Low Functioning Autism Spectrum Disorder

Transcription

1 Low Functioning Autism Spectrum Disorder Walter E. Kaufmann Center for Translational Research Greenwood Genetic Center Department of Neurology, Boston Children s Hospital MIT Simons Center for the Social Brain

2 Disclosures Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest to disclose Consultant to Neuren, Edison, Newron, EryDel, Marinus, Echo Pharmaceuticals and GW Pharmaceuticals. Research support from Ipsen and Eloxx.

3 DSM-5 s Impact on: Intellectual Disability & Autism Spectrum Disorder

4 DSM-5 & Intellectual Disability: Potential Decrease in Prevalence 9% decrease

5 Autism Spectrum Disorder 51 E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism DSM-5 & Autism Spectrum Disorder: Autism spectrum Spectrum disorder Disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder Disorder, and intellectual Not disability, Explained social communication by Cognitive should Impairment be below that ex- 51 Selective pected for general developmental level. E. These disturbances are not better explained by intellectual disability (intellectual developmental Individuals disorder) with a well-established or global developmental DSM-IV diagnosis delay. Intellectual of autistic disability disorder, and Asperger s autism Note: disorder, spectrum or pervasive disorder developmental frequently co-occur; disorder to not make otherwise comorbid specified diagnoses should of autism be given spectrum disorder of autism and spectrum intellectual disorder. disability, Individuals social communication who have marked should be deficits below in that social ex- the diagnosis communication, pected for general but whose developmental symptoms level. do not otherwise meet criteria for autism spectrum disorder, Note: Individuals should be with evaluated a well-established for social (pragmatic) DSM-IV diagnosis communication of autistic disorder. disorder, Asperger s Specify disorder, if: If or Cognitive pervasive developmental Impairment disorder is Present, not otherwise it Should specified Be should Specified be given the diagnosis With or without of autism accompanying spectrum disorder. intellectual Individuals impairment who have marked deficits in social communication, With or without but accompanying whose symptoms language do not otherwise impairment meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder. Associated with a known medical or genetic condition or environmental factor Specify if: Also (Coding problematic note: Use features additional leading code to mainly identify to the false associated positive medical diagnosis: or genetic condition.) With or without accompanying intellectual impairment behavioral Associated phenotypical another features neurodevelopmental, & psychiatric co-morbidities mental, or behavioral disorder (Coding With or note: without Use accompanying additional code[s] language to identify impairment the associated neurodevelopmental, mental, Associated or behavioral with a known disorder[s].) medical or genetic condition or environmental factor With (Coding catatonia note: Use (refer additional to the criteria code to for identify catatonia the associated associated medical with or another genetic mental condition.) dis- IAL

6 ASD in DSM-5 The Challenge of Demonstrating Selectivity Is there a problem with diagnosing ASD in ID? Too Early to Be Definitive but It Seems to Be the Case

7 Is there a problem with ASD Dx in ID (using DSM-5)? Decreased prevalence of ASD affects less ID

8 Is there a problem with ASD Dx in ID? Insights from Down syndrome, fragile X syndrome & Phelan- McDermid syndrome

9 % of subjects % of subjects Low Functioning Autism Spectrum Disorder Is there a problem with ASD Dx in ID? Insight from fragile X syndrome & Down syndrome Level of Intellectual Disability is Associated with ASD Dx Down Syndrome Fragile X Syndrome Intellectual ability and adaptive behavior profiling: DQ/IQ < Cognitive Level (IQ) DS+ASD DS+SMD DS Typical 10 0 < Cognitive Level (IQ) Capone et al. Am J Med Genet 134A: , 2005 Carter et al. Am J Med Genet 144B:87-94, 2007 FXS+ASD FXS Typical Kaufmann et al. Am J Med Genet 129A: , 2004 Budimirovic et al. Am J Med Genet 140A: , 2006

10 revised definitions of ASD 12 and by a better understanding of behavioral phenotypes associated with FXS. 6 Although variable in degree, a large proportion of individuals with FXS exhibit poor eye contact, difficulties with peer relationships, social withdrawal, Is there a problem with ASD Dx in ID? repetitive behaviors, and need for sameness (i.e., distress at apparently small changes in Insight from fragile X syndrome daily activities) 6,13,14. Depending on the gold standard research criteria used for the Variable prevalence of ASD in FXS diagnosis of autism or ASD, studies on males with FXS have reported that 30-54% met diagnostic criteria for autism by direct assessment and 46% by parent report 18. In Kaufmann et al. Pediatrics: in press addition, 30-43% of males met diagnostic criteria for ASD 19 or Pervasive Developmental Even controversial diagnosis Disorder-Not Otherwise Specified (PDD-NOS) 17. For females, 16-20% met diagnostic Journal of the American Academy of Child & Adolescent Psychiatry criteria for autism 16 or were assigned by parent report Several studies have Volume 49, Issue 9, September 2010, Pages New research attempted to delineate unique features of ASD in FXS; their findings show relatively Autism in Fragile X Syndrome: A Category Mistake? Scott S. Hall, Ph.D.,, Amy A. Lightbody, Ph.D., Melissa Hirt, M.A., Ava Rezvani, H.S., Allan L. Reiss, more prominent social M.D. withdrawal, higher levels of anxiety, and less intense simple and

11 Is there a problem with ASD Dx in ID? Insight from fragile X syndrome Psychiatric co-morbidities may influence diagnosis Hagerman et al. Pediatrics 123: , 2009

12 Is there a problem with ASD Dx in ID? Insight from fragile X syndrome Decreased prevalence of ASD using DSM-5 (males: 29% SCI, 86% RRB) Wheeler et al. J Autism Dev Disord 45: , 2015

13 Is there a problem with ASD Dx in ID (using DSM-5)? Insight from Phelan-McDermid syndrome Over-diagnosis of ASD in PMS (90% SCI, 55% RRB) Oberman et al. Orphanet J Rare Dis 10:105, 2015 Also Soorya et al. Mol Autism 4:18, 2013

14 Is there a problem with ASD Dx in ID? Insight from Down syndrome Is the diagnosis of ASD in DS (7-15%) Valid? Cluster Analysis of ABC-C: Likely Ji et al. J Intellect Disabil Res 55: , 2011

15 Is there a problem with ASD Dx in ID? Data from FXS, PMS & DS: several factors may contribute Intellectual impairment Unique behavioral phenotype features Psychiatric co-morbidities

16 Is there a problem with ASD Dx in ID? Potential Solutions Intellectual impairment

17 Is there a problem with ASD Dx in ID? Potential Solutions Intellectual ability and adaptive behavior profiling: DQ/IQ & AB ID is Inherent to ASD but Social rather than Communication skills predict Dx (& severity) Kaufmann et al. Am J Med Genet 129A: , 2004 Hernandez et al. Am J Med Genet 149A: , 2009

18 Is there a problem with ASD Dx in ID? Potential Solutions Intellectual ability and adaptive behavior profiling: AB Relatively Preserved Social Domain: Lower Concern for ASD Oberman et al. Orphanet J Rare Dis 10:105, 2015

19 Is there a problem with ASD Dx in ID? Potential Solutions Behavioral Phenotype Features

20 Is there a problem with ASD Dx in ID? Potential Solutions Analysis of Behavioral Phenotype Features ASD in DS: Impairment in Nonverbal Social Communication (e.g., gestures) Non-ASD in DS: Stereotypic Behavior ASD in FXS: Impairment in (Peer) Relationships Non-ASD in FXS: Eye Gaze Avoidance, Social Anxiety ASD in PMS: Abnormal Sensory Reactivity & Nonverbal Social Communication Impairment Non-ASD in PMS: Impairment in Social Communication

21 Is there a problem with ASD Dx in ID? Potential Solutions Psychiatric Co-morbidities

22 Is there a problem with ASD Dx in ID? Potential Solutions Analysis of Psychiatric Co-Morbidities ASD in DS: Stereotypic Behavior (SMD) & ADHD-like behaviors ASD in FXS: Anxiety- & ADHD-like behaviors ASD in PMS: Stereotypic Behavior (SMD) & ADHD-like behaviors

23 Is there a problem with ASD Dx in ID? Potential Solutions Adapting Diagnostic Instruments

24 Autism Spectrum Disorder ample, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers. Low Functioning Autism Spectrum Disorder Autism Spectrum Disorder Specify current severity: Severity is based on social communication impairments and restricted, repetitive patterns of behavior (seetable 2). Diagnostic Criteria (F84.0) B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the Is following, there currently a problem or by history in (examples ASD with are illustrative, ID? not exhaustive; Persistent see text): deficits in social communication and social interaction across multiple con- A. 1. texts, Stereotyped as manifested or repetitive by the following, Potential motor movements, currently Solutions or use by of history objects, (examples or speech are (e.g., illustrative, simple not motor exhaustive; stereotypies, see text): lining up toys or flipping objects, echolalia, idiosyncratic 1. phrases). Deficits in social-emotional reciprocity, ranging, for example, from abnormal social 2. Insistence approach and on sameness, failure of normal inflexible back-and-forth adherence conversation; to routines, or to ritualized reduced patterns sharing of verbal interests, or nonverbal emotions, behavior affect; to (e.g., DSM-5 failure extreme to initiate distress or respond at small to changes, social interactions. difficulties 2. with Deficits transitions, in nonverbal rigid communicative thinking patterns, behaviors greeting used rituals, for need social to interaction, take same ranging, route or eat for example, same food from every poorly day). integrated verbal and nonverbal communication; to abnormalities restricted, in eye contact fixated and interests body language that are or abnormal deficits in in understanding intensity or focus and use (e.g., of SCI 3. Highly strong gestures; attachment to a total to lack or of preoccupation facial expressions with unusual and nonverbal objects, communication. excessively circumscribed Deficits or in developing, perseverative maintaining, interests). and understanding relationships, ranging, for ex Hyper- ample, from or hyporeactivity difficulties adjusting to sensory behavior input to or suit unusual various interest social in contexts; sensory to aspects difficulties of the in sharing environment imaginative (e.g., play apparent or in making indifference friends; to to absence pain/temperature, of interest in peers. adverse response RRB Specify current to specific severity: sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement). Severity is based on social communication impairments and restricted, repetitive current patterns severity: of behavior (seetable 2). Specify B. Restricted, Severity repetitive is based patterns on social of behavior, communication interests, impairments or activities, as and manifested restricted, by reat Using ID- & syndrome-adapted instruments: DSM-5 s Novel Features CO NTIA

25 Is there a problem in ASD with ID? Potential Solutions Using ID- & syndrome-adapted instruments: Selected DSM Items DSM-IV-TR criteria (Combined AUC 0.923, prediction error rate 13.6%) Pedersen et al. Child Psychiatry Hum Dev: Aug 24, 2016

26 Is there a problem in ASD with ID? Potential Solutions Using ID- & syndrome-adapted instruments: SCQ & SRS in FXS Sensitivity FXS SCQ Sensitivity 61%, Specificity 70% SRS Sensitivity 97%, Specificity 21% D = ROC Curve for SRS Total CY C Y D= Specificity 0.00 Points labeled by: srs_t_tot_calc _cutpt optcorr optdist opty optsesp_ Correct rate Value Tentative SRS Cut-off: 73 (norm: 60) Correct Youden SRS T score (calculated) - total Distance to 0,1 Sens - Spec Idiopathic ASD Correct Dx SCQ (+) 97%, SRS (+) 80% ADOS (+) 96%. ADI-R (+) 98% J Autism Dev Disord 42: , 2012 Distance Sens - Spec SRS T score (calculated) - total

27 Summary Too early to be definitive: Slight decrease in ASD Dx with DSM-5 (perhaps also decrease in ID Dx) The challenge of demonstrating selectivity: beyond communication and overall intellectual impairment Psychiatric co-morbidities & behavioral phenotype can also affect ASD Dx Evaluating intellectual ability is essential in ASD Dx Considering psychiatric co-morbidities & behavioral phenotype in ASD Dx Using ID-, syndrome-adapted instruments

28 Acknowledgements Down Syndrome Team at the Kennedy Krieger Institute (G. Capone, J. Carter) Fragile X Team at the Kennedy Krieger Institute (D. Budimirovic, V. Talisa) & FXCRC (E. Berry-Kravis, S. Sherman, S. Kidd, R. Hagerman, D. Hessl, etc.) Phelan-McDermid Team at the Greenwood Genetic Center & Boston Children s Hospital (L. Boccuto, L. Oberman, K. Phelan, S. Sarasua) MIT Simons Center colleagues (M. Sur, R. Jaenisch) DSM-5 NDD Workgroup colleagues