured the existing peer-reviewed research literature - "from January 1988 to February 2017" - to "systematically review the efficacy, acceptability and tolerability of risperidone in children and adolescents with ASD." They concluded that, on balance, around "one in every three ASD children and adolescents has benefits from treatment with risperidone." They also cautioned that there is a further scheme of work to follow, looking at the use of risperidone in this particular patient group as per the findings of previous reviews. The continued examination of potential adverse side-effects associated with risperidone use is one such important area to be investigated (see here and see here for examples).

Risperidone is categorised as an antipsychotic medicine. It's typically used to treat psychosis and mania. It's also sometimes used in the context of certain 'challenging behaviours' being presented as a function of a diagnosis of autism or autism spectrum disorder (ASD): "explosive and aggressive behavior" according to one source. Importantly however, the use of risperidone as a tool to intervene on the 'core features' of autism is not, at the time of writing, currently indicated.

Maneeton et al looked specifically for studies classified as a randomised controlled trials (RCTs) in the context of risperidone use with children and adolescents aged up to 18 years of age and diagnosed with autism or ASD. They found seven RCTs including some 370 participants. All of the trials relied on the DSM-IV description of autism or ASD and, aside from two trials, most lasted for between 6 and 8 weeks. The Aberrant Behaviour Checklist (ABC) was a commonly used tool in the studies included for review, with response criteria on such an instrument anticipating between a 25% and 50% reduction in scores (specifically on the irritability subscale) as a result of risperidone use.

Results: as per the opening sentence of this post, a positive behavioural response typically favoured risperidone use over the placebo used as a comparator when it came to certain challenging behaviours. This was noted across those short-term studies ("acute response") and also longer-term intervention (6 months). The authors also reported that a variety of side-effects - adverse side-effects - were noted alongside the use of risperidone. These included things like an increase in appetite, "drowsiness, somnolence, fatigue, anxiety, hypersalivation and elevation of prolactin level." The prolactin bit has been discussed before on this blog (see here) specifically in the context that: "There is no known normal function for prolactin in men."

Bearing in mind that Maneeton and colleagues were discussing risperidone use in 'children and adolescents' with autism, and the requirement for particular caution when using such a powerful medicine on the [still] developing body and brain, these are useful findings. Of course in an ideal world, no-one would want children and young people to have to take risperidone. But like other medicines indicated for other behavioural labels (see here), with regular and appropriate monitoring and medicines management, such pharmacotherapy can be transformative in its effects for some.

The situation however does need improving; particularly in the context of those side-effects and the worry they carry especially into the longer-term. I'm also minded to suggest that science needs to delve a little further into the proposed mechanism of effect when using medicines like risperidone in terms of immune system effects (see here) and other important biological pathways (see here) outside of the known "dopamine D2, 5-HT2A, alpha1-adrenoceptor, and histamine-1 receptor antagonist" biological action. By doing so, one *could* perhaps foresee future medicines with the 'anti-irritability' action but perhaps minus the considerable risk of side-effects?

And without any comment or opinion from me, the recent ruling here in Blighty that 'aggressive behaviour is not a choice for children with autism' (see here for my take) needs to be very carefully managed from a pharmacotherapy point of view. I say this so as not to make medicines such as risperidone, the first line of intervention or worse still, a 'chemical cosh'...

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[1] Maneeton N. et al. Risperidone for children and adolescents with autism spectrum disorder: a systematic review. Neuropsychiatr Dis Treat. 2018 Jul 11;14:1811-1820.

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Is 'escape' the most common function of challenging behaviours in autism?

'Challenging behaviour', 'disruptive behaviour' and 'behavioural crises' are terms that have been used to describe a range of behaviours "that are not culturally or socially acceptable, put the physical safety of the individual and/or others in jeopardy, affect learning, and/or limit access to community setting" in the context of autism and beyond.

A recent paper published by Esther Hong and colleagues [1] continued the research interest in this area (see here and see here) specifically focusing on gaining "perspective on what are the most commonly treated topographies of challenging behaviors" and "to identify the most commonly reported functions of those challenging behaviors." I'm assuming use of the word 'topography' in this context means 'profile' in terms of what types of challenging behaviours were noted.

Relying on behavioural data from over 3200 people diagnosed with an autism spectrum disorder (ASD) who were "receiving a minimum of 20 h of ABA [applied behavior analysis] treatment per month", researchers examined data on a range of behaviours falling into the category of 'challenging'. These included: "(a) aggression, (b) disruption, (c) elopement, (d) inappropriate sexual behavior, (e) lying, (f) noncompliance, (g) obsessive behaviors, (h) pica, (i) self-injurious behavior, (j) stealing, (k) stereotypy, (l) tantrums, and (m) teasing/bullying." Accepting that ABA in the context of autism is not everyone's cup of tea (despite some important data emerging [2]), one of the 'benefits' to this study at least, was that behaviour was recorded in some detail as a function of the implementation of ABA using something called The Skills™ database. This also allowed researchers to examine the potential 'function' of such behaviours too: "Skills™ also contains a field denoting the function of the behavior as identified by the supervising behavior analyst at the time of observation. Functions are classified as “attention,” “automatic,” “escape,” or “tangible.”."

Results: "The most commonly treated challenging behaviors were stereotypy, noncompliance, aggression, tantrums, SIB, elopement, disruption, and obsessive behaviors, respectively." Although 'stereotypy' ('the persistent repetition of an act) was the most frequently observed 'challenging behaviour', I'd personally be a little reluctant to put it into this category. I say this because there have been some reports suggesting that such a behaviour serves an important purpose in terms of being calming and aiding coping in certain situations for certain people. The majority of those challenging behaviours were coded most frequently in terms of 'escape' when it came to perceived function by the therapists who were doing the coding. Interestingly, and going back to my point about stereotypy, this behaviour was most frequently coded as 'automatic' alongside another behaviour that probably shouldn't be seen as a challenging behaviour: obsessive behaviours. Automatic, I assume, means just that: involuntary and well, automatic.

Alongside such information, authors also detail some nice Venn diagrams to illustrate how various categories of behaviours (and their specific manifestations) might meet and *correlate* based on their acquired data. Certainly, in the context of aggression and self-injurious behaviour (another important topic), there are some potentially important details to discern.

Although ABA still remains a point of contention among some, in the context of the Hong report, I can see how the quite detailed data collection on behaviour that it accrues holds some important information in the presence of some often, quite distressing behaviours. I'm happy to think that 'escape' could be a quite common function of various challenging behaviour(s), and moves to making 'some controlled escape' from particular situations might perhaps be useful to reduce the presence of such challenging behaviours. I know others will talk about 'demand avoidance' as being important too, but I'm cautious that this might not be an effective strategy in the longer term in helping people to build up 'resilience' to certain situations and environments.

But... I also think that 'escape' is not the whole story when it comes to challenging behaviours. I do still think that issues such as 'frustration' for example, can play a role. Also moving away from a purely 'behavioural' point of view, there is other evidence pointing to biology and physiology as being potentially involved in the presence of certain challenging behaviours. Fatigue? Yep, that's been mentioned (see here). Communication? Yep, that too (see here); particularly when verbal communication might be limited. And I'm also minded to mention that challenging behaviours can also be associated with things like the expression of pain (see here) that probably ties into the communication issue(s) too. In short, it's going to be complicated [3].

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[1] Hong E. et al. Topography and Function of Challenging Behaviors in Individuals with Autism Spectrum Disorder. Advances in Neurodevelopmental Disorders. 2018; 2: 206-215.

[2] Makrygianni MK. et al. The effectiveness of applied behavior analytic interventions for children with Autism Spectrum Disorder: A meta-analytic study. Research in Autism Spectrum Disorders. 2018; 51: 18-31.

[3] Rattaz C. et al. Challenging behaviours at early adulthood in autism spectrum disorders: topography, risk factors and evolution. J Intellect Disabil Res. 2018 May 24.

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"A greater understanding of ASD-related violence risk is needed to combat stigma"

This is another one of my long posts, so please, bear with me.

The topic of violence is always an emotional one. I know that even to mention the word 'violence' in the context of any label/diagnosis/condition/group carries the risk of making some people believe that there is some sort of generalisable connection. No smoke without fire eh? And one only needs to look at another label to see how a link with violence and by inference, 'dangerousness' has left a deep and long-lasting mark (see here) that continues today. So we're stuck between a rock and hard place: to talk about something and the risks attached in doing so, or just leave it, let people make their own judgements...

I've discussed quite a few uncomfortable topics on this blog down the years in light of various peer-reviewed research publications. I'm not one for shying away from calm and proportionate discussion where science - peer-reviewed science - has some vitally important input. In that context, I continue my discussions on the topic of violence and autism (see here). By doing so, I'm not making any sweeping generalisations. I'm not making any wild claims. I don't offer any brilliant insights into this topic. I'm just following the science and keeping emotions as far away from such cold, objective science as possible.

But there is a message before I continue. A message to those who might, in light of various media headlines, make some snap judgements about some of the people in your community. The message is simple: violence, in all it's forms, is not inherent to any one group. No-one is violent because of generalisations about who they are, whether on the basis of age, race, socio-economic circumstances or anything else. There are typically reasons for violence, and in many cases they're complicated. By saying all that, I'm not trying to talk down the very real effects that violence can have on individuals, families and society in general and the strong need for justice and more importantly, prevention. Just that seemingly apparent correlations and simple answers rarely provide an accurate insight into the particular hows-and-whys of violence and violent acts...

So today I'm talking about the paper published by Jill Del Pozzo and colleagues [1] who "provide a comprehensive review of the literature bearing on the relationship between ASD [autism spectrum disorder] and violent behavior." This is a timely publication because I'm sure many people have seen the word 'autism' being used among the coverage of a quite horrendous act recently. Indeed, even Del Pozzo et al allude to other similar attention: "Over the last decade, there has been increased media attention focused on the relationship between ASD [autism spectrum disorder] and violent behavior due to a number of school shootings and high-profile criminal cases involving offenders with alleged ASD diagnoses."

Perhaps I need to mention that the word/description 'violence' covers a lot of ground. It of course covers violence against others, whether on an individual or collective basis, but importantly, also covers violence in many other forms including against oneself in the form of self-injury and/or self-abuse. Most media coverage of violence covers violence against others. But I'd wager that violence against oneself is the predominant form of violence in many circumstances minus any big headlines...

Del Pozzo et al set about providing a "comprehensive review of the literature" on autism and violence. Following their surveying of the current peer-reviewed research literature in this area, the authors concluded that whilst a diagnosis of autism is by no means protective of someone committing a violent act, there is generally more peer-reviewed scientific support for the idea that "ASD does not cause violence" over and above the sometimes negative media portrayals of the label in this context (see here). A welcome conclusion it has to be said, and one that needs to be circulated widely; but again, minus any sweeping generalisations and bearing in mind that science is all about probability not absolutes.

There are caveats to the statement that 'ASD does not cause violence' insofar as the multiple observations that autism typically does not exist in a diagnostic or social vacuum (see here), and how various factors (environment, psychiatric comorbidity, criminality) can potentially elevate the risk of violence for some people. All of this is not about passing the diagnostic buck (see here) as some people quite unceremoniously have decided to do, but needs to be mentioned; particularly in light of these days where 'autism plus' [2] is more typically the norm (see here) over and above the label of autism existing as some sort of stand-alone diagnosis. The pertinent question therefore may not necessarily be one of 'does autism cause violence?' but rather what role autism may or may not play [3] when it comes to violence, taking into account an often very complicated, very individual clinical picture. I say this also acknowledging that a diagnosis of autism is not some 'magical status' automatically reserved only for 'good people' (see here); just as any other behavioural/psychiatric label does not similarly distinguish between 'good' and 'bad' people.

As per the title of this post utilising a quote from Del Pozzo and colleagues - "A greater understanding of ASD-related violence risk is needed to combat stigma" - there is a pressing need to further understand how and why violence can/does occur for some alongside the label of autism or rather autism plus. Whether as part of the often nebulous term that is 'challenging behaviours' (see here) or in other related contexts (importantly also including that self-aggression angle), trying to answer such how/why questions can only be of benefit to all concerned. Indeed, alongside another quite sweeping generalisation made by Del Pozzo et al that: "Violence results from undetected or untreated third variables (e.g. psychosis)" and "Individuals with ASD have an elevated risk of psychosis", various lessons continue to be learned [4] (see here also) albeit stressing how complicated any relationship is likely to be [5]. As I mentioned before, easy answers are not likely to forthcoming.

Finally, I want end by again introducing the concept of 'vulnerability' in the context of autism into proceedings. I'm not specifically talking about vulnerability to various comorbidity that 'probably' influence the presentation of violence in the context of autism, but rather vulnerability in more general terms (see here). The writings of Tom Berney [6] provide some particularly insightful details on such vulnerability in relation to violent and other offending acts within the context of some autism or rather some 'autism plus'. Such vulnerability issues stress how, minus hype or sensationalism or indeed any calls for censorship in this most delicate area, investigations need to continue and sensitively continue without stigmatising and without further disadvantaging an already quite disadvantaged community...

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[1] Del Pozzo J. et al. Violent behavior in autism spectrum disorders: Who's at risk? Aggression and Violent Behavior. 2018. Jan 31.

[2] Gillberg C. & Fernell E. Autism plus versus autism pure. J Autism Dev Disord. 2014 Dec;44(12):3274-6.

[3] Allely CS. et al. Violence is Rare in Autism: When It Does Occur, Is It Sometimes Extreme? J Psychol. 2017 Jan 2;151(1):49-68.

[4] Långström N. et al. Risk factors for violent offending in autism spectrum disorder: a national study of hospitalized individuals. J Interpers Violence. 2009 Aug;24(8):1358-70.

[5] Bell V. et al. A symptom-based approach to treatment of psychosis in autism spectrum disorder in October 2017. BJPsych Open. 2018 Jan;4(1):1-4.

[6] Berney T. Asperger syndrome from childhood into adulthood. Brit Journal Psych Advances. 2044; 10: 341-351.

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Challenging behaviour and autism: how do parents manage it?

I'm not going to dwell too much on the findings reported by Elizabeth O’Nions and colleagues [1] discussing some of the ways-and-means used "to manage problem behaviour" in the context of autism, but I did want to bring it to your attention.

It's an important summary because (a) it highlights how a diagnosis of autism or autism spectrum disorder (ASD) does seem to increase the risk of various 'challenging behaviours' appearing above and beyond what would typically be expected (see here), (b) it illustrates how said behaviours have an important impact both on the person themselves and significant others around them (see here), and (c) it details 'what might help' in terms of parents or significant others managing such behaviour(s) as well as providing a road map for further study and potentially, further guidance.

The O'Nions paper is open-access so you can read for yourself what the findings were. The main points as I saw them were:

• Challenging behaviours covers a lot of ground.
• Said behaviours can and do affect quality of life for all concerned.
• Various strategies are employed by parents to cope with such behaviours including "accommodating the child... modifying the environment... providing structure, routine and occupation... managing non-compliance with everyday tasks and activities... [and] managing distress."
• Strategies for 'dealing' with such behaviour(s) often take into account their effects not only on the person/child concerned but also the family unit.

What's missing from this review? Well, accepting that the focus was "to identify how parents and caregivers spontaneously manage problem behaviour in ASD" I found the O'Nions paper to be rather light on anything not related to behaviour and/or psychology. Take for example, the growing realisation that challenging behaviour(s) seem to show some connection to sleep patterns in the context of autism [2] and what that could mean for intervention(s) to manage sleep issues for example (see here). Similarly, the idea that challenging behaviours can, on some occasions, seem to be linked to the experience of pain (see here) and/or fatigue (see here) is perhaps something else important to reiterate, as part of a suite of potential factors to consider (see here). I might also add that a certain type of pain/discomfort (e.g. gastrointestinal) together with sleep issues in the context of autism have been a source of some joint inquiry (see here). There is also a case for further research looking at targeted pharmacotherapy in the context of some challenging behaviours too (see here) with appropriate concerns and caveats noted.

There is another aspect raised by the O'Nions review that also needs to be mentioned: "This analysis shows that many of the strategies used by parents of children with ASD are specifically targeted to manage particular vulnerabilities (e.g., sensory sensitivities, rigidity, insistence on sameness), or accomplish particular behavioural goals, and may be relatively unique to this population." I stress of course, the idea that the core features of autism / ASD seem to be 'targets' of intervention in this area illustrating the link between core behaviours and challenging behaviours. Although I've made quite a big thing on this blog about how 'comorbidity' appearing alongside autism is probably not just comorbidity (see here), I'm taking a slightly opposite view on this occasion, and suggesting that one also needs to be mindful that issues such as anxiety and depression may very well exert an effect on the presentation of challenging behaviour(s) and perhaps need to be looked at separately?

And whilst we're on the topic of challenging behaviours in the context of autism, the review of social outcomes for a sample of adults with autism published by Megan Farley and colleagues [3] provides some further interesting discussions on this topic. Specifically that: "most participants were only aggressive in response to frustrating situations or when experiencing problems with medical conditions." There's [seemingly] always a reason...

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[1] O'Nions E. et al. How do Parents Manage Irritability, Challenging Behaviour, Non-Compliance and Anxiety in Children with Autism Spectrum Disorders? A Meta-Synthesis. J Autism Dev Disord. 2017. Dec 8.

[2] Cohen S. et al. Sleep patterns predictive of daytime challenging behavior in individuals with low-functioning autism. Autism Res. 2017 Dec 1.

[3] Farley M. et al. Mid-life social outcomes for a population-based sample of adults with ASD. Autism Res. 2017 Dec 20.

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Simvastatin + risperidone for autism?

"This study provides preliminary evidence for potential therapeutic effects of simvastatin in the treatment of autism that warrants further investigations."

So said the results of the trial published by Ehsan Moazen-Zadeh and colleagues [1] looking at whether adding simvastatin - a lipid-lowering medicine - (20-40 mg/day) or placebo to a daily regime of risperidone - an antipsychotic medicine - to a cohort of "70 drug-free children aged 4 to 12 years old with diagnosis of autistic disorder" would have any effect on the primary outcome of irritability as measured by the "Aberrant Behavior Checklist-Community (ABC-C) scale irritability subscale score." A trial entry for this study can be found here (including reference "to evaluate the efficacy of L-carnosine in the treatment of autism" in the translated version for some reason?).

Anyhow, under "randomized, double-blind, placebo-controlled" conditions, researchers noted something of a potential effect from the addition of simvastatin to risperidone when compared with risperidone + placebo on the group irritability subscale scores over 10 weeks of use. They conclude that further study is required in this area.

There is very little other peer-reviewed science literature in this area of the autism research landscape. I note that Peter over at Epiphany has talked about statins and autism on a couple of occasions (see here for example) and how useful they have seemed to be for his son. Albeit based on an N=1, Peter speculated that the effect of statin use for his son (Atorvastatin) was not necessarily due to its effect on lipid lowering but rather other actions. Noting that simvastatin has specifically been linked to 'cognitive dysfunction' in some isolated cases [2] I understand that other studies have talked about a more protective 'pro-cognitive' effect from such statin use under other circumstances [3]. I do wonder if there could be something more to see in this area pertinent to at least some on the autism spectrum.

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[1] Moazen-Zadeh E. et al. Simvastatin as an Adjunctive Therapy to Risperidone in Treatment of Autism: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial. J Child Adolesc Psychopharmacol. 2017 Jul 18.

[2] Suraweera C. et al. Simvastatin-induced cognitive dysfunction: two case reports. J Med Case Rep. 2016 Apr 5;10:83.

[3] Ling Q. & Tejada-Simon MV. Statins and the brain: New perspective for old drugs. Prog Neuropsychopharmacol Biol Psychiatry. 2016 Apr 3;66:80-6.

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Caring for the carers continued

Consider this post a brief extension to a previous one talking about how greater efforts need to be put into supporting those raising and caring for a person diagnosed as being on the autism spectrum (see here).

The science accompanying this post is that published by Cécile Rattaz and colleagues [1] who drew on data derived from the EpiTED cohort (see here), an initiative designed to "understand the heterogeneity of developmental trajectories among children with a diagnosis of PDD [pervasive developmental disorder] and the role of clinical, biological and environmental factors in their adaptive outcome." Researchers concluded that certain aspects associated with a diagnosis of autism in offspring - "young adults' level of adaptive skills... symptom severity and the presence of challenging behaviors" - can very much impact on parental quality of life (QoL). They argue for "the importance to propose specific interventions to target associated challenging behaviors in ASD [autism spectrum disorder]."

Quality of life when it comes to parents or primary caregivers of those young people on the autism spectrum is an often overlooked area when it comes to research and practice. Yes, the focus should quite rightly be on the person who lives with and experiences autism (in it's many different forms) but QoL for children/offspring is often inter-connected with QoL of parents and other family members. I appreciate that some might construe this work as autism presenting a 'burden' to the family and that is not something that anyone really wants to perpetuate. It is however important to realise that issues like challenging behaviours for example (bearing in mind what this covers) can affect many aspects of parenting behaviours, including those related to fatigue (see here) and perhaps further over the longer term [2]. When added to the dwindling resources available to parents (see here for example) there can be real strains placed on parents; more so bearing in mind other factors such as one-parent families and the demands placed on parents also potentially caring for siblings or even other family members.

There are no easy answers to the question of what to do to improve parental (and child) QoL in the context of autism. As mentioned, the sentiments of 'doing more with less' in these days of continued austerity for example, do not readily lend themselves to improving the situation in terms of the availability of something like respite care for example. The onus therefore continues to fall on parents and primary caregivers...

Music to close: The Saw Doctors - I Useta Lover.

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[1] Rattaz C. et al. Quality of Life in Parents of Young Adults with ASD: EpiTED Cohort. J Autism Dev Disord. 2017 Jun 17.

[2] Benson PR. The impact of child and family stressors on the self-rated health of mothers of children with autism spectrum disorder: Associations with depressed mood over a 12-year period. Autism. 2017 Jun 1:1362361317697656.

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Autism 'disclosure cards' and negative judgements?

I have to say that I initially felt slightly uncomfortable reading the study results published by Jillian Austin and colleagues [1] providing "preliminary validation for the use of autism disclosure cards in buffering negative judgment." Uncomfortable because, despite the fact that it is human nature for people to stop, stare and perhaps question something when it seems 'out of the ordinary', the idea that when children with autism specifically 'misbehave' in a public place their parents need to somehow justify their child's behaviour to a staring crowd of strangers seems a trifle unfair.

As is the experience of most parents, whether their child is diagnosed or not with autism or anything else, children are not always 'little angels' every time they are out and about ("no, it is not appropriate to start a public conversation about farting when one 'catches a whiff' of something in the shopping centre"). Most parents can usually get away with a nervous smile to any interested on-lookers (or nosey parkers) and that really should be the end of it. Of course, for some children under some circumstances, behaviour can sometimes go beyond just tantrums and onward can raise a few eyebrows but...

Austin et al started with the premise that parents of children with autism are "increasingly using disclosure cards to reduce negative perceptions" when out and about with their children to make "an invisible diagnosis apparent". They devised an experiment using "vignettes of a parent-child interaction in which the child was misbehaving and investigated the efficacy on 160 parents' perceptions." Disclosure cards were provided to some of the parent participants all of whom had at least one child aged between 6-12 years. Various factors covering "Maternal Skill Deficit and Negative Reaction" and "Sympathy for Mother" were analysed as a function of receipt of disclosure cards or not.

"Those who received the disclosure card reported significantly lower Maternal Skill Deficit and Negative Reaction to the Dyad and no difference in Sympathy for the Mother." In other words, making an 'invisible' diagnosis more visible seemed to have an effect in terms of views around 'it must the parent's fault that their child is behaving that way' (negative judgement) but did little when it came to empathising with the mother's position in that situation.

Austin and colleagues discuss how the 'invisibility' of autism and frames of reference - "people will evaluate and compare individuals to some perceived norm or standard" - in this case, so-called typically developing children, may be driving forces underlying those negative judgements from others about children on the spectrum and their parents. I can't quibble with this line of thought or what impact it might have on children and their parents (and other significant others). But it strikes me that in these days of increased numbers of children being diagnosed with autism (see here) - indeed the numbers just keep on growing - and accompanying high-profile campaigns to raise awareness about autism, movement towards the idea that every parent has to 'identify' their child as being on the autism spectrum as and when they, pardon my French, 'fart the wrong way' seems to place too much emphasis on the child and parent and not enough on their fellow citizens and their own understanding and reactions.

OK, I get that people have busy lives and that outside of media depictions (see here), most people wouldn't typically ask 'could it be autism?' when a child has a 'meltdown' in a public spot. I also get that under some circumstances, making particular groups of people aware of a person's autism might be a good thing as per contact with law enforcement agencies for example. The question however of whether strangers really need to be given quite sensitive information about a person and 'their diagnosis' just because they (the stranger) 'can't deal with a particular situation' strikes me as being more than a little one-sided...

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[1] Austin JE. et al. Influencing Perception About Children with Autism and their Parents Using Disclosure Cards. J Autism Dev Disord. 2016 May 30.

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Austin JE, Zinke VL, & Davies WH (2016). Influencing Perception About Children with Autism and their Parents Using Disclosure Cards. Journal of autism and developmental disorders PMID: 27241346

Antipsychotic prescribing trends in autism meta-analysed

"Almost 1 in 10 antipsychotic-treated youth were diagnosed with ASD [autism spectrum disorder] and/or ID [intellectual disability], and 1 in 6 youth with ASD received antipsychotics."

The findings reported by Su Young Park and colleagues [1] have not surprisingly garnered some media attention (see here). Meta-analysing the available peer-reviewed data on "the frequency of youth diagnosed with ASDs and/or ID among antipsychotic-treated youth, as well as antipsychotic use in youth with ASD/ID", researchers came to some important conclusions when it came to prescribing patterns for the important class of medicines known as the antipsychotics. The focus was on youths this time around, complementing what is currently known about such medication use when it comes to adults (see here and see here) and a younger cohort (see here).

One or two details are worthy of promotion regarding the Park findings aside from the idea that antipsychotic use might not be unfamiliar when a diagnosis of autism is received: "In 5 longitudinal studies, the proportion of antipsychotic-treated youth with ASD did not change significantly from 1996 to 2011." That being said, the authors did note that later 'study time point' did seem to moderate "higher antipsychotic use among patients with ASD" and also among those with ASD/ID combined. This could indicate that reaching for the antipsychotic meds in response to things like 'challenging behaviour' is slowly becoming a little more common in recent times [2]; something that might have a few implications for corresponding health screening and monitoring for example (see here).

Indeed, in the accompanying media about their study, the authors make some interesting points: "Although the increased prescribing of antipsychotics in youth with autism spectrum disorders or intellectual disability cannot be judged as appropriate or inappropriate based on database studies, side effects of antipsychotics can be quite problematic, especially in children and adolescents." Additionally that: "clinicians should consider using psychosocial interventions that are proven to be efficient for behavioral dysregulation such as irritability and aggression, before prescribing antipsychotics to adolescents with autism or intellectual disability."

All I will say on the matter (with no medical or clinical advice given or intended) is that, yes, when faced with challenging behaviours, clinicians and others should always be first asking the question 'why' (see here) before immediately reaching for the antipsychotic or other meds. If and when important factors such as pain (see here) are ruled out, there may be grounds for the use of antipsychotic meds appropriate and proportionate to the scale of the behaviour(s) being presented, bearing in mind the name 'antipsychotic' provides the proper basis for such medication use [3]. But, as with any intervention of this type, the words 'time-limited experiment' should always be on the lips of the prescribing physician, allowing for the fact that the technology now exists to monitor things like plasma levels of various antipsychotics [4] and other important parameters routinely and mindful of what the research literature tells us about risks associated with such medicine use [5]. Said side-effects can include a variety of different issues [6].

Bear also in mind, that antipsychotics for 'tackling' challenging behaviour might not necessarily be the only option in future (see here)...

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[1] Park SY. et al. Antipsychotic Use Trends in Youth With Autism Spectrum Disorder and/or Intellectual Disability: A Meta-Analysis. J Am Acad Child Adolesc Psychiatry. 2016 Jun;55(6):456-468.e4.

[2] Satoh M. et al. Prescription trends in children with pervasive developmental disorders (PDD): A claims data-based study in Japan. World J Pediatr. 2016 Jun 10.

[3] Marston L. et al. Prescribing of antipsychotics in UK primary care: a cohort study. BMJ Open. 2014 Dec 18;4(12):e006135.

[4] Wijma RA. et al. Identification and quantification of the antipsychotics risperidone, aripiprazole, pipamperone and their major metabolites in plasma using ultra-high performance liquid chromatography-mass spectrometry. Biomed Chromatogr. 2016 Jun;30(6):794-801.

[5] Yu ZH. et al. Use of Antipsychotics and Risk of Myocardial Infarction: A Systematic Review and Meta-analysis. Br J Clin Pharmacol. 2016 May 16.

[6] Shirazi A. et al. Prevalence and Predictors of Clozapine-Associated Constipation: A Systematic Review and Meta-Analysis. Int. J. Mol. Sci. 2016, 17(6), 863

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Park SY, Cervesi C, Galling B, Molteni S, Walyzada F, Ameis SH, Gerhard T, Olfson M, & Correll CU (2016). Antipsychotic Use Trends in Youth With Autism Spectrum Disorder and/or Intellectual Disability: A Meta-Analysis. Journal of the American Academy of Child and Adolescent Psychiatry, 55 (6), 456-4680000 PMID: 27238064

The persistence of self-injury in relation to autism

Some behaviours associated with a diagnosis of autism don't make for great dinner table discussion. Self-injurious behaviours (SIBs), as exemplified by head banging, hair pulling and eye gouging must rank as some of the more distressing facets of [some] autism insofar as their potential effect on the person and also the people around them.

These and other types of behaviour commonly headed under the category of so-called 'challenging behaviours' have tended not to be too evident when it comes to the public depiction of autism it has to be said. I can appreciate why, but what this can mean is that such issues tend to get 'brushed under the carpet'. In recent times however, there does seem to be a greater willingness for research to delve into such behaviours [1].

The paper by Caroline Richards and colleagues [2] (open-access) looking at the persistence of such behaviour(s) and the potential correlates associated with their persistence is a welcome piece of research added to the research interest. Highlighting how for a small research sample of 67 children/young adults with autism over three-quarters reported SIB persisting over a 3-year period, the data provide some interesting insights into the nature of this issue and, potentially how it should be screened for and managed.

Based here in Blighty, researchers initially managed to recruit 190 participants, the data for some of whom were previously published [3]. As perhaps one might expect, the follow-up after on average 36.4 months had elapsed was not so well-populated. No mind, various findings are reported including that "the presence, topography and severity of self-injury were persistent and stable over three years" and that "individuals with self-injury were significantly more likely to be non-verbal than those who did not engage in self-injury." Further: "individuals with self-injury were significantly more likely to be less able and non-verbal and to show higher levels of stereotyped behaviour, compulsive behaviour, insistence on sameness, overactivity, impulsivity, repetitive behaviour and impairments in social interaction."

There is quite a bit more to do on this topic including facing up to issues around the small (eventual) participant size and the reliance on 'a questionnaire pack' as the chosen method of assessment. The authors also talk quite a bit about how some of the behaviours observed in connection with self-injury - impaired behavioural inhibition - might overlap with other diagnoses such as attention-deficit hyperactivity disorder (ADHD) but as far as I can see, they did not directly screen for ADHD outside of the use of something called The Activity Questionnaire (TAQ). I might also have liked to have seen a little more information about how parents/professionals had 'tackled' SIB in this cohort and what effect that might have had on results. Investigations remain.

Having said all that, the insights provided by the Richards article are important and provide plenty of food for thought when it comes to SIB and autism. Without trying to generalise SIB to all autism nor to come across as portraying too negative an image of what autism can mean to someone, recognition and management (dare I say treatment) of such behaviours when present should really be a priority [4].

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[1] Maddox BB. et al. Untended wounds: Non-suicidal self-injury in adults with autism spectrum disorder. Autism. 2016 May 12. pii: 1362361316644731.

[2] Richards C. et al. Persistence of self-injurious behaviour in autism spectrum disorder over 3 years: a prospective cohort study of risk markers. Journal of Neurodevelopmental Disorders 2016; 8: 21.

[3] Richards C. et al. Self-injurious behaviour in individuals with autism spectrum disorder and intellectual disability. J Intellect Disabil Res. 2012 May;56(5):476-89.

[4] Lee Y-H. et al. Cataract secondary to self-inflicted blunt trauma in children with autism spectrum disorder. Journal of American Association for Pediatric Ophthalmology and Strabismus. 2016. May 17.

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Richards, C., Moss, J., Nelson, L., & Oliver, C. (2016). Persistence of self-injurious behaviour in autism spectrum disorder over 3 years: a prospective cohort study of risk markers Journal of Neurodevelopmental Disorders, 8 (1) DOI: 10.1186/s11689-016-9153-x

Autism and the [different] expression of pain

Two papers provide some brief discussion today. The first by Janice Goldschmidt [1] titled: 'What Happened to Paul? Manifestation of Abnormal Pain Response for Individuals With Autism Spectrum Disorder' provides an account of a young man with autism who during a "pilot nutrition intervention designed to teach cooking skills to young adults with autism spectrum disorder (ASD)" fell quite seriously. We are told that: "After his accident, which resulted in broken and dislocated bones in his ankle, his demeanor was dramatically altered, program gains were lost, and staff noted the appearance of many new challenging behaviors."

The second paper by Andrea Courtemanche and colleagues [2] continues a theme looking to "measure expressions of pain among young children being evaluated for autism and other neurodevelopmental disabilities." Authors concluded that their results among other things "support that individuals with self-injury may have enhanced expressions of pain."

The commonality in these papers, aside from looking at pain, is the idea that autism might 'lead' to a "blunted pain response" is not necessarily one that fits uniformly across the autism spectrum. To quote: "The consequence is not a reduction in pain sensation, but a different expression of pain, determined by that individual's particular communicative, cognitive, or physiological challenges." Of course science already knows much of what is being said here as I've covered topics such as the fact that yes, people on the autism spectrum do get headaches (see here) and how pain may be quite a significant predictor of things like sleeping problems in relation to autism (see here). I might add that some of the source of that pain could also be linked to some of the over-represented comorbidity that can/does follow a diagnosis of autism (see here) (and hence should be perfectly treatable).

The discussions about self-injury being potentially linked to the expression of pain also ties into related topics covered on this blog insofar as such 'challenging behaviours' normally having some reasoning behind them (see here). Self-injurious behaviour (SIB) can often be a harrowing thing to see (no parent or sibling wants to see a loved one hurting themselves) but with the right investigative approach can sometimes provide important information about a person and their wants and wishes (see here). I don't say that to somehow encourage SIB nor to lessen the impact that biology can have on its expression; merely that some other person perspective-taking should accompany analysis of any behaviours that challenge as and when they present (before reaching for the anti-challenging behaviour meds) as well as making moves towards breaking down things like communication barriers (see here) that potentially contribute to such behavioural manifestations.

Pain is very much part of the human experience. Whilst efforts should indeed continue to ensure that everyone lives a life as pain-free as possible, the importance of short-term pain or rather the importance of short-term pain expression should not be under-estimated. Likewise, sweeping generalisations about altered pain sensitivity applying across the autism spectrum need not necessarily apply. I'm also happy to report that pain is a topic being discussed at IMFAR today...

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[1] Goldschmidt J. What Happened to Paul? Manifestation of Abnormal Pain Response for Individuals With Autism Spectrum Disorder. Qual Health Res. 2016 Apr 26. pii: 1049732316644415.

[2] Courtemanche AB. et al. The Relationship Between Pain, Self-Injury, and Other Problem Behaviors in Young Children With Autism and Other Developmental Disabilities. Am J Intellect Dev Disabil. 2016 May;121(3):194-203.

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Goldschmidt J (2016). What Happened to Paul? Manifestation of Abnormal Pain Response for Individuals With Autism Spectrum Disorder. Qualitative health research PMID: 27117957




Courtemanche AB, Black WR, & Reese RM (2016). The Relationship Between Pain, Self-Injury, and Other Problem Behaviors in Young Children With Autism and Other Developmental Disabilities. American journal on intellectual and developmental disabilities, 121 (3), 194-203 PMID: 27119211

On the use of risperidone and young children with autism

Without trying to scaremonger, it is already well known that certain anti-psychotics potentially indicated for some of the more 'challenging behaviours' associated with conditions like autism for example, carry their own important side-effects. Risperidone, one of the more commonly used medicines, has quite an extensive list of possible side-effects, some of which have been previously mentioned on this blog (see here). Increased appetite and weight gain are some of the more commonly observed side-effects.

The paper by Lawrence Scahill and colleagues [1] indeed concluded that weight gain and increased appetite also seemed to be present in their cohort of children with autism (mean age 6.9 years) who were in receipt of risperidone for approximately 30 weeks. Worryingly, the authors reported that there was an average of about 5 kg weight gain among 97 of their cohort with "risperidone exposure" and: "At baseline, 7 patients met conventional criteria for metabolic syndrome; by Week 16, 12 additional patients were so classified." The authors suggested that: "Rapid weight gain with risperidone treatment may promote the cascade of biochemical indices associated with insulin resistance and metabolic syndrome. Appetite, weight, waist circumference, liver function tests, blood lipids, and glucose warrant monitoring."

As per other posts on this blog, I'm not adverse to the selective use of medication to manage certain 'challenging behaviours' with autism in mind (see here) bearing in mind appropriate screening and 'detective work' before immediately reaching for such meds (see here). With appropriate medicines management and monitoring procedures in place, medicines such as antipsychotics (even with appropriate adjuvant therapy) can play an important role in managing symptoms and onwards positively affecting quality of life.

But it is important to note that there are risks attached to such medication use and the possible benefits to the presentation of certain behaviours have to be balanced with the those risks and specifically the potential role of side-effects. The additional important focus on children  - "mean age 6.9 + 2.35 years" - highlighted in the Scahill study also invites quite a lot more scrutiny. I know some people might be a little shocked that young children on the autism spectrum are being medicated in such a fashion, but other evidence has reported on the potential value of such an approach [2] particularly when quite extreme behaviours are present and are able to be so utterly disruptive. To tie in those findings on the presence of something like metabolic syndrome and the young age of medication recipients however, suggests that moves should continue (at a pace) towards the discovery of new methods and means of managing such behaviours without potentially setting recipients up for a lifetime of possible future health complaints.

Indeed, I'll be blogging about the related results from Chen et al [3] soon enough.

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[1] Scahill L. et al. Weight Gain and Metabolic Consequences of Risperidone in Young Children With Autism Spectrum Disorder. Journal of the American Academy of Child & Adolescent Psychiatry. 2016. March 7.

[2] Fung LK. et al. Pharmacologic Treatment of Severe Irritability and Problem Behaviors in Autism: A Systematic Review and Meta-analysis. Pediatrics. 2016 Feb;137 Suppl 2:S124-35.

[3] Chen MH. et al. Risk of Developing Type 2 Diabetes in Adolescents and Young Adults With Autism Spectrum Disorder: A Nationwide Longitudinal Study. Diabetes Care. 2016 Mar 22. pii: dc151807.

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Scahill, L., Jeon, S., Boorin, S., McDougle, C., Aman, M., Dziura, J., McCracken, J., Caprio, S., Arnold, L., Nicol, G., Deng, Y., Challa, S., & Vitiello, B. (2016). Weight Gain and Metabolic Consequences of Risperidone in Young Children With Autism Spectrum Disorder Journal of the American Academy of Child & Adolescent Psychiatry DOI: 10.1016/j.jaac.2016.02.016