Autism Spectrum Disorders

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					       Autism Spectrum Disorders

              Modified from a conference
                by Dr. Chuck Conlin

Continuity Clinic
   • 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

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   • Prevalence
      – Estimated anywhere from 1 to 6 per 1,000
   • Is there a rise in incidence? If so why?
      – Increased surveillance and detection
      – Unknown environmental triggers?
   • Neurobiologic disorder with question of
     environmental triggers
   • 6 to 10% recurrence rate in families
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   • 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

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   •   Autistic Disorder
   •   Rett’s Disorder
   •   Childhood Disintegrative Disorder
   •   Asperger’s Disorder
   •   Pervasive Developmental Disorder. Not
       Otherwise Specified

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         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 (self-
     directed play)

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         Early Indicators of Autism
          Communication Deficits
   • Less communication to direct another
     person’s attention e.g., hold up object to
   • Less use of gestures i.e., proto-imperative
     & proto-declarative pointing
   • Less use of eye contact during interactions
   • Inconsistent response to sounds

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       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

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         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

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       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
   • Early intervention study for children with ASD <
     3 years: Dr Landa at 1-877-850-3372 or e-mail

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        ASD: Published Guidelines
   • AAP; Committee on Children with
     Disabilites 2001 (Pediatrics, 107(5): 1221-
   • 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.

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     Integration of Recommendations
         from Guidelines on ASD
   • Developmental surveillance and screening
   • Best screening - PARENTAL CONCERN but
     lack of parental concern does not r/o disorder
   • Referral to community resources
   • 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

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     Integration of Recommendations
         from Guidelines on ASD
   • 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

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         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
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        ASD: Role of Primary Care
   • 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

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       ASD: Educational Programs
   • Should facilitate functional communication,
     social skills, learning and improve
   • Vary in philosophy, curricula and
   • “Autism Programs” – reduced ratio classes
     to work on joint attention, imitation, etc.
   • TEACCH- classroom & parent training
   • Applied behavioral analysis, discrete trials
     (Lovaas method)
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       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

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              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
      –   ASA:
      –   Families for Early Autism Tx:
      –   Yale Child Center:

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       ASD: Medication Management
   •   Identify target symptoms or indications
   •   Need for Functional Behavioral Analysis
   •   Research is VERY limited/small sample size
   •   Medication responsive problems
       –   “Attention” disorder; internal or external
       –   Anxiety & obsessive compulsive symptoms
       –   Aggression/tantrums/self-injurious behaviors
       –   Sleep difficulties/ Appetitie or feeding issues

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     ASD: Hyperactive/ADHD Sxs
   • Overactivity, inattention, impulsivity – not
   • Heterogenous response to stimulants
   • Subset will show increased irritability,
     hyperactivity, stereotypic behaviors &
     agitation (adverse events are short lived)
   • Start very low, titrate slowly

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     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

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   • 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
   • Open-label trials: prozac, zoloft, buspar
   • Subset will have increased activity/impulsivity
   • Anxiolytics: ativan (dental work), xanax

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        ASD: Disruptive & Irritable
   • 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

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                     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 -
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    ASD: Appetitie/Feeding Issues
   • Often behaviorally based on color, texture,
   • 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

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             ASD: Complimentary
               Interventions I
   • Anecdotal studies, single-subject
     trials,nonrandomized designs & non-
     placebo-controlled studies
   • Vit B6 and Mg –? sensory neuropathy
   • DMG/TMG (Di-/Trimethylglycine)
   • Vit C – inhibits central DA; dec
   • Vit A – improve immune function
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             ASD: Complimentary
               Interventions II
   • Casein and gluten free diets i.e., “Special
     Diets for Special Kids by Lisa Lewis;
   • Secretin – 6 clincal trials, PC – no effect
   • Chelation – DSMA has liver & kidney
     potential toxicities
   • Auditory integration therapy
   • MMR

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