Angelman Syndrome
Guidance for primary care clinicians diagnosing and managing children with Angelman syndrome
Angelman syndrome is a genetic disorder that causes severe developmental delay, intellectual disability, and a distinctive and recognizable pattern of behaviors, including frequent smiling, laughing, and hyperactivity. Although children with Angelman syndrome are typically social, delays in language and other features, such as decreased eye contact, are reminiscent of autism. Seizures, acquired microcephaly, gait ataxia, tremors, scoliosis, sleep and eating problems, and speech impairment are common. Children with Angelman syndrome appear normal at birth and then show progressive developmental delays. It is not until 2 years of age or later that the typical syndrome phenotype becomes obvious. Although feeding problems and hypotonia may be present at birth, developmental delay is often apparent by 6 months of age. Eighty percent of children with Angelman syndrome have seizures, usually presenting before 3 years of age. The diagnosis of Angelman syndrome is based on clinical features and genetic testing, which confirms the diagnosis of individuals with the typical phenotype.
In addition to well-child and acute-care visits, the medical home may want to schedule periodic chronic-care visits to help with ongoing issues, including behavior and educational progress. Needs will change over the life of the child; an infant may require only early intervention, whereas an adolescent with seizures, difficulty sleeping, hyperactivity, and self-injurious behavior may need many more interventions.
Key Points
Testing for suspected Angelman syndrome
Consider beginning with methylation studies (detects approximately
85% of individuals with Angelman syndrome, including those with a deletion,
uniparental disomy (UPD), or an imprinting defect). If methylation studies are
normal, proceed with UBE3A sequence analysis (detects an additional 11%
of individuals with Angelman syndrome).
Screening for Angelman syndrome
Screen for feeding difficulties, constipation, gastroesophageal
reflux, strabismus, scoliosis, seizures, and sleep dysregulation. Refer to GI,
neurology, ortho, or sleep if needed.
Therapies
Physical therapy, occupational therapy, and speech therapy with an
emphasis on nonverbal methods of communication, including augmentative
communication aids (e.g., picture cards or communication boards) and signing,
are beneficial.
Detecting pain
The happy affect seen in children with Angelman syndrome is so
persistent that medical causes for pain, such as severe gastroesophageal reflux,
should be considered when patients appear irritable or “miserable” for prolonged
periods. See Pediatric Pain Assessment & Rating Scales.
Diagnosing seizures
Most children with Angelman syndrome will require treatment for
seizures; however, diagnosis can be challenging since movement abnormalities can
be mistaken for seizures, and EEG abnormalities can exist despite the absence of
seizures.
Seizure medications may worsen seizures
The use of vigabatrin, carbamazepine, and tiagabine in children
with Angelman syndrome may lead to an increase in absence and myoclonic
seizures.
Consult a specialist
When facing the complexities of Angelman syndrome, seeking
guidance from specialists becomes paramount. Their expertise in various domains,
such as gastroenterology, neurology, orthopedics, and sleep medicine, can
provide insights and tailored recommendations for managing the unique challenges
posed by Angelman syndrome. Angelman Syndrome Foundation (ASF) clinics offer access to a range of professionals who
specialize in treating Angelman syndrome. By utilizing its global network of
patient-powered data, the clinics are working towards improving the quality of
life, empowering families, and transforming the future of Angelman syndrome
care. All individuals with Angelman syndrome are eligible and welcome to visit
an ASF Clinic, and each clinic accepts a variety of insurance plans and
policies. See Find a Clinic (ASF).
Roles of the primary care pediatrician
The medical home plays a central role in coordinating various
aspects of care. This includes orchestrating referrals to subspecialists,
overseeing therapeutic interventions, monitoring pain management strategies,
aiding in accurate seizure diagnosis, and collaborating closely with specialists
to ensure comprehensive and holistic care for the affected individuals.
Practice Guidelines
Duis J,Nespeca M,Summers J,Bird L,Bindels-de Heus KGCB,Valstar MJ,de Wit MY,Navis C,Ten Hooven-Radstaake M,van Iperen-Kolk
BM,Ernst S,Dendrinos M,Katz T,Diaz-Medina G,Katyayan A,Nangia S,Thibert R,Glaze D,Keary C,Pelc K,Simon N,Sadhwani A,Heussler
H,Wheeler A,Woeber C,DeRamus M,Thomas A,Kertcher E,DeValk L,Kalemeris K,Arps K,Baym C,Harris N,Gorham JP,Bohnsack BL,Chambers
RC,Harris S,Chambers HG,Okoniewski K,Jalazo ER,Berent A, Bacino CA,Williams C,Anderson A.
A multidisciplinary approach and consensus statement to establish standards of care for Angelman syndrome.
Mol Genet Genomic Med.
2022;10(3):e1843.
PubMed abstract / Full Text
Diagnosis
Presentations
Diagnostic Criteria & Classifications
- Developmental delay, functionally severe
- Movement or balance disorder, usually ataxia of gait and/or tremulous movement of limbs. Movement disorder can be mild. It may not appear as frank ataxia but can be forward lurching, unsteadiness, clumsiness, or quick, jerky motion.
- Behavioral uniqueness: any combination of frequent laughter/smiling; apparent happy demeanor; easily excitable personality, often with uplifted hand-flapping or waving movements; hyper-motoric behavior
- Speech impairment, none or minimal use of words; receptive and non-verbal communication skills higher than verbal ones
- Delayed, disproportionate growth in head circumference, usually resulting in microcephaly (≤2 S.D. of normal OFC) by age 2 years. Microcephaly is more pronounced in those with 15q11.2-q13 deletions.
- Seizures, onset usually <3 years of age. Seizure severity usually decreases with age, but the seizure disorder lasts throughout adulthood.
- Abnormal EEG, with a characteristic pattern. The EEG abnormalities can occur in the first 2 years of life and precede clinical features; they are often not correlated with clinical seizure events.
- Flat occiput
- Occipital groove
- Protruding tongue
- Tongue thrusting; suck/swallowing disorders
- Feeding problems and/or truncal hypotonia during infancy
- Prognathia
- Wide mouth, wide-spaced teeth
- Frequent drooling
- Excessive chewing/mouthing behaviors
- Strabismus
- Hypopigmented skin, light hair, and eye color (compared to family), seen only in deletion cases
- Hyperactive lower extremity deep tendon reflexes
- Uplifted, flexed arm position, especially during ambulation
- Wide-based gait with pronated or valgus-positioned ankles
- Increased sensitivity to heat
- Abnormal sleep-wake cycles and diminished need for sleep
- Attraction to/fascination with water; fascination with crinkly items such as certain papers and plastics
- Abnormal food-related behaviors
- Obesity (in the older child)
- Scoliosis
- Constipation
Screening & Diagnostic Testing
Genetic Testing
DNA methylation analysis identifies approximately 85% of individuals with Angelman syndrome, including microdeletions of the AS/Prader-Willi syndrome critical region in 68%, paternal uniparental disomy of chromosome 15 in 7%, and imprinting defects in 3%. If this test is negative, yet Angelman syndrome is still highly suspected, UBE3A sequence analysis should be ordered by genetics. If negative, it’s highly recommended to proceed with more comprehensive genetic testing, since there are AS-like conditions, which can be clinically similar, like Phelan-McDermid, Christianson syndrome, Pitt-Hopkins syndrome, Kleefstra, and others.
See Diagnostic Testing for Angelman Syndrome (Angelman.org) for a diagram with a suggested order for testing, Lab Testing for AS (Genetic Testing Registry) for testing sites, and Practice Guidelines for the Molecular Analysis of Prader-Willi and Angelman Syndrome [Ramsden: 2010]] for more details.
Laboratory Testing
No routine screening or diagnostic labs are recommended other than genetic testing.
Sensory
Obtain a baseline ophthalmology examination to look for strabismus and ocular albinism (seen in a subgroup of children with Angelman syndrome) and to evaluate visual acuity.
Imaging
Recommended baseline assessments for diagnosis and preventive care: [Dagli: 2017]
- Brain MRI - baseline. Does not usually need to be repeated unless clinical picture changes. It may show atrophy and delayed myelination but no structural lesions.
- EEG –
- Baseline and as clinically indicated for the management of seizures. Many seizure types are associated with Angelman syndrome, including grand mal, absence, and others; infantile spasms are rare. The typical abnormalities involve generalized changes with areas of high-amplitude delta activity alternating with spike and slow-wave activity.
- The electroencephalogram (EEG) waveforms in Angelman syndrome are usually quite abnormal and consist of variable frequency (mostly in Delta but can be in Theta range), high-amplitude, and rhythmic activity mixed with spikes regardless of the presence of epilepsy. When seen in an appropriate clinical context, EEG findings can help identify those with Angelman syndrome at an early age.
Genetics & Inheritance
- Deletions in the 15q11.2-q13 region of the maternally inherited chromosome 15
- Paternal uniparental disomy, where both copies of the gene derive from the father
- Mutations in the maternally inherited UBE3A gene
- An imprinting defect of the maternally inherited 15q11.2-q13 locus
Prevalence
Differential Diagnosis
Comorbid Conditions
Conditions or problems commonly found in children with Angelman syndrome include:
- Seizures
- Sleep disturbance
- Strabismus
- Aspiration pneumonia
- Scoliosis
- Gastroesophageal reflux
- Constipation
- Contractures
Larson et al. reviewed the frequency of secondary conditions and their impact based on phone interviews of caregivers of 110 adolescents and young adults with Angelman syndrome. [Larson: 2015]
Prognosis
Most children with Angelman syndrome will have seizures, need antiepileptic therapy, and communicate non-verbally. Children with Angelman syndrome do not show developmental regression and, with good proactive care, should have normal life expectancies. They are, however, at risk for early death due to seizures, aspiration pneumonia, and accidents.
Treatment & Management
No treatments are available for the underlying cause of Angelman syndrome. However, researchers are currently exploring gene therapy as well as strategies (such as antisense oligonucleotides) to “reactivate the expression” of the paternal UBE3A gene to allow it to express, mitigating the impact of the defective maternal gene. [Beaudet: 2016] [Meng: 2015]
Development
Neurology
- Strongly consider referral to Pediatric Neurology to discuss seizure types and prescribe rescue medication in the event an initial seizure is prolonged. At a minimum, obtain a baseline EEG if there is clinical suspicion of seizures or if looking for the EEG “signature” to help determine if UBE3A sequencing is needed for a child whose methylation studies are negative.
- Monitor antiepileptic medication levels and associated labs if necessary. Use of vigabatrin, carbamazepine, and tiagabine in children with Angelman syndrome and other individuals may lead to an increase in absence and myoclonic seizures.
Orthopedics
Children with Angelman syndrome tend to walk late, between 2 1/2 and 6 years of age. The gait may appear jerky and stiff. Obtain an orthopedic assessment if gait impairment, subluxed or pronated ankles, tight Achilles tendons, and/or moderate to severe hypotonia are present. These problems may require bracing and sometimes surgery.
Scoliosis tends to appear later in childhood or in adolescence. Because scoliosis occurs in about 50% of individuals with Angelman syndrome and is diagnosed at a mean age of 12 years, early and routine scoliosis screening may be useful. [Larson: 2015] Refer to Orthopedics for management of scoliosis.
They might also have reduced bone density with immobility and prolonged anti-epileptic drug treatment. Hence, mobility is encouraged. Adequate Vitamin D intake is recommended. Consider checking the bone density of women using Depo-Provera every couple of years.
Ear, Nose, Throat
Gastro-Intestinal & Bowel Function
Pulmonology
Sleep
Drooling
Eyes/Vision
Mental Health/Behavior
Pharmacy/Medications
Maturation/Sexual/Reproductive
Surgery
Transitions
- Medical care - Families should discuss the transition of medical care from their pediatric medical home to an adult care provider. All necessary screening evaluations, e.g., scoliosis evaluation, should be performed before transition.
- Financial considerations - If appropriate, once the individual turns 18 years of age, caregivers can apply for guardianship. (See Guardianship/Estate Planning for more information for families.) In many states, supplemental security income will automatically qualify the individual for Medicaid benefits.
- Life planning - The public education system covers individuals with Angelman syndrome until they turn 22. Transition planning, covering topics such as where the individual will live and what support will be needed, should begin early. Individuals with Angelman syndrome generally need livelong supervision and have limited independence due to intellectual disability.
Services & Referrals
Find a Clinic (ASF)
A multidisciplinary approach for care of children with Angelman
syndrome with DMD is preferred.
Pediatric Physical Medicine & Rehabilitation
(see UT providers
[11])
Refer for developmental evaluation and care planning.
Pediatric Gastroenterology
(see UT providers
[2])
Gastroesophageal reflux and constipation are common; referral may
help with evaluation and management.
Pediatric Orthopedics
(see UT providers
[10])
Consider baseline referral and periodic follow-up for gross motor
delay, hypotonia, tight Achilles tendons, and/or scoliosis. Frequency of
evaluations will depend on degree of scoliosis.
Pediatric Ophthalmology
(see UT providers
[4])
Refer for problems with eye muscle coordination, acuity, and
evaluation of ocular albinism.
Speech - Language Pathologists
(see UT providers
[65])
Evaluation and treatment are helpful for enhancing verbal and
nonverbal communication skills.
Medical Genetics
(see UT providers
[7])
Periodic visits can help establish an appropriate referral base
and can help explore differential diagnoses.
Pediatric Neurology
(see UT providers
[8])
Seizures may be difficult to control, and periodic evaluations or
concurrent care with a pediatric neurologist may be helpful. Recommend to
establish baseline and if there is a significant change in seizure pattern.
Gynecology: Pediatric/Adolescent; Special Needs
(see UT providers
[9])
Consider referral for problems associated with menses and concern
about pregnancy prevention.
ICD-10 Coding
Q93.51, Angelman syndrome
ICD-10 Other Deletions of Part of a Chromosome (icd10data.com) provides further coding details.
Resources
Information & Support
Related Portal
Content
The Medical Home Portal provides related general diagnositic
and management information, including:
- Osteoporosis and Pathologic Fractures
- Seizures/Epilepsy
- CBD for Neurologic Conditions in Children
- Dental and Oral Health Screening
- Mental Health Screening for Children & Teens
- Depression
- Anxiety Disorders
- Toilet Training Children with Complex Medical Conditions
- Constipation
- Angelman Syndrome (FAQ)
- Constipation (FAQ)
- Management and Prevention of Constipation in Children
- Depression (FAQ)
- Anxiety Disorders & Attention Deficit Hyperactivity Disorder (ADHD)
- School Accommodations: IEPs & 504s
For Professionals
Angelman Syndrome (GeneReviews)
Detailed information addressing clinical characteristics, diagnosis/testing, management, genetic counseling, and molecular
pathogenesis; from the University of Washington and the National Library of Medicine.
Angelman Syndrome (OMIM)
Information about clinical features, diagnosis, management, and molecular and population genetics; Online Mendelian Inheritance
in Man, authored and edited at the McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine
Management of Angelman Syndrome ( 274 KB)
Evidence-based recommendations from the UK (2010) for the management of patients with Angelman Syndrome.
Facts About Angelman Syndrome (ASF)
Detailed information about genetics, medical issues, behavior, and education; Angelman Syndrome Foundation
For Parents and Patients
Angelman Syndrome Foundation (ASF)
Information, resources, and discussion forums for individuals with AS and their families. This organization also raises money
for research on AS.
Angelman Syndrome (Orphanet)
Information and links about AS.
American Epilepsy Society
Information and resources to understand epilepsy, especially for those who are not familiar with the condition.
Tools
Sample Letter of Medical Necessity, Angelman/Rett (GeneDx.com) ( 24 KB)
A customizable letter in Word format to provide support for testing for Angelman and Rett syndromes; from GeneDx, a commercial
company that provides genomic testing and related services.
Services for Patients & Families in Utah (UT)
Service Categories | # of providers* in: | UT | NW | Other states (3) (show) | | NM | NV | RI |
---|---|---|---|---|---|---|---|---|
Gynecology: Pediatric/Adolescent; Special Needs | 9 | 3 | ||||||
Medical Genetics | 7 | 1 | 2 | 5 | 4 | |||
Pediatric Gastroenterology | 2 | 2 | 5 | 18 | ||||
Pediatric Neurology | 8 | 5 | 5 | 18 | ||||
Pediatric Ophthalmology | 4 | 1 | 6 | 6 | 8 | |||
Pediatric Orthopedics | 10 | 4 | 7 | 8 | 16 | |||
Pediatric Physical Medicine & Rehabilitation | 11 | 3 | 3 | 3 | 6 | |||
Speech - Language Pathologists | 65 | 4 | 23 | 11 | 34 |
For services not listed above, browse our Services categories or search our database.
* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.
Studies
Angelman Syndrome Studies (clinicaltrials.gov)
Studies looking at better understanding, diagnosing, and treating this condition; from the National Library of Medicine.
Angelman Syndrome Foundation Contact Registry
Sponsored by the Angelman Syndrome Foundation, the registry asks for contact and demographic data for individuals with Angelman
syndrome and their families so they can: notify potential participants about Angelman research trials and alert families about
recent events and research findings.
Helpful Articles
Articles about Angelman syndrome published within the last 5 years
Samanta D.
Epilepsy in Angelman syndrome: A scoping review.
Brain Dev.
2021;43(1):32-44.
PubMed abstract / Full Text
Cassater D, Bustamante M, Sach-Peltason L, Rotenberg A, Nespeca M, Tan WH, Bird LM, Hipp JF.
Clinical Characterization of Epilepsy in Children With Angelman Syndrome.
Pediatr Neurol.
2021;124:42-50.
PubMed abstract / Full Text
Bindels-de Heus KGCB, Hooven-Radstaake MT, Legerstee JS, Hoopen LWT, Dieleman GC, Moll HA, Mous SE, de Wit MY.
Sleep problems in children with Angelman Syndrome: The effect of a behavioral intervention program.
Res Dev Disabil.
2023;135:104444.
PubMed abstract
Khan N, Cabo R, Burdine RD, Tan WH, Keary CJ, Ochoa-Lubinoff C, Bird LM.
Health-related quality of life and medication use among individuals with Angelman syndrome.
Qual Life Res.
2023;32(7):2059-2067.
PubMed abstract
Carson RP, Herber DL, Pan Z, Phibbs F, Key AP, Gouelle A, Ergish P, Armour EA, Patel S, Duis J.
Nutritional Formulation for Patients with Angelman Syndrome: A Randomized, Double-Blind, Placebo-Controlled Study of Exogenous
Ketones.
J Nutr.
2021;151(12):3628-3636.
PubMed abstract / Full Text
Shaffer RC, Reisinger DL, Schmitt LM, Lamy M, Dominick KC, Smith EG, Coffman MC, Esbensen AJ.
Systematic Review: Emotion Dysregulation in Syndromic Causes of Intellectual and Developmental Disabilities.
J Am Acad Child Adolesc Psychiatry.
2023;62(5):518-557.
PubMed abstract
Authors & Reviewers
Author: | Kirti Sivakoti, MD |
Reviewers: | Lynne M. Bird, MD |
Adriana Gomes, MD |
2019: update: Alan F. Rope, MDA |
2019: revision: Arthur Beaudet, MDR |
2018: update: Alan F. Rope, MDA |
2015: update: Alan F. Rope, MDA |
2011: first version: Alan F. Rope, MDA; Lynne M. Kerr, MD, PhDA |
Page Bibliography
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Hum Mol Genet.
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Current evidence for adjunct pyridoxine (vitamin B6) for the treatment of behavioral adverse effects associated with levetiracetam:
A systematic review.
Epilepsy Behav.
2023;140:109065.
PubMed abstract
Bindels-de Heus KGCB, Hooven-Radstaake MT, Legerstee JS, Hoopen LWT, Dieleman GC, Moll HA, Mous SE, de Wit MY.
Sleep problems in children with Angelman Syndrome: The effect of a behavioral intervention program.
Res Dev Disabil.
2023;135:104444.
PubMed abstract
Carson RP, Herber DL, Pan Z, Phibbs F, Key AP, Gouelle A, Ergish P, Armour EA, Patel S, Duis J.
Nutritional Formulation for Patients with Angelman Syndrome: A Randomized, Double-Blind, Placebo-Controlled Study of Exogenous
Ketones.
J Nutr.
2021;151(12):3628-3636.
PubMed abstract / Full Text
Cassater D, Bustamante M, Sach-Peltason L, Rotenberg A, Nespeca M, Tan WH, Bird LM, Hipp JF.
Clinical Characterization of Epilepsy in Children With Angelman Syndrome.
Pediatr Neurol.
2021;124:42-50.
PubMed abstract / Full Text
Clayton-Smith J, Laan L.
Angelman syndrome: a review of the clinical and genetic aspects.
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Duis J,Nespeca M,Summers J,Bird L,Bindels-de Heus KGCB,Valstar MJ,de Wit MY,Navis C,Ten Hooven-Radstaake M,van Iperen-Kolk
BM,Ernst S,Dendrinos M,Katz T,Diaz-Medina G,Katyayan A,Nangia S,Thibert R,Glaze D,Keary C,Pelc K,Simon N,Sadhwani A,Heussler
H,Wheeler A,Woeber C,DeRamus M,Thomas A,Kertcher E,DeValk L,Kalemeris K,Arps K,Baym C,Harris N,Gorham JP,Bohnsack BL,Chambers
RC,Harris S,Chambers HG,Okoniewski K,Jalazo ER,Berent A, Bacino CA,Williams C,Anderson A.
A multidisciplinary approach and consensus statement to establish standards of care for Angelman syndrome.
Mol Genet Genomic Med.
2022;10(3):e1843.
PubMed abstract / Full Text
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Semin Pediatr Neurol.
2007;14(3):108-17.
PubMed abstract
Khan N, Cabo R, Burdine RD, Tan WH, Keary CJ, Ochoa-Lubinoff C, Bird LM.
Health-related quality of life and medication use among individuals with Angelman syndrome.
Qual Life Res.
2023;32(7):2059-2067.
PubMed abstract
Larson AM, Shinnick JE, Shaaya EA, Thiele EA, Thibert RL.
Angelman syndrome in adulthood.
Am J Med Genet A.
2015;167A(2):331-44.
PubMed abstract / Full Text
MedlinePlus.
Aripiprazole.
U.S. National Library of Medicine; (2017)
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Nature.
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PubMed abstract / Full Text
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Menstrual Management for Adolescents With Disabilities.
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Practice guidelines for the molecular analysis of Prader-Willi and Angelman syndromes.
BMC Med Genet.
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PubMed abstract / Full Text
Samanta D.
Epilepsy in Angelman syndrome: A scoping review.
Brain Dev.
2021;43(1):32-44.
PubMed abstract / Full Text
Shaffer RC, Reisinger DL, Schmitt LM, Lamy M, Dominick KC, Smith EG, Coffman MC, Esbensen AJ.
Systematic Review: Emotion Dysregulation in Syndromic Causes of Intellectual and Developmental Disabilities.
J Am Acad Child Adolesc Psychiatry.
2023;62(5):518-557.
PubMed abstract
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Behaviour problems in Angelman syndrome.
J Intellect Disabil Res.
1995;39 ( Pt 2):97-106.
PubMed abstract
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If not Angelman, what is it? A review of Angelman-like syndromes.
Am J Med Genet A.
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