Repercussions of the COVID-19 lockdown for autistic people in Mexico: The caregivers’ perspective

Introduction. The COVID-19 lockdown has posed new challenges for individuals with autism spectrum disorder (ASD), including service suspension and reductions in support. Objective. To explore the perspectives of caregivers on the impact of the COVID-19 lockdown on people with ASD in Mexico. Method. 126 caregivers from Mexico completed a survey on the impact of lockdown on people with ASD. Results. Suspension of at least one service was reported for 38.9% of subjects, with no significant association being found between symptom worsening and service administration modality. Discussion and conclusion. Service suspension for people with ASD in Mexico has been a side effect of the pandemic, negatively impacting their behavior. Results indicate that certain services could be remotely maintained and provided to individuals with ASD in underserved areas - Introducción. El confinamiento debido a la pandemia por COVID-19 ha implicado nuevos desafíos para las personas con trastorno del espectro autista (TEA), incluyendo la suspensión de algunos servicios, y la disminución de los apoyos. Objetivo. Explorar las perspectivas de los cuidadores acerca de las reper-cusiones del confinamiento por COVID-19 en las personas con TEA en México. Método. 126 cuidadores residentes de México completaron una encuesta acerca del impacto del confinamiento en personas con TEA. Resultados. Aunque el 38.9% de los participantes reportó la suspensión de al menos un servicio de salud tras el confinamiento, no hubo asociaciones significativas entre retroceso y modalidad de administración de los servicios. Discusión y conclusión. La suspensión de servicios a las personas con TEA en México es uno de los efectos secundarios de la pandemia, y afecta negativamente su comportamiento. Los resultados indican que algunos tratamientos pudieran ser mantenidos remotamente y brindar servicios a personas con TEA en zonas de difícil acces

Global prevalence of autism and other pervasive developmental disorders

We provide a systematic review of epidemiological surveys of autistic disorder and pervasive developmental disorders (PDDs) worldwide. A secondary aim was to consider the possible impact of geographic, cultural/ethnic, and socioeconomic factors on prevalence estimates and on clinical presentation of PDD. Based on the evidence reviewed, the median of prevalence estimates of autism spectrum disorders was 62/10 000. While existing estimates are variable, the evidence reviewed does not support differences in PDD prevalence by geographic region nor of a strong impact of ethnic/cultural or socioeconomic factors. However, power to detect such effects is seriously limited in existing data sets, particularly in low-income countries. While it is clear that prevalence estimates have increased over time and these vary in different neighboring and distant regions, these findings most likely represent broadening of the diagnostic concets, diagnostic switching from other developmental disabilities to PDD, service availability, and awareness of autistic spectrum disorders in both the lay and professional public. The lack of evidence from the majority of the world's population suggests a critical need for further research and capacity building in low- and middle-income countries

Age of autism diagnosis in Latin American and Caribbean countries

An earlier diagnosis of autism spectrum disorder might lead to an earlier intervention, yet knowledge and awareness of autism spectrum disorder in Latin America and Caribbean Countries are limited. A later autism spectrum disorder diagnosis has been associated with negative consequences, as it might imply later access to services. This study aims to identify factors associated with the age of autism spectrum disorder diagnosis as reported by 2520 caregivers of autistic children from six Latin America and Caribbean Countries. Results indicate that on average, caregivers were concerned about their child’s development by 22 months of age; however, the diagnosis was 24 months later. Current age of autistic individuals, better language abilities, and having public health coverage increased the age of diagnosis. On the contrary, the presence of medical comorbidities, severity level, and type of diagnosis decreased the age of diagnosis. The age of diagnosis of autistic individuals in Latin America and Caribbean Countries corresponded to the start of formal schooling despite a much earlier age of first noticed developmental concern, highlighting the need to reduce this age gap and increase children’s probability of benefiting from early intervention. Taken together, autism spectrum disorder personal/clinical characteristics and access to health service are the main determinants for the age of diagnosis. Lay abstract An earlier diagnosis of autism spectrum disorder might lead to earlier intervention. However, people living in Latin American and Caribbean countries do not have much knowledge about autism spectrum disorder symptoms. It has been suggested that the older a child is when diagnosed, the fewer opportunities he or she will have to receive services. We asked 2520 caregivers of autistic children in six different Latin America and Caribbean Countries, the child’s age when they noticed some developmental delays and their child’s age when they received their first autism spectrum disorder diagnosis. Results indicate that, on average, caregivers were concerned about their child’s development by 22 months of age; however, the diagnosis was received when the child was 46 months of age. In addition, older children with better language abilities and public health coverage (opposed to private health coverage) were diagnosed later. On the contrary, children with other medical problems and more severe behaviors received an earlier diagnosis. In our study, children were diagnosed around the time they entered formal schooling, delaying the access to early intervention programs. In summary, the characteristics of the autistic person and the type of health coverage influence the age of diagnosis in children living in Latin America and Caribbean Countries

Algoritmo de Tratamiento Multimodal para Preescolares Latinoamericanos con Trastorno por Déficit de Atención con Hiperactividad (TDAH)

Introduction During the first Latin American ADHD consensus held in Mexico in 2007 a treatment algorithm for attention-deficit/hyperactivity disorder (ADHD) in preschoolers was proposed. Since then, some studies have emerged regarding not only pharmacological treatment but also psychosocial managing strategies for this population that require a review. The main objective was to review the recent literature on preschool ADHD clinical management in order to update the treatment algorithm and to include together both psychopharmacological treatment and psychosocial management strategies into the decision tree. Method A task force with six experts from five Latinamerican countries was constituted. The task force included different health specialties: child and adolescent psychiatry, neuropaediatrics, psychology and neuropsychology. Literature in the field of preschool ADHD, published between 2006 and 2008, was reviewed, and the evidence level of studies was assessed, to develop the Multimodal Treatment Algorithm for Preschool ADHD in accordance with the Latin American population needs. From the gathered information, the experts elaborated the main recommendations for the assessment and management of ADHD Latin American preschoolers, and constructed the decision tree according to the evidence level of each treatment intervention. Results ADHD is among the most common neuropsychiatric consultations in preschool-aged children. There are five studies in Latin America showing a preschool ADHD prevalence between 3.24% and 11.2%. The main clinical manifestations are mostly related with poor impulse control, difficulty to follow simple instructions, overactivity and, in some cases, aggression and rejection by peers. Many studies show high comorbidity with oppositional defiant disorder and other neuropsychiatric disorders, such as language, learning and motor disorder and anxiety and depression as well. The ADHD clinical presentation in preschoolers has the same severity level and comorbidity as in school-age children, and it requires comprehensive treatment. There are some helpful scales to assess ADHD preschool children, such as the Parent and Teacher versions of the Conners Rating Scale, the IDC-PRE Scale, and the Early Childhood Inventory4. A diagnosis of preschool ADHD requires patient fulfilling DSM-IVTR criteria. Special recommendations made by the Latin American Multimodal Treatment Algorithm for Preschool ADHD group were: 1. to guarantee a minimum duration of ADHD symptoms of nine months; 2. to verify the report of symptoms directly with teachers; 3. to obtain clear-cut impact and repercussion criteria for «clear evidence of clinically significant impairment in social, academic, or family functioning»; severity is more important than the number of symptoms, and finally; 4. to rule out a list of different disorders mimicking ADHD, and also to detect factors and psychosocial situations influencing the ADHD presentation. There are several alternatives for the preschool ADHD treatment, population, which were inserted in the decision tree according to their evidence level. The Latin American Multimodal Treatment Algorithm for Preschool ADHD group recommends the integrated and rational use of both pharmacological and psychosocial treatments. Psychosocial treatments for the ADHD preschooler with good clinical evidence are: psychoeducation, parental management training (PMT), parentchild interaction therapy (PCIT) and behavioral school-based intervention. After parental assessment on ADHD knowledge, parent’s psychoeductation promotes good information about ADHD, and also gives parents guidance and support. There are some published studies about the efficacy of PMT and PCIT in Latin American preschool population. These therapeutic interventions help families to learn how to manage their children difficulties and improve family functioning. PCIT was designed for 2-7 year old children; it has a clinical orientation and involves the child, parents, and other family members in the treatment. Recent studies show a robust response to the PCIT reducing the ADHD symptomatology. Finally, behavioral school-based intervention has some evidence, and its implementation includes teacher training in contingency management plans in order to promote children self-regulation. Methylphenidate (MPD) is the most studied psychopharmacological agent in this young population. Due to its robust clinical evidence, it is the first-line agent for the treatment of preschool children with ADHD. The group for the development of the Multimodal Treatment Algorithm for Latin American Preschool ADHD recommends to start with low doses of MPD, 1.25–2.5 mg/day, and gradually increase them every 2-3 weeks, until the maximum dose of 2.5-7.5 mg/day is reached. There are only two open-studies showing atomoxetine efficacy in this population. Atomoxetine has a medium evidence level and further studies are needed for more conclusions. The group recommends the use of atomoxetine with a maximum dose of 1.25 mg/kg/day. Other agents have a low level of evidence. Ampehtamines (available only in Chile and Puerto Rico), with only one study, and the alpha-agonists (clonidine and guanfacine) have been used based on clinical experience only. Further research is needed, especially head to head studies, comparing these agents with the MPD gold standard in both short and long-term follow-up studies. Any treatment decision should be closely monitored in order to make efficacy accurate in clinical response and to provide security for the young patient. While a child is using psychopharmacological treatment, it is important to monitor weight and size monthly. The main modifications to the former version of the Multimodal Treatment Algorithm for Latin American Preschool ADHD are: 1. the specific recommendation of psychosocial treatment such as psychoeducation, PMT, PCIT, and behavioral school-based intervention; 2. the recommendation of methylphenidate (available in all Latin American countries) as first pharmacological agent, followed by atomoxetine or amphetamines, and, in last instance, to consider the use of clonidine, and; 3. psychosocial treatment continuation is recommended for the maintenance jointly with the medication showing the best response. Conclusions There are two main pillars for the adequate treatment of preschool ADHD. On the one hand, there are psychosocial interventions such as psychoeducation, PMT, PCIT and behavioral school-based interventions; on the other hand, pharmacological treatment, especially with methylphenidate. Other pharmacological agents have a lack of scientific evidence. As the Multimodal Treatment Algorithm for Latin American Preschoolers with ADHD group, we recommend to start with the psychosocial treatment intervention, and then to follow the pharmacological options. New proposals should be developed according to the special needs and contexts of Latin America. - Introducción: En el Primer Consenso Latinoamericano de TDAH, celebrado en México en 2007 se propuso un algoritmo de tratamiento farmacológico para preescolares con Trastorno por Déficit de Atención con Hiperactividad (TDAH). Desde entonces han surgido algunos estudios no solo sobre tratamiento farmacológico, sino también sobre estrategias de manejo psicosociales en esta población que ameritan una revisión. El objetivo fue integrar la literatura reciente sobre el manejo clínico del TDAH en preescolares con el fin de actualizar el algoritmo latinoamericano de tratamiento e incorporar al árbol de decisiones las medidas psicosociales. Metodología: Se integró un panel de expertos con seis especialistas de diferentes áreas: psiquiatría infantil y de la adolescencia, neuropediatría, psicología y neuropsicología de cinco países latinoamericanos. Se revisó la literatura de entre 2006 y 2008; se evaluó el nivel de evidencia científica de los estudios, y se desarrolló el algoritmo de tratamiento de preescolares con TDAH, de acuerdo con las necesidades de la población latinoamericana. A partir de la información obtenida los especialistas propusieron las principales recomendaciones para evaluar y manejar a los preescolares latinoamericanos con TDAH y construyeron un árbol de decisiones según el nivel de evidencia científica de cada propuesta de tratamiento. Resultados: El algoritmo multimodal para el tratamiento de preescolares latinoamericanos con TDAH plantea como primer recurso el manejo psicosocial y luego el tratamiento farmacológico. Los principales cambios en el algoritmo son: la recomendación específica de los tratamientos psicosociales como la psicoeducación, el Entrenamiento en Manejo Parental (EMP) y la Terapia Interaccional Padre-Hijo (TIPH). La recomendación del metilfenidato como primera etapa farmacológica (disponible en todos los países de Latinoamérica), seguido de la atomoxetina o las anfetaminas; en el último término se puede considerar el uso de clonidina. Finalmente, se recomienda continuar con los tratamientos psicosociales para el mantenimiento en conjunto con la medicación con la que se mostró la mejor respuesta. Conclusiones: Existen diversas alternativas de tratamiento para esta población; éstas se distribuyeron en el árbol de decisiones de acuerdo con el nivel de evidencia. El algoritmo para preescolares latinoamericanos con TDAH recomienda el uso conjunto y racional de tratamientos farmacológicos y psicosociales

Profile of Service Use and Barriers to Access to Care among Brazilian Children and Adolescents with Autism Spectrum Disorders

Delayed diagnosis and a lack of adequate care for people with autism spectrum disorder (ASD) are related to worse outcomes and quality of life. This study aimed to identify the profile of service use, barriers to access care, and factors related to those barriers in Brazilian families with children with ASD. A total of 927 families with children with ASD (3-17 years) from five Brazilian regions completed an online version of the Caregivers Needs Survey. Results showed that the most used services were behavioral interventions and pharmacotherapy, while the most used professionals were neurologists, nutritionists, speech therapists, psychiatrists, psychologists, and pediatricians. The main barriers included waiting lists, costs, and the absence of services or treatment. Service use varied according to age, the region of residence, type of health care system used, and the parents/caregivers\u27 education. Access to behavioral interventions was more frequent among users of the private system/health insurance and families whose caregivers had higher education. The absence of specialized services/treatments was less frequent among residents of state capitals and families whose caregivers had higher levels of education. This study highlights how families with children/adolescents with ASD in Brazil face significant barriers to access care related to sociodemographic factors

Prevalence of treated autism spectrum disorders in Aruba

To study autism outside of a narrow range of settings previously studied, and in a particularly distinctive setting in the Caribbean. The aim of the Aruba Autism Project was to determine the prevalence of autism spectrum disorders (ASDs) in birth years 1990–1999 in Aruba. A record review study was conducted; cases were ascertained from children treated at the Child & Adolescent Psychiatry Clinic of Aruba, the first and only child psychiatry service on the island. In these 10 birth years we found a prevalence for autistic disorder (AD) of 1.9 per 1,000 (95% CI 1.2–2.8) and for autism spectrum disorders of 5.3 per 1,000 (95% CI 4.1–6.7). Comparison analysis with a cumulative incidence report from the UK, showed a similar cumulative incidence to age five in Aruba. Prevalence of ASDs in birth years 1990–1999 and cumulative incidence to age five in Aruba are similar to recent reports from the United Kingdom and the United States

COVID-19 Pneumonia and ROX index: Time to set a new threshold for patients admitted outside the ICU

High flow nasal cannula (HFNC) is used to treat acute hypoxemic respiratory failure (AHRF) even outside the ICU and the ROX index (pulse oximetry/fraction of inspired oxygen/respiratory rate) may predict HFNC failure. Objective: The purpose of this investigation was therefore to verify whether the ROX index is an accurate predictor of HFNC failure for COVID-19 patients treated outside the intensive care unit (ICU) and to evaluate the validity of the previously suggested threshold. Design: Multicenter study. Retrospective observational analysis of prospectively collected data. Setting: 3 centres specialized in non-invasive respiratory support (Buenos Aires, Argentina; Bolzano and Treviso, Italy). Patients treated outside the ICU were analysed Measurements: The variables to calculate the ROX index were collected during the first day of therapy at 2, 6, 12 and 24 hours and then recorded every 24 hours. HFNC failure was defined as escalation of respiratory support to invasive mechanical ventilation (IMV) or death. Main results: A total of 35 (29%) patients failed HFNC and required intubation. ROC analysis identified the 12-hour ROX index as the best predictor of intubation with an AUC of 0.7916[CI 95% 0.6905-0.8927] and the best threshold to be 5.99[Specificity 96% Sensitivity 62%]. In the survival analysis, a ROX value <5.99 was associated with an increased risk of failure (p = 0008 log – rank test). The threshold of 4,9 identified by Roca as the best predictor in non-COVID patients, was not able to discriminate between success and failure (p = 0.4 log-rank test) in our patients. Conclusions: ROX index may be useful in guiding the clinicians in their decision to intubate patients, especially in patients with moderate ARF, treated therefore outside the ICU. Indeed, it also demonstrates a different threshold value than reported for non-COVID patients, possibly related to the different mechanisms of hypoxia