Children With Autism go to Emergency Room Nine Times More Than Peers

We work very hard to keep children with autism and neuropsychiatric / neurobehavioral problems out of emergency rooms.  Early recognition and treatment often avoids emergencies. JR


A study showed that children with autism are nine times more likely to show up at the emergency room with a psychiatric condition than other children.

In the first study to compare mental health-related emergency department (ED) visits between children with and without autism spectrum disorders (ASD), researchers found that ED visits are nine times more likely to be for psychiatric reasons if a child has an ASD diagnosis. Published in the journalPediatric Emergency Care (Epub ahead of print), the study found externalizing symptoms, such as severe behaviors tied to aggression, were the leading cause of ED visits among children with ASD. Importantly, the likelihood of a psychiatric ED visit was higher if a child carried private health insurance rather than medical assistance.

"This finding of higher rates of emergency room visits among children with autism demonstrates that many children with autism aren't receiving sufficient outpatient mental health care to prevent and manage the type of crises that are driving these families to seek urgent help," said Dr. Roma Vasa, senior study author and a child psychiatrist in Kennedy Krieger Institute's Center for Autism & Related Disorders. "These findings should highlight the urgent need for better comprehensive outpatient mental health care and insurance coverage for children with autism, along with greater education and training for emergency medical staff."

Using the 2008 National Emergency Department Sample, the largest all-payer ED database in the US, researchers examined data from a total of 3,974,332 ED visits for patients ages 3 to 17, of which 13,191 visits were from children with ASD. Mental health-related ED visits were based on International Classification of Disease (ICD) billing diagnoses that included mood, anxiety and psychotic disorders, suicide and self-injury, and externalizing behaviors such as aggression.

Researchers also studied the influence of different types of insurance coverage on the likelihood of an ED visit for psychiatric reasons. They found that children with ASD whose families had private medical insurance were 58 percent more likely to visit the ED for mental health-related reasons than those whose health insurance was provided through state medical assistance programs.

"We think this is because private insurance plans often exclude autism from behavioral health coverage, have few in-network providers or place restrictive limits on the amount of mental health expenses that they will reimburse," said Luther Kalb, MHS, first study author and a research scientist in Kennedy Krieger Institute's Center for Autism & Related Disorders.

With 1 in 88 children in the U.S. diagnosed with ASD, the use of the ED to treat psychiatric behaviors is likely to increase unless changes occur. Dr. Vasa suggests that this trend is especially troublesome because the ED is not an optimal setting for children with ASD since chaotic environments can exacerbate autism-related or comorbid psychiatric symptoms.

"Children with autism, especially those with co-occurring psychotic disorders or severe behaviors, need to have an emergency crisis plan in place," said Kalb. "Everyone involved in the life of a child with autism, from parents to medical professionals to school educators, needs to have routine discussions about what to do in the case of an escalating situation."

This study also suggests that emergency departments should consider adopting new measures to accommodate children with ASD. This includes greater education and training for ED professionals about how to properly assess and interact with children on the autism spectrum. Additionally, researchers suggest that the large numbers of children with autism accessing the ED may necessitate a separate area for children with ASD that is less chaotic and contains less stimulation than found in the otherwise busiest part of any hospital.

Further research on adults with ASD using the ED for psychiatric reasons and general trends associated with mental health care is needed. With more information, medical professionals and insurance providers can have a greater understanding of the gaps in care and work to improve services.

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Children with Autism Get Bullied More Often

A new study claims that children with autism are bullied much more often than the average child.

A study based on information collected from 920 parents suggests an estimated 46.3 percent of adolescents with an autism spectrum disorder were the victims of bullying, according to a report published Online First by Archives of Pediatrics & Adolescent Medicine, a JAMA Network publication.

Bullying involves negative actions toward a peer and is characterized by a power imbalance -- physical, social or cognitive -- between the victim and the perpetrator. Relatively little research has examined bullying involvement among adolescents with an autism spectrum disorder (ASD), according to the study background.

Paul R. Sterzing, Ph.D., M.S.S.W., previously of Washington University, St. Louis but now affiliated with the University of California, Berkeley, and colleagues used nationally representative surveys to identify the prevalence of bullying involvement, compare prevalence rates of bullying involvement with adolescents with developmental disabilities that overlap with the core deficits of an ASD, and identify the social ecological correlates of bullying involvement.

The prevalence of bullying involvement for adolescents with an ASD was 46.3 percent for victimization and was "substantially higher" than the national prevalence estimates for the general adolescent population (10.6 percent). The rates of perpetration of bullying (14.8 percent) and victimization/perpetration (8.9 percent, i.e. those who perpetrate and are victimized), were about equivalent to national estimates found among typically developing adolescents, according to the study results.

Victimization was related to having a non-Hispanic ethnicity, attention-deficit/hyperactivity disorder, lower social skills, some form of conversational ability, and more classes in general education. Perpetration was correlated with being white, having attention-deficit hyperactivity disorder, and getting together with friends at least once a week. Victimization/perpetration was associated with being white non-Hispanic, having attention-deficit/hyperactivity disorder and getting together with friends at least once a week, the results indicate.

"Future interventions should incorporate content that addresses the core deficits of adolescents with an ASD, which limits their verbal ability to report bullying incidents," the authors comment. "Schools should incorporate strategies that address conversational difficulties and the unique challenges of those with comorbid conditions."

The authors also concluded: "Inclusive classrooms need to increase the social integration of adolescents with an ASD into protective peer groups while also enhancing the empathy and social skills of typically developing students toward their peers with an ASD and other developmental disabilities."

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Gluten-Free, Casein-Free Diet May Help Some Children With Autism, Research Suggests

A gluten-free, casein-free diet may lead to improvements in behavior and physiological symptoms in some children diagnosed with an autism spectrum disorder (ASD), according to researchers at Penn State. The research is the first to use survey data from parents to document the effectiveness of a gluten-free, casein-free diet on children with ASD.

"Research has shown that children with ASD commonly have GI [gastrointestinal] symptoms," said Christine Pennesi, medical student at Penn State College of Medicine. "Notably, a greater proportion of our study population reported GI and allergy symptoms than what is seen in the general pediatric population. Some experts have suggested that gluten- and casein-derived peptides cause an immune response in children with ASD, and others have proposed that the peptides could trigger GI symptoms and behavioral problems."

The team -- which included Laura Cousino Klein, associate professor of biobehavioral health and human development and family studies -- asked 387 parents or primary caregivers of children with ASD to complete a 90-item online survey about their children's GI symptoms, food allergy diagnoses, and suspected food sensitivities, as well as their children's degree of adherence to a gluten-free, casein-free diet. The team's results appeared online this month in the journal Nutritional Neuroscience.

Pennesi and Klein and their team found that a gluten-free, casein-free diet was more effective in improving ASD behaviors, physiological symptoms and social behaviors for those children with GI symptoms and with allergy symptoms compared to those without these symptoms. Specifically, parents noted improved GI symptoms in their children as well as increases in their children's social behaviors, such as language production, eye contact, engagement, attention span, requesting behavior and social responsiveness, when they strictly followed a gluten-free, casein-free diet.

According to Klein, autism may be more than a neurological disease -- it may involve the GI tract and the immune system.

"There are strong connections between the immune system and the brain, which are mediated through multiple physiological symptoms," Klein said. "A majority of the pain receptors in the body are located in the gut, so by adhering to a gluten-free, casein-free diet, you're reducing inflammation and discomfort that may alter brain processing, making the body more receptive to ASD therapies."

The team found that parents who eliminated all gluten and casein from their children's diets reported that a greater number of their children's ASD behaviors, physiological symptoms and social behaviors improved after starting the diet compared to children whose parents did not eliminate all gluten and casein. The team also found that parents who implemented the diet for six months or less reported that the diet was less effective in reducing their child's ASD behaviors.

According to the researchers, some of the parents who filled out the surveys had eliminated only gluten or only casein from their children's diets, but survey results suggested that parents who completely eliminated both gluten and casein from their child's diet reported the most benefit.

"While more rigorous research is needed, our findings suggest that a gluten-free, casein-free diet might be beneficial for some children on the autism spectrum," Pennesi said. "It is also possible that there are other proteins, such as soy, that are problematic for these children."

The reason Klein and Pennesi examined gluten and casein is because they are two of the most common "diet offenders."

"Gluten and casein seem to be the most immunoreactive," Klein said. "A child's skin and blood tests for gluten and casein allergies can be negative, but the child still can have a localized immune response in the gut that can lead to behavioral and psychological symptoms. When you add that in with autism you can get an exacerbation of effects."

Klein's advice to parents of children with ASD?

"If parents are going to try a gluten-free, casein-free diet with their children, they really need to stick to it in order to receive the possible benefits," she said. "It might give parents an opportunity to talk with their physicians about starting a gluten-free, casein-free diet with their children with ASD."

Read more: http://www.sciencedaily.com/releases/2012/02/120229105128

Eye-Tracking Reveals Variability in Successful Social Strategies for Children With Autism Spectrum Disorders

In a study published in the March 2012 issue of the Journal of the American Academy of Child and Adolescent Psychiatry, Katherine Rice and colleagues, from the Marcus Autism Center, Children's Healthcare of Atlanta, and Emory University School of Medicine, used eye-tracking technology to measure the relationship between cognitive and social disability in children with autism spectrum disorders (ASD) and the ability of children with ASD to pay attention to social interactions.

The study is the largest to date to observe children with ASD watching scenes of social interaction; 135 children, 109 with ASD and 26 without, all approximately 10 years old, participated. The children were shown movie scenes of school-age children in age-appropriate social situations. One set of analyses focused on the differences between children with ASD and typically-developing children, by closely matching a subset of those with ASD to typically-developing peers on IQ, gender, and age. A second set of analyses focused on measures that quantify the broad spectrum of adaptive and maladaptive behavior in ASD by analyzing variation across all 109 ASD participants.

Results indicated that children with ASD were less likely than typically-developing peers to look at other people's eyes and faces, and were more likely to fixate on bodies and inanimate objects. The results also revealed the varying ways in which children with ASD use the information they observe. For the entire group of children with ASD, increased observation of inanimate objects rather than people was associated with more severe social disability. However, for some subsets of the autism spectrum, such as highly verbal children with ASD, whose verbal IQs were larger than their nonverbal IQs, increased looking at others people's mouths was associated with less disability.

"These results help us tease apart some of the vast heterogeneity of the autism spectrum," said Rice. "For some children, atypical looking patterns may be serving as a compensatory strategy; but for others, these patterns are clearly associated with maladaptive behaviors. Objective, quantitative measures of social disability help us to identify these subsets in a data-driven manner."

Read more: http://www.sciencedaily.com/releases/2012/02/120227094108

Study Compares Traits of Autism, Schizophrenia

A UT Dallas professor is studying the differences between the social impairments found in autism and schizophrenia to help develop better treatments for people with both disorders.

Autism spectrum disorder (ASD) and schizophrenia are distinct disorders with unique characteristics, but they share similarities in social dysfunction. For many years, this similarity resulted in confusion in diagnosis. Many young people with ASD were thought to have a childhood version of schizophrenia, said Dr. Noah Sasson, assistant professor in the UT Dallas School of Behavioral and Brain Sciences.

Sasson points out that clear differences exist between people diagnosed with schizophrenia and ASD. Symptoms of ASD can be seen from very early in life, while the onset of schizophrenia typically occurs in young adulthood. And individuals who have schizophrenia often experience hallucinations and delusional thoughts, which are far less common in individuals with ASD.

An overlapping problem for both clinical groups is a difficulty with social interaction. Both groups are known to be poor at recognizing social cues. They often have difficulty identifying emotion in other people, so their reactions may seem inappropriate. By not picking up on the subtle cues in interactions, adults with ASD or schizophrenia may alienate other people and have trouble making friends or getting along with classmates or co-workers.

Along with collaborators at Southern Methodist University, Sasson is conducting new research at the UT Dallas Callier Center for Communication Disorders that compares the basis for social interaction impairments between adults with ASD and adults with schizophrenia. He is attempting to understand the mechanisms that underlie their social limitations.

"Because the two disorders are different in so many ways, it is likely that the basis for their social impairments differs as well," he said. "Understanding these differences will be key for developing effective treatments. What works well for individuals with ASD might be very different than those with schizophrenia."

In previous research, Sasson and his colleagues used eye-tracking technology and found that neither adults with ASD nor adults with schizophrenia look at social information in the same way as those without either disorder. His colleagues also found that parts of the brain that process social information are underactive in those with ASD and schizophrenia. But the researchers have also found differences. Individuals with ASD do not spontaneously orient to emotional information, while individuals with schizophrenia do. While both groups show aspects of paranoia in social situations, Sasson and his colleagues are discovering that the root cause of the paranoia is different for each disorder.

"People with schizophrenia have a much higher likelihood than the general population to attribute ill will to others, and this is likely tied to their delusions," he said. "On the other hand, people with autism are more 'socially cynical.' They seem to be exhibiting fairly realistic responses to people as a result of the challenges they've faced in life because of their condition."

By differentiating between schizophrenia and autism, and by examining how patients react in social settings, Sasson said he hopes researchers can develop new ways to counteract the negative social experiences of patients. This could result in a profound improvement in their ability to navigate life successfully.

Read more: http://www.sciencedaily.com/releases/2012/02/120228114312