Prevalence of Autism Spectrum Disorders & Autistic Traits in a Youth Mental Health Service

1. Prevalence of Autism Spectrum Disorders & Autistic Traits in a Youth Mental Health Service Dr Rick Fraser Sussex EIP service SPRiG June 24th 2011

2. Overview • Autism spectrum disorders • Autism and psychosis • ASD in Orygen data • Further research/clinical development

3. Autism Spectrum Disorders • Autism as a concept has developed over the past 50 years since Kanner first described it in 1943 • Developmental disorder • Classic triad of symptoms • qualitative impairments in social interaction • qualitative impairments in communication • restricted/repetitive patterns of interests and behaviours • Impairments present before age 3 years • Present model of a continuum of related disorders, referred to as autism spectrum disorders, with classic Kannerian autism lying at one extreme.

4. Epidemiology of ASD • ASD ~ 1 per 100 (Schechter , 2008) • Autism ~ 0.5 per 1000 (Fombonne, 2009) • More common in the paediatric population than are some better known disorders such as diabetes, spina bifida, or Down syndrome (Matson, 2007) • Male:female ratio of approx 4:1 (Fombonne, 2005)

5. Misdiagnosis of ASDs • Schizophrenia spectrum • Social phobia • OCD • Depression/Bipolar • GAD • Schizoid PD • Other developmental disorders & LD • Conduct disorder

6. Autism and Psychosis • Can co-occur (Skokauskas , 2010) • Can be difficult to distinguish some psychopathology (Dossetor, 2007) • Some commonalities in cognitive dysfunction eg Theory of Mind (Pilowsky, 2000) • Historically • Autism definition = from Greek autos ‘self ’ (Oxford Dictionary) • 1911 - Bleuler’s 4 As of schizophrenia (ambivalence, loosening of associations, affective incongruity & autism) • 1960’s – Autism as ‘Childhood schizophrenia’

7. Autism and Schizophrenia • Both neurodevelopmental disorders. • Symptoms of autism first appear during early life while schizophrenic positive symptoms do not typically appear until adolescence at the earliest (Delisi, 1992). • Distinct disorders – but are they?? • May be some degree of clinical and phenomenological overlap (Skokauskas, 2010). • Potential for misdiagnosis (Nylander & Gillberg, 2001)

8. Autism and Schizophrenia • Autism shares many negative features of schizophrenia, such as social withdrawal and communication deficiencies, but not positive symptoms such as hallucinations and delusions (Andreasen et al, 1986). • No greater rate of schizophrenia reported in those with ASD compared to normal population (Asperger 1:200) • - or is there? (Mouridsen, 2008) • Early onset SCZ – may show premorbid ASD (McKenna, 1994) • Possible common genes eg MECP2 (Shibayama, 2004) • Recent study – higher rate of schizophrenia in parents of those with ASD (Daniels, 2008)

9. Psychotic Disorders and ASD(Skokauskas, 2010)

10. Prevalence of Autism Spectrum Conditions in a Youth Mental Health ServiceFraser R, Cotton S, Angus B, Gentle E, Allott K, Thompson A, 2011

11. Orygen Youth Health • First YMHS in Australia (? world) • 15 – 25 year olds • >1,000,000 in catchment area • 180,000 in age range • >2000 referrals per annum (screening & assessment) • Provision of services to around 600 young people at any one time • EPPIC, PACE, Mood, HYPE clinics • Caseloads of 20-35 per full time case manager

12. Orygen ASD Prevalence Study 2008 • Cross sectional study • Total 523 young people • Information from treating clinicians – interview with DSMIV PDD classification as prompt – preceded by 3 in-house education sessions re ASD/psychiatric comorbidity • Autism, Asperger’s Syndrome and PDD NOS (not Rett’s or Childhood Disintegrative Disorders) • 1) Definite diagnosis • 2) Autistic traits (> 1 trait from 3 domains) • 3) No traits

13. Sample Characteristics • Mean age – 19.7 • Male – 45.5% • Female – 54.5%

14. Audit Results - EPPIC • Total – 282 • ASD confirmed = 3.4% • ASD traits = 9.6% • Potential total ASD – 13% • Male 72% • Female 28%

15. Audit Results - PACE • Total - 89 • ASD confirmed = 1.7% • ASD traits = 10.3% • Potential total ASD = 12% • Male – 39% • Female – 61%

16. Mood Clinic • Total - 152 • ASD confirmed = 5.0% • ASD traits = 3.57% • Potential ASD = 8.57% • Note – none in HYPE

17. Audit Results - OYH • 3.4% confirmed rate of ASD in OYH • 7.8 % ASD traits in OYH • 11.2% total confirmed and ASD traits in OYH • Approx 60% in EPPIC • Approx 10% in PACE • Mean ages • ASD confirmed = 17.0 • ASD traits identified = 19.81 • No ASD = 20.02

18. Conclusions • Rate of ASDs in youth mental health service higher than in community settings (3.4%) • Significant number of other young people with ASD traits and possible undiagnosed ASD (7.8%) • ASD/psychiatric comorbidity potentially complicates diagnosis and treatment • Younger age for those with prior diagnosis of ASD – possibly indicating greater impairment when comorbid conditions

19. Validation of an ASD screening tool for use in a community based youth mental health service(Fraser, Cotton, Gentle, Thompson) • Cross sectional 3 phase study • Phase 1 screening questionnaire of all OYH clients via case manager – ASDASQ – 10 item screening questionnaire • Phase 2 further questionnaires of screen positives plus control group – looking at comorbidity - SCID I & II • Phase 3 gold standard for ASD diagnosis – clinical interview/ADI for screen positives and sample of controls • Aims • Validate ASDASQ for use in youth population • Further information regarding comorbidity and potential misdiagnosis

20. ASDASQ • 1. Does the patient have any problems regarding contacts with others? (e.g. cannot get or keep friends the same age, or cannot get reciprocally satisfying contacts with sexual partners). • 2. Is the patient odd, eccentric “one of a kind”? • 3. Do you find the patient compulsive or rigid, occupied by rituals, routines or rules? • 4. Has the patient trouble with clothing, grooming and personal care? (e.g. conspicuously old-fashioned or ill-fitting clothing). • 5.Has the patient, or has he/she earlier had special interests, i.e. an intense interest that keeps the patient from engaging in other activities, or an interest that the patient wants to talk about all the time? (The subject of interest is not important, but the intense engagement or repetitive talking about it) • 6. Has the patient a bizarre language or a strange/unusual voice? Does he/she speak in a very grammatical or old-fashioned way, or use standard phrases or clichés, or talk in an unnecessarily loud or low voice? Does he/she talk in a monotonous, shrill or whining voice? • 7. Has the patient an unusual non-verbal communication, e.g. abnormalities in gaze, gestures or facial expression, unusual posture, stiff gait etc? • 8. Does the patient seem to have a lack of common sense, or lack the ability to understand or foresee the consequences of his/her doings or sayings? This might cause the patient to repeatedly get into difficult or embarrassing situations, or get others into these situations. • 9. Is the patient very uneven in his/her abilities i.e. very skilful in some areas while lacking elementary knowledge or skills in others? • 10. Has the patient had any contacts with child and adolescent psychiatry?

21. Preliminary results from Phase 1 • Total 506 registered clients • 482 ASDASQ (24 missing) • 36 scored > 7 = 7.5% (at risk of ASD) • 7 scored 8 • 4 scored 9 • 5 scored 10 •  13 scoring 6 • If cut off is > 6 then = 10.2% (at risk of ASD) • 1 scoring 5 with a previously diagnosed ASD

22. ASDASQ scores

23. Initial conclusions • Similar rates of ASD & at risk of ASD to previous study reinforcing idea that there are potential undiagnosed ASDs within the service • Potentially short 10 item screening tool will be valid in youth population • Comorbidity data not yet analysed

24. ASD Comorbidity Clinic in OYH • Diagnostic review • Reviews • Treatment • 2ry consultation • Group programme • Research • Database • ASD special interest group • Links with other clinics and research centres

25. Psychoeducation materials

26. Future possibilities for Sussex • Increase awareness of ASDs among clinicians • Staff training • Research collaborations • Increase knowledge base through publication • Practice guidelines – esp comorbidity and working with young people/adults • Service development in EIS – ASD Special Interest Group • Encourage links with existing services – CAMHS/Neurobehavioural clinic/ADHD service etc • Youth ASD/developmental disorders service?

27. Thank you