AUTISM: THE MIND-BRAIN CONNECTION Ricki Robinson, MD, MPH Co-Director, Descanso Medical Center for Development and Learning - La Canada CA Clinical Professor of Pediatrics, Keck School of Medicine-USC www.drrickirobinson.com Richard Solomon, MD Medical Director, Ann Arbor Center for Developmental and Behavioral Pediatrics www.aacenter.org www.playproject.org Profectum Medical Work Group Discipline Specific Certificate Curriculum I II III IV Autism: The Mind Brain Connection Evidence base for using developmental models to diagnose and treat ASD and related disorders Medical conditions and ASD: implications for diagnosis, treatment and impact on developmental progress ASD and brain based co morbidities (e.g. anxiety, mood, attentional issues) throughout the life span + Elective Webcasts Developmental Approach to Treating Anxiety in ASD Behavior As Communication: What a Child is Really Telling You More to come watch Profectum.org for announcements Copyright 2012 1
MODULE I Autism: The Mind Brain Connection Learning Objectives Review the history of ASD Review emerging science for cause and underlying neurobiology of ASD Understand criteria for the clinical diagnosis of ASD today and tomorrow Overview of the evidence base for ASD treatment: spotlight on Play Project Autism: The Mind Brain Connection Richard Solomon, MD Medical Director Ann Arbor Center for Developmental and Behavioral Pediatrics www.aacenter.org www.playproject.org Copyright 2012 2
ASD Science Update Prevalence: 1:110 births; 1:70 boys Genetics: Synapse, synapse, synapse Form Function Epigenetics: The environmental impact is key Treatment: Growth of evidence based practice research Joint Attention/Symbolic Play Model Kasari et al Early Start Denver Model Rogers & Dawson Play Project (NIMH study) Solomon et al Copyright 2012 3
Definition Autism Spectrum Disorders (ASD) Changes are coming! Potential implications for Treatment availability Financial resources for individuals and families in need Diagnostic Statistical Manual of Mental Disorders (DSM) DSM 5 due in May 2013 Used to diagnose mental and behavioral conditions Diagnosis influences Choice and availability of treatments Insurance coverage Public funding resources DSM is a work in progress Incorporates scientific understanding to refine diagnoses Current ASD diagnosis did not align with what is known PDD NOS, Autistic Disorder, Aspergers, Childhood Disintegrative Disorder, not related to: Treatment approach Brain physiology Genetics Outcomes Diagnostic change for ASD is extremely controversial Copyright 2012 4
DSM IV DIAGNOSTIC CRITERIA FOR AUTISTIC DISORDER Qualitative impairment in social interaction Qualitative impairment in communication Restricted repetitive and stereotyped patterns of behavior, interests and activities Delays or abnormal functioning prior to age 3 years in: Social interaction Language Symbolic or imaginative play Not Rett s or Childhood Disintegrative Disorder DSM IV AUTISTIC DISORDER BEHAVIORS A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3): (1) qualitative impairment in social interaction, as manifested by at least two of the following: (a) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction (b) failure to develop peer relationships appropriate to developmental level (c) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest) (d) lack of social or emotional reciprocity (2) qualitative impairments in communication as manifested by at least one of the following: (a) delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime) (b) in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others (c) stereotyped and repetitive use of language or idiosyncratic language (d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level (3) restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: (a) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus (b) apparently inflexible adherence to specific, nonfunctional routines or rituals (c) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole body movements) (d) persistent preoccupation with parts of objects Copyright 2012 5
Major ASD Changes Proposed for DSM 5 Classification System eliminates separate subcategories within the autism spectrum Autistic Disorder Rett s Disorder CDD Asperger s Disorder PDD NOS Autism Spectrum Disorder (ASD) All sub categories subsumed under broad umbrella term Define solely on behaviors Major ASD Changes Proposed for DSM 5 Instead of 3 domains of ASD symptoms, 2 categories will be used Social communication impairment Restricted interests/repetitive behaviors Current (DSM IVR) ASD diagnosis: 6/12 behaviors Proposed (DSM 5) ASD diagnosis: 3 behaviors in social communication 2 behaviors in repetitive interests/behaviors Copyright 2012 6
Major ASD Changes Proposed for DSM 5 New repetitive behavior Hyper or hypo reactivity to sensory input or unusual interest in sensory aspects of environment (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects) Symptoms present in early childhood but may not become fully manifest until social demands exceed limited capacity Major ASD Changes Proposed for DSM 5 Introduces new Diagnostic Category Social Communication Disorder For individuals with these issues but no repetitive behaviors Copyright 2012 7
Major ASD Changes Proposed for DSM 5 In addition to the diagnosis each person evaluated will also be described by: Level of challenge in each diagnostic category Known genetic cause (e.g. Fragile X, Rett s) Level of language Intellectual disability Presence of medical problems ASD (Proposed DSM 5) Must meet criteria A, B, C, and D A. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following: 1. Deficits in social emotional reciprocity; ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction, 2. Deficits in nonverbal communicative behaviors used for social interaction; ranging from poorly integrated verbal and nonverbal communication, through abnormalities in eye contact and body language, or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures. 3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers); ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play and in making friends to an apparent absence of interest in people Copyright 2012 8
ASD (Proposed DSM 5) Must meet criteria A, B, C, and D B. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following: 1. Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases). 2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes). 3. Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests). 4. Hyper or hypo reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects). ASD (Proposed DSM 5) Must meet criteria A, B, C, and D C. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities) D. Symptoms together limit and impair everyday functioning Copyright 2012 9
Proposed ASD Criteria for DSM 5 How will these changes affect an individual s: Diagnosis Treatment Support services Identity Research suggests some high functioning individuals who still need service may be missed Huge media attention ASD advocacy groups form national coalition Autism Speaks supporting field trials using current diagnostic tools to test range of proposed definition Proposed ASD Criteria for DSM 5 New definition more aligned with the developmental approach Requires garnering information from multiple sources including: Skilled clinical observation in multiple settings Reports from parents, caregivers, teachers Allows for assessment of child s ability to develop and sustain relationships using all forms of social communication Recognizes individual differences as critical factor Understands medical conditions integral to child s level of functioning Recognizes the role of social emotional development in overall functioning of a child Copyright 2012 10