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Scahill L.,Marcus Autism Center | Page C.,Marcus Autism Center
Journal of Obsessive-Compulsive and Related Disorders | Year: 2014

Background: Prevalence is a simple statement about the frequency of a disease in the population. For many medical conditions, including Tourette syndrome, there are true cases that have not been previously diagnosed due to problems of access to appropriate clinical services. Therefore, to obtain a trustworthy estimate of prevalence, it is necessary to go beyond cases identified in clinical settings and evaluate community samples. Method: We reviewed 11 community surveys in children with Tourette syndrome (TS) published since 2000. We also examined the frequency of co-occurring psychiatric conditions in community samples and large clinically-ascertained samples. Results: Transient tics are relatively common affecting as many as 20% of school-age children. The 11 studies reviewed here offer a wide range of estimates from 2.6 to 38 per 1000 children for TS. Six studies provide estimates in a narrower range from 4.3 to 7.6 per 1000 but the confidence interval around this narrower range remains wide. Six studies provided results on chronic tic disorders ranging from 3 to 50 per 1000 for Chronic Motor Tic Disorder and 2.5 to 9.4 per 1000 for Chronic Vocal Tic Disorder. Community samples and large clinically-ascertained samples consistently show high rates of ADHD, disruptive behavior and anxiety disorders in children with TS. Conclusions: The wide range of prevalence estimates for TS and chronic tic disorders is likely due to differences in sample size and assessment methods. The best estimate of prevalence for TS in school-age children is likely to fall between 4 and 8 cases per 1000. Clinical assessment of children with chronic tic disorders warrants examination of other problems such as ADHD, disruptive behavior and anxiety. © 2014 Elsevier Inc.


News Article | November 11, 2016
Site: www.eurekalert.org

A new study finds positive outcomes associated with intensive multidisciplinary treatment for children with pediatric feeding disorder who may require a feeding tube to support growth and development. The results are reported in the early edition of The Journal of Pediatrics, from researchers at the Marcus Autism Center, Children's Healthcare of Atlanta and Emory University School of Medicine. The meta-analysis of published work on feeding treatment methods in the United States and Europe showed that, on average, dependence on tube feeding was eliminated in 71 percent of children at discharge from multidisciplinary day hospital and inpatient treatment programs. Treatment gains endured over time, with 80 percent of patients tube-free at follow-up. Treatment was also associated with increased oral intake, improved mealtime behaviors and reduced caregiver stress. "Our findings suggest that intensive multidisciplinary intervention holds clear benefit for children and families impacted by pediatric feeding disorders," says co-author William Sharp, PhD, director of the Pediatric Feeding Disorders Program at Marcus Autism Center and assistant professor in the Department of Pediatrics at Emory University School of Medicine. "Our hope is that this study raises awareness regarding the significant daily struggle too many families face surrounding mealtimes." While many toddlers and early school-age children experience some mealtime difficulties, a subset of children - many with complex medical histories -- refuse most or all food presented during meals. Feeding problems of this magnitude are referred to as pediatric feeding disorders due to their chronic and more severe course, often involving the complex interaction among biological, psychological and social factors. Pediatric feeding disorders lead to significant disruptions in a child's nutritional and caloric intake -- which may manifest as faltering growth, significant nutritional deficiencies and/or reliance on a feeding tube to meet energy needs. Estimates suggest this level of severe feeding problem affects as many as five percent of children, representing a common source of stress and anxiety for caregivers. Children with chronic medical concerns, such as respiratory, cardiac or gastrointestinal problems, face an even greater risk of developing a significant feeding concern. As many as 70 percent of children with complex medical histories experience chronic feeding difficulties. This study is the first meta-analysis of all published, peer-reviewed research focusing on children receiving intensive multidisciplinary intervention at day hospital and inpatient treatment programs. "In many cases, children learn to avoid food by engaging in significant disruptive behaviors -- such as tantrums and tearful protests -- aimed at avoiding contact with food," says Sharp. "These behaviors often arise after food is consistently paired with medical problems that cause pain or nausea. Understandably, caregivers may remove food in response to intense refusal behaviors and increasingly rely on artificial supports -- such as the use of a feeding tube -- to support growth and development. A primary goal of intervention is to help children develop a positive relationship with food while re-establishing a constructive parent-child interaction during meals." A multidisciplinary approach, Sharp adds, also provides important safeguards when introducing food to children with little or no experience consuming food. In addition to providing support for multidisciplinary intervention, recommendations from the study include: 1) active participation of caregivers in the treatment process - ideally with structured training procedures to support generalization into the home; 2) a formal discharge plan that involves regular outpatient follow-up to support families in maintaining and expanding upon treatment gains; and 3) use of a behavioral approach to structure meals and address mealtime difficulties (e.g., tantrums; food refusal) that prohibit consumption. The authors suggest that advancement in this field will require improved outcome measures (e.g., more consistent reporting of follow-up data); providing increased specificity regarding children receiving intervention. "Our study also provides important guidance for enhancing the standard of care while identifying important key areas to improve the evidence base," says co-author Barbara McElhanon, MD, pediatric gastroenterologist at Children's Healthcare of Atlanta and assistant professor in the Department of Pediatrics at Emory University School of Medicine. "At a minimum, treatment of pediatric feeding disorders should involve a professional team that includes psychology, medicine, nutrition and speech-language pathology or occupational therapy during treatment. This allows intervention to be designed with consideration to the unique combination of behavioral, organic, dietary and oral-motor concerns often ubiquitous in pediatric feeding disorders." McElhanon also noted that "better documentation of specific medical diagnoses and types of behaviors most impeding progress toward oral intake will allow the field to better predict patients at risk for needing this type of intervention as well as those who attain greatest results." Marcus Autism Center is a not-for-profit organization and an affiliate of Children's Healthcare of Atlanta that treats more than 5,700 children with autism and related disorders a year. As one of the largest autism centers in the U.S. and one of only three National Institutes of Health Autism Centers of Excellence, Marcus Autism Center offers families access to the latest research, comprehensive evaluations and intensive behavior treatments. With the help of research grants, community support and government funding, Marcus Autism Center aims to maximize the potential of children with autism today and transform the very nature of autism for future generations. Visit marcus.org for more information. Children's Healthcare of Atlanta, a not-for-profit organization, is dedicated to making kids better today and healthier tomorrow. Our specialized care helps children get better faster and live healthier lives. Managing more than 850,000 patient visits annually at three hospitals and 24 neighborhood locations, Children's is the largest healthcare provider for children in Georgia and one of the largest pediatric clinical care providers in the country. Children's offers access to more than 60 pediatric specialties and programs and is ranked among the top children's hospitals in the country by U.S.News & World Report. With generous philanthropic and volunteer support, Children's has impacted the lives of children in Georgia, the United States and throughout the world. Visit http://www. for more information. Faculty-physicians in the Emory Department of Pediatrics provide the highest quality state-of-the-art clinical care, with a commitment to improving treatment for children through scientific research as well as training the next generation of leaders in pediatrics.


News Article | November 18, 2016
Site: www.eurekalert.org

A new study conducted by researchers at Marcus Autism Center, Children's Healthcare of Atlanta, and Emory University School of Medicine helps put to rest a longstanding controversy and question about children with autism spectrum disorder. Eye-tracking measures developed by the group demonstrate that young children with autism do not avoid eye contact on purpose; instead, they miss the significance of social information in others' eyes. While reduced eye contact is a well-known symptom of autism used in early screeners and diagnostic instruments, why children with autism look less at other people's eyes has not been known. New research, reported in the American Journal of Psychiatry, helps answer that question. "This is important because we're disentangling very different understandings of autism," said Jennifer Moriuchi, a graduate student at Emory University. "Depending on why you think children with autism are making less eye contact, you might have different approaches to treatment and different ideas about the brain basis of autism. Drug treatments and behavioral interventions are already being developed and tested on the basis of these different explanations. By clarifying which explanation is correct, we can make sure that we're addressing the correct underlying concern." Two explanations for reduced eye contact have been proposed. One explanation holds that children with autism avoid eye contact because they find it stressful and negative. The other explanation holds that children with autism look less at other people's eyes because the social cues from the eyes are not perceived as particularly meaningful or important. The new research, conducted on the day when children were first diagnosed, shows that young children with autism do not actively avoid eye contact, and it confirms that other people's eyes are not aversive to young children with autism. Instead, young children with autism look less at the eyes because they appear to miss the social significance of eye contact. Together with Drs. Ami Klin and Warren Jones, Moriuchi studied how 86 two-year-old children with and without autism paid attention to other people's eyes. Children with autism watched a series of carefully made videos. "Before each video, we flashed a small picture to capture the child's attention, and when they looked to where the picture had been, they found that they were either looking directly at another person's eyes or looking away from the eyes," said Moriuchi. "When we did this repeatedly, we found that young children with autism continued to look straight at the eyes. Like their peers without autism, they didn't look away from the eyes or try to avoid the eyes in any way." However, when varying levels of socially meaningful eye contact were presented, children with autism looked less at other people's eyes than their peers without autism. "These results go against the idea that young children with autism actively avoid eye contact," said Warren Jones. "They're looking less at the eyes not because of an aversion to making eye contact, but because they don't appear to understand the social significance of eye contact." The researchers studied eye gaze responses in young children with autism at the time of their initial diagnosis in order to have clearer evidence about the initial underlying reasons for reduced eye contact. Some adults and older children with autism have reported feeling anxious in response to eye contact. "Our results aren't meant to contradict these personal experiences," emphasized Jones. "For children with autism, social signals can be confusing. And as children grow up to be adults, those signals can become even more challenging to understand. This research highlights the opportunity to target the right underlying concerns as early as possible." "Studies like this one help advance our understanding of autism and improve the way scientists and clinicians develop new treatments," said Lisa Gilotty, Chief of the Research Program on Autism Spectrum Disorders at the National Institute of Mental Health, one of the agencies that funded the study. Additional support was given by the Autism Science Foundation, the Marcus Foundation, the Whitehead Foundation, and the Georgia Research Alliance. Jennifer Moriuchi is a graduate student in the Psychology Department at Emory University. Ami Klin, PhD, is director of Marcus Autism Center, Children's Healthcare of Atlanta, and is Chief of the Division of Autism & Related Disorders in the Department of Pediatrics at Emory University School of Medicine. Warren Jones, PhD, is Director of Research at the Marcus Autism Center and faculty in the Department of Pediatrics at Emory University School of Medicine. The Marcus Autism Center is a not-for-profit organization and an affiliate of Children's Healthcare of Atlanta that works with than 5,000 children and families affected by autism each year. As one of the largest autism centers in the U.S. and one of three National Institutes of Health Autism Centers of Excellence, Marcus Autism Center offers families access to the latest research, comprehensive evaluations and intensive behavior treatments. With the help of research grants, community support and government funding, Marcus Autism Center aims to maximize the potential of children with autism today and transform the very nature of autism for future generations. Visit marcus.org for more information. Children's Healthcare of Atlanta has been 100 percent dedicated to kids for more than 100 years. A not-for-profit organization, Children's is dedicated to making kids better today and healthier tomorrow. Our specialized care helps children get better faster and live healthier lives. Managing more than 920,000 patient visits annually at three hospitals and 27 neighborhood locations, Children's is the largest healthcare provider for children in Georgia and one of the largest pediatric clinical care providers in the country. Children's offers access to more than 60 pediatric specialties and programs and is ranked among the top children's hospitals in the country by U.S. News & World Report. With generous philanthropic and volunteer support since 1915, Children's has impacted the lives of children in Georgia, the United States and throughout the world. Visit http://www. for more information. Faculty-physicians in the Emory Department of Pediatrics provide the highest quality state-of-the-art clinical care, with a commitment to improving treatment for children through scientific research as well as training the next generation of leaders in pediatrics.


Goodman S.H.,Emory University | Rouse M.H.,Emory University | Connell A.M.,Case Western Reserve University | Broth M.R.,Georgia Gwinnett College | And 2 more authors.
Clinical Child and Family Psychology Review | Year: 2011

Although the association between maternal depression and adverse child outcomes is well established, the strength of the association, the breadth or specificity of the outcomes, and the role of moderators are not known. This information is essential to inform not only models of risk but also the design of preventive interventions by helping to identify subgroups at greater risk than others and to elucidate potential mechanisms as targets of interventions. A meta-analysis of 193 studies was conducted to examine the strength of the association between mothers' depression and children's behavioral problems or emotional functioning. Maternal depression was significantly related to higher levels of internalizing, externalizing, and general psychopathology and negative affect/behavior and to lower levels of positive affect/behavior, with all associations small in magnitude. These associations were significantly moderated by theoretically and methodologically relevant variables, with patterns of moderation found to vary somewhat with each child outcome. Results are interpreted in terms of implications for theoretical models that move beyond main effects models in order to more accurately identify which children of depressed mothers are more or less at risk for specific outcomes. © 2011 Springer Science+Business Media, LLC.


News Article | November 18, 2016
Site: www.sciencedaily.com

A new study conducted by researchers at Marcus Autism Center, Children's Healthcare of Atlanta, and Emory University School of Medicine helps put to rest a longstanding controversy and question about children with autism spectrum disorder. Eye-tracking measures developed by the group demonstrate that young children with autism do not avoid eye contact on purpose; instead, they miss the significance of social information in others' eyes. While reduced eye contact is a well-known symptom of autism used in early screeners and diagnostic instruments, why children with autism look less at other people's eyes has not been known. New research, reported in the American Journal of Psychiatry, helps answer that question. "This is important because we're disentangling very different understandings of autism," said Jennifer Moriuchi, a graduate student at Emory University. "Depending on why you think children with autism are making less eye contact, you might have different approaches to treatment and different ideas about the brain basis of autism. Drug treatments and behavioral interventions are already being developed and tested on the basis of these different explanations. By clarifying which explanation is correct, we can make sure that we're addressing the correct underlying concern." Two explanations for reduced eye contact have been proposed. One explanation holds that children with autism avoid eye contact because they find it stressful and negative. The other explanation holds that children with autism look less at other people's eyes because the social cues from the eyes are not perceived as particularly meaningful or important. The new research, conducted on the day when children were first diagnosed, shows that young children with autism do not actively avoid eye contact, and it confirms that other people's eyes are not aversive to young children with autism. Instead, young children with autism look less at the eyes because they appear to miss the social significance of eye contact. Together with Drs. Ami Klin and Warren Jones, Moriuchi studied how 86 two-year-old children with and without autism paid attention to other people's eyes. Children with autism watched a series of carefully made videos. "Before each video, we flashed a small picture to capture the child's attention, and when they looked to where the picture had been, they found that they were either looking directly at another person's eyes or looking away from the eyes," said Moriuchi. "When we did this repeatedly, we found that young children with autism continued to look straight at the eyes. Like their peers without autism, they didn't look away from the eyes or try to avoid the eyes in any way." However, when varying levels of socially meaningful eye contact were presented, children with autism looked less at other people's eyes than their peers without autism. "These results go against the idea that young children with autism actively avoid eye contact," said Warren Jones. "They're looking less at the eyes not because of an aversion to making eye contact, but because they don't appear to understand the social significance of eye contact." The researchers studied eye gaze responses in young children with autism at the time of their initial diagnosis in order to have clearer evidence about the initial underlying reasons for reduced eye contact. Some adults and older children with autism have reported feeling anxious in response to eye contact. "Our results aren't meant to contradict these personal experiences," emphasized Jones. "For children with autism, social signals can be confusing. And as children grow up to be adults, those signals can become even more challenging to understand. This research highlights the opportunity to target the right underlying concerns as early as possible." "Studies like this one help advance our understanding of autism and improve the way scientists and clinicians develop new treatments," said Lisa Gilotty, Chief of the Research Program on Autism Spectrum Disorders at the National Institute of Mental Health, one of the agencies that funded the study. Additional support was given by the Autism Science Foundation, the Marcus Foundation, the Whitehead Foundation, and the Georgia Research Alliance.


Goldstein F.,Marcus Autism Center | Glueck D.,Washington University in St. Louis
Journal of Child and Adolescent Psychopharmacology | Year: 2016

Objective: The purpose of this study was to describe the special considerations for building rapport and establishing a therapeutic alliance when conducting mental health evaluations for children and adolescents via videoconferencing. Methods: The authors review the literature and describe their experience in conducting mental health evaluations, developing rapport, and establishing a therapeutic alliance during telemental health practice. Results: Clinical need and shortages of clinicians with expertise in evaluating mental conditions for children and adolescents in underserved communities have stimulated the rapid expansion of telemental health programs while the research base continues to develop. The emerging evidence base and clinical experience suggest that teleclinicians can, and do, build rapport and establish a therapeutic alliance during telemental health sessions with youth and families. Families may be more accepting of telemental health approaches than clinicians. The impact that technology, equipment, site staff, community supports, cultural identification, and teleclinicians' characteristics have on building rapport and establishing a therapeutic alliance should be considered when establishing a telemental health service. Staff at the patient site and referring providers have a valuable role in supporting the therapeutic alliance between telemental health providers and their patients, and ultimately supporting the success of a telemental health program. Conclusions: Teleclinicians are creative in transcending the videoconferencing technology to evaluate patients using guideline-based care. Further research is needed to determine how clinicians build rapport and establish a therapeutic alliance during telemental health sessions, and whether the therapeutic alliance is associated with the accuracy of evaluation and outcomes. © Copyright 2016, Mary Ann Liebert, Inc. 2016.


Sharp W.G.,Marcus Autism Center | Sharp W.G.,Emory University | Jaquess D.L.,Marcus Autism Center | Jaquess D.L.,Emory University | Lukens C.T.,Children's Hospital of Philadelphia
Research in Autism Spectrum Disorders | Year: 2013

Estimates suggest that atypical eating is pervasive among children with autism spectrum disorders (ASD); however, much remains unknown regarding the nature and prevalence of feeding problems in this population due to methodological limitations, including lack of adequate assessment methods and empirical evaluation of existing measures. In the current study, a sample of 30 children ages 3-8 years completed a multi-method assessment battery involving a standardized mealtime observation, a food preference inventory, and the Brief Autism Mealtime Behavior Inventory (BAMBI), which represents the first attempt to assess the correspondence between direct observation and parent-report measures of feeding concerns and dietary intake in ASD. During the mealtime observation, fourteen participants either rejected (n = 8) or accepted (n = 6) all bites, while the remaining 16 participants demonstrated selective patterns of acceptance by type and/or texture. Among this subgroup, vegetables were the most frequently rejected food type during the behavioral observation. Vegetables were also the most frequently rejected food based on parent report for the sample. Increased food selectivity was positively correlated with problem behaviors during the observation, while ASD symptom severity and growth parameters were unrelated to feeding data. We discuss findings in relation to clinical and research activities and recommend strategies to achieve more systematic research in this area. © 2012 Elsevier Ltd. All rights reserved.


Coles C.D.,Emory University | Coles C.D.,Marcus Autism Center
Alcohol Research and Health | Year: 2011

Fetal alcohol syndrome and fetal alcohol spectrum disorders are underdiagnosed in general treatment settings. Among the factors involved in identifying the effects of prenatal alcohol exposure are (1) the evidence for prenatal alcohol exposure; (2) the effects of the postnatal, caregiving environment; (3) comorbidities; and (4) differential diagnosis, which includes identifying the neurodevelopmental effects of alcohol and discriminating these effects from those characterizing other conditions. This article reviews findings on the neurodevelopmental effects of prenatal alcohol exposure, including learning and memory, motor and sensory/motor effects, visual/spatial skills, and executive functioning and effortful control. Encouraging clinicians to discriminate the effects of prenatal alcohol exposure from other conditions may require more education and training but ultimately will improve outcomes for affected children.


Call N.A.,Emory University | Lomas Mevers J.E.,Marcus Autism Center
Behavioral Interventions | Year: 2014

Research has demonstrated the feasibility of using positive reinforcement to treat problem behavior maintained by negative reinforcement. This line of research was extended in the current study. A functional analysis (FA) was conducted that suggested problem behavior was maintained by positive and negative reinforcement. Following the FA, a demand analysis was conducted with three demand conditions: one that replicated the demand condition from the FA, one that included presession exposure to a preferred item, and another that included presession exposure to preferred items and access to those items during breaks from demands. Although problem behavior occurred in all three demand conditions, within session analyses showed that problem behavior ceased during breaks from demands only when they included access to preferred items. This finding suggests that the motivating operation responsible for evoking problem behavior did not decrease when only a break was provided. Subsequent functional communication training and treatment analysis showed that treatments based on positive reinforcement were effective at reducing problem behavior, but those based on a negative reinforcement hypothesis were not. © 2013 John Wiley & Sons, Ltd.


McElhanon B.O.,Emory University | McCracken C.,Emory University | Karpen S.,Emory University | Sharp W.G.,Emory University | Sharp W.G.,Marcus Autism Center
Pediatrics | Year: 2014

BACKGROUND: In pediatric settings, parents often raise concerns about possible gastrointestinal (GI) symptoms in autism spectrum disorder (ASD), yet the specificity of these concerns are not well studied. OBJECTIVE: To conduct a meta-analysis of research investigating GI symptoms among children with ASD. METHODS: We searched Medline, PsycINFO, and PubMed databases (1980-2012) in peer-reviewed journals. Analysis involved studies with a comparison group presenting quantitative data on GI symptoms using combinations of terms for ASD and GI indicators. The systematic search yielded 15 studies. We calculated effect sizes and 95% confidence intervals (CIs) using a random-effects model. RESULTS: Children with ASD experience significantly more general GI symptoms than comparison groups, with a standardized mean difference of 0.82 (0.24) and a corresponding odds ratio (OR) of 4.42 (95% CI, 1.90-10.28). Analysis also indicated higher rates of diarrhea (OR, 3.63; 95% CI, 1.82-7.23), constipation (OR, 3.86; 95% CI, 2.23-6.71), and abdominal pain (OR, 2.45; 95% CI, 1.19-5.07). CONCLUSIONS: Results indicate greater prevalence of GI symptoms among children with ASD compared with control children. Identified studies involved high methodological variability and lack of comprehensive data prohibited analysis of GI pathophysiologies (eg, gastroesophageal reflux) typically associated with organic etiologies, limiting conclusions about the underpinnings of the observed association. Future research must address critical questions about the causes and long-term impact of GI symptoms in ASD. Such analyses will require more systematic research and clinical activities, including improved diagnostic screening, standardized assessment, and exploration of potential moderators (eg, dietary restrictions). Copyright © 2014 by the American Academy of Pediatrics.

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