Autism

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Autism

• Saundra Stock, M.D.

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Disease Overview
Pervasive Developmental Disorders (PDDs)
Childhood Disintegrative Disorder (CDD)
Autism Spectrum Disorders (ASDs)
Retts Disorder
Pervasive Developmental Disorder Not Otherwise
Specified (PDD-NOS)
Autistic Disorder
Aspergers Disorder
ASD is not a DSM-IV TR definition but reflects
categorization in the general public.
Tidmarsh L et al. Can J Psychiatry.
200348517-525 DSM-IV TR. Washington, DC
American Psychiatric Association 2000.
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Diagnostic Criteria
Autism is characterized by deficits in 3 core
areas before age 3 At least 6 items are needed
for diagnosis
Social Interaction(2)
Communication (1)
Behavior (1)

• Marked impairment in multiple nonverbal
  behaviors
• Failure to have developmentally appropriate peer
  relationships
• Lack of showing, bringing, or pointing out
  objects of interest
• Lack of social or emotional reciprocity

• Delay in, or total lack of, development of spoken
  language
• Marked impairment in ability to initiate or
  sustain conversation
• Stereotyped and repetitive use of language, or
  use of idiosyncratic language (echolalia, pronoun
  reversals, odd cadence, scripting)
• Lack of varied, spontaneous make-believe play or
  social imitative play appropriate to
  developmental level

• Preoccupation with 1/more stereotyped and
  restricted patterns of interest that are abnormal
  in intensity or focus
• Apparently inflexible adherence to specific,
  nonfunctional routines or rituals
• Stereotyped and repetitive motor mannerisms
• Persistent preoccupation with parts of objects

DSM-IV TR. Washington, DC American Psychiatric
Association 2000.
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Autismwhat is not

• Not synonymous with mental retardation
• Not related to IQ
• Mental retardation is IQ below 70 plus problems
  in social or occupational functioning
• Not the same as delays in developmental
  milestones or learning difficulties

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Theory of MindWhat does the boy thing is on the
fishing line?
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Screening questions

• Does your child take an interest in other
  children?
• Does your child ever point to things with the
  index finger to indicate interest in something?
• Does your child ever bring you objects to show
  you?
• Does your child imitate you? For example facial
  expression.
• Does your child respond if you call his name?
• If you point to something across the room, does
  your child look at it?

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Neurobiology

• No evidence linking MMR vaccine
• 1st birthday videos
• Fusiform gyrus for pts and relatives
• Whos afraid of Virginia Wolfe
• Theory of Mind (Baron-Cohen)
• Mirror neurons - pars opercularis inf orbital
  frontal cortex ? Social stories (carol gray)

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Visual tracking of faces

• People with autism viewing movie attend to
  different parts of the face compared to normal
  controls

Klin 2002 Arch Gen Psych
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Autism

• First described in 1943 by Leo Kanner
• Can show signs as early as 6 months
• Trouble with intersubjectivity - understanding
  what others think/feel
• Theory of mind
• Myths- MMR vaccine, low b vitamin

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Autism

• 1 in 150 children has autism (MgtF 41)
• 3/4 are mentally retarded
• Lower IQ associated with greater risk of seizures
  and poor outcomes
• 25-50 develop szs, often as adolescent
• Increased concordance monzygotic twins
• Idiot savants only 10 of pts with autism
• Larger brain size by age 1, abnl fusiform gyrus
  fxn

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Autism

• Co-occurs with many other medical conditions.
  Work up may include
• Genetic screening or chromosomal analysis
  (fragile X etc.)
• Brain imaging to r/o tuberous sclerosis
• EEG and neurologic consult

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Autism

• Best predictor of prognosis is language function
  at age 5
• Wait times to get into programs can be lengthy
• Treatment mainly psychosocial
• School programs, social skills, teaching theory
  of mind (carol grays social stories), parent
  education, respite for parents, support groups

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Importance of an Early Diagnosis

• Facilitates earlier educational planning
• Participation in intensive early intervention
  programs during toddler and preschool years
  improves long-term outcome for many children
• May ease family problems
• Identifies the need for family support and
  education
• Introduces strategies designed to help manage
  stress
• Ensures early delivery of appropriate medical care

1. Committee on Children With Disabilities.
Pediatrics. 2001107E85. 2. Filipek PA et al.
Neurology. 200055468-479.
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Children and Adolescents With Autistic Disorder
The Treatment Team
General or Developmental Pediatrician
Child Psychiatrist
Pediatric Neurologist
Effective patient care may include an
interdisciplinary treatment team
Psychologist
Speech Pathologist
Teachers
Social Worker
Parents
The Autism Society. http//www.autism-society.org/
site/PageServer?pagenameabout_whatis_diagnosis.
Accessed 11.15.06
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Behavioral Problems in Autism

• Associated Symptoms
• Agitation or aggression
• Hyperactivity
• Irritability
• Self-injurious behaviors
• Temper Tantrums
• Inflexible behavior
• When they emerge, these behavioral problems may
  have serious consequences for children and their
  families

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Pharmacology

• No curative medication
• Only to relieve symptoms
• End up on all kinds of medications
• Stimulants, antidepressants, mood stabilizers,
  antipsychotics
• Be cautious about medication interactions and the
  number of meds

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Pharmacology

• Stimulants were thought to be contraindicated in
  past
• Do not work as well for inattention in this
  population as basis for inattention different
  (I.e. not traditional ADHD)
• Often have more side effects than for other kids

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Pharmacology

• Serotinergic agents used for rigid or obsessive
  qualities
• Restricted range of interests
• Stereotypies
• Tantrums due to trouble with transitions
• SSRIs buspirone evidence equivocal in RCTs

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Pharmacology

• Mood stabilizers may help with impulsive
  aggression or explosive behavior - more recent
  studies indicate limited use
• Lithium, divalproex sodium, carbamazepine,
  oxcarbazine
• Blood draws can limit usefulness
• Can be difficult to assess toxicity

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Pharmacologyantipsychotics

• Many kids on chlorpromazine or thioridazine in
  past (rapid titration)
• Now use atypical antipsychotics
• Risperidone and aripiprazole studies in popn with
  autism and found to ?hyperactivity and
  irritability
• Risperidone FDA approved down to age 5
• Aripiprazole FDA approved down to age 6
• Lower doses than adults (start low go slow)
• Weight gain more problematic in kids

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Compared to older medication

• 43 difference btwn Risp and plc on Irritability
  scale - similar study with haloperidal showed 20
  difference
• 78 of kids on haloperidal had excessive sedation
  and 25 had an acute dystonic reaction
• RUPP study 59 of kids had mild sedation and no
  dystonic reactions with risp

Anderson LT J Autism Dev Disord 198919227-39
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Summary

• The core treatment for autism is psychosocial
• Medication can be adjunctive to behavioral
  treatment
• Targets of medication include rigid behaviors,
  aggression, irritability, hyperactivity and
  stereotypies
• Further info
• Autismspeaks.com
• Cure autism now