Autism Spectrum Disorder: A Primer for PCPs Learning Objectives 1. Define current ASD diagnostic criteria 2. Identify ASD screening tools, including the M-CHAT-R/F 3. Describe treatments/interventions for ASD 4. Recognize common co-occurring problems and comorbid conditions Faculty Leandra N. Berry, PhD Assistant Professor, Section of Psychology Department of Pediatrics Baylor College of Medicine Clinical Neuropsychologist and Associate Director of Clinical Services Autism Center at Texas Children's Hospital Houston, Texas Slides are current as of the time of printing and may differ from the live presentation due to copyright issues. Please reference www.pri-med.com/southwest for the most up-to-date version of slide sets. Southwest Annual Conference Houston, Texas June 23-25, 2016
What is Autism Spectrum Disorder (ASD)? Deficits in Social Communication and Interaction Deficits in social emotional reciprocity Deficits in nonverbal communication Deficits in developing, maintaining, and understanding relationships Deficits in Social Interaction & Social Communication Autism Spectrum Disorder Restricted Interests/ Repetitive Behaviors Restricted Interests/Repetitive Behaviors Stereotyped or repetitive motor movements, use of objects, or speech Insistence on sameness, inflexible adherence to routines, or ritualized patterns of behavior Highly restricted, fixated interests Hyper or hyporeactivity to sensory input or unusual sensory interests DSM 5, American Psychiatric Association, 2013 What is ASD? What is ASD? Symptoms present in early developmental period May not fully manifest until social demands exceed limited capacities May be masked by learned strategies in later life Clinically Significant Impairment Asperger s Disorder Autistic Disorder PDD NOS Symptoms NOT better explained by intellectual disability or global developmental delay Autism Spectrum Disorder ASD Prevalence 1 in 68 children (aged 8 years) 1 in 42 boys 1 in 189 girls Disparities in estimated prevalence by race/ethnicity. Prevalence estimates similar for 2010 and 2012 Current Age at Diagnosis On average, children in the US are not diagnosed with ASD until after age 4 (CDC, 2010) Can be reliably diagnosed in children as young as 18-24 months Lag time between parents first concern and eventual dx (Chakrabarti, 2009; CDC 2016) Need to close this gap Prevalence and Characteristics of Autism Spectrum Disorder Among Children Aged 8 Years Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2012 (Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report, April 1, 2016) Developmental concerns noted Referral for diagnostic evaluation Diagnosis
No medical test or cure Statistics for ASD Considered the most heritable among behaviorally defined disorders Occurs in all racial, ethnic, and socioeconomic groups Commonly co-occurs with other developmental, psychiatric, neurologic, chromosomal, and genetic diagnoses Common Comorbid Conditions Developmental Delay and Intellectual Disability ADHD OCD DBD/ODD Specific phobia, Social phobia Major Depressive Disorder/Dysthymia Anxiety Disorder Tourette s Disorder Associated Medical/Genetic Conditions Tuberous sclerosis (1% of ASD cases) Fragile X (30% have ASD; 7-8% of ASD cases) Down Syndrome (7-10% have ASD) Neurofibromatosis (rare) Angelman and Prader-Willi Syndromes Mitochondrial disease Intrauterine exposure to thalidomide and valproate Intrauterine rubella or cytomegalovirus (affecting infant s brain) Common Associated Signs & Symptoms Mood-related difficulties Aggression Self-injurious behavior Irritability/depression/anxiety Sleep disturbances GI problems and poor feeding Sensory issues Over-reactive, under-reactive, sensory-seeking Epilepsy (1/3 of cases) ASD Screening Tools Modified Checklist for Autism in Toddlers Revised with Follow-Up (M-CHAT-R/F) Screening Tool for Autism in Toddlers and Young Children (STAT) Social Communication Questionnaire (SCQ) See http://pediatrics.aappublications.org/content/120/5/1183.full for a more comprehensive list of screening tools Modified Checklist for Autism in Toddlers Revised with Follow-Up (M-CHAT-R/F) M CHAT R/F 20 yes/no items <5 mins to complete Ages 16 30 months Revisions: Elimination of three items Simplification of language Addition of examples to help clarify items M-CHAT vs. M-CHAT-R/F: M-CHAT-R/F has a lower screen positive rate (7% vs. 9%) and an improved detection rate
This imag e ca Interpreting the MCHAT-R/F Children are placed into categories of risk: The M-CHAT-R/F is available for FREE at: Low Risk: Total Score: 0-2 <24 mos, screen again after 2 nd birthday >24 mos: no action is required other than ongoing developmental surveillance UNLESS surveillance indicates ASD risk. http://www.mchatscreen.com Medium Risk: Total Score: 3-7 Administer Follow-Up Interview High-Risk: Total Score: 8-20 Refer immediately for diagnostic evaluation and early intervention. MCHAT-R/F Follow-Up Interview Give when scores indicate Medium Risk Identify all failed items and use algorithm for each If child has 2 failed items after follow-up interview, refer for evaluation and early intervention About 1/3 of children continue to show ASD risk after follow-up interview Response to a Failed Score If a child fails the M-CHAT-R/F at the 18-month visit, do not wait and see until the next visit Immediate dual-referral to specialist evaluation and early intervention The 24-month M-CHAT-R/F is critical for children who initially failed the screening tool but then passed the followup interview Myriad of Interventions Behavioral/educational Pharmacological Complimentary and Alternative Medicine (CAM) Average combination of treatments (Kochel, Myers & Mackintosh, 2007) Current use of between 4 and 6 Ever trying between 7 and 9 Pharmacological Interventions Medication should be considered only after educational/behavioral therapies have been used Risperdal has been successful in reduction of tantrums, aggression, and self-injurious behavior (Scahill et al., 2002) Risperdone (Risperdal) and aripiprazole (Abilify) only medications FDA-approved for use in children with ASD
Complementary and Alternative Medicine (CAM) (Adapted from Atkins, Angkustsiri, & Hansen 2010) Safe, effective, and may be recommended (as indicated): Melatonin CAM: Tolerate But Monitor, Efficacy Inconclusive (Adapted from Atkins, Angkustsiri, & Hansen 2010) Music therapy Yoga Gluten-free/Casein-free diet* Massage/therapeutic touch Acupuncture* Multivitamins*, Vitamin C* and Vitamin B6/Magnesium* Carnosine Carnitine* Essential fatty acids* Methyl B12, folic acid, dimethylglycine, glutathione* *Indicates safety may be questionable CAM: Discourage as Unsafe, Safety Unknown, or Definitely Not Efficacious Chelation Secretin Chiropractic manipulation Craniosacral manipulation Antifungal agents Hyperbaric oxygen therapy Immune therapies Behavioral/Educational (Dawson & Burner, 2011) Early Intensive Behavioral Intervention (EIBI) Applied Behavior Analysis (ABA) Early Start Denver Model (ESDM) Social skills interventions Enhance peer relationships and social competence Targeted, brief behavioral interventions Improve social communication in young children Parent-Mediated interventions Improve parent-child relations; mixed effects on child outcome Applied Behavior Analysis (ABA) Evidence-based best practice treatment Based on principles of learning and behavior Increases functional/appropriate behaviors Decreases/eliminates challenging behaviors Elements of Good ABA Programs Structured Data collection Positive reinforcement Staff supervision and training Emphasis on functional skills Family training Team meetings
Effective for improving Language Cognitive abilities Adaptive behavior Social skills ABA Cost Savings of ABA Recognized as having the greatest impact on long-term outcomes (Reichow, 2012) Early intensive behavioral intervetnion is key to reducing the cost burden of ASD (Wright, 2015) Reducing anxiety and aggression Aggression: Antipsychotic medication + behavioral intervention > medication alone Early identification of ASD is key to initiating appropriate intervention. Other Potential Interventions TEACCH Relationship Development Intervention (RDI) Floortime/DIR SCERTS Related Services Speech-Language Therapy Occupational Therapy Physical Therapy Sensory Integration (? Effectiveness) Resources Autism Speaks: www.autismspeaks.org CDC: www.cdc.gov Autism Society of America: www.autism-society.org/ First Signs: www.firstsigns.org Texas Autism Advocacy : www.texasautismadvocacy.org Texas Council on Autism and Pervasive Developmental Disorders: www.dads.state.tx.us/autism