Clonidine and Sleep problems in children with Autism

Title:Use of clonidine in children with autism spectrum disorders.
Source:MING, X. (2008). Use of clonidine in children with autism spectrum disorders. Brain and Development DOI: 10.1016/j.braindev.2007.12.007

In this study the authors wanted to evaluate the effectiveness of clonidine in the treatment of insomnia and other behavioral difficulties in children with autism spectrum disorder. The researchers evaluated 19 children with a diagnosis of ASDs obtained via ADI and ADOS. The researchers assessed sleep and behavioral problems as reported by the parents before and during the initiation of the treatment. Seventeen of the 19 children had sleep difficulties including prolonged sleep initiation and or difficulty maintaining sleep. All children with difficulty falling asleep (16) were able to fall asleep faster after taking the medication. In addition 16 of 17 children with sleep maintenance problems had a reduction in the frequency of awakening during the nights. The authors concluded that clonidine was effective in managing sleep difficulties in this sample of children with ASDs. However, the authors also correctly noted some major limitations of this study. This was an open label retrospective study. Open label means that all participants knew which medication they were taking. Under ideal conditions, such as in a randomized double-blind placebo study, both the clinicians and the patients are blind to what medication (or placebo) they are taking, which greatly increases our ability to reach conclusions about the true effects of the medication. In an open label study, there is always the possibility that the results are not due to the actual effect of the medication but to a ‘placebo’ effect.

Autism, IQ, and the Stanford–Binet

Title: Brief Report: Data on the Stanford–Binet Intelligence Scales (5th ed.) in Children with Autism Spectrum Disorder
Source: Coolican, J., Bryson, S.E., Zwaigenbaum, L. (2008). Brief Report: Data on the Stanford–Binet Intelligence Scales (5th ed.) in Children with Autism Spectrum Disorder. Journal of Autism and Developmental Disorders , 38(1), 190-197.

In 2003 the Stanford-Binet-Intelligence Scales published a new edition (The SB-5). The SB is one of the most commonly used IQ scales for the assessment of children with special needs because it is believed to provide a more valid estimate of the child’s cognitive capacities. Although such assertion is still debated, in my experience working at several outpatient and hospital settings, the SB was always the tool of choice when conducting assessment with children with autism. Now, the problem that clinicians and researchers encounter is that when a new version of the test is launched, there is little information, apart for what is provided by the publisher, about how children with specific neurodevelopmental disorders are expected to perform. Thus, a team a Dalhousie University in Canada provided this brief report on the performance on the SB-5 by children with ASDs. The study included 63 children (12 girls and 51 boy) who have received a diagnosis of Autism, Asperger’s, or PDD-NOS via ADI or ADOS evaluation. The final count included 32 children with autism, 20 children with Asperger’s, and 11 children with PDD-NOS. Here are the most relevant results: Age was not significantly associated with performance as expected. This means that when compared to very large population sample of peers of the same age, younger children and older children perform at the same level in relation to their peers. Thus, differences between these children and the population sample do not change with age. The average full scale IQ scores using the entire SB-5 for the groups were 67.75 for Autism, 105.60 for Asperger’s, and 82.18 for PDD-NOS. When using an abbreviated version of the SB-5, the results were slightly higher but this varied significantly by individual. When comparing the Verbal vs. Non-Verbal subscales, it was surprising that in all three groups the scores in these scales were very similar, without any major discrepancy between verbal and non-verbal performance. This is surprising because traditionally children with Asperger’s show a pattern of performance consistent with a Non-verbal learning disability. That is, you would expect a significant discrepancy with much higher verbal scores as compared to non-verbal scores.

Commentary: The issue of IQ and intellectual assessment in children with Austim is highly controversial. However, the controversy is largely political and outside the research and clinical world. I want to address two issues that seem to be commonly debated in the autism community. First I want to briefly explain when, why and how an intellectual assessment test is used. An intellectual assessment is never, or should never, be provided in isolation. That is, an IQ test for the sake of knowing an IQ score provides no clinical utility. IQ scores, outside the larger scope of a full neurocognitive or educational evaluation conducted to answer specific clinical questions, are simply meaningless. Instead, an intellectual assessment is provided as part of a larger evaluation to understand the specific patterns of relative neurocognitive strengths and weaknesses with the ultimate goal of providing recommendations for services, treatment, accommodations, etc , which will maximize the functional capacities of the child and will facilitate growth and improvement. Second, there is usually a debated as to whether these intellectual assessment tools truly reflect the capacities of the child. This is a very, very, very important question. For example, performance in these types of tests is highly influenced by social desirability (wanting to please). A typically developing child may be attentive to instructions in order to please the clinician. But what if the child simply has other priorities at that particular moment than to listen to the clinicians explain how to do this clearly boring task? Does poor performance on this task reflect limited capacity in the area of functioning assessed? That is, did the child performed poorly because he/she couldn’t do it, or simply because he/she didn’t want to do it? So to the extent that IQ tests measure TRUE capacity, or are reflective of the child’s TRUE abilities, we simply have to say we don’t know. We hope that our assessment tools tap and real capacities as much as possible, but it is nearly impossible to ascertain why someone did not perform well in a particular task. HOWEVER, what the test does, at least more accurately, is to assess for FUNCTIONAL capacity. From a purely theoretical perspective, we can say that it does not matter why the child performed poorly if such performance generalizes into other contexts and affect the functional capacity of the child (not being able to do school work, difficulty keeping a job, etc). Thus, to the extend that neurocognitive assessment tools reflect functional capacities and help us provide recommendations that result in REAL benefits for the child, then I see these tests as important tools if used correctly for the right reasons and in the right context.

Update - Clarification: I was asked to clarify the statement “the controversy is largely political and outside the research and clinical world”. I apologize and agree that I should have been more precise about what I meant with that statement. I did not mean to imply that there is no controversy regarding the relative utility or appropriates of particular instruments (SB vs. WISC vs. TONY vs. other non-verbal assessment tool, etc). I was making a commentary about the commonly accepted position that in the right context, intellectual assessment as part of a comprehensive evaluation provides useful clinical information that could benefit the child or adult with autism. In my experience, the utility of using intellectual assessment tools has not been an issue of major controversy in any of the clinical settings I have worked in, including large university-based hospitals and autism clinics. In addition, I just conducted another superficial review of the two top journals in autism during the last 24 months and I was unable to find articles that provide appropriate empirical support for the idea that intellectual assessments should not be conducted in children with autism, although there are compelling articles discussing the appropriateness of specific tests. However, I accept that it is possible that the controversy in the research and clinical arena about this issue could more pronounced than how I characterized it, and if that is the case I stand corrected.

Autism, Services, and Co-morbidity: Insights from Kansas. PART II

Title: Characteristics of children with autism spectrum disorders who received services through community mental health centers.
Authors: Stephanie A. Bryson, Susan K. Corrigan, Thomas P. Mcdonald, and Cheryl Holmes
Source: Autism 2008 12: 65-82. (January).

I apologize for the lack of posts since Friday. I was in Washington at a National Institutes of Health round table discussion on research in childhood-onset disorders. Although the meeting was focused on child depression, there are several issues that were debated that apply to Autism research and I will post some observations later this week.

This is the second part of my summary of the Kansas community mental health study. Please see the previous post for some background and basic description of the methodology. As you may remember, the authors compared children with autism to children with other ASD, all of whom had received services at community mental health centers in Kansas. The researchers explored differences in a variety of demographic factors but they were most interested in examining differences in rates of co-morbid disorders. Here are their basic findings: Children with PDD and Asperger’s, when compared to children with autism, had higher rates of co-morbid ADHD, Depressive Disorders, Oppositional Defiant Disorder, Bi-Polar Disorder, and Post Traumatic Stress Disorder. Children with Asperger’s and PDD were also more likely to have experienced a psychiatric hospitalization. Yet, children with Autism were more likely to receive special education services than children with other ASDs.

Brief Commentary: The authors discussed some possible interpretations of the data, and I want to reiterate one major point. At least 2 things may be at play here. It is possible that children with PDD and Asperger’s do in fact experience higher rates of these disorders. Some of the findings are consistent with our current understanding of ASDs. For example, some researchers have characterized the differences between Asperger’s and Autism (especially high functioning autism) to be mostly related to differences in social desirability. The basic premise is that children with Asperger’s HAVE a desire for social interactions and relationships with peers, but they have social limitations that make it difficult for them to develop such social interactions. One the other hand, children with autism are believed to lack an “explicit or apparent” desire to establish and maintain relationships with peers. This limited social desirability may actually be “protective” for depression and other disorders in children with Autism; while the apparent social affiliation needs of children with Asperger’s, coupled with their social limitations, may lead to higher levels of frustration and possibly more emotional distress. HOWEVER, the results may also be a byproduct of our clinical diagnostic practices. There are many reasons why clinicians may provide a co-morbid diagnosis. In my own clinical experience, most often a second diagnosis is provided only when such diagnosis serves a function that helps the child. For example, up to 70% of children with autism score in the mental retardation range of standard IQ tests, yet most kids with Autism do not receive a second diagnosis of Mental Retardation. Why? Because it serves no purpose (in addition to other theoretical consideration). However, I have seen children receive a second diagnosis of MR when such diagnosis served a purpose, such as allowing the family and child to receive extended services, insurance coverage, etc. Thus it is possible that the differences in diagnoses observed by the researchers are not differences in ACTUAL rates of the disorders but instead in the relevant utility of providing a co-morbid diagnosis to children with PDD, Asperger’s, and Autism.