"The PIT Experience": A Young Adult with Autism Spectrum Disorder's Opinion of how a Wellness Program Changed her Life.

Piece it Together (PIT) is a comprehensive wellness program designed for transitional age youth with Autism Spectrum Disorder and mild neurodevelopmental disabilities that focuses on exercise, nutrition, socialization, and stress-reduction. The PIT Summer Program is a 6-week program, consisting of 90-min classes, twice a week. Each class incorporates 45-min of exercise and health and wellness lessons in goal setting, nutrition, bones and muscle anatomy, and stress management. The PIT program has successfully brought together a unique group to build friendships and make healthier lifestyle choices. One female participant has felt positively impacted and many of her in-class achievements have translated to greater success in work and school environments. She describes the impacts of the PIT program in this letter.

Pharmacotherapy of Autism Spectrum Disorder: Results from the Randomized BAART Clinical Trial.

The objective of this trial, Biomarkers in Autism of Aripiprazole and Risperidone Treatment (BAART), was to provide support and guidance for an evidence-based approach for the selection and monitoring of initial pharmacotherapy in patients with autism by assessing predictors of efficacy, tolerability, and safety. This randomized double-blind parallel-group study was conducted in three academic medical centers and a single private pediatric practice. Eighty children or adolescents (aged 6-17 yrs) with autistic disorder were enrolled, and 61 patients were randomized to the study drug. Of those patients, 51 completed the 10-week trial, and 31 completed an optional 12-week blinded extension phase. All patients were treated with 2 weeks of placebo before random assignment to receive aripiprazole (31 patients) or risperidone (30 patients) for 10 weeks. Sixteen placebo responders (20%) were excluded from further analysis. Drug dosing followed U.S. Food and Drug Administration (FDA) labeling, and weekly dosage adjustments were allowed until week 4; patients were then maintained on a fixed dose for 6 additional weeks. Safety, physical, and psychological assessments were recorded weekly or every 2 weeks. No significant differences in severity of illness between the aripiprazole and risperidone groups were noted at baseline. All patients significantly improved on the Aberrant Behavior Checklist-Irritability subscale after 1 week and continued for the remaining 9 weeks and the extension phase. Improvement was greatest in the risperidone group at every assessment period and was statistically significantly better than that in the aripiprazole group at weeks 3 and 6 (p<0.05). No dose-limiting adverse events occurred during the dose-titration period. Mean weight gain in the aripiprazole group was significantly less than that in the risperidone group at week 4 (0.62 vs 1.38 kg, p=0.033) and week 10 (1.61 vs 3.31 kg, p<0.001), but the difference became nonsignificant for the 31 patients completing the 3-month extension phase (4.36 vs 5.55 kg, p=0.26). Pharmacotherapy of patients with autism spectrum disorder resulted in behavioral improvement within 1 week and lasted at least 22 weeks. Weight gain occurred to a greater degree with risperidone than aripiprazole initially, but the differences became nonsignificant by the end of the trial. Our trial supports previous results of drug efficacy and safety in patients with autism spectrum disorder from other trials and extends the evidence-based support for choosing an FDA-approved drug for initial pharmacotherapy for autism spectrum disorder.

Translating benefits of exercise on depression for youth with autism spectrum disorder and neurodevelopmental disorders.

Young adults with Autism Spectrum Disorder (ASD) are at increased risk of poor health and depressive symptoms due to difficulty with communication, limited interests, sensory deficits, and sedentary lifestyles. The Piece It Together program was developed to provide socialization and wellness goals for teens and young adults with ASD and other mild neurocognitive deficits. The curriculum includes strength and endurance training, nutrition education, and stress reduction techniques to promote healthy lifestyle choices. Twelve participants, aged 15-27, attended 90-minute classes at the MUSC Wellness Center twice a week for six weeks and were encouraged to increase their activity level every day. The Patient Health Questionnaire (PHQ-9) was administered to each participant at the first and last class. Results showed significantly decreased PHQ-9 depression scores at the end of the program, from mild (7.69) to minimal depression (3.42) (p=0.000063). Overall, the activities completed in the Piece It Together program successfully unified this group to promote healthy lifestyle choices and resulted in improved mood.

Biologic effects of stress and bonding in mother-infant pairs.

OBJECTIVE: Maternal stress in humans influences behavior of children and can be assessed using biological markers. Mothers and their one-month-old infants were recruited from an existing study to examine baseline maternal serum oxytocin and hypothalamic-pituitary-adrenal axis response to infant blood heel stick stress as measured by salivary cortisol in the dyads. Objectives were to explore (1) relationships between mother and infant cortisol levels, (2) gender differences in infant biologic cortisol response, and (3) the association of cortisol levels in the dyads and maternal oxytocin levels METHODS: Forty-two mother-infant dyads provided biologic samples and self-report data. Maternal oxytocin samples were obtained. Initial salivary cortisol was assessed in both the mother and infant, followed by a heel stick blood draw. Twenty minutes later, salivary cortisol was collected again from dyads. RESULTS: Self-report measures were negative for depression and risk for childhood neglect. Although oxytocin and baseline cortisol in the infants was higher in mothers that did some breast-feeding, there was no statistically significant difference (p = 0.2 and p = 0.1, respectively). Analyses showed (a) higher baseline cortisol in mothers was related to higher baseline cortisol in infants (p ≤ 0.0001), (b) following the stressor, female infants had a larger positive change in cortisol, after adjusting for baseline cortisol (p = 0.045), and (c) there was no relationship between dyad cortisol levels and maternal oxytocin. CONCLUSIONS: Maternal and infant biologic stress measures are related. Female infants have a larger hypothalamic-pituitary-adrenal response to a blood draw stressor as measured by salivary cortisol than male infants.

Pilot Study and Review: Physiological Differences in BDNF, a Potential Biomarker in Males and Females with Autistic Disorder.

AIMS: There is a need for more biologic research in autistic disorder (AD) to determine if biomarkers exist that would be useful for correlating to symptom severity and/or clinical improvement during treatment. Given the fact that AD is 4 times more common in males than females, gender differences in physiological biomarkers may be present. One potential biomarker that has begun to be studied is brain-derived neurotropic factor (BDNF), a peptide involved in the regulation of neuronal cell survival, differentiation, and plasticity, and possessing an ability to influence neurotransmitter systems by modulating gene expression. This pilot study examined whether serum BDNF differed according to gender in children with AD and whether differences were associated with a behavioral phenotype or severity of illness. STUDY DESIGN: Data for this investigation were collected during the participants' baseline visit of an intervention study. Participants were males (n=29) and females (n=7), aged 5 to 12 years diagnosed with AD. Baseline serum BDNF concentration was determined for comparison to clinical ratings using an autism severity measure and the Pervasive Developmental Disorder-Behavior Inventory (PDD-BI). RESULTS: BDNF serum concentrations were higher in females (p<0.049). The baseline BDNF value corresponded significantly to hyperactivity in females (p<0.0002) but not in males. BDNF did not correlate with severity of disease in either gender. CONCLUSION: Although this is a small study, a better understanding of the central role of BDNF may provide insight into the pathophysiology of the disease and elucidate why gender differences exist in prevalence and behavioral phenotype of AD.

Growth failure associated with early neglect: pilot comparison of neglected US children and international adoptees.

The long-lasting impact of different neglectful environments on growth in children is not well studied. Three groups of children, 3-10 years old, were recruited (n=60): previously institutionalized international adoptees living in stable home environments for at least 2 years (IA; n=15), children with a history of neglect born in the USA (USN; n=17), and controls (n=28). Children underwent physical examination, anthropometry, and collection of serum for growth parameters. Mean height standard deviation scores (SDS) were different (p<0.05). Age-adjusted head circumference (HC) was significantly smaller (p<0.05) in IAs. Insulin growth factor (IGF-1), a marker of growth hormone action, was higher in US neglected children. IGF-1 adjusted for age and weight SDS were different (p<0.05) between control and US neglect groups. The degree of growth failure in height and HC in IAs was more severe than neglected US children. These findings may reflect differences between the impact of chronic and intermittent deprivation on the growth hormone system.

Enhanced cortisol response to stress in children in autism.

Children with Autism often show difficulties in adapting to change. Previous studies of cortisol, a neurobiologic stress hormone reflecting hypothalamic-pituitary-adrenal (HPA) axis activity, in children with autism have demonstrated variable results. This study measured cortisol levels in children with and without Autism: (1) at rest; (2) in a novel environment; and (3) in response to a blood draw stressor. A significantly higher serum cortisol response was found in the group of children with autism. Analysis showed significantly higher peak cortisol levels and prolonged duration and recovery of cortisol elevation following the blood-stick stressor in children with autism. This study suggests increased reactivity of the HPA axis to stress and novel stimuli in children with autism.

Crecemos juntos: understanding and alleviating parental stress among lowcountry migrant workers.

The focus of this study was to determine challenges and needs faced by families of migrant farm workers served by Rural Mission Migrant Head Start in the South Carolina Lowcountry. Data on common problems was collected via surveys, and results were analyzed. The Crecemos Juntos (We Grow Together) program was developed with the support of a Helping Hands Grant from the American Psychiatric Foundation, which funds service initiatives by medical students. A multimedia library of materials was compiled, addressing frequently encountered issues in mental health and child development. A presentation on effective positive disciplinary techniques was provided to parents.

The Effects of Early Neglect on Cognitive, Language, and Behavioral Functioning in Childhood.

OBJECTIVES: Few studies have explored the impact of different types of neglect on children's development. Measures of cognition, language, behavior, and parenting stress were used to explore differences between children experiencing various forms of neglect, as well as to compare children with and without a history of early neglect. METHODS: Children, ages 3 to 10 years with a history of familial neglect (USN), were compared to children with a history of institutional rearing (IA) and children without a history of neglect using the Differential Abilities Scale, Test of Early Language Development, Child Behavior Checklist, and Parenting Stress Index. Factors predicting child functioning were also explored. RESULTS: Compared with youth that were not neglected, children with a history of USN and IA demonstrated lower cognitive and language scores and more behavioral problems. Both internalizing and externalizing behavior problems were most common in the USN group. Externalizing behavior problems predicted parenting stress. Higher IQ could be predicted by language scores and an absence of externalizing behavior problems. When comparing the two neglect groups, shorter time spent in a stable environment, lower scores on language skills, and the presence of externalizing behavior predicted lower IQ. CONCLUSION: These findings emphasize the importance of early stable, permanent placement of children who have been in neglectful and pre-adoptive international settings. While an enriching environment may promote resilience, children who have experienced early neglect are vulnerable to cognitive, language and behavioral deficits and neurodevelopmental and behavioral evaluations are required to identify those in need of intervention.

Neurodevelopmental biology associated with childhood sexual abuse.

Child maltreatment appears to be the single most preventable cause of mental illness and behavioral dysfunction in the United States. Few published studies examine the developmental and the psychobiological consequences of sexual abuse. There are multiple mechanisms through which sexual abuse can cause post-traumatic stress disorder, activate biological stress response systems, and contribute to adverse brain development. This article will critically review the psychiatric problems associated with maltreatment and the emerging biologic stress system research with a special emphasis on what is known about victimization by sexual abuse.

Gender differences in the effect of early life trauma on hypothalamic-pituitary-adrenal axis functioning.

BACKGROUND: The objective of this study was to examine the modifying effect of gender on the association between early life trauma and the hypothalamic-pituitary-adrenal (HPA) axis response to a pharmacologic challenge and a social stress task in men and women. Participants (16 men, 23 women) were the control sample of a larger study examining HPA axis function. Individuals with major depressive disorder, posttraumatic stress disorder, bipolar disorder, or psychotic or eating disorders were excluded. METHODS: In two test sessions, subjects received 1 µg/kg of corticotropin-releasing hormone (CRH) intravenously and participated in the Trier Social Stress Test (TSST). Primary outcomes included plasma cortisol and corticotropin levels measured at baseline and more than five time points following the challenges. Predictors included gender and early life trauma, as measured by the Early Trauma Index. Using factor analysis, the domains general trauma, severe trauma, and the effects of trauma were established. Using regression, these constructs were used to predict differential HPA reactivity in men and women following the challenges. RESULTS: The three factors accounted for the majority of the variance in the ETI. Following the CRH challenge, women had higher overall corticotropin response as dictated by the area under the curve analysis. There were no significant associations between trauma and neuroendocrine response to the TSST. CONCLUSIONS: CRH challenge results indicate that gender differences in the impact of early trauma may help explain the differential gender susceptibility to psychopathology following adverse childhood events. This may help explain gender differences in some stress-sensitive psychiatric disorders.

Influence of cocaine dependence and early life stress on pituitary-adrenal axis responses to CRH and the Trier social stressor.

Long-term changes in the hypothalamic-pituitary-adrenal (HPA) axis as a result of early life stress could be related to the development of substance use disorders during adulthood. In this study, the neuroendocrine, physiologic (HR), and subjective responses to corticotropin releasing hormone (CRH) and the Trier Social Stress Task (TSST) in individuals with cocaine dependence, with (n=21)/without early life stress (n=21), non-dependent individuals with early life stress (n=22), and a control group were examined (n=21). CRH increased cortisol and ACTH levels in all groups. However, a significant effect of early life stress on ACTH was observed indicating that the increase in ACTH was greatest in subjects with a history of childhood stress. Post hoc analysis indicated the early life stress/non-cocaine dependent individuals exhibited significantly higher levels of ACTH as compared to the early life stress/cocaine-dependent group. Despite the elevated ACTH response there was no difference between the groups in the cortisol response to CRH. The TSST produced a significant elevation in ACTH and cortisol all study groups. No significant group differences were observed. The subjective stress and peak heart rate responses to the TSST were greatest in cocaine-dependent subjects without early life stress. In response to CRH, subjective stress and craving were positively correlated in cocaine-dependent subjects regardless of early life stress history, while stress and craving following the TSST were correlated only in cocaine-dependent subjects without a history of early life stress. Findings support previous studies demonstrating that subjects with a history of childhood adversity exhibit elevated ACTH and blunted cortisol levels in response to stress. In contrast, HR and subjective stress in response to the TSST were greatest in cocaine-dependent subjects without a history of early life stress, suggesting that childhood adversity may desensitize autonomic and subjective responding to social stress in adults with cocaine dependence.

Bullying and ostracism experiences in children with special health care needs.

OBJECTIVE: Bullying experiences are becoming increasingly common in children and can have devastating consequences. Ostracism threatens a child's need for self-esteem, sense of belonging, sense of control, and meaningful existence. Recent literature suggests that children with special health care needs may be at risk for these negative events and consequences. This study compares bullying and ostracism experiences in children with and without various special health care needs. METHODS: Participants aged 8 to 17 years completed questionnaires during a routine primary care or subspecialty clinic visit. Children with learning disabilities (N = 34), attention deficit or hyperactivity disorder (N = 100), autism spectrum disorders (N = 32), behavioral or mental health disorders (N = 33), and cystic fibrosis (CF, N = 22) were compared with 73 control children with no diagnosis on Reynolds' Bully-Victimization Scale scores and a 15-item pilot ostracism scale. RESULTS: Compared with the control group, children in the learning disabilities, autism spectrum disorders, and attention deficit or hyperactivity disorder groups exhibited significant victimization scores on the Bully-Victimization Scale, whereas the behavioral or mental health disorders group had increased mean victimization scores. The learning disabilities group also reported clinically significant bullying. The CF group did not report involvement as bullies or victims. All children with special health care needs groups had increased mean frequency of threats to basic needs related to ostracism, and children with attention deficit or hyperactivity disorder and autism spectrum disorders were at higher risk for ostracism experiences. CONCLUSION: Children with special health care needs may be at higher risk for bullying, victimization, and ostracism. Further research is needed to explore this relationship, especially as it relates to child adjustment. Children with special health care needs should be asked about bullying and ostracism experiences and potential effects as part of mental health screening.

Reactivity to laboratory stress provocation predicts relapse to cocaine.

BACKGROUND: Cocaine dependence is a chronic relapsing disorder characterized by periods of abstinence and high rates of return to drug using behavior. Elevated levels of stress have been associated with relapse to cocaine; however, the nature of this association is not well understood. METHODS: The relationship between reactivity to three human laboratory provocations and relapse to cocaine was investigated. Participants were 53 cocaine-dependent individuals who were admitted for a 2-day inpatient stay during which a psychosocial provocation (i.e., the Trier Social Stress Task), a pharmacological provocation (i.e., administration of 1 microg/kg corticotrophin releasing hormone; CRH), and a drug cue exposure paradigm were completed. Adrenocortico-trophic hormone (ACTH), cortisol, heart rate, and subjective cocaine craving and stress were assessed at baseline and at multiple time points post-task. Participants' cocaine use was monitored for approximately 1 month following testing. RESULTS: The majority (72.3%) of participants relapsed to cocaine during the follow-up period. In response to the CRH and drug cue exposure, elevated subjective craving and stress were significant predictors of cocaine use during follow-up. In response to the Trier, attenuated neuroendocrine responses were significant predictors of cocaine use. CONCLUSIONS: The findings provide further evidence of the ability of laboratory paradigms to predict relapse. The observed associations between stress reactivity and subsequent cocaine use highlight the clinical importance of the findings. Predictors of relapse may vary based on the type of provocation utilized. Interventions aimed at normalizing stress response, as measured using laboratory paradigms, may prove useful in relapse prevention.

Community-dwelling cocaine-dependent men and women respond differently to social stressors versus cocaine cues.

UNLABELLED: There are likely to be gender differences in determinants of relapse to drug use following abstinence in cocaine-dependent individuals. Cocaine-dependent women are more likely to attribute relapse to negative emotional states and interpersonal conflict. Cocaine dependence has also been linked to dysregulation of stress response and the hypothalamic pituitary adrenal (HPA) axis which may differ between genders. Subjective and HPA-axis responses to a social evaluative stressor, the Trier Social Stress Test (TRIER), and in vivo cocaine-related cues were examined in the present study. RESULTS: There were no gender differences in magnitude of craving responses to the TRIER or the CUE. Both genders had a greater craving response to the CUE than to the TRIER, but the magnitude of the difference was greater for men than women (p=0.04). Cocaine-dependent subjects, compared to the control group, had significantly higher response throughout the TRIER (p<0.0001) and CUE (p<0.0001) testing sessions. There were no gender differences and no gender by cocaine interaction for ACTH responses to the TRIER, although women had lower baseline ACTH (p=0.049). On the CUE task, in contrast, female cocaine-dependent subjects had a more blunted ACTH response than did the other three groups (p=0.02). Female cocaine-dependent subjects also had a lower odds of a positive cortisol response to the TRIER as compared to the other three groups (OR=0.84, 95% CI=[0.02, 1.01]). During the CUE task, cocaine-dependent subjects had overall higher mean cortisol levels (p=0.0001), and higher odds of demonstrating a positive cortisol response to the CUE (OR=2.61, 95% CI=[1.11, 6.11]). No gender differences were found in ACTH responses to the CUE. The results are reviewed in the context of the existing literature on gender differences in cocaine dependence and potential implications for treatment are discussed.

Neuropsychological findings in childhood neglect and their relationships to pediatric PTSD.

Although child neglect is the most prevalent form of child maltreatment, the neurocognitive effects of neglect are understudied. We examined IQ, reading, mathematics, and neurocognitive domains of fine-motor skills, language, visual-spatial, memory/learning, and attention/executive functions in two groups of nonsexually abused medically healthy neglected children, one with DSM-IV posttraumatic stress disorder (PTSD) and one without, and a demographically similar healthy nonmaltreated control group. Significantly lower IQ, reading, mathematics, and selected differences in complex visual attention, visual memory, language, verbal memory and learning, planning, problem solving, and speeded naming were seen in Neglect Groups. The Neglect with PTSD Group performed worse than controls on NEPSY Design Copying, NEPSY Tower, and Mathematics; and performed worse than controls and Neglect without PTSD on NEPSY Memory for Faces-Delayed. Negative correlations were seen between PTSD symptoms, PTSD severity, and maltreatment variables, and IQ, Academic Achievement, and neurocognitive domains. Neglected children demonstrated significantly lower neurocognitive outcomes and academic achievement than controls. Lower IQ, neurocognitive functions, and achievement may be associated with more PTSD symptoms (particularly re-experiencing symptoms), greater PTSD severity, and a greater number of maltreatment experiences. Trauma experiences may additionally contribute to subsequent neurodevelopmental risk in neglected children. (JINS, 2009, 15, 868-878.).

Relationship between child abuse and adult smoking.

OBJECTIVE: A strong association between a history of child abuse and subsequent psychiatric disorders including substance use has been demonstrated. However, few studies have examined the relationship between child abuse and cigarette smoking in individuals without co-occurring psychiatric disorders. In this study, the relationship between severe childhood abuse and smoking were examined in a group of adults without significant psychopathology. METHODS: Participants (N = 57) represent the control group of a larger study of substance dependence. Participants were without major DSM-IV psychopathology, including substance use disorders, major depression, or posttraumatic stress disorder. The Early Trauma Inventory [20] assessed history of exposure to traumatic events prior to age 18. RESULTS: The majority of individuals with, as compared to without, a history of severe child abuse (79% vs. 47%, p = .02) were current cigarette smokers. The odds of smoking was four times as high in participants with versus without a severe childhood abuse history (OR = 4.0, p = 0.04). CONCLUSIONS: Although preliminary, the findings demonstrate a strong link between early childhood trauma and later adult cigarette smoking among individuals without significant substance use or other psychopathology.

Pediatric case study and review: is it a conversion disorder?

OBJECTIVE: It is common in health care settings for adolescent patients to report physical symptoms that are unexplained by physical disease or pathophysiologic processes. The diagnosis of conversion disorder is difficult to make as many of these patients present to primary care with complex, difficult-to-understand medical symptoms. Patients can present with a medical dilemma and a symptom model consistent with a conversion disorder, but there is a danger of misdiagnosis without a thorough medical work up. METHOD: This case report describes a patient where the misdiagnosis of conversion disorder could have had devastating long-lasting neurologic sequelae. It appeared as if an unconscious conflict was being expressed through physical symptoms as she had ongoing family stressors prior to the onset of mysterious symptoms. CONCLUSIONS: The patient was found to have a spinal cord arteriovenous malformation. This condition is relatively uncommon in the pediatric age group, and early diagnosis is rarely made.

Early life trauma and sensitivity to current life stressors in individuals with and without cocaine dependence.

This study investigated the link between exposure to early life trauma, sensitivity to current daily stressors, and cocaine dependence. Individuals with (n = 105) or without (n = 53) cocaine dependence completed the Early Trauma Inventory and the Daily Hassles Scale. In comparison to controls, cocaine-dependent individuals reported almost twice as many daily hassles and perceived those hassles more negatively (p < .001). For participants with cocaine dependence, a significant relationship between exposure to early life trauma and negative perception of current daily hassles was observed (p < .01), whereas no such relationship was observed for participants without cocaine dependence. Adverse childhood events may lead to an altered view of the environment that contributes to increased irritability with daily life events among cocaine-dependent individuals.

Effects of gender and cigarette smoking on reactivity to psychological and pharmacological stress provocation.

We examined the influence of gender and smoking status on reactivity in two human laboratory stress paradigms. Participants were 46 (21 men, 25 women) healthy individuals who completed the Trier Social Stress Task (i.e., performed speech and math calculations in front of an audience) and a pharmacological stress provocation (i.e., administration of corticotrophin releasing hormone (CRH)) after an overnight hospital stay. Approximately half (53%) of the participants were smokers. Cortisol, adrenocorticotrophin hormone (ACTH), physiologic measures (heart rate, blood pressure), and subjective stress were assessed at baseline and at several time points post-task. Men demonstrated higher baseline ACTH and blood pressure as compared to women; however, ACTH and blood pressure responses were more pronounced in women. Women smokers evidenced a more blunted cortisol response as compared to non-smoking women, whereas smoking status did not affect the cortisol response in men. Finally, there was a more robust cardiovascular and subjective response to the Trier as compared to the CRH. Although preliminary, the findings suggest that women may be more sensitive than men to the impact of cigarette smoking on cortisol response. In addition, there is some evidence for a more robust neuroendocrine and physiologic response to acute laboratory stress in women as compared to men.