NORD gratefully acknowledges Illana Gozes, PhD, Professor of Clinical Biochemistry, The Lily and Avraham Gildor Chair for the Investigation of Growth Factors, Department of Human Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, The Adams Super Center for Brain Studies and Sagol School of Neuroscience, Tel Aviv University; Raphael Bernier, PhD, Professor of Psychiatry and Behavioral Sciences, Research Affiliate, Center on Human Development and Disability, University of Washington; Frank Kooy, PhD, Professor, Cognitive Genetics, Department of Medical Genetics, University of Antwerp; and Sandra Bedrosian-Sermone, President, ADNP Kids Research Foundation, for assistance in the preparation of this report.
ADNP syndrome, also known as Helsmoortel-Van Der Aa syndrome, is a neurodevelopmental genetic disorder caused by changes (mutations) in the ADNP gene. These mutations occur spontaneously in the majority (97%) of reported patients, meaning there has been no family history of the disorder (de novo mutations).
The hallmark features of the syndrome are intellectual disability, global developmental delays, global motor planning delays and autism spectrum disorder or autistic features. Although ADNP syndrome was only discovered in 2014, it is projected to be one of the most frequent single gene causes of autism.
The genetic changes that cause ADNP syndrome vary from person to person. The symptoms can also vary and can cause a wide range of medical, developmental, intellectual and behavioral changes. The most common characteristics found in those with ADNP syndrome are developmental delays (100%), intellectual delays (100%), motor planning delays (96%) of varying degrees, delayed or absent speech (98%) and autism spectrum disorder including autistic features (93%). Autistic features in ADNP syndrome are quite similar and most children display a very happy demeanor similar to Angelman syndrome as infants and toddlers. Feeding and gastrointestinal problems (83%) are also very common. Additional symptoms are low or weak muscle tone in newborns and infants (hypotonia) (78%), neonatal/infant feeding disorders, sensory processing disorder, sleep disorder, high pain threshold and additional symptoms and behavioral disorders of varying levels of severity.
The disorder can potentially affect multiple systems of the body including the brain, heart, immune system, gastrointestinal system, endocrine system, and musculoskeletal system. The specific signs and symptoms associated with the disorder can vary greatly from one individual to another but the majority of children exhibit distinctive facial features. Many infants (>80%) develop early primary tooth eruption and often have a happy disposition and unprovoked episodes of laughter and smiling. Parents report that approximately 50% of the children develop breathing irregularities (breath holding episodes) and episodes of developmental regression of speech that is usually regained over time with intensive therapy.
Although researchers have established a clear syndromic presentation with characteristic or “core” symptoms associated with pathogenic variants in the ADNP gene, much about the disorder is not fully understood. Several factors have impeded the identification of a complete picture of the associated symptoms and prognosis; these include the small number of identified children, the lack of large clinical studies, and a lack of understanding of moderating effects of genetic background, the presence of additional gene variants, or environmental contributions. Therefore, it is important to note that every child is unique and that affected individuals may not have all of the symptoms discussed below.
Many infants (78%) present with hypotonia and, thus, can appear abnormally “floppy.” Cerebral imaging shows structural brain abnormalities in slightly over half of the patient population (56%). Other neurological problems may exist. Individuals with ADNP syndrome may develop seizures (16%). Many parents report absent like seizures as infants along with breath holding episodes. Reported brain abnormalities include wide ventricles (29%), cerebral atrophy (18%), delayed myelination (9%) and white matter lesions (8%). Approximately 50% of children with ADNP syndrome have had one or more episodes of developmental regression of speech.
Hypotonia and oral movement problems such as oral motor apraxia and oral motor dyspraxia (oral motor dysfunction) are often seen together in children with ADNP syndrome. This contributes to causing the majority of infants to experience feeding difficulties (83%). Poor sucking or chewing ability may occur in infancy. Swallowing problems may also be seen and there can be a risk of food or drink ending up in the lungs (aspiration). Some children who have difficulties with feeding may benefit from thickened liquids and some may require a feeding tube for nutrition.
Missed milestones such as delays in sitting and holding up ones head are seen in infancy and children have mild to severe global developmental delays. Walking independently is often delayed until a few years later in childhood and children may have an unusual manner of walking (abnormal gait). Most children experience mild to moderate global motor planning delays. As they age, they will exhibit mild to severe intellectual disability. There are often delays in developing speech. Some children may not be able to speak, while others speak a few words or in short sentences. Apraxia or other oral motor disorders specifically affecting the tongue appear to cause the most difficulty in the majority of the non-verbal children.
Children with ADNP syndrome in their younger years tend to be easily amused and have a happy demeanor similar to Angleman syndrome. This often delays diagnosis for behavior disorders such as autism even when the child displays many autistic features early in life. Sleep disorders can also occur, including sleep apnea, frequent waking throughout the night as well as early waking. There may be bladder training delays.
The majority of affected children may meet the criteria for autism spectrum disorder and may exhibit poor social interaction and mild to severe repetitive (stereotypic) behaviors such as repetitive speech, rocking back and forth, hand flapping, hand clapping, rubbing fingers or snapping fingers (93%).The majority of children with ADNP syndrome seek direct “adult” interaction. Specifically, at a very young age they appear to enjoy direct social interactions with adults and often smile, laugh and make eye contact. This is atypical for autism but it is very typical for ADNP syndrome. This often delays the autism diagnosis even when the child displays many autistic features at a young age.
Sensory sensitivities, interests, and aversions (resulting in both seeking and avoiding sensory stimuli) are often seen (67%), with oral sensory seeking behaviors most prevalent. Because of this, children tend to lick their hands or other objects often, chew on non-edible items, gag, and put objects in their mouth. They often have an obsession for music and water play. They also tend to place tablets and other lit objects or devises directly in front of their eyes for stimulation.
In addition to autism and sensory sensitivities and aversions, children may have a variety of behavioral issues including attention deficit hyperactivity disorder, obsessive compulsive disorder, temper tantrums and aggression, mood disorders, and anxiety.
Children with ADNP syndrome often have a high pain threshold (64%). Many parents report that their child does not seem to feel pain, some reporting fractures with no sign of uncomfortableness or destress. Low perception of pain in conjunction with communication issues can make it difficult for parents to know when their child has pain or an injury.
Gastrointestinal symptoms are common. Affected individuals can develop backflow of stomach acids into the esophagus (gastroesophageal reflux). This has been reported as mild to severe. Some children require the placement of a feeding tube due to severe feeding problems. Episodes of chronic constipation and diarrhea are seen in almost all children with ADNP syndrome. Other symptoms include cyclic vomiting, delayed digestion, and irritable or inflammatory bowel conditions.
Some children as they grow past the toddler years have an abnormal increased appetite and have difficulties feeling full (hyperphagia), similar to Prader Willi syndrome. This can lead to excessive weight gain. Some children also develop an abnormally increased desire to drink water.
Some affected individuals may have congenital heart defects (38%). Ventricle or atrial septal defect is a common heart defect in ADNP syndrome. Additional congenital heart defects that have been reported in ADNP syndrome include enlargement of the main artery that supplies oxygen-rich blood to the body (aorta), the abnormal location of the aortic arch on the right side of the body instead of the left (right aortic arch), an abnormally rapid heartrate (tachycardia), and mitral valve prolapse. Affected individuals may also have an abnormal opening between the main artery of the lungs (pulmonary artery) and the aorta (patent ductus arteriosus), narrowing (stenosis) of blood vessels of the pulmonary artery system (peripheral pulmonary artery stenosis), or tetralogy of Fallot, a specific combination of heart defects.
Affected individuals have distinctive facial features including a prominent forehead, high hairline, droopy eyelids (ptosis), thin upper lip, broad nasal bridge, malformed ears, eyes that are farther apart than normal (hypertelorism), and crossed eyes (strabismus). Affected individuals may see objects that are farther away clearer than they see objects that are close up (farsightedness or hypermetropia). Cortical vision impairment has also been reported in multiple affected children.
Some infants experience early eruption of their baby (deciduous or primary) teeth, showing a full set of baby teeth by the first birthday, including molars. To date, this has not been reported in any other known syndrome making it potentially unique to ADNP syndrome. The teeth may be abnormally small, jagged, and discolored. Because of early tooth eruption, some children develop tooth decay as toddlers due to the decrease in enamel.
Some affected individuals have underdeveloped (hypoplastic) fingernails and toenails, extra fingers or toes (polydactyly), and abnormally small pinkies that are fixed or ‘locked’ in a bent position (clinodactyly). Certain joints of fingers may be abnormally prominent.
Additional symptoms include abnormally loose (lax) joints that have a larger range of motion than normal (hyperlaxity), abnormal sideways curvature of the spine (scoliosis), and recurrent infections, especially upper respiratory and urinary tract. These recurrent infections may indicate an underlying problem with the immune system. Some children exhibit growth delays and will be shorter than expected for their age and gender (short stature). Some children have tended to develop truncal obesity, in which the trunk of the body is affected as opposed to the arms and legs. There have also been reports that some children have difficulty regulating their body temperature and many have cold feet and hands. Parents also report that children spike fevers extremely fast.
ADNP syndrome is caused by a change (mutation) in the activity-dependent neuroprotective protein (ADNP) gene. Genes provide instructions for creating proteins that play a critical role in many functions of the body. When a mutation of a gene occurs, the protein product may be faulty, inefficient, absent, or overproduced. Depending upon the functions of the particular protein, this can affect many organ systems of the body, including the brain.
Researchers have determined that the ADNP gene produces a protein called activity-dependent neuroprotective protein that helps to regulate as many as 400 other genes in the body. These genes and the proteins they produce are extremely important for the proper development and maturation of the brain and other organs. Collectively, they are involved with almost every system of the body.
ADNP syndrome occurs most frequently as a new (sporadic or de novo) mutation, which means that in most reported patients, the gene mutation has occurred at the time of the formation of the egg or sperm/during embryonic development for that child only, and no other family member will be affected. The disorder is usually not inherited from or “carried” by a healthy parent; however, several hereditary cases have been reported, in most instances when the mutation is at the end of the protein, probably resulting in a very mild presentation of symptoms.
If a person with ADNP syndrome were to have a child, they could pass the altered ADNP gene on to their children through autosomal dominant inheritance. Genetic diseases are determined by the combination of genes for a particular trait that are on the chromosomes received from the father and the mother. Dominant genetic disorders occur when only a single copy of a mutated gene is necessary for the appearance of the disease. The mutated gene encoding a dysfunctional protein can be inherited from either parent, or can be the result of a new mutation in the affected individual. The risk of passing the mutated gene from affected parent to offspring is 50% for each pregnancy. The risk is the same for males and females.
Investigators have determined that the ADNP gene is located on the long arm (q) of chromosome 20 (20q12). Chromosomes, which are present in the nucleus of human cells, carry the genetic information for each individual. Human body cells normally have 46 chromosomes. Pairs of human chromosomes are numbered from 1 through 22 and the sex chromosomes are designated X and Y. Males have one X and one Y chromosome and females have two X chromosomes. Each chromosome has a short arm designated “p” and a long arm designated “q”. Chromosomes are further sub-divided into many bands that are numbered. For example, “chromosome 20q12” refers to band 12 on the long arm of chromosome 20. The numbered bands specify the location of the thousands of genes that are present on each chromosome.
ADNP syndrome affects females and males in equal numbers. The exact number of people who have this disorder is unknown. According to one estimate, about 1 in 20,000 people in the general population in the United States and Europe have the disorder. Rare disorders like ADNP syndrome often go misdiagnosed or undiagnosed, making it difficult to determine their true frequency in the general population. ADNP syndrome is believed to account for about .17% of individuals with autism, making it one of the most common, single-gene causes of an autism spectrum disorder. Approximately 205 affected children have been identified worldwide in the medical literature and as reported by the ADNP Kids Research Foundation as of January 2019.
A diagnosis of ADNP syndrome may be suspected based upon identification of characteristic symptoms, a detailed patient history, a thorough clinical evaluation and a variety of specialized tests. Premature tooth eruption and abnormal tooth development when occurring along with developmental delays or intellectual disabilities and autism symptoms can also lead to a suspicion of ADNP syndrome.
The diagnosis of ADNP syndrome is confirmed by molecular genetic testing that can detect mutations in the ADNP gene. Testing for mutations in the ADNP gene is included in whole genome sequencing.
Clinical Testing and Workup
Imaging techniques such as magnetic resonance imaging (MRI) may be used to aid in a diagnosis. An MRI uses a magnetic field and radio waves to produce cross-sectional images of particular organs and bodily tissues. An MRI of the brain can reveal distinctive changes including atypical white matter lesions, abnormally-wide, fluid-filled cavities called ventricles, and cysts within specific areas of the brain (choroid cysts).These findings alone are not sufficient for a diagnosis of ADNP syndrome.
An echocardiogram is a test that uses reflected sound waves to create images of the heart and can reveal structural heart defects associated with the disorder. An eye doctor will conduct a thorough, extensive eye examination to look for eye abnormalities that may be associated with the disorder.
The treatment of ADNP syndrome is directed toward the specific symptoms that are apparent in each individual. Treatment may require the coordinated efforts of a team of specialists. Pediatricians, a physician who specializes in the diagnosis and treatment of disorders of the brain, nerves and nervous system in children (pediatric neurologists), neurologists, a physician who specializes in the diagnosis and treatment of disorders of the eye (ophthalmologists), a physician who specializes in the diagnosis and treatment of disorders of the gastrointestinal tract (gastroenterologist), a physician who specializes in the diagnosis and treatment of disorders of the heart in children (pediatric cardiologist), speech pathologist, physical therapist, occupational therapist, psychologist, and other healthcare professionals may need to systematically and comprehensively plan treatment. Psychosocial support for the entire family is essential as well.
Genetic counseling is recommended for affected individuals and their families.
There are no standardized treatment protocols or guidelines for affected individuals. Due to the rarity of the disease, there are no treatment trials that have been tested on a large group of patients. Various treatments have been reported in the medical literature as part of single case reports or small series of patients. Treatment trials would be very helpful to determine the long-term safety and effectiveness of specific medications and treatments for individuals with ADNP syndrome.
Infants with ADNP syndrome should be evaluated for feeding issues treated with standard methods if necessary. Surgery may be necessary to treat certain complications associated with ADNP syndrome including cardiac defects. Eyeglasses or surgery may help with vision and other eye problems. Assistive and augmentative communication devices can help children express thoughts, wants, needs and ideas. Medications may be tried to treat seizures and certain neuropsychiatric conditions including sleep disorders or behavioral problems. Some children with sleep disorders have responded positively to melatonin treatment.
Affected children may benefit from occupational, physical, and speech therapy and should be done frequently due to difficulties in learning and motor planning. Some children require daily year round therapy. Water and music therapy have also been beneficial for some affected children. ABA therapy has been beneficial for most affected children with autism. Additional medical, social, and/or vocation services including specialized learning programs may be necessary. Behavioral modification therapy may be useful, especially if self-injurious behavior is present.
In 2017, the ADNP Kids Research Foundation (ADNP-KRF) launched a research partnership with the Seaver Autism Center for Research and Treatment at Mount Sinai. This innovative ADNP syndrome study works at developing precision approaches to the treatment of individuals of ADNP syndrome.
The ADNP-KRF has partnered with Coronis Neurosciences on a clinical trial of CP201/NAP for the treatment of ADNP syndrome. CP201/NAP was designated as an orphan drug by the U.S. Food and Drug Administration (FDA) in 2018.
The ADNP-KRF also supports the Investigation of Genetic Exome Research (TIGER) Study at the University of Washington, ongoing studies through the University of Tel Aviv, and the Cognitive Genetics Program at the University of Antwerp, Belgium.
For more information on potential participation in these studies or for more general information, physicians and parents may contact:
Information on current clinical trials is posted on the Internet at https://clinicaltrials.gov/. All studies receiving U.S. Government funding, and some supported by private industry, are posted on this government web site.
For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:
Tollfree: (800) 411-1222
TTY: (866) 411-1010
Email: [email protected]
Some current clinical trials also are posted on the following page on the NORD website:
For information about clinical trials sponsored by private sources, contact:
For information about clinical trials conducted in Europe, contact:
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