Psychiatric disorders in children with autism spectrum disorders: prevalence, comorbidity, and associated factors in a population-derived sample

Objective: Autism spectrum disorders are now recognized to occur in up to 1% of the population and to be a major public health concern because of their early onset, lifelong persistence, and high levels of associated impairment. Little is known about the associated psychiatric disorders that may contribute to impairment. We identify the rates and type of psychiatric comorbidity associated with ASDs and explore the associations with variables identified as risk factors for child psychiatric disorders. Method: A subgroup of 112 ten- to 14-year old children from a population-derived cohort was assessed for other child psychiatric disorders (3 months' prevalence) through parent interview using the Child and Adolescent Psychiatric Assessment. DSM-IV diagnoses for childhood anxiety disorders, depressive disorders, oppositional defiant and conduct disorders, attention-deficit/hyperactivity disorder, tic disorders, trichotillomania, enuresis, and encopresis were identified. Results: Seventy percent of participants had at least one comorbid disorder and 41% had two or more. The most common diagnoses were social anxiety disorder (29.2%, 95% confidence interval [CI)] 13.2-45.1), attention-deficit/hyperactivity disorder (28.2%, 95% CI 13.3-43.0), and oppositional defiant disorder (28.1%, 95% CI 13.9-42.2). Of those with attention/deficit/hyperactivity disorder, 84% received a second comorbid diagnosis. There were few associations between putative risk factors and psychiatric disorder. Conclusions: Psychiatric disorders are common and frequently multiple in children with autism spectrum disorders. They may provide targets for intervention and should be routinely evaluated in the clinical assessment of this group.

Developing social interaction and understanding in individuals with autism spectrum disorder: a groupwork intervention

Background: Difficulties with social interaction and understanding lie at the heart of the communication disorder that characterises the autism spectrum. This study sought to improve social communication for individuals with autism spectrum disorder (ASD) by means of a groupwork intervention focusing on social and emotional perspective-taking, conversation skills, and friendship skills. It also aimed to address some of the limitations of previous interventions, including a lack of generalisation to other settings, so as to maximise inclusion in the community. Method A group of 46 high functioning children and adolescents with ASD (38 boys, 8 girls, age range 6-16 years) were allocated to one of 6 intervention groups. Each group met over a period of 12-16 weeks for a minimum of one 1 1/2-hour weekly session aimed at promoting key areas of social interaction and understanding, supported by home-based practice. Results: Significant gains were achieved in comparison with a normative population, and individual parent ratings showed marked and sustained changes in the key areas targeted in the group sessions. Conclusion: Social communication in children and adolescents with ASD can be enhanced through the use of a groupwork intervention addressing social interaction and understanding.

Loss of language in early development of autism and specific language impairment

Background:  Several authors have highlighted areas of overlap in symptoms and impairment among children with autism spectrum disorder (ASD) and children with specific language impairment (SLI). By contrast, loss of language and broadly defined regression have been reported as relatively specific to autism. We compare the incidence of language loss and language progression of children with autism and SLI. Methods:  We used two complementary studies: the Special Needs and Autism Project (SNAP) and the Manchester Language Study (MLS) involving children with SLI. This yielded a combined sample of 368 children (305 males and 63 females) assessed in late childhood for autism, history of language loss, epilepsy, language abilities and nonverbal IQ. Results:  language loss occurred in just 1% of children with SLI but in 15% of children classified as having autism or autism spectrum disorder. Loss was more common among children with autism rather than milder ASD and is much less frequently reported when language development is delayed. For children who lost language skills before their first phrases, the phrased speech milestone was postponed but long-term language skills were not significantly lower than children with autism but without loss. For the few who experienced language loss after acquiring phrased speech, subsequent cognitive performance is more uncertain. Conclusions:  Language loss is highly specific to ASD. The underlying developmental abnormality may be more prevalent than raw data might suggest, its possible presence being hidden for children whose language development is delayed.

Informing early intervention: preschool predictors of anxiety disorders in middle childhood

Background: To inform early intervention practice, the present research examines how child anxiety, behavioural inhibition, maternal overinvolvement, maternal negativity, mother-child attachment and maternal anxiety, as assessed at age four, predict anxiety at age nine. Method: 202 children (102 behaviourally inhibited and 100 behaviourally uninhibited) aged 3–4 years were initially recruited and the predictors outlined above were assessed. Diagnostic assessments, using the Anxiety Disorders Interview Schedule, were then conducted five years later. Results: Behavioural inhibition, maternal anxiety, and maternal overinvolvement were significant predictors of clinical anxiety, even after controlling for baseline anxiety (p,.05). No significant effect of negativity or attachment security was found over and above baseline anxiety (p..1). Conclusions: Preschool children who show anxiety, are inhibited, have overinvolved mothers and mothers with anxiety disorders are at increased risk for anxiety in middle childhood. These factors can be used to identify suitable participants for early intervention and can be targeted within intervention programs.

Syntactic complexity in the comprehension of wh-questions and relative clauses in typical language development and autism

This study investigates effects of syntactic complexity operationalised in terms of movement, intervention and (NP) feature similarity in the development of A’ dependencies in 4-, 6-, and 8-year old typically developing (TD) French children and children with Autism Spectrum Disorders (ASD). Children completed an off-line comprehension task testing eight syntactic structures classified in four levels of complexity: Level 0: No Movement; Level 1: Movement without (configurational) Intervention; Level 2: Movement with Intervention from an element which is maximally different or featurally ‘disjoint’ (mismatched in both lexical NP restriction and number); Level 3: Movement with Intervention from an element similar in one feature or featurally ‘intersecting’ (matched in lexical NP restriction, mismatched in number). The results show that syntactic complexity affects TD children across the three age groups, but also indicate developmental differences between these groups. Movement affected all three groups in a similar way, but intervention effects in intersection cases were stronger in younger than older children, with NP feature similarity affecting only 4-year olds. Complexity effects created by the similarity in lexical restriction of an intervener thus appear to be overcome early in development, arguably thanks to other differences of this intervener (which was mismatched in number). Children with ASD performed less well than the TD children although they were matched on non-verbal reasoning. Overall, syntactic complexity affected their performance in a similar way as in their TD controls, but their performance correlated with non-verbal abilities rather than age, suggesting that their grammatical development does not follow the smooth relation to age that is found in TD children.

Early impact of the BEST intervention for parents stressed by adolescent substance abuse.

Youth involvement in substance abuse can be a source of considerable distress for their parents. Unilateral family interventions have been advocated as one means by which concerned family members can be supported to assist substance-abusing family members. To date there has been little research examining the impact of unilateral family interventions on the directly participating family members. In this study the early impact of an 8-week parent-group programme known as Behavioural Exchange Systems Training (BEST) was evaluated using a quasi-experimental, waiting list control design. The professionally led programme had been developed to support and assist parents in their efforts to cope with adolescent substance abuse. Subjects were 66 parents (48 families) accepted for entry into the programme between 1997 and 1998. Comparison was made between 46 parents offered immediate entry into the programme and 20 parents whose entry to the programme was delayed by an 8-week waiting list. At the first assessment 87% of parents showed elevated mental health symptoms on the General Health Questionnaire. Evidence suggested exposure to the intervention had a positive impact on parents. Compared to parents on the waiting list, parents entered immediately into the intervention demonstrated greater reductions in mental health symptoms, increased parental satisfaction, and increased use of assertive parenting behaviours.

The infant feeding activity and nutrition trial (INFANT) an early intervention to prevent childhood obesity : cluster-randomised controlled trial

Background : Multiple factors combine to support a compelling case for interventions that target the development of obesity-promoting behaviours (poor diet, low physical activity and high sedentary behaviour) from their inception. These factors include the rapidly increasing prevalence of fatness throughout childhood, the instigation of obesity-promoting behaviours in infancy, and the tracking of these behaviours from childhood through to adolescence and adulthood. The Infant Feeding Activity and Nutrition Trial (INFANT) aims to determine the effectiveness of an early childhood obesity prevention intervention delivered to first-time parents. The intervention, conducted with parents over the infant's first 18 months of life, will use existing social networks (first-time parent's groups) and an anticipatory guidance framework focusing on parenting skills which support the development of positive diet and physical activity behaviours, and reduced sedentary behaviours in infancy.

Methods/Design : This cluster-randomised controlled trial, with first-time parent groups as the unit of randomisation, will be conducted with a sample of 600 first-time parents and their newborn children who attend the first-time parents' group at Maternal and Child Health Centres. Using a two-stage sampling process, local government areas in Victoria, Australia will be randomly selected at the first stage. At the second stage, a proportional sample of first-time parent groups within selected local government areas will be randomly selected and invited to participate. Informed consent will be obtained and groups will then be randomly allocated to the intervention or control group.

Discussion : The early years hold promise as a time in which obesity prevention may be most effective. To our knowledge this will be the first randomised trial internationally to demonstrate whether an early health promotion program delivered to first-time parents in their existing social groups promotes healthy eating, physical activity and reduced sedentary behaviours. If proven to be effective, INFANT may protect children from the development of obesity and its associated social and economic costs.

Is early intervention in psychosis cost-effective over the long term?

Objective: This study assesses the long-term cost-effectiveness of a comprehensive model of mental health care for first-episode psychosis. The study is an extension of a previous economic evaluation of the Early Psychosis Prevention and Intervention Centre (EPPIC) that assessed the first-year costs and outcomes of treatment.

Method: The current study used a matched, historical control group design with a follow-up of approximately 8 years. Complete follow-up data were available for 65 of the original 102 participants. Direct public mental health service costs incurred subsequent to the first year of treatment and symptomatic and functional outcomes of 32 participants initially treated for up to 2 years at EPPIC were compared with a matched cohort of 33 participants initially treated by generic mental health services. Treatment-related resource use was measured and valued using Australian published prices.

Results: Almost 8 years after initial treatment, EPPIC subjects displayed lower levels of positive psychotic symptoms (P = .007), were more likely to be in remission (P = .008), and had a more favorable course of illness (P = .011) than the controls. Fifty-six percent of the EPPIC cohort were in paid employment over the last 2 years compared with 33% of controls (P = .083). Each EPPIC patient costs on average A$3445 per annum to treat compared with controls, who each costs A$9503 per annum.

Conclusions: Specialized early psychosis programs can deliver a higher recovery rate at one-third the cost of standard public mental health services. Residual methodological limitations and limited sample size indicate that further research is required to verify this finding.

Constructing a Malaysian early intervention programme for children with disabilities

This case study of a parent-initiated community project called Wings Melaka has helped improve provision of early intervention services to Malaysian children with disabilities, and their families, by making contributions specifically to the workplace at Wings Melaka, and more generally, to the much-neglected field of early intervention in Malaysia.

Evaluation of an early intervention program for childhood conduct problems

Treatment outcomes of an early intervention program for childhood conduct problems were evaluated. Results provided support for the longitudinal effectiveness of the program in reducing conduct problems, social difficulties, and psychosocial impairment for young primary school aged children. Children's experience and expression of anger also reduced across the program's duration. The portfolio presents four case studies whose results provide further support for Exposure and Response Prevention (ERP) as an effective and clinically useful treatment for paediatric OCD in everyday clinical contexts.

Reducing obesity in early childhood : results from romp & chomp, an Australian community-wide intervention program

Background: There is growing evidence that community-based interventions can reduce childhood obesity in older children.
Objective: We aimed to determine the effectiveness of the Romp & Chomp intervention in reducing obesity and promoting healthy eating and active play in children aged 0–5 y.
Design: Romp & Chomp was a community-wide, multisetting, multistrategy intervention conducted in Australia from 2004 to 2008. The intervention occurred in a large regional city (Geelong) with a target group of 12,000 children and focused on community capacity building and environmental (political, sociocultural, and physical) changes to increase healthy eating and active play in early-childhood care and educational settings. The evaluation was repeat cross-sectional with a quasiexperimental design and comparison sample. Main outcome measures were body mass index (BMI), standardized BMI (zBMI; according to the Centers for Disease Control and Prevention 2000 reference charts), and prevalence of overweight/obesity and obesity-related behaviors in children aged 2 and 3.5 y.
Results: After the intervention there was a significantly lower mean weight, BMI, and zBMI in the 3.5-y-old subsample and a significantly lower prevalence of overweight/obesity in both the 2- and 3.5-y-old subsamples (by 2.5 and 3.4 percentage points, respectively) than in the comparison sample (a difference of 0.7 percentage points; P < 0.05) compared with baseline values. Intervention child-behavioral data showed a significantly lower intake of packaged snacks (by 0.23 serving), fruit juice (0.52 serving), and cordial (0.43 serving) than that in the comparison sample (all P < 0.05).
Conclusion: A community-wide multisetting, multistrategy intervention in early-childhood settings can reduce childhood obesity and improve young children's diets. This trial was registered with the Australian Clinical Trials Registry at anzctr.org.au as ACTRN12607000374460.

Does stage of illness impact treatment response in bipolar disorder? Empirical treatment data and their implication for the staging model and early intervention

Objective: The staging model suggests that early stages of bipolar disorder respond better to treatments and have a more favourable prognosis. This study aims to provide empirical support for the model, and the allied construct of early intervention.

Methods: Pooled data from mania, depression, and maintenance studies of olanzapine were analyzed. Individuals were categorized as having had 0, 1–5, 6–10, or >10 prior episodes of illness, and data were analyzed across these groups.

Results: Response rates for the mania and maintenance studies ranged from 52–69% and 10–50%, respectively, for individuals with 1–5 previous episodes, and from 29–59% and 11–40% for individuals with >5 previous episodes. These rates were significantly higher for the 1–5 group on most measures of response with up to a twofold increase in the chance of responding for those with fewer previous episodes. For the depression studies, response rates were significantly higher for the 1–5 group for two measures only. In the maintenance studies, the chance of relapse to either mania or depression was reduced by 40–60% for those who had experienced 1–5 episodes or 6–10 episodes compared to the >10 episode group, respectively. This trend was statistically significant only for relapse into mania for the 1–5 episode group (p = 0.005).

Conclusion: Those individuals at the earliest stages of illness consistently had a more favourable response to treatment. This is consistent with the staging model and

Evidence and implications for early intervention in bipolar disorder

Aims: To review the evidence that supports early intervention in the treatment of bipolar disorder.

Background: Bipolar disorder is a pleomorphic condition, with varying manifestations that are determined by a number of complex factors including the ‘‘stage’’ of illness. It is consequently a notoriously difficult illness to diagnose and as a corollary is associated with lengthy delays in recognition and the initiation of suitable treatment.

Methods: A literature search was conducted using MEDLINE augmented by a manual search.

Results: Emerging neuroimaging data suggests that, in contrast to schizophrenia, where at the time of a first-episode of illness there is already discernible volume loss, in bipolar disorder, gross brain structure is relatively preserved, and it is only with recurrences that there is a sequential, but marked loss of brain volume. Recent evidence suggests that both pharmacotherapy and psychotherapy are more effective if instituted early in the course of bipolar disorder, and that with multiple episodes and disease progression there is a noticeable decline in treatment response.

Conclusions: Such data supports the notion of clinical staging, and the tailored implementation of treatments according to the stage of illness. The progressive nature of bipolar disorder further supports the concept that the first episode is a period that requires energetic broad-based treatment, with the hope that this could alter the temporal trajectory of the illness. It also raises hope that prompt treatment may be neuroprotective and that this perhaps attenuates or even prevents the neurostructural and neurocognitive changes seen to emerge with chronicity. This highlights the need for early identification at a population level and the necessity of implementing treatments and services at a stage of the illness where prognosis is optimal.

Early intervention in bipolar disorders : clinical, biochemical and neuroimaging imperatives

In the absence of clear targets for primary prevention of many psychiatric illnesses, secondary prevention becomes the most feasible therapeutic target, and is best encompassed by the concept of early intervention. This construct encompasses the goals of minimising diagnostic delay and the prompt initiation of clinically appropriate therapy. This paper develops the rationale for early intervention in bipolar disorder. Three interrelated themes are discussed; the clinical data supporting the value of prompt diagnosis and treatment in bipolar disorder, the putative biochemical mechanisms underlying the pathophysiological processes, and the parallel concept of neuroprotection, and the developing neuroimaging data that supports early intervention. Early initiation of appropriate therapy may potentially facilitate improved clinical outcomes, and further might allow the secondary prevention of the sequelae of untreated illness, which include the deleterious impact on family relationships, psychosexual and vocational development, identity and self-concept and self-stigma.