Autism and Psychiatric Management

1. Autism and Psychiatric Management By Faisal Ahmed, M.D

3. Classical Autism – typical presentation A three year old boy Pays little attention to his parents or other adults Repeats certain words in a stereotyped manner Fascinated with running water Watches fans and rotating wheels

4. Autism Part of pervasive developmental disorders Children with autism generally have problems in three crucial areas of development 1. social interaction 2. language 3. behavior Subnormal intelligence in two third of the patients

5. Social skills • Fails to respond to his or her name • Has poor eye contact • Appears not to hear you at times • Resists cuddling and holding • Appears unaware of others' feelings • Seems to prefer playing alone — retreats into his or her "own world

6. Language • Starts talking later than other children • Loses previously acquired ability to say words or sentences • Does not make eye contact when making requests • Speaks with an abnormal tone or rhythm — may use a singsong voice or robot-like speech • Can't start a conversation or keep one going • May repeat words or phrases verbatim, but doesn't understand how to use them

7. Behavior • Performs repetitive movements, such as rocking, spinning or hand-flapping • Develops specific routines or rituals • Becomes disturbed at the slightest change in routines or rituals • Moves constantly • May be fascinated by parts of an object, such as the spinning wheels of a toy car • May be unusually sensitive to light, sound and touch and yet oblivious to pain

8. Causes • No single cause. • May include: - Genetic Errors* - Environmental factors** - Other causes***

9. NEUROBIOLOGICAL FINDINGS IN AUTISM • Increased (peripheral) serotonin levels. • Persistent primitive” reflexes. • Increased head size (macrocephaly). • Changes in brain morphology/cytoarchitecture. • Failure to activate fusiform face region. • High rates of EEG abnormality/seizure disorder

10. Differential Diagnosis of Autism Hearing loss/ congenital deafness Childhood onset schizophrenia Mixed receptive/expressive language disorder Psychosocial deprivation

11. Age of Onset In most cases, the apparent onset of autism occurs within the first or second year of life. Age of onset (cases with clinical diagnosis of autism in DSM-IV field trial). (F Volkmar and A Klin, Issues in the classification of autism and related conditions, . New York: Wiley, vol. 1, p. 20.)

12. EVALUATION PROCEDURES: • Historical information* • Developmental and psychological assessment** ( CHAT scale, etc) • Psychiatric examination*** • Medical evaluations****

13. Commonly used instruments include: • Childhood Autism Rating Scales (CARS) (Schopler, et al., 1988) - an instrument in which individuals of different ages are rated, some training is required, • Autism Behavior Checklist (Krug, Arick, and Almond, 1980) - a screening instrument completed by teachers, • Autism Diagnostic Interview - Revised (ADI-R) (Lord, Rutter & Le Couteur, 1994), a semistructured interview for parents, • Autism Diagnostic Observation Scale (ADOS) (DiLavore, Lord & Rutter, 1995) an observational scale for children and adults.

14. Prevalence of Autism More common in boys 3 to 5:1 1 to 2 per thousand to 1 in 500

15. Treatment in Autism Educational therapies * Behavior and communication therapies** Medications for self-injurious behavior and repetitive behavior*** Atypical antipsychotics Stimulants SSRIs

16. Prognosis Most are severely impaired as adults and need assistance with living

17. Bad Parenting Skills

18. Asperger’s Disorder – case presentation Three year old can communicate verbally Few hand gestures Poor eye contact Little social interest Odd behavior patterns Age appropriate cognitive and self care skills

20. Asperger’s Disorder At the milder end of this Autism spectrum. Different from Autism.*

21. AUTOBIOGRAPHICAL STATEMENT OF A 10 YEAR OLD BOY WITH ASPERGER DISORDER My name is Robert Edwards. I am an intelligent, unsociable but adaptable person. I would like to dispel any untrue rumors about me. I cannot fly. I cannot use telekinesis. My brain is not large enough to destroy the entire world when unfolded. I did not teach my long haired guinea pig, Chronos, to eat everything in sight (that is the nature of the long haired guinea pig).*Name changed. Volkmar, Klin, Schultz, Rubin, & Bronen, Asperger's disorder: Clinical case conference. American Journal of Psychiatry, 157(2), 262–67, 2000.

22. Age of onset Noticed between 3 to 5 years of age or even later More common in boys Incidence as high as 1 in 500

23. Differential Diagnosis Autistic Disorder (language developed) Schizophrenia of childhood onset Rett’s disorder (in girls) Obsessive Compulsive Disorder Schizoid Personality Disorder

24. Prognosis Better than autism Likely to hold a job where socialization is not required Computers programmers, mathematicians, engineering One study reported more than twice the of first degree relatives of children with Asperger's in these fields.

25. Rett’s Disorder – case presentation Infant girl Six months of normal development Losing her acquired skills By 18 months little social interaction, ataxic gait, odd finger tapping and hand wringing gestures

26. Rett’s Disorder Decreased social interest and skills Brief period of normal functioning Stereotyped hand-wringing movements Psychomotor retardation Mental retardation Associated with a specific genetic defect in MECP2, a regulator gene on the X chromosome.

27. Rett Syndrome

28. Onset and Occurrence Before 4 years of age Usual onset between 5 and 48 months Only in girls. Prevelance between 1 in 15,000 and 1 in 22,000 females

29. Treatment & Prognosis Progressive and lifelong At this time there are no specific treatments. Various supportive treatments are used, including special education, occupational, physical and respiratory therapies

30. Childhood Disintegrative Disorder-case presentation Three year old boy Previous normal functioning* Stops speaking and interacting with others Can no longer dress himself Begins to wet and soil himself Mental retardation

31. Onset & Occurrence Two to ten years of age when skills are lost Very rare More common in boys

32. Prognosis Chronic and lifelong

33. Pervasive Developmental Disorders: Treatments • The multiple developmental and behavioral problems associated with these conditions often require the care of multiple providers; coordination of services and advocacy for individuals and their families is important. • Early, sustained intervention is indicated as is the use of various treatment modalities (e.g., pharmacotherapy, special education, speech-communication therapy, and behavior modification).

34. Treatment plan • Establishing goals for educational intervention. • Establishing target symptoms for intervention. • • Prioritizing target symptoms/co-morbid conditions. • • Monitoring multiple domains of functioning (including behavioral adjustment, adaptive skills, academic skills, social-communicative skills, and social interaction with family members and peers). • Monitoring medication for efficacy and side effects, as appropriate.

35. Pervasive Developmental Disorders: Treatments Intensive behavioral intervention Goals: Decrease behavioral symptoms Aid in development of delayed, rudimentary, or nonexistent functions (i.E. Language and self-care skills)

36. Pervasive Developmental Disorders: Treatments Intensive behavioral intervention Components: Intensive one on one tutoring utilizing positive reinforcement Ex: reward appropriate behaviors with food or praise (waving bye-bye) Parent training Show parent’s how to shape appropriate behaviors using reward system

37. Pharmacotherapy • Increase the ability of persons with PDD to profit from educational and other intervention (McDougle, 1997). • interventions should be focused on the target symptom without losing sight of the larger clinical picture, • Since individuals with autism/PDD are often nonverbal, reliance typically is made on reports and observation of specific behaviors.

38. Neuroleptics • intensively investigated in individuals with autism • fundamental mode of action appears to be dopamine receptor blockade • Haldol, Risperdal, Abilify • The results of numerous controlled clinical trials in children with autism suggest the potential for significant benefit in terms of reduced stereotype and withdrawal thus facilitating learning (Campbell, Anderson & Small, 1990a). • In the US, risperidone and abilify are approved by FDA for the treatment of irritability associated with autistic disorder in children and adolescents . • The most frequent side effects include sedation and irritability but in general are dose related • Longer-term administration can be associated with other side effects such as drug related dyskinesias including tardive dyskinesia , weight gain, Risk of Diabetes, Abnormal Cholesterol levels. • the long-term safety of neurolpetics in children and adolescents with autistic disorder remains to be fully determined

39. Selective Serotonin Reuptake Inhibitors. • potent inhibitors of the serotonin transporter and were initially of interest in autism given the observation of high peripheral serotonin levels in autism. • Fluvoxamine, Fluoxetine, Clomipramine • Target Symptoms: Depression, Anxiety, obsessive-compulsive-like behaviors • Cook et al. (1992) found that fluoxetine (in doses ranging from 20 mg every other day to 80 mg daily) was associated with improved levels of functioning in individuals with autism and with mental retardation without autism • Side effects: insomnia, hyperactivity, restlessness, agitation, and decreased appetite, Seizure and heart conduction delays with Clomipramine.

40. Mood Stabilizers • Valproic Acid, Lithium, Carbamazapine, Oxycarbamazapine • Most effective in comorbid Bipolar disorder or other mood disorders. • Mixed results in studies. • Side effect Burdon

41. Anxiolytics

42. Question Children with autism generally have problems in three crucial areas: Social interaction, anxiety, aggression Conduct, humor, expressed language Social interaction, behaviors, language Impulse control, Mood and affect, cognitive ability.

43. Answer • C: Social interaction, behaviors, language

44. Question • Autism is known to be caused by a single gene located on Chromosome 14? • True • False

45. Answer • False • Causes include: - Genetic Errors - Environmental factors - Other causes

46. Question • Asperger disorder is another form of autism with a difference of mood unstability. • True • False

47. Answer • False • Only difference is language and Age appropriate cognitive and self care skills