Brian Bonfardin M.D. brianbonf@aol.com Clinical Faculty ETSU Dept. of Psychiatry

1. ASD: Clinical Applications Brian Bonfardin M.D. brianbonf@aol.com Clinical Faculty ETSU Dept. of Psychiatry

3. Objectives

4. History of DSM and Autism • 1968: DSM II used the label autism to describe childhood schizophrenia. • 1980: DSM III included Autism as Infantile Autism. • 1994: DSM IV introduced PDD with 5 subtypes.

7. Types of PDD • DSM IV labels basically historical labels. • Usefulness and connection of labels were questioned. • Coincided with a new clinical awareness of ASD. • Triggered the “Asperger’s awakening.”

9. Rhett’s Syndrome • 1966 Andreas Rhett published reports of girls with similar symptoms. • 1983 BengtHagberg introduced Rhett’s to Annals of Neurology. • 1999 Ruthie Amir discovered MECP2 X- linked dominant disorder. • Methyl Cytosine Binding Protein dysregulation.

10. Rhett’s Syndrome • CerebroatrophicHyperammoneia starts at 6 to 18 months of age. • Hand wringing, washing/clapping movements, head growth stops. • Prone to apnea/hyperventilation. • Limited awareness, seizures and motor loss.

11. Childhood Disintegrative Disorder (CDD) • 1908 Theodor Heller described dementia infantilis marked by psychosis. • After 2 years normal development abrupt onset of ASD in severe form and loss of motor skills. • Rare cause of ASD.

13. Kanner’s Autism • 1943 paper Autistic Disturbances of Affective Contact describing 11 children. • 1930 to 1959 directed Johns Hopkins Child Psychiatry. • 1960’s to 1970’s oversaw and edited Journal of Autism.

14. Classic Autism • Noticeable social problems at 1 year of age. • Plateau or regression at 10 to 30 months. • Core symptoms: social skills, communication, restricted interests. • Subsequent intellectual, sensory and motor disabilities. • Variety of behavioral problems.

15. PDD NOS • Atypical Autism doesn’t meet all three categories. • Clear causative factor (genetic, sensory, medical). • Later age of onset. • Milder (IQ, motor, sensory) than Classic Autism.

16. Aspergers Syndrome • 1944 Autistic Psychopaths in Childhood described four “little professors” with mild ASD symptoms. • 1981 Lorna Wing added AS to ASD. • 1991 UtaFrithtranslated original paper adding much to concept.

19. Epidemiology • “90% of Autism is Genetic.” • Not related to environment. • No clear drug or chemical causes. • Autism 5-10/10,000. • PDD NOS 8-5/10,000. • Aspergers 2-60/10,000. • Total 15-85/10,000. • Prevalence of 1/1000 or greater.

21. Asperger Explosion • ASD without Intellectual disabilities. • Replaced A Cluster personality disorders. • Represents social impairments. • High Function Autism (HFA) intelligent and odd. • Easiest to assess, study and treat.

22. Epidemic of Autism • Study found a 230% increase in cases of Autism in CA over the past 10 years. • School systems are providing comprehensive behavioral services for Autism in early childhood.

29. Broader Autistic Phenotype • Broader Autistic Phenotype is marked by personality qualities seen in families. • Revolves around Asperser's Syndrome. • Aloof, rigid, anxious, social isolated, restricted nonverbal skills. • Deficits in Executive Functions.

32. Treatment Spectrum • Rarest ASD is genetic/metabolic/medical, most severe (least responsive to treatment). • Mildest ASD is most common and least medical (most responsive to treatment). • In the middle is most typical/classic.

33. Behavioral Treatments • Behavioral treatments are always the first step prior to any medication. • The three pillars: communication, transitional programs, sensory integration. • Behavioral research has focused mainly on Intensive Behavioral Modification ABA and communication programs.

34. Communication • Programming addresses one of the core deficits of Autism. • Most training focuses in on picture or symbolic language. • Training is intensive, time consuming and repetitive. • Some research completed: TEACCH, PECS, Lovaas.

35. Social Skills Training • Social skills training utilizes variety of techniques breaking down complex social behaviors. • Communication training benefits day to day functioning. • Includes social cues, transition rituals, transition objects, and picture cards.

36. Sensory Integration • Uses a wide variety of stimulation—vestibular, skin, deep touch, massage—to enrich and calm. • May involve cerebellar pathways and ACH/serotonin stimulation to the brain. • Requires training, equipment and usually daily stimulation. • Little research.

37. Benefits of Early Interventions • Jacobson, et. al, 1998, showed a substantial savings with Early Behavioral Interventions (EBI). • Treatment costs are $30,000 to $40,000 and require 3 years of training. • 30% of patients achieve independent living.

38. ASD in Remission • Children getting early intensive treatments can lose many symptoms of ASD. • Move into average range in many areas. • Stereotypy, odd movements and social problems continue. • More mild more likely.

39. ASD in DSM 5 • Little change to original Autism criteria. • Three levels of severity based on social, communication, and rituals/repetitions. • Added language on supports needed. • All historical labels lost.

40. Social Communication Disorder • Impairment of pragmatics, social uses of verbal and nonverbal communicationand social relationships. • Functional limitations in effective communication, social participation, academic achievement, or occupational performance, alone or in any combination.

41. SCD • Rule out Autism Spectrum Disorder (ASD). • Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities).

42. ASD Spectrum • Consistent with clinical practice. • Level of severity of symptoms, medical, behavioral problems and IQ loss. • DSM V criteria based on Kanner’s Autism. • Devoid of genetic/medical causes, qualifiers for IQ, Behavioral or psychiatric symptoms. • No remission concept.