Autism Spectrum Disorders (ASD): Identification

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Autism Spectrum Disorders (ASD) Identification
Management including Co-Morbidities

• Chuck J. Conlon, MD, FAAP
• cconlon_at_cnmc.org
• Director of Developmental Pediatrics
• Childrens National Medical Center

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ASD Objectives

• Discuss early indicators importance of early
  identification
• Explain current practice guidelines from AAP
  AAN
• Discuss medical management of common behavioral
  disturbances (co-morbidities) in children with
  ASD

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Autism Spectrum Disorders Overview I

• Prevalence 1 to 2.to 6 per 1,000 children
• Is there a rise in incidence? If so why?
• Neurobiologic disorder with question of
  environmental triggers
• First described in the 1940s Drs Kanner
  Asperger
• 6 to 10 recurrence rate in families

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Autism Spectrum Disorders Overview II

• Characterized by deficits in 3 domains i.e.,
  communication, social interactions, restricted,
  repetitive ritualistic behaviors
• Must meet DSM IV Diagnostic Criteria
• Onset prior to 3 years of age for Autism
• Rule out medical causes

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Autism Spectrum Disorders Classification

• Autistic Disorder
• Retts Disorder
• Childhood Disintegrative Disorder
• Aspergers Disorder
• Pervasive Developmental Disorder. Not Otherwise
  Specified

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Early Indicators of AutismSocial Interaction
Flags

• Less responsive to social overtures i.e., hard to
  reach
• Less participation in reciprocal play
• Less showing off for attention
• Less imitation of the actions of others e.g.,
  waving good-bye
• Less interested in other children (self-directed
  play)

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Early Indicators of AutismCommunication Deficits

• Less communication to direct another persons
  attention e.g., hold up object to show
• Less use of gestures i.e., proto-imperative
  proto-declarative pointing
• Less use of eye contact during interactions
• Inconsistent response to sounds

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Early Indicators of AutismRepetitive
Restricted Behavior

• Less functional play, especially with dolls or
  stuffed animals e.g., feeds with a spoon
• Less imaginative play.often imitative from
  favorite videos or books
• Repetitive motor behaviors e.g., spinning hand
  flapping, finger flicking, sifting
• Unusual visual interests

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Early Indicators of AutismRed Flags (AAN, 2000)

• No babbling, pointing or other gestures by 12
  months
• No single words by 16 months
• No meaningful 2-word phrases by 2 years
• ANY loss of ANY language or social skills at ANY
  age
• www.firstsigns.org

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Autism Spectrum DisordersBenefits of Early Id

• Early identification leads to early intervention
• Helps families to understand their child and
  advocate for services
• Early intervention can lead to improved cognitive
  function, communication, as well as enhanced peer
  interactions and decreased behavioral
  difficulties
• Early intervention study for children with ASD lt
  3 years Dr Landa at 1-877-850-3372 or e-mail
  reach_at_kennedykrieger.org

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ASD Published Guidelines

• AAP Committee on Children with Disabilites 2001
  (Pediatrics, 107(5) 1221-26)
• American Academy of Neurology Child Neurology
  Society (Filipek et al., 2000 Neurology, 55
  468-479)
• CAN Consensus Statement (Geschwind et al., 1998,
  CNS Spectrums, 3 40-49.

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Integration of Recommendationsfrom Guidelines on
ASD I

• Developmental surveillance and screening
• Best screening - PARENTAL CONCERN but lack of
  parental concern does not r/o disorder
• Referral to community resources i.e., ITP/PIE/CF
• Diagnosis best by multidisciplinary team BUT
  availability is limited waiting lists are long
• Single subspecialty providers e.g., dev peds,
  child neurologist, child psychologist/psychiatrist

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Inegration of Recommendations from Guidelines on
ASD II

• Evaluation of cognitive and adaptive skills
• Comprehensive eval of communication including
  higher order language function i.e., semantic
  pragmatic language (Infant Rosetti CASL or
  Comprehensive Assessment of Spoken Language)
• Audiological evaluation
• Other medical work-up

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ASD Medical Evaluation

• Genetic studies high resolution karyotype, DNA
  probe for Fragile X, FISH studies in children
  with MR, dysmorphic facies or FH
• Metabolic screening plasma amino acids, urine
  organic acids, urine metabolic screen (as above
  and/or lethargy, cyclic vomiting, early seizures)
• Others.lead, etc
• EEG if regression, seizures, significant staring
  spells or child is nonverbal
• CT scan or MRI usually not indicated even with
  megalencephaly

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ASD Role of Primary Care Provider

• The Medical Home (Pediatrics 2002, 110 184 to
  186) care coordination/screen
• Provide early identification referral to
  community based programs for treatment
• Referral to medical subspecialists for further
  evaluation, diagnosis treatment
• Provide parent education and support

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ASD Educational Programs

• Should facilitate functional communication,
  social skills, learning and improve behavior
• Vary in philosophy, curricula and strategies
• Autism Programs reduced ratio classes to work
  on joint attention, imitation, etc.
• TEACCH- classroom parent training
• Applied behavioral analysis, discrete trials
  (Lovaas method)

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ASD Additional Treatments

• Behavioral support (ABCs of Behavior)
• Social pragmatic language skills training
• Family support, i.e. education, respite, parent
  groups
• Medications
• Complimentary alternative interventions

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ASD Family Support

• Respite options in the community e.g., McLean
  Bible Church Saturday program, CARD, Autism
  Society of America or ASA (parent groups,
  Advocate, etc.)
• Websites
• ASA www.autism-society.org
• Families for Early Autism Tx www.feat.org
• Yale Child Center info.med.yale.edu/chldstdy/auti
  sm
• www.aspergersyndrome.org

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ASD Medication Management

• Identify target symptoms or indications
• Need for Functional Behavioral Analysis
• Research is VERY limited/small sample size
• Medication responsive problems
• Attention disorder internal or external
• Anxiety obsessive compulsive symptoms
• Aggression/tantrums/self-injurious behaviors
• Sleep difficulties/ Appetitie or feeding issues

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ASD Hyperactive/ADHD Sxs

• Overactivity, inattention, impulsivity not
  universal
• Heterogenous response to stimulants
• Subset will show increased irritability,
  hyperactivity, stereotypic behaviors agitation
  (adverse events are short lived)
• Start very low, titrate slowly

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ASD Hyperactive/ADHD Sxs

• Stimulants (RUPP study underway studying MPH)
  e.g., concerta 18mg focalin 1.25 to 2.5 mg
  metadate CD 5 to 10 mg, etc
• Alpha adrenergic agonists e.g., clonidine 0.025mg
  2 to 3x/day tenex 0.25 to 0.5 mg qhsthen bid
• Strattera 0.5 mg/kg/day titrate slowly
• Others atypical/typical antipsychotics,
  anafranil, naltrexone, wellbutrin

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ASD Anxiety/Perseveration(OCD)

• SSRIs e.g., luvox, prozac, zoloft, celexa,
  lexapro, paxil as well as anafranil
• Luvox in adults (DB/PC) reduced repetitive
  thoughts, behaviors, aggression may improve
  language/social skills 6.25 to 12.5mg titrate
  up
• Open-label trials prozac, zoloft, buspar
• Subset will have increased activity/impulsivity
• Anxiolytics ativan (dental work), xanax

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ASD Disruptive Irritable Behaviors

• Tantrums, aggression, self-injury, agitation,
  screaming, rigidity
• Atypical antipsychotics risperdal, zyprexia,
  seroquel, geodon, abilify
• McCracken et al (NEJM2002347314-21)
• Risperdal improved behaviors in 69 vs placebo in
  11.5 extrapyramidal sxs/tardive dyskinesia rare
  unless on medicationfor many years
• Watch weight! Monitor FBS/HgbA1C/lipids
• Start 0.25 mg 1 to 2X/day titrate

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ASD Sleep

• Importance of developing good sleep hygiene or
  routine
• Medications as an adjunct
• Antihistamines such as Benadryl
• Other meds clonidine (0.025 0.05mg), remeron
  (7.5mg), trazodone (12.5mg)
• Melatonin 0.5 mg (physiologic dose)
• Increase by 0.5 mg every 4 to 5 nights up to 3 -
  6mg

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ASD Appetitie/Feeding Issues

• Often behaviorally based on color, texture, smell
  
• Prevent food jags i.e., zip lock bags, vary
  food preparations, etc.
• Appetite enhancer periactin 4mg qhs to 4mg 2 to
  3x/day
• Appetitie suppressor topamax 7.5 to 15 mg

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ASD Complimentary Interventions I

• Anecdotal studies, single-subject
  trials,nonrandomized designs non-placebo-control
  led studies
• Vit B6 and Mg ? sensory neuropathy
• DMG/TMG (Di-/Trimethylglycine)
• Vit C inhibits central DA dec stereotypies
• Vit A improve immune function

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ASD Complimentary Interventions II

• Casein and gluten free diets i.e., Special Diets
  for Special Kids by Lisa Lewis
  http//members.aol.com/autismndi
• Secretin 6 clincal trials, PC no effect
• Chelation DSMA has liver kidney potential
  toxicities
• Auditory integration therapy
• MMR