Transcript TM TM Prepared for your next patient. Autism Update 2011 Patricia Manning-Courtney, MD, FAAP The Kelly O’Leary Center for Autism Spectrum Disorders Division of Developmental and Behavioral Pediatrics Cincinnati.

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Prepared for your next patient.
Autism Update 2011
Patricia Manning-Courtney, MD, FAAP
The Kelly O’Leary Center
for Autism Spectrum Disorders
Division of Developmental and
Behavioral Pediatrics
Cincinnati Children’s Hospital Medical Center
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product label.
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Learning Objectives
 Define and describe autism spectrum disorders
(ASDs).
 Review epidemiology, demographics, and etiology.
 Review screening and diagnosis recommendations.
 Review treatment approaches.
 Discuss current controversies.
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PERVASIVE DEVELOPMENTAL DISORDERS
Autism
Asperger
Syndrome
Rett
Syndrome
Childhood
Disintegrative
Disorder
Abbreviation: PDD-NOS, pervasive developmental disorder-not otherwise specified.
PDD-NOS
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Changes in 2013…
 Diagnostic and Statistical Manual of Mental Disorders, 5th
Edition (DSM-5) revisions
− Autism spectrum disorders
• Includes autism, Asperger syndrome, PDD-NOS, and child
disintegrative disorder (CDD)
− Concentrates on required features
• Social/communication deficits
• Restricted, repetitive patterns of behavior, interests, activities
o Addition of sensory criteria
− Increases specificity while maintaining sensitivity
• Important to distinguish spectrum from non-spectrum
developmental disabilities
• Improves stability of diagnosis
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DSM-5 Criteria:
Social Communication
 Persistent deficits in social communication and social
interaction across contexts, not accounted for by
general developmental delays, manifested by all of
the following:
– Deficits in social-emotional reciprocity
– Deficits in nonverbal communicative behaviors
– Deficits in developing and maintaining relationships
appropriate to the developmental level
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DSM-5 Criteria:
Restricted/Repetitive Behaviors
 Restricted, repetitive patterns of behavior, interests,
or activities as manifested by at least 2 of the
following:
– Stereotyped or repetitive speech, motor movements, or
use of objects
– Excessive adherence to routines
– Highly restricted, fixated interests that are abnormal in
intensity or focus
– Hyper- or hypo-reactivity to sensory input or unusual
sensory interests
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DSM-5 Criteria
 Symptoms must be present in early childhood.
 Symptoms together limit and impair everyday
functioning.
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What Else Can Look Like ASD?
 Attention-deficit/hyperactivity disorder (ADHD) plus
anxiety
 Nonverbal learning disability
 Obsessive compulsive disorder
 Anxiety plus language delay (with/without sensory
issues)
 Cognitive delay plus anxiety
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Diagnostic Stability
 Likelihood of stable diagnosis is high
– If diagnosed with autism at 2 years of age with standard
tests by highly experienced clinicians
 If diagnosed with PDD-NOS at 2 years of age,
diagnostic shift is more likely, but still not common
– >10% shifted from PDD-NOS to out of spectrum
– 30% maintained PDD-NOS diagnosis at 9 years of age
– Most change occurred between 2 and 5 years of age
 We may see more “shift” than is reported in this
study…
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Epidemiology
 Traditionally a rare disorder occurring in 4–5 per
10,000
 Ratio of males to females unchanged (3–4:1)
 Recent studies show 1% of all 8 year olds with an
ASD
Kogan MD, Blumberg SJ, Schieve LA, et al. The prevalence of parent-reported diagnosis of autism spectrum disorder among
children in the US, 2007. Pediatrics. 2009;124(5):1395–1403; Centers for Disease Control and Prevention. Prevalence of autism
spectrum disorders—autism and developmental disabilities monitoring network, United States, 2006. MMWR Surveill Summ.
2009;58(10):1–20.
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Epidemiology
 Many studies rely either on parent report or school
record review.
 Kogan study found that of people reporting their
child had received a diagnosis of ASD, 40% reported
their child no longer had ASD.
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A More Recent Study
 Study in South Korea
– 1 in 38 children diagnosed with ASD (7–12 years of age)
– Collaboration with researchers at Yale Child Study Center
– Typical children and children in special education
participated in a 2 level screening/evaluation process
– A large number identified in typical schools
• 16% with intellectual disability
• 12% with superior intelligence
• 2/3 with milder form
Kim YS, Leventhal BL, Koh YJ, et al. Prevalence of autism spectrum disorders in a total population sample. Am J Psychiatry.
2011;168(9):904–912.
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Epidemiology
*Recent research has indicated that changes in diagnostic practices may account for at least 25% of the increase in prevalence
over time, however much of the increase is still unaccounted for and may be influenced by environmental factors.
©2009 Autism Speaks Inc. Autism Speaks and Autism Speaks It’s Time to Listen & Design are trademarks owned by Autism Speaks
Inc. All rights reserved.
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Changes in Prevalence of ASDs among
Children 8 Years of Age, 2002 to 2006
Abbreviation: ADDM, Autism and Developmental Disabilities Monitoring.
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Epidemiology
 “True” increase or “epidemic?”
 Increased awareness, broader diagnostic criteria,
diagnostic substitution…
 Probably a little of both…
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Etiology
 Unknown
– Initially described as a disorder of parenting/“refrigerator
mothers”
 Neurobiologic disorder
 Gene/environment interaction
 Role of other systems
– Immune
– Gastrointestinal (GI)
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Genetics
 Complex, yet strong genetic factors influencing
 Strongest evidence from twin studies with 60% of
monozygotic twins concordant for full syndrome;
90% for related social or cognitive abnormalities
 Risk of any form of PDD for sibling of proband with
autism as high as 5%
 Relatives may be affected by difficulties that are
conceptually related to autistic behaviors (broader
autistic phenotype)
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Recent Studies Suggest
Larger Environmental Role
 Previous studies suggested strong genetic role
 Current study looked at 192 twin pairs
– 54 identical, 138 fraternal
– Identical twins with 60–70% chance of dual diagnoses
– Fraternal twins with 20–30% chance of dual diagnoses
 Two-fold increase risk for ASD when mother on a
selective serotonin reuptake inhibitor (SSRI)
Hallmayer J, Cleveland B, Torres A, et al. Genetic heritability and shared environmental factors among twins with autism. Arch Gen
Psychiatry. Online July 2011; Croen LA, Grether JK, Yoshida CK, et al. Antidepressant use during pregnancy and childhood autism
spectrum disorders. Arch Gen Psychiatry. Online July 2011.
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Screening for ASD
 AAP recommendations
– Developmental surveillance at all well child visits
• Elicit parent concerns
– Developmental screening at 9, 18, and 30 (or 24) month
well child visits
• Use structured developmental assessment
– Screening for autism at 18 and 30 (or 24) month well child
visits
American Academy of Pediatrics Council on Children With Disabilities, Section on Developmental Behavioral Pediatrics, Bright
Futures Steering Committee and Medical Home Initiatives for Children With Special Needs Project Advisory Committee.
Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental
surveillance and screening. Pediatrics. 2006;118(1):405–420; Johnson CP, Myers SM, and American Academy of Pediatrics Council
on Children With Disabilities. Identification and evaluation of children with autism spectrum disorders. Pediatrics.
2007;120(7):1183–1215.
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This Just In!
 Study in Pediatrics
– Recommended against routine screening due to lack of
solid support for screening based on traditional “rules” for
screening tools
– Excellent points made:
• Poor specificity of screening tools
• Lack of validated interventions
• Long wait lists
 Still supportive of surveillance
Al-Qabandi M, Gorter JW, Rosenbaum P. Early autism detection: are we ready for routine screening? Pediatrics.
2011;128(1):e211–e217.
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Surveillance of ASDs
 Direct observation/interactions/“clinical probes”
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Pointing and directing child to “look” (12–15 months)
Calling child’s name (12 months)
Asking “Where’s mommy?”
Eye contact, gaze referencing, pointing—evidence of joint
attention
– Observe for unusual movements (looking at things closely,
out of corner of eye, repetitive movements, sensitivities)
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Surveillance of ASDs
 Probing questions for parents:
– What is your child’s favorite toy/type of play? (12 to 18
months)
– Does your child babble? Wave bye-bye? Raise arms to be
lifted? Hear your voice as well as other things in the
environment? (9 to 12 months)
– Does your child have echolalia, “pop-up” words,
exceptional labeling? (12, 15, and 24 months)
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Surveillance of ASDs
 “Development of social skills and language is more delayed
and characteristically ‘out of sync’ with motor, adaptive and
cognitive functioning.”
Johnson CP. Recognition of autism before age 2 years. Pediatr Rev. 2008;29(3):86–96.
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Screening Tools
 No validated tools for use in children under 18
months
 Level 1 screening tools for at risk or no risk children
– Checklist for Autism in Toddlers (CHAT)
– Modified Checklist for Autism in Toddlers (M-CHAT)
– Pervasive Developmental Disorders Screening Test-II
(PDDST-II)
 No recommendation for screening school age
children
– Consider Social Communication Questionnaire
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M-CHAT
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23 yes-no questions
Measures social reciprocity, language, some motor
18 months to 4 years of age
Detects ASD, language impairment, mental
retardation
 Sensitivity/specificity
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M-CHAT and Autism Screening
 Failing score if 2 or more critical items or any 3 items
are failed
 Free download at www.firstsigns.org
 2-page scoring guide
 Takes 5 minutes to complete and 5 minutes to score
 Autism screen recommended by AAP Autism Expert
Panel for use at 18–24 month well-child visit
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Diagnosis
 Comprehensive, multidisciplinary evaluation
 Autism Treatment Network Protocol
– Medical evaluation
– Psychological evaluation
– Autism Diagnostic Observation Schedule (ADOS), other
autism specific diagnostic tools
– Screening for common, related medical issues
• Sleep problems, GI problems
 DSM-IV criteria insufficient
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Treatment: Getting Started
 Speech/Language Therapy
– Picture Exchange Communication System
– Auditory Integration Therapy
 Occupational Therapy
– Sensory Integration
 Behavior Management
 Early Intervention/Pre-School/School-Age
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Treatment:
More Intensive Approaches
 Applied Behavioral Analysis
– Only “evidence based” intensive intervention
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Son-Rise Program
Floor-time
Relationship Development Intervention (RDI)
Rapid Prompting Method (RPM)
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Treatment: Teach
 Treatment and Education of Autistic and Related
Communication Handicapped Children (TEACHH)
 Statewide system of services for individuals with
autism and their families
 Increase level of skill through adapting the
environment to accommodate the characteristics of
children with autism
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Treatment: Medical
 Regular follow-up recommended
– Monitoring, screening of common medical issues
• Sleep issues, GI issues, nutritional concerns
– Medication management
 Medications
 Alternative medical treatments
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Medications
 Target symptoms
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Anxiety
Aggression
Obsessive/compulsive features
ADHD features
Sleep problems
Seizures
Mood lability
Repetitive behaviors
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Medications
 Stimulants
 SSRIs
 Atypical antipsychotics
– Risperdal
 Melatonin
 Seizure medication
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Alternative Treatments
 Diet
– Gluten and casein free diet
 Vitamins
– B6, Mg, B12
– Super Nu Thera
 Yeast treatments
 Manipulation
 Secretin, intravenous immune globulin (IVIG),
steroids, antivirals, chelation
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Autism and Vaccines
 Currently no evidence to support a relationship
between vaccines and autism
 Theories continue to change
 Recent retraction of Lancet article
 Families still “caught in the middle” between
research and media
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Retraction
Retraction—Ileal-lymphoid-nodular hyperplasia, nonspecific colitis, and pervasive developmental disorder
in children
Following the judgment of the UK General Medical Council’s Fitness to Practise
Panel on Jan 28, 2010, it has become clear that several elements of the 1998
paper by Wakefield et al1 are incorrect, contrary to the findings of an earlier
investigation.2 In particular, the claims in the original paper that children were
“consecutively referred” and that investigations were “approved” by the local
ethics committee have been proven to be false. Therefore we fully retract this
paper from the published record.
The Editors of The Lancet
The Lancet, London NW1 7BY, UK
1Wakefield
AJ, Murch SH, Anthony A, et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in
children. Lancet. 1998;351:637–641.
2Hodgson H. A statement by The Royal Free and University College Medical School and The Royal Free Hampstead NHS Trust. Lancet.
2004;363:824.
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Prognosis
 Previous studies summarized:
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10–15% with good outcomes
15–25% with fair outcomes
15–25% with poor outcomes
30–50% with very poor outcomes
 Few current longitudinal studies exist
 Issues of diagnostic “shift,” diagnostic stability
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Resources
 Autism Society of America −
www.autism-society.org
 Autism Speaks – 100 Day Kit −
www.autismspeaks.org
 Centers for Disease Control and Prevention −
www.cdc.gov
 American Academy of Pediatrics −
www.aap.org
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