The analysis of interview data led to the identification of three overarching themes: symptoms, therapies, and challenges. While there is considerable overlap in their content, each theme describes a distinct element of the participants’ experiences and opinions. Our results are thus presented by theme, and further broken down into the codes that comprise each theme. As is standard in qualitative research, quotes from caregivers are also provided to illustrate themes.
3.1. Symptoms
Children with ADNP syndrome exhibit a wide range of medical and behavioral symptoms, many of which require complex management.
“She didn’t hit any of her developmental milestones at all. So it was pretty clear as early as like five months that there was something going on.”
The majority of participants noted that their child did not meet developmental milestones within the first year of life. In several cases, dysmorphic features present from birth such as hypertelorism and low-set ears had raised immediate suspicion of a genetic disorder. Most children had been delayed in crawling and walking, and several had had delays in sitting upright, which was likely due to low muscle tone. Those who were verbal had been severely delayed in achieving speech. Lack of eye contact, minimal crying, and poor feeding had also been commonly noted in early infancy. All 10 caregivers interviewed noted that their children had exhibited premature tooth eruption.
“Speech, cognition and sleep—those are the three things everybody talks about.”
All participants cited problems with communication, cognition, and sleep as being among the most challenging symptom domains to manage on a daily basis.
Communication: The symptom domain most commonly discussed by parents was speech and communication. Eight of ten children had few-to-no words, and these parents all identified their child’s inability to communicate their needs as a major source of stress for the entire family. Lack of verbal ability was seen by several parents as the trigger for aggressive and impulsive behaviors; these parents described their children as becoming frustrated and acting out when unable to communicate their needs. The parents of the two verbal children both expressed difficulty with social situations, as the children tended to say inappropriate or offensive things.
Cognition: All children exhibited cognitive impairment to varying degrees. Motor planning deficits, poor visuospatial skills, short attention span, and short-term memory deficits were common. Caregivers noted that cognitive symptoms were among the most debilitating aspects of ADNP syndrome, as they greatly contributed to the lack of independence in daily activities such as dressing and feeding.
Sleep: Most children had had difficulty with sleep since birth, most commonly in the form of frequent nighttime awakenings. This may have been a symptom of sleep apnea in at least some children (see “physical health problems”). The insomnia was severe in some cases, with one parent stating that they “can count on one hand the number of times [child] has slept through the night since she was born.” This lack of sleep did not seem to translate to daytime sleepiness, as most parents reported that their child was nevertheless highly active throughout the day. One family had seen improvement in sleep with a bowel regimen, and a second family had experienced improvement with a combination of guanfacine and clonazepam. However, the remaining eight caregivers interviewed stated they had not found any behavioral or pharmacological interventions to improve their child’s sleep.
Motor skills: All parents interviewed described a combination of gross motor, fine motor, and motor planning deficits. Most of the children were unable to feed themselves or hold a pencil due to poor grip and dexterity. All of the children exhibited motor planning deficits to some degree. While one was able to independently complete most activities of daily living, the majority had difficulty with any two-step motor process as well as movements that cross the midline of the body. Several children had also been diagnosed with low muscle tone, making them “wobbly” and prone to falls.
Aggressive/impulsive and stereotypic behaviors: All of the children exhibited aggressive, impulsive, and/or stereotypic behaviors to varying degrees. The most common aggressive behaviors were biting, hitting, hair-pulling, throwing objects, and self-injury. These behaviors were more prevalent in children with more severe language delay. Vocal stereotypies were also common. The frequency of maladaptive behaviors was noted to correlate with perceived frustration and anxiety.
Sensory seeking: Several parents expressed concern over sensory seeking behaviors. Oral fixation was the most common (“their hands are in their mouths 24/7”); one child had swallowed household items on numerous occasions, while another had recurrent episodes of cellulitis requiring hospitalization and intravenous antibiotics as a result of chewing on their fingers.
High pain threshold: The majority of parents stated that their child had an extremely high tolerance for pain. This often led to injuries going unnoticed by caregivers. One child had suffered multiple lacerations in his mouth due to a PROMPT speech therapy tool that had gone unnoticed for weeks, and several had had fractures and other injuries that had healed poorly due to having been initially overlooked.
“He was hospitalized half the year for the first three years of his life. We were living in the hospital.”
All of the children had medical issues requiring specialist care.
Cardiovascular: Two children were born with ventricular septal defects that had closed without intervention. One child had required multiple cardiac surgeries to repair “four holes in his heart;” the caretaker was not able to provide further details.
Neurologic: Three children had been diagnosed with cortical visual impairment and were legally blind. Of three children who had undergone brain magnetic resonance imaging, two revealed leukomalacia, and the third had thinning of the corpus callosum.
Musculoskeletal: The majority of children had issues with their feet, most commonly pronation and connective tissue tightness leading to an unstable gait. One child had required tendon lengthening surgery in their feet at age 5 and received monthly botox injections. Low muscle tone was also mentioned by three parents and is presumed to be the underlying cause of sleep apnea in the two children with that diagnosis.
Gastrointestinal: The majority of children in the study suffered from chronic constipation, and two had been diagnosed with gastroesophageal reflux disease.
Other: Two children had had frequent illness and recurrent infections, likely due to oral sensory seeking behaviors. Two children had hypothyroidism. One child was born with hypospadias requiring surgery, and another had required surgery for strabismus.
“If it could speed up her response time to things and help her focus, and maybe help with her short-term memory loss… I feel like that would make a real meaningful improvement in her life.”
We asked participants to describe the clinical changes that would have most improved the quality of life for them and their child, and what they would have hoped to see if they enrolled their child in a clinical trial. All 10 participants stated that the most meaningful outcome would have been increased independence in activities such as feeding, dressing and toileting, as assisting with these activities required significant time and energy from caregivers. All participants also identified poor sleep as an important symptom to address. Several parents discussed improvement in verbal communication as particularly important to both reduce frustration and ensure that their child’s needs were being met. Cognitive issues such as motor planning deficits, short attention span, and poor short-term memory were also mentioned as meaningful clinical targets. Parents whose children were sensory-seeking also prioritized reduction in associated behaviors, particularly oral fixation.
In regards to participating in clinical trials, all interviewees stated that they would have been willing to enroll their child in any study that might have provided benefit. Several parents expressed concerns about access to clinical trials and disappointment if participation required extensive travel.
3.2. Therapies
Participants had made use of a wide variety of medical and behavioral therapies. Most described having seen improvement in symptoms with intensive therapy, but nearly all had had difficulty in accessing an adequate level of care.
“She has a one-to-one behavioral therapist with her all day and gets PT [physical therapy], OT [occupational therapy], speech and PROMPT [speech] therapy all in school, plus 15 h per week of a behavioral therapist at home and an at-home oral motor therapist… I can’t tell you how many things we’ve tried.”
Study participants had found varied success with a broad range of therapies. The most commonly utilized and overall most successful intervention discussed was applied behavioral analysis (ABA) therapy. ABA is a technique used in children with developmental disabilities that focuses on teaching skills in specific domains of functioning using traditional principles of positive reinforcement. All parents had utilized ABA, with the greatest benefits being seen in children who were able to receive therapy both at school and at home. While some parents had found ABA to be minimally effective, others had seen marked reductions in problem behaviors with consistent therapy. Physical and occupational therapy were considered important and generally effective by all parents interviewed, though again, the degree of efficacy was highly variable. For several children, speech therapy (including PROMPT therapy) had improved communication, though a subset of children had not responded to speech therapy. One child had exhibited significant improvement in symptoms with music therapy and horseback riding (hippotherapy); another child had also benefited from hippotherapy.
The majority of participants had trialed at least one medication for their child’s symptoms, but few had found success with pharmacologic treatments. As noted, one child had had improvement in problem behaviors and sleep with guanfacine and clonazepam. Another child had exhibited significantly improved attention and impulse control with methylphenidate but discontinued the medication after developing motor tics. Several families had been able to effectively manage chronic constipation with laxatives and diet alterations.
“I don’t think you’re going to solve any of his problems with medications.”
All participants had tried multiple therapies that had not provided significant benefit to their child. While ABA therapy had been effective for most children, one parent believed that it had worsened their child’s symptoms and caused behavioral regression to the point where they “didn’t even recognize him anymore.” For children with cortical visual impairment and/or difficulty focusing their attention, speech therapy was not seen as viable or effective. Several parents reported having tried various stimulant and antidepressant medications for behavioral control, but these had most often produced adverse effects without clear benefit. The majority of parents had trialed multiple interventions for sleep, including diet changes, light therapy, melatonin, benzodiazepines, and magnesium, all with minimal success.
“He got the basic therapies, and it wasn’t until after his diagnosis that we started asking for aggressive therapies. And then come to find out, this is a neuroplasticity-blocking gene… but a lot of the younger kids are getting more intensive, almost rehab-level therapy and they’re crushing it. They’re saying the days of the week and singing songs.”
The importance of early diagnosis and intervention for improved long-term outcomes in ADNP syndrome was repeatedly reported throughout the interviews. Most participants described a strong belief based on personal experience that the earlier in an affected child’s life treatment is begun, the less delayed the developmental trajectory is. One parent stated that their child had one of the most severe cases known and believed this to be due to a lack of therapy in early childhood. Another parent attributed their child’s relatively mild symptoms to early intervention, stating that “as disabled as she is, when I see the other kids with ADNP [syndrome] I know that the reason she’s as high functioning as she is, is the therapy she got at a young age.” Two other parents whose children were comparatively high-functioning attributed this to obtaining early diagnosis and treatment.
“What ADNP kids need is frequency, frequency, frequency. They need to keep it up. If you don’t do it, you lose it—and you need to do a lot of it.”
Most participants felt that a minimum of several hours per day of one-on-one therapy should be the standard for children with ADNP syndrome. While the parent of one child had noted improvement in symptoms with as little as 2 hours of therapy daily, most children received at least 4 hours, and some had only seen benefit with 8 or more hours daily. The amount of therapy received by the children in our study ranged from 2 hours on weekdays to 12 hours daily including weekends. Several parents mentioned the importance of consistency and believed that their child only benefited when receiving therapy 7 days per week. A combination of at-school and at-home behavioral therapies was seen as most effective. One participant reported that in the past, their child had failed to make any measurable progress even when receiving daily therapy; however, they had noted major improvements in a number of symptom domains after being approved for an at-home behavioral therapist eight hours per day. Another caregiver stated that getting a full-day one-on-one therapist for their child at school “has made all the difference in the world,” and that being able to supplement therapy at school with at-home therapy had accelerated their child’s progress. The COVID-19 pandemic was mentioned by several parents as a major barrier to receiving adequate care at the time of interview, and two reported having seen significant regression in their child’s behaviors as a result. Some parents also expressed that even before the COVID-19 pandemic, they often worried that they could lose access to services at any time for financial or insurance-related reasons, and that a lack of consistency in therapy could lead to regression.
3.3. Challenges
There were several challenging aspects of managing ADNP syndrome discussed by participants that were distinct from the other identified themes and highlight challenges faced by caregivers that are unique to parenting a child with a rare genetic disorder.
“We needed to have therapy in the house, which is really hard to find, almost impossible to find in-network for a child… and so he’s getting very little services.”
The majority of participants identified obtaining adequate care for their children as one of the most consistently difficult things they had encountered. Children with ADNP syndrome likely require consistent, intensive physical and occupational therapy at a level that is challenging to find and to get reimbursed for by insurance. While most participants reported that they were currently satisfied with the care their child received, nearly all shared several examples of times when their child had been forced to go for extended periods with little or no daily therapy. The lack of adequate disability accommodation and therapy at public schools in particular was identified as a major problem. For several parents, geography posed an issue, as there were very few behavioral therapists in their respective areas, and waitlists could be years long.
All interviewees brought up insurance coverage and described having dedicated significant time and energy to attempts to have services reimbursed. While some families were able to pay out of pocket for intensive therapy when not covered, others were severely limited by their insurance. One parent expressed frustration at not being able to access at-home therapy, which was the only viable option for their family as their child had severe separation anxiety.
“The autism diagnosis was really crucial for us. They wouldn’t have covered anything if we didn’t have that.” “I can’t tell you how many families, no matter where they’re from… they all try to get autism diagnoses for their kids when they’re little, but they don’t meet the criteria because they’re too social.”
Nine of ten participants indicated obtaining a diagnosis of ASD as a critically important step in obtaining adequate care for their child. While in the majority of cases, the diagnosis of ASD preceded the diagnosis of ADNP syndrome, most participants expressed that they did not believe that their child had ASD but that they would have had significantly less access to care without the diagnosis (“She has ADNP syndrome, she doesn’t have autism. But that diagnosis has been the only thing that has gotten us any reimbursement with insurance.”). However, the majority of parents had undergone a lengthy process of fighting for the ASD diagnosis, and several described the frustration of waiting months or years knowing that their child was not receiving appropriate therapies that could potentially alter their developmental trajectory. The most common obstacles to obtaining an ASD diagnosis were long wait times for clinical evaluations and patients not meeting diagnostic criteria due to being too socially high-functioning.
“We need to advocate. We need people to stand up and take stances on behalf of these children…”
Parents of children with ADNP syndrome must often advocate for school accommodation and medical services, and on a larger scale, for greater recognition of the syndrome. All the participants spoke extensively of the need to advocate for their children in a variety of contexts, often due to a lack of knowledge and understanding about ADNP syndrome. The majority of parents interviewed had spent a significant amount of time and energy negotiating with their insurance companies to get services covered; one parent likened this to having a second full-time job. All participants had had difficulty arranging for adequate at-school accommodation and therapy, and three had sued their school districts to varying degrees of success. Several parents also described feeling a responsibility to advocate for research on ADNP syndrome and to “lead the scientific effort to understand it.”
“We didn’t have our answer until she was almost 7... the second whole [exome] sequencing we did came back with ADNP. The first one, ADNP wasn’t discovered yet, so we got no hits.” “It was really scary and hard to kind of wrap our minds around. What does this mean for our child? And what type of life can we lead with this syndrome that nobody really knows anything about?”
Participants described the impact of uncertainty in caring for a child with ADNP syndrome, from the initial onset of symptoms to diagnosis and treatment. Given the rarity of the disorder, the process of obtaining a diagnosis is often lengthy and difficult. Even following the diagnosis, caregivers may be forced to make decisions about treatment with limited information. The majority of families had gone several years without the genetic diagnosis; one child had not received a diagnosis until age 16. While receiving an ADNP syndrome diagnosis was relieving to parents, in most cases, it created a great deal of stress and uncertainty given that there “was no roadmap.” Parents described feeling worried about their child’s prognosis and their ability to ensure that their child’s needs were met into adulthood.