Tuesday, March 15, 2016

GI Distress in Children on the Autism Spectrum

GI Distress in Autistic Children 

A number of clinical and epidemiological studies have indicated that children with autism spectrum disorder (ASD) are at increased risk for gastrointestinal (GI) problems. Research suggests that certain behaviors among children with ASD may reflect underlying GI problems and that the presence of these behaviors may indicate the need to evaluate a child with ASD for GI problems. Specific behavior problems proposed as possible expressions of GI distress include sleep disturbances, stereotypic or repetitive behaviors, self-injurious behaviors, aggression, oppositional behavior, irritability or mood disturbances, and tantrums. A recent pediatric consensus report called for additional research on the association between problem behaviors and GI problems, and for the development of a screen for GI problems in autistic children.            
                                                                    
                                                                              Research

A brief report published in the Journal of Autism and Developmental Disabilities compared the behavioral features of children with and without a history of GI problems. The purpose of this population-based study of 487 children with ASD, including 35 (7.2%) with a medically documented history of GI problems, was to determine whether particular behavioral characteristics occur more frequently among those who have been diagnosed with a GI problem than those without a medically documented history of GI problems. The researchers implemented a cross-sectional study of children who were 8 years of age and met the case definition for ASD through the Centers for Disease Control and Prevention’s Autism and Developmental Disabilities Monitoring (ADDM).  
Eight behavioral features were identified that may be indicative of GI problems among children with ASD which had analogous measures in the ADDM data set: 1. abnormalities in sleeping; 2. stereotyped and repetitive motor mannerisms; 3. self-injurious behaviors; 4. abnormal eating habits, 5. abnormalities in mood or affect; 6. argumentative, oppositional, defiant, or destructive behaviors; 7. aggression; and 8. temper tantrums. Demographic data, healthcare and medical records, descriptions of behaviors, diagnostic summaries, psychometric test results, and information about co-occurring disorders or disabilities were collected and entered into a centralized composite record and reviewed by trained clinicians according to a specified protocol to determine case status and associated behavioral features (e.g., abnormalities in sleeping).
Results
The results indicated that children with sleep abnormalities were more likely to have a medically documented history of GI problems (11%) than those without sleep problems (3.6%). Similar associations were seen for argumentative, oppositional or destructive behavior, abnormal eating habits, mood disturbances and tantrums, although the associations for mood disturbances and tantrums did not reach statistical significance. In contrast, the researchers found no associations between the presence of GI problems and stereotypic/repetitive behaviors and self-injurious behaviors.  Notably, nearly all of the children with ASD, including all 35 with a documented history of GI problems, exhibited at least one of the behavior problems hypothesized to be potential indicators of GI distress. For this reason, these behaviors would not be useful as a potential screen for GI problems in that virtually all children with ASD would potentially be referred for GI evaluations.
Implications
This study provides some support for the association between selected behavioral characteristics in autistic children and the occurrence of GI problems. The study found significant positive associations for several behaviors hypothesized to be expressions of GI problems in children with ASD. Certain behaviors, including abnormalities in sleep patterns, abnormalities in eating habits, and argumentative, oppositional, defiant or destructive behavior were described significantly more often in autistic children who also had GI problems than in those with ASD and no history of GI problems.
Perhaps the most important contribution of this study is the finding that the behavioral characteristics hypothesized to be expressions of GI problems are very common in autistic children, yet not specific to those with GI problems. Although GI problems may contribute to selected behaviors in some children with ASD, these behaviors are also frequent in children with and without ASD (nearly all children had 1 or more behaviors) and are unlikely to efficiently predict GI problems in children with ASD. As a result, the presence of these behaviors would not be useful on their own for screening or identifying children requiring GI evaluation.
Practitioners should be aware that certain behavioral problems observed in autistic children may be indicative of a child’s response to, or attempt to communicate the discomfort of, an underlying GI problem. This condition can seriously affect the individual’s quality of life and ability to participate education and therapeutic activities. Consideration of medical, biological, or physiological co-occurring conditions, genetic susceptibility, diet and nutrition, and medication use are necessary to determine whether co-occurring behavioral problems and GI distress may be present in a child with ASD. A comprehensive developmental assessment approach requires the use of multiple measures including, but not limited to, verbal reports, direct observation, direct interaction and evaluation, and third-party reports. This should include a record review, developmental and medical history, further medical screening and/or evaluation, and parent/caregiver interview. Lastly, further research is needed to develop recommendations for diagnostic evaluation and management of GI problems for individuals on the spectrum. 
Maenner, M. J., Arneson, C. L., Levy, S. E., Kirby, R. S., Nicholas, J. S., & Durkin, M. S. (2012). Brief report: Association between behavioral features and gastrointestinal problems among children with autism spectrum disorder. J Autism Dev Disord 42:1520–1525. DOI 10.1007/s10803-011-1379-6

Wednesday, March 2, 2016

Improving Maternal Mental Health After a Diagnosis of Autism Spectrum Disorder


Improving Maternal Mental Health After a Diagnosis of Autism

Parents worldwide often experience a range of emotions when their child is first diagnosed with autism, including shock, sadness and grief, anger, and loneliness. Mothers, in particular, appear to face unique challenges that potentially have an impact on their mental health and wellbeing. This includes high levels of psychological distress, depressive symptoms, and social isolation. Almost 40% of mothers report levels of clinically significant parenting stress and between 33% and 59% report significant depressive symptoms following a diagnosis of autism spectrum disorder (ASD). The prevalence of psychological distress among mothers of children with ASD suggests a need to address parental mental health during the critical period after the child’s autism diagnosis and when parents are learning to navigate the complex system of autism services.
Research

A study published in the journal Pediatrics examined whether a brief cognitive behavioral intervention, problem-solving education (PSE), decreases parenting stress and maternal depressive symptoms during the period immediately following a child’s diagnosis of ASD. A randomized clinical trial compared 6 sessions of PSE with usual care. Settings included an autism clinic and 6 community-based early intervention programs. Participants were mothers of 122 young children who recently received a diagnosis of ASD. The intervention group received PSE, a manualized cognitive behavioral intervention delivered in six 30-minute individualized sessions. The usual care group mothers received the services specified in the child’s Individualized Family Service Plan or Individualized Educational Plan (IEP) which typically includes speech and language therapy, occupational therapy, and social skills training. Neither specifically includes parent-focused mental health services.
The results indicated that at a 3-month follow-up assessment, PSE mothers were significantly less likely than those serving as controls to have clinically significant parental stress (3.8% vs 29.3%). For depressive symptoms, the risk reduction in clinically significant symptoms did not reach statistical significance; however, the reduction in mean depressive symptoms was statistically significant. The findings demonstrate evidence of PSE’s short-term efficacy and potential to reduce clinically significant psychological distress during this critical juncture—when parents first learn of an ASD diagnosis and must navigate a complex service system on their child’s behalf.
Implications

The findings have implications for practice in both clinical and educational contexts. Practitioners need to be aware that parents experience a myriad of emotions when receiving a diagnosis of ASD and many go through stages of grief. Likewise, professionals working with families of children with an ASD should be aware of negative effects of stress and anxiety and assist in offering services that directly address parental needs and support maternal mental health. Strengthening maternal problem-solving skills might serve as a buffer against the negative impact of life stressors and thereby reduce parental stress and attenuate depressive symptoms in the months immediately following a child’s ASD diagnosis. Future research is needed to examine the effect of intervention over a longer follow-up period and to assess whether the intervention worked differently among subgroups of mothers, which could help better identify those who are most likely to benefit from the intervention.
Reference

Improving Maternal Mental Health After a Child’s Diagnosis of Autism Spectrum Disorder: Results From a Randomized Clinical Trial. Emily Feinberg, CPNP, ScD; Marilyn Augustyn, MD; Elaine Fitzgerald, DrPH; Jenna Sandler, MPH; Zhandra Ferreira-Cesar Suarez, MPH; Ning Chen, MSc; Howard Cabral, PhD; William Beardslee, MD; Michael Silverstein, MD, MPH. JAMA Pediatrics. doi:10.1001/jamapediatrics.2013.3445
Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, chartered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a best-selling text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

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