Autism & Epilepsy: Which Comes First? December 6, 2011 Roberto Tuchman, M.D. Director, Autism and Neurodevelopment Program Miami Children s Hospital Dan Marino Center Clinical Professor of Neurology and Psychiatry Herbert Wertheim College of Medicine, FIU American Epilepsy Society Annual Meeting
Disclosure Name of Commercial Interest Type of Financial Relationship No Disclosures American Epilepsy Society Annual Meeting
Learning Objectives Autism and Epilepsy Shifting Perspectives & Common Mechanisms Which comes first Autism or Epilepsy Clinical and Research Synergies American Epilepsy Society Annual Meeting
Autism and Epilepsy: Shifting Perspectives Neurodevelopmental Disorders Happe, F., et al. (2006). "Time to give up on a single explanation for autism." Nat Neurosci Berg, A., Scheffer I. (2011). "New concepts in classification of the epilepsies: Entering the 21st century." Epilepsia Epilepsy, like autism, is increasingly being described as a spectrum disorder Jensen, F. E. (2011). "Epilepsy as a spectrum disorder: Implications from novel clinical and basic neuroscience." Epilepsia multiple etiologies variable clinical symptoms variable outcomes
Epilepsy and Autism Commonly Co-exist Mouridsen, S. E., et al. (2011). "A longitudinal study of epilepsy and other central nervous system diseases in individuals with and without a history of infantile autism." Brain Dev Clark DF, et al. (2005) The prevalence of autistic spectrum disorder in children surveyed in a tertiary care epilepsy clinic. Epilepsia Matsuo, M., et al. (2010). Frequent association of autism spectrum disorder in patients with childhood onset epilepsy Brain Dev Sansa, G., et al. (2011). "Medically refractory epilepsy in autism." Epilepsia
Increased morbidity and mortality Danielsson, S., et al. (2005). "Epilepsy in young adults with autism: a prospective population-based followup study of 120 individuals diagnosed in childhood Epilepsia Gillberg, C., et al. (2010). "Mortality in autism: a prospective longitudinal community-based study." J Autism Dev Disord Sillanpaa, M. and S. Shinnar (2010). "Long-Term Mortality in Childhood-Onset Epilepsy." New England Journal of Medicine Pickett, J., et al. (2011). "Mortality in Individuals with Autism, with and without Epilepsy." J Child Neurol
Autism, Epilepsy, and Intellectual Disability: Common Mechanisms Brooks-Kayal, A. (2011). "Molecular mechanisms of cognitive and behavioral comorbidities of epilepsy in children." Epilepsia Fassio, A., et al. (2011). "SYN1 loss-of-function mutations in autism and partial epilepsy cause impaired synaptic function." Human molecular genetics Tsai, P. and Sahin M. (2011). "Mechanisms of neurocognitive dysfunction and therapeutic considerations in tuberous sclerosis complex." Current opinion in neurology Wegiel, J., et al., (2010). The neuropathology of autism: defects of neurogenesis and neuronal migration, and dysplastic changes. Acta Neuropathol
Common Mechanisms: Common Number Variants (CNVs) Common recurrent microdeletions associated with generalized epilepsy seen at a frequency of 1% at 15q13.3, 16p13.11, and 15q11.2 These three regions have been tied to multiple neurobehavioral phenotypes including epilepsy, autism, intellectual disability, and schizophrenia Mulley, J. C. and H. C. Mefford (2011). "Epilepsy and the new cytogenetics." Epilepsia
Intellectual Disability mtor pathway specific synaptic or other molecular pathways Epilepsy SHARED MECHANISMS INTERVENTION Behavioral Risk Factors: risk genes Risk Process: (Epileptogenesis- Sociogenesis) Altered neuronal excitation/inhibition (interneuron) Altered neuronal networks Altered pattern of interaction between child and environment Autism Spectrum Disorders
Which comes first
Intellectual Disability RRBIs Motor Language Social Interaction Social Definitions: Autism Deconstructed
Which comes first: Joint Attention capacity of individuals to coordinate attention with a social partner in relation to some object or event begins to emerge by 6 months of age early and critical foundation language & social cognition
After 6 months ASD group shows a rapid decline in eye contact social smiling examiner-rated social responsiveness Ozonoff, S., et al. (2010). "A prospective study of the emergence of early behavioral signs of autism." J Am Acad Child Adolesc Psychiatry
By 12 months.. Not Responding to Name by 8 to 12 months Pointing or Gestures by 12 months Responding to Joint Attention by 12 to 18 months Repetitive Actions Unusual Sensory Responses Zwaigenbaum, L., et al. (2009). "Clinical assessment and management of toddlers with suspected autism spectrum disorder: insights from studies of high-risk infants." Pediatrics Zwaigenbaum, L., et al. (2011). "The NeuroDevNet Autism Spectrum Disorders Demonstration Project." Seminars in pediatric neurology
Epilepsy in Children with ASD Tuchman, et al. (1991). "Autistic and dysphasic children. II: Epilepsy." Pediatrics 1.0 0.8 0.6 0.4 Epileptic Encephalopathy Infantile Spasms ongoing neurological process 0.2 0 5 10 15 20 25 AGE AT TIME OF SEIZURE (Years) 30
In a meta-analysis of 24 reports on autism and epilepsy published from 1963 to 2006: Pooled prevalence of epilepsy 21.4% in 1485 individuals with autism and intellectual disability versus 8% in 627 persons with autism without intellectual disability Amiet, C. et al., Epilepsy in autism is associated with intellectual disability and gender: evidence from a meta-analysis. Biol Psychiatry 2008
Autism spectrum disorders in children with seizures in the first year of life - a population-based study. Epilepsia 7% with ASD all with intellectual disability Risk of autism spectrum disorders after infantile spasms: a population-based study nested in a cohort with seizures in the first year of life. Epilepsia Overall 14% with ASD ASD in 46% of those with Infantile Spasms ASD in 69% of those whose seizures were associated with brain insults Saemundsen, E., P. Ludvigsson, et al. (2007) Saemundsen, E., P. Ludvigsson, et al. (2008).
Berg, A, et al. (2011). "Risk and correlates of autism spectrum disorder in children with epilepsy: a community-based study." J Child Neurol 5% met criteria for ASD 10% of those whose seizures start in the first 2 years of life met criteria for ASD 13.8 % in those with IQ less than 80 met criteria for ASD 2.2 % with normal cognitive abilities met criteria for ASD West syndrome (Infantile Spasms) (30% with ASD), intellectual impairment, male sex independently associated with ASD Younger age (of seizures) at onset did not contribute independently to ASD
Clinical and Research Synergies ILAE-AS Task Force
AS-CURE-ILAE: Scientific Research Synergies from a Global Perspective: Key Points Brooklyn December 10, 2010 Key Points Identify infants with seizures at risk for autism and those with autism at risk for epilepsy Identify genetic and environmental risk factors common to epilepsy-autism Explore the underlying mechanisms of convergence between autism and epilepsy
AS-CURE-ILAE: Scientific Research Synergies from a Global Perspective: Key Points Brooklyn December 10, 2010 Key Points Coordinate tissue and brain banking efforts in epilepsy-autism Develop treatment models behavioral and pharmacological in infants with epilepsy-autism (or at risk for autism)
The NINDS, in conjunction with Autism Speaks and CURE, will host a workshop in the spring of 2012 Research Agenda Coordination of Resources Common Mechanisms Treatment approaches