Transcript Autism Spectrum Disorders

Autism Spectrum Disorders
(ASD):
Identification & Management
including “Co-Morbidities”
Chuck J. Conlon, MD, FAAP
[email protected]
Director of Developmental Pediatrics
Children’s National Medical Center
ASD Objectives
• Discuss early indicators & importance of
early identification
• Explain current practice guidelines from
AAP & AAN
• Discuss medical management of common
behavioral disturbances (co-morbidities) in
children with ASD
Autism Spectrum Disorders:
Overview I
• Prevalence 1 to 2….to 6 per 1,000 children
• Is there a rise in incidence? If so why?
• Neurobiologic disorder with question of
environmental triggers
• First described in the 1940s; Drs Kanner &
Asperger
• 6 to 10% recurrence rate in families
Autism Spectrum Disorders:
Overview II
• Characterized by deficits in 3 domains i.e.,
communication, social interactions,
restricted, repetitive & ritualistic behaviors
• Must meet DSM IV Diagnostic Criteria
• Onset prior to 3 years of age for Autism
• Rule out medical causes
Autism Spectrum Disorders:
Classification
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Autistic Disorder
Rett’s Disorder
Childhood Disintegrative Disorder
Asperger’s Disorder
Pervasive Developmental Disorder. Not
Otherwise Specified
Early Indicators of Autism
Social Interaction “Flags”
• Less responsive to social overtures i.e., hard
to reach
• Less participation in reciprocal play
• Less “showing off” for attention
• Less imitation of the actions of others e.g.,
waving good-bye
• Less interested in other children (selfdirected play)
Early Indicators of Autism
Communication Deficits
• Less communication to direct another
person’s attention e.g., hold up object to
show
• Less use of gestures i.e., proto-imperative &
proto-declarative pointing
• Less use of eye contact during interactions
• Inconsistent response to sounds
Early Indicators of Autism
Repetitive & Restricted Behavior
• Less functional play, especially with dolls
or stuffed animals e.g., feeds with a spoon
• Less imaginative play….often imitative
from favorite videos or books
• Repetitive motor behaviors e.g., spinning
hand flapping, finger flicking, “sifting”
• Unusual visual interests
Early Indicators of Autism
Red Flags (AAN, 2000)
• No babbling, pointing or other gestures by
12 months
• No single words by 16 months
• No meaningful 2-word phrases by 2 years
• ANY loss of ANY language or social skills
at ANY age
• www.firstsigns.org
Autism Spectrum Disorders
Benefits of Early Id
• Early identification leads to early intervention
• Helps families to understand their child and
advocate for services
• Early intervention can lead to improved cognitive
function, communication, as well as enhanced
peer interactions and decreased behavioral
difficulties
• Early intervention study for children with ASD <
3 years: Dr Landa at 1-877-850-3372 or e-mail
[email protected]
ASD: Published Guidelines
• AAP; Committee on Children with
Disabilites 2001 (Pediatrics, 107(5): 122126)
• American Academy of Neurology & Child
Neurology Society (Filipek et al., 2000
Neurology, 55: 468-479)
• CAN Consensus Statement (Geschwind et
al., 1998, CNS Spectrums, 3: 40-49.
Integration of Recommendations
from Guidelines on ASD I
• Developmental surveillance and screening
• Best screening - PARENTAL CONCERN but lack
of parental concern does not r/o disorder
• Referral to community resources i.e., ITP/PIE/CF
• Diagnosis best by multidisciplinary team BUT
availability is limited & waiting lists are long
• Single subspecialty providers e.g., dev peds, child
neurologist, child psychologist/psychiatrist
Inegration of Recommendations
from Guidelines on ASD II
• Evaluation of cognitive and adaptive skills
• Comprehensive eval of communication
including higher order language function
i.e., semantic & pragmatic language (Infant
Rosetti; CASL or Comprehensive
Assessment of Spoken Language)
• Audiological evaluation
• Other medical work-up
ASD: Medical Evaluation
• Genetic studies: high resolution karyotype, DNA
probe for Fragile X, FISH studies in children with
MR, dysmorphic facies or + FH
• Metabolic screening: plasma amino acids, urine
organic acids, urine metabolic screen (as above
and/or lethargy, cyclic vomiting, early seizures)
• Others….lead, etc
• EEG if regression, seizures, significant staring
spells or child is nonverbal
• CT scan or MRI usually not indicated even with
megalencephaly
ASD: Role of Primary Care
Provider
• The Medical Home (Pediatrics 2002, 110:
184 to 186); care coordination/”screen”
• Provide early identification & referral to
community based programs for treatment
• Referral to medical subspecialists for
further evaluation, diagnosis & treatment
• Provide parent education and support
ASD: Educational Programs
• Should facilitate functional communication,
social skills, learning and improve behavior
• Vary in philosophy, curricula and strategies
• “Autism Programs” – reduced ratio classes
to work on joint attention, imitation, etc.
• TEACCH- classroom & parent training
• Applied behavioral analysis, discrete trials
(Lovaas method)
ASD: Additional Treatments
• Behavioral support (ABCs of Behavior)
• Social & pragmatic language skills training
• Family support, i.e. education, respite,
parent groups
• Medications
• Complimentary & alternative interventions
ASD: Family Support
• Respite options in the community e.g., McLean
Bible Church Saturday program, CARD, Autism
Society of America or ASA (parent groups,
“Advocate”, etc.)
• Websites
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ASA: www.autism-society.org
Families for Early Autism Tx: www.feat.org
Yale Child Center: info.med.yale.edu/chldstdy/autism
www.aspergersyndrome.org
ASD: Medication Management
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Identify target symptoms or indications
Need for Functional Behavioral Analysis
Research is VERY limited/small sample size
Medication responsive problems
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“Attention” disorder; internal or external
Anxiety & obsessive compulsive symptoms
Aggression/tantrums/self-injurious behaviors
Sleep difficulties/ Appetitie or feeding issues
ASD: Hyperactive/ADHD Sxs
• Overactivity, inattention, impulsivity – not
universal
• Heterogenous response to stimulants
• Subset will show increased irritability,
hyperactivity, stereotypic behaviors &
agitation (adverse events are short lived)
• Start very low, titrate slowly
ASD: Hyperactive/ADHD Sxs
• Stimulants (RUPP study underway studying
MPH) e.g., concerta 18mg: focalin 1.25 to 2.5 mg;
metadate CD 5 to 10 mg, etc
• Alpha adrenergic agonists e.g., clonidine 0.025mg
2 to 3x/day; tenex 0.25 to 0.5 mg qhs…then bid
• Strattera 0.5 mg/kg/day & titrate slowly
• Others: atypical/typical antipsychotics, anafranil,
naltrexone, wellbutrin
ASD:
Anxiety/Perseveration(OCD)
• SSRIs e.g., luvox, prozac, zoloft, celexa, lexapro,
paxil as well as anafranil
• Luvox in adults (DB/PC) reduced repetitive
thoughts, behaviors, & aggression; may improve
language/social skills – 6.25 to 12.5mg & titrate
up
• Open-label trials: prozac, zoloft, buspar
• Subset will have increased activity/impulsivity
• Anxiolytics: ativan (dental work), xanax
ASD: Disruptive & Irritable
Behaviors
• Tantrums, aggression, self-injury, agitation,
screaming, rigidity
• Atypical antipsychotics: risperdal, zyprexia,
seroquel, geodon, abilify
• McCracken et al (NEJM;2002;347:314-21)
– Risperdal improved behaviors in 69% vs placebo in
11.5%; extrapyramidal sxs/tardive dyskinesia rare
unless on medicationfor many years
– Watch weight! Monitor FBS/HgbA1C/lipids
– Start 0.25 mg 1 to 2X/day & titrate
ASD: Sleep
• Importance of developing good sleep
“hygiene” or routine
• Medications as an adjunct
– Antihistamines such as Benadryl
– Other meds: clonidine (0.025 – 0.05mg),
remeron (7.5mg), trazodone (12.5mg)
– Melatonin 0.5 mg (physiologic dose)
• Increase by 0.5 mg every 4 to 5 nights up to 3 - 6mg
ASD: Appetitie/Feeding Issues
• Often behaviorally based on color, texture,
smell
• Prevent food “jags” i.e., zip lock bags, vary
food preparations, etc.
• Appetite enhancer: periactin 4mg qhs to
4mg 2 to 3x/day
• Appetitie suppressor: topamax 7.5 to 15 mg
ASD: Complimentary
Interventions I
• Anecdotal studies, single-subject
trials,nonrandomized designs & nonplacebo-controlled studies
• Vit B6 and Mg –? sensory neuropathy
• DMG/TMG (Di-/Trimethylglycine)
• Vit C – inhibits central DA; dec stereotypies
• Vit A – improve immune function
ASD: Complimentary
Interventions II
• Casein and gluten free diets i.e., “Special
Diets for Special Kids by Lisa Lewis;
http://members.aol.com/autismndi
• Secretin – 6 clincal trials, PC – no effect
• Chelation – DSMA has liver & kidney
potential toxicities
• Auditory integration therapy
• MMR