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AUTISM SPECTRUM DISORDER. DSM-V Criteria Criterion A: Persistent deficits in social communication and interaction Can include social-emotional reciprocity,

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Presentation on theme: "AUTISM SPECTRUM DISORDER. DSM-V Criteria Criterion A: Persistent deficits in social communication and interaction Can include social-emotional reciprocity,"— Presentation transcript:

1 AUTISM SPECTRUM DISORDER

2 DSM-V Criteria Criterion A: Persistent deficits in social communication and interaction Can include social-emotional reciprocity, nonverbal communicative behaviors, developing/maintaining relationships Criterion B: Restricted, repetitive patterns of behavior Repetitive motor movements (rocking), ecolalia, insistence on sameness and a routine, highly restricted, fixated interests, unusual interest in sensory aspects of the environment Symptoms must be present in early developmental period and cannot be better explained by intellectual disability or global developmental disability 3 levels of severity Viewed as a dimensional disorder Specifiers for each criterion

3 Secondary Features Intellectual disability Often large discrepancies in abilities in high functioning kids Motor disabilities Odd gait, clumsiness, walking on tiptoes Self-injury Inattention Disruptive behavior Catatonia Possible, not particularly common Most likely during adolescent years

4 Controversy DSM-IV included categories for Autism, Pervasive Development Disorder NOS, High Functioning Autism, and Asperger’s Syndrome Sevin et al (1995) studied 34 kids with autism and PDD- NOS. Did not find discrete categories. Categories were collapsed into Autism Spectrum – PDD- NOS, HFA, and AS now “on the spectrum” Concern about retaining diagnoses, receiving services, stigma

5 Controversy Intent was NOT to remove anyone’s diagnosis Will actually help some higher functioning kids get services Everyone should convert to Autism Spectrum with specifications if criteria used correctly DSM-IV included category for communication difficulty This is covered by DSM-V criteria A and B. Separate category was not needed

6 DSM-V Schematic Genetics Unknown Biological Substrate Unknown Core Symptoms Social Deficits Restricted, repetitive behaviors Secondary Symptoms Intellectual, motor disabilities Self-injury Inattention/Disruptive Behavior Catatonia

7 Assessment – ADI-R Gold Standards are Autism Diagnostic Interview – Revised (ADI-R) and Autism Diagnostic Observation Scale (ADOS) ADI-R is semi-structured interview for caregivers 93 items, about 2 hours Based on DSM-IV criteria (Communication difficulties, social reciprocity, restricted, repetitive behaviors) Chakrabarti and Fombonne (2001) found that interrater reliability was excellent on those subscales

8 Assessment - ADOS Observational Can be used in nonverbal 2-year-olds – verbal adults and all between 4 Modules: Pre-Verbal-Single Words Phrase speech Fluent Speech Activities for daily living, plans, hopes

9 Psychometric Issues in Diagnosis Low test-retest reliability on many instruments Little investigation of specificity or validity of screening measures Lack sensitivity and specificity Severity scores quantifying social deficits needed Sometimes alternative thresholds are suggested for research vs clinical diagnoses Children of color or of less-educated parents less likely to receive ASD diagnosis than Caucasian kids or kids with well-educated parents (Mandell et al 2009)

10 Psychometric Issues in Diagnosis In a study of children with language disorder, both the ADOS and ADI- R were administered to children Studied 21 children ages 6-9 Correlation between instruments low (Bishop 2011) Χ^2 (4) = 1.86, p=.762

11 Social Problems Most universal, specific characteristic of ASD Consistent and replicated across studies Lack joint attention, theory of mind Cannot correctly assign motives, understand someone’s goals, difficulty participating in spontaneous symbolic play Other groups show problems with theory of mind but may not show same deficits in joint attention Down Syndrome, severe hearing impairment Pay proportionately less attention to people than objects Spend less time than TD kids doing something that shows intent Children are attached to mothers as much as age- and IQ-matched TD kids (Rogers et al., 1991) Tend not to point, show objects – attention-sharing behaviors (Sigman et al., 1986) Do not seem to recognize emotions (facial expression, gesture, nonverbal vocalizations of emotion)

12 Restricted, Repetitive Behaviors Verbal and nonverbal repetitive, stereotyped behaviors More heterogeneous and context-dependent than social deficits Including them on diagnostic instruments increases specificity with little change in sensitivity One study showed only 9 of 2700 children with ASD diagnosis did not show any RRB’s (Lord et al., 2012)

13 Restricted, Repetitive Behaviors Four subdomains: Motor stereotypies – lining things up, flipping things, step counting, unusual responses to sensory input, rocking Some of these may be common in young children – clinicians must look at the number and intensity of behaviors to discriminate TD from ASD Tend to emerge early in life but are somewhat malleable Most common subdomain Rituals and sameness – like Rain Man’s pancake Tuesdaypancake Tuesday Prevalent in about 25% of ASD population Develop later than motor type, stable throughout life Circumscribed interests – highly fixated or unusual interests A particular movie, cartoon character, topic, the phone book, shoe size Self-injurious behavior – hand flapping, hitting Present in other disorders More common in ASD than general population Subdomains show different trajectories

14 Language Delay Language delay is not specific to ASD Delays in receptive language may be specific to ASD as opposed to other communication disorders (Philofsky, Hepburn, Hayes, Hageran, & Rogers 2004) Not yet connected to specific neurobiological problem Language (particularly receptive language) scores correlate with IQ (specifically verbal) (Luyster et al., 2008)

15 Prevalence In 1990’s it was 1 per 2,000, including Asperger’s Syndrome 1 per 1,000 (Tanguay 2000) Current prevalence rates around 1/150 to 1/100 for ASDs (Croen et al., 2002, Rice, 2009) True increase in milder cases True increase of all case types More awareness Problems with diagnostic instruments Incorrect diagnoses Studies differ in screening methods, diagnostic instruments, diagnostic criteria Diagnosed 4x as often in males than females

16 Diagnostic Criteria Projects using ICD-10 criteria show prevalence around 1/2,000 (Autism) and 1/600 (Autism plus other pervasive developmental disorders) Studies using less strict criteria show much higher prevalence rates Bryson et al., 1988, 1/1,000 Used ABC (checklist) Sugiyama and Abe (1989) used DSM-III and noted 1/760 Ehlers and Gillberg (1993) set of criteria specifically designed to diagnose ASD found 1/143

17 Onset and Course Symptoms are usually noted first in months of a child’s life Delayed language, odd play patterns, lack of social interaction Pay attention to type, frequency, intensity of symptoms Can experience developmental plateaus or regression Rarely a severe regression after 2 years of normal development Onset must occur by age 3 Individuals generally improve throughout lives Robust diagnosis Sensitivity of.82 and specificity of.87 (Volkmar et al 1994)

18 Common Comorbidities 70% of ASD individuals have one comorbid disorder, up to 40% may have 2 or more (DSM-V) Medical conditions such as epilepsy and sleep problems somewhat common Comorbid diagnoses of ADHD, anxiety and depressive disorders, and developmental coordination disorder seen First degree relatives have higher incidence of major depression and social phobia than the rest of the population (Bolton et al., 1998) Relatives have 20% frequency of social phobia (Smalley et al., 1995) 10 times higher than controls Over half (64%) had first episode before the birth of autistic child

19 Common Comorbidities? Posited that autism shared genetic cause and thus comorbidities with: Fragile X (no more than 2-5% have FRA-X mutation, Bailey et al., 1993) Tuberous sclerosis (mostly seen in autistic people with severe deficits, Guiterrez et al., 1998) Celiac disease (Pavone et al., 1997 study of 120 people with celiac disease showed none with diagnosis of autism based on DSM-III, nor celiac disease in the 11 patients with autism)

20 Biological Contributions ?

21 Genetics Concordance rates in monozygotic versus dizygotic twins range from 60-91% (MZ), 0-10% (DZ) ( Folstein and Rutter, 1977, Steffenburg et al., 1989, Bailey et al., 1995.) Variation in behavioral and cognitive deficits as great within MZ pairs as between pairs These findings suggest that autism is highly heritable (broad cognitive and social impairment) Different sets of genes do not act to produce different symptoms

22 Genetics Gender disparity led some researchers to wonder if ASD linked to X chromosome Hallmayer et al (1996) found no major gene effect on X chromosome causing autism International Molecular Genetic Study of Autism Consortium (1998) found possible connections for regions on chromosomes 7 and 16 Significance is not yet known Found most often in those with severe language delays

23 Neuroligins and Neurexins Neuroligins and neurexins are the “building blocks” of synapses Small percentage of those with ASD have mutations which can cause neurexin deletions This affects synaptic formation and function May increase risk for developing ASD

24 Neuropharmacological Studies Cook and Leventhan (1996) noted that serotonin may be involved in many of the symptoms of autism This is neither surprising nor particularly helpful One study found people with ASD have autoantibodies to brain serotonin receptors (Todd and Ciaranello, 1985) Two studies failed to confirm findings People with ASD may have increased 5-HT on blood platelets

25 Electroencephalography ASD people unlikely to show more EEG abnormalities than the normal population This is nonspecific and not particularly helpful

26 Neuroimaging and Neuropathological Studies General difficulty confirming neuroimaging findings Different measures used to correlate with brain function, generally weak measures Future studies will probably add comparisons of ADHD or language impairments to ASD Increased volume in amygdala, hippocampus, and limbic system, decreased Purkinje cells We don’t know how high functioning these individuals were Harris et al. (2006) claimed to find abnormal patterns of activity in the brains of those with ASD and claimed near-perfect identification This has not been replicated Ongoing NIMH effort to form neurobiologically based dimensions to help diagnose ASD, but no published data yet

27 Macroencephaly 14-30% of ASD people have increase in head circumference (Fombonne et al., 1999) Developed in early/middle childhood (Lainhart et al), but this finding relies on retrospective data Increase is in temporal, parietal, and occipital lobes (not frontal) Cause and effects of increase unknown Not correlated with IQ, verbal ability, seizure, other mental illness

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30 Neuropsychological Patterns Compared to normal controls, ASD people have intact or superior performance in attention, simple memory, simple language, and visual-spatial domains Impaired in skilled motor tasks, complex memory, complex language, and reasoning While interesting, not helpful in understanding much more about autism than is already known

31 Neuropsychological patterns Executive functioning deficits Impairments in cognitive flexibility and set-shifting Nonspecific to autism May underlie theory of mind deficits Price et al., (1990) study of 2 individuals with widespread frontal damage (early in developmental process) Both showed severe impairment in role-taking, also seen in ASD and is part of theory of mind

32 Neuropsychological Patterns 20 ASD, 19 Down’s Syndrome kids, 20 TD kids Two tasks: Delayed Non-Matching to Sample Rule-learning ability, visual recognition memory Amygdala and hippocampus Delayed Response Working memory and response inhibition Dorsolateral PFC Social and nonsocial stimuli task

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35 Vaccines

36 One study published in a medical journal concluded a link between vaccines (MMR) and autism Article was fully retracted in 2010 Lead author Andrew Wakefield had many undeclared conflicts of interest and manipulated some of his data Found guilty of serious medical misconduct and no longer allowed to practice medicine Study has been disproved many times since its original publication in 1998

37 Vaccines DeStefano et al (2013) evaluated 256 ASD kids and 752 TD kids matched on birth year and sex, ages Confirmed diagnoses via ADI-R and ADOS Study inclusion criteria required elevated scores on both assessments and onset before 36 months Obtained vaccination histories, Looked at total antigen exposure, amount per day No significant differences

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40 Environmental Factors Mouridsen et al. studied 328 children with autism, “autism-like conditions,” or “borderline child psychosis” Children with autism had greater incidence of births in March or August Children with autistic-like conditions most often born in May and November Essentially, this means nothing.

41 Environmental Factors Rutter 1998 study looked at institutionalized children in Romania sent to the UK Experienced horrible living conditions 7/165 met criteria for autism based on a screening questionnaire Severe social deprivation may lead to autistic-like social and emotional difficulties Could less severe social deprivation interact with genes to cause autism in some kids or worsen symptoms?

42 Treatment

43 Medication Tricyclics and SSRI’s seem to decrease hyperactivity, anger, and compulsive behaviors (Gordon et al., 1993, Brodkin et al., 1997) Neuroleptics may be effective in reducing hyperactivity, impulsivity, aggressiveness (Potenza et al., 1999 ) (Obviously) Pharmacological interventions have a limited role

44 Medication Double-blind study of 40 kids, given placebo or haloperidol Given semistructured interviews, rated by teachers on Connors Parent-Teach Questionnaire While on haloperidol, kids showed significant decreases in withdrawl, hyperacitvity, abnormal object relationships, fidgetiness, negativeism, angry affect, and lability of affect as compared to baseline or placebo

45 Therapy The key is early intervention! This means developing specific measures is crucially important Two types Traditional behavior learning (ABA) Focus is on adult control and child compliance, uses positive reinforcement Social-pragmatic teaching (child-centered therapy, incidental teaching) Focuses mainly on social skills Focus of therapy is on increasing independence and quality of life

46 Applied Behavior Analysis Gold standard Based on behaviorism Uses positive reinforcement to decrease maladaptive and unwanted behaviors, increase adaptive behaviors Uses negative reinforcement/negative punishment when necessary (rarely) Treatment can begin when children are as young as 3 In severe cases, focus is on compliance Intensive (20-40 hours/week), one-on-one format Targets a wide range of skills Includes parents (and important others when possible – siblings, teachers, etc.)

47 ABA Effect Size Metrics Meta-Analysis of 22 studies (Virués-Ortega 2010) Different outcome reported: full-scale IQ (18 studies), nonverbal IQ (9), receptive language (10), expressive language (9), language composite (5), adaptive behavior- communication (10), adaptive behavior – daily living skills (10), adaptive behavior – socialization (10), adaptive behavior – motor skills (3), overall composite adaptive behavior (14) Mean age ranged from months Some studies included PDD-NOS

48 ABA ABA positively impacted: IQ – 1.19 no evidence of effect from intensity/duration Nonverbal IQ – 0.67 Receptive language – 1.48 Expressive language – 1.47 General language skills – 1.07 Communication – 1.45 Daily living skills – 0.62 Socialization Motor skills – 0.71 Adaptive behavior (composite score) – 1.09 ABA leads to long-term medium to high positive effect sizes for adaptive behaviors Social support (siblings) moderate response (Hastings, 2003)

49 CBT CBT has been modified for ASD kids presenting with anxiety Goal is to remediate social skills in the hopes that this will translate to decreased anxiety Random assignment to 16 sessions of CBT or 3-month waitlist CBT model emphasized adaptive behavior, parental training, school consultation 78% of CBT group had reductions in anxiety on Clinical Global Impressions-Improvement scale compared to 8.7% of waitlist CBT did not reduce self-reports of anxiety

50 Virtual Interactive Environments Used for teaching social skills, theory of mind Practical situations, such as taking the bus, going to the grocery store Some studies use robots (can play games with kids) Interactions (eye gaze, tough, contact time) increase Not yet known if this generalizes to real life

51 Complimentary and Alternative Medicine Therapies (Mostly pseudoscience) Auditory integration Training Facilitated communication Nonverbal/severely handicapped people are suddenly writing emotional, grammatically correct messages This is due to the facilitator (Bomba et al 1996) Viamin B6 and Magnesium 30% of children showed improvement in Martineau (1998) study. Other studies show no improvement Changes in nutrition All are ineffective

52 Genetics Some combination of: Neurexin and neuroligin abnormality Chromosome 16 abnormality Chromosome 7 inversion Biological Substrate Some combination of: Enlarged amygdala, hippocampus Abnormal fusiform gyrus Macroencephaly Decreased Purkinje cells Increased 5-HT Genetics Some combination of: Neurexin and neuroligin abnormality Chromosome 16 abnormality Chromosome 7 inversion Genetics Some combination of: Neurexin and neuroligin abnormality Chromosome 16 abnormality Chromosome 7 inversion Biological Substrate Some combination of: Enlarged amygdala, hippocampus Abnormal fusiform gyrus Macroencephaly Decreased Purkinje cells Increased 5-HT Core Features Social difficulties Restricted, repetitive behaviors Secondary Features Intellectual disability Inattention Motor problems Therapy ABA Medication SSRI’s Antipsychotics Environment Abuse Social support

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55 References Gillespie-Lynch, K., Sepeta, L., Wang, Y., Marshall, S., Gomez, L., Sigman, M., & Hutman, T. (2012). Early childhood predictors of the social competence adults with autism. Journal of Autism Developmental Disorders, 42(2), Gotham, K., Risi, S., Pickles, A., & Lord, C. (2007). The Autism Diagnostic Observation Schedule: Revised algorithms for improved diagnos validity. Journal of Autism Developmental Disorders, 37(4), Harris, G.J., Chabris, C.F., Clark, J., Urban, T., Aharon, I., Steele, S. … & Tager-Flusberg, H. (2006). Brain activation during semantic processing in autism spectrum disorders via functional magnetic resonance imaging. Brain Cognition, 61(1), Hazlett, H.C., Poe, M.D., Gerig, G., Styner, M., Chappell, C., Smit, R.G., & Piven, J. (2011). Early brain overgrowth in autism associated with an increase in cortical surface area before age 2 years. Archives of General Psychiatry, 68(5), Insel, T.R., & Cuthbert, B.N. (2009). Endophenotypes: Bridging genomic complexity and disorder heterogeneity, Biological Psychiatry, 66(11), Jones, W., Carr, K., & Klin, A. (2008). Absence of preferential looking to the eyes of approaching adults predicts level of social desirability in 2-year-old toddlers with autism spectrum disorder. Archives of General Psychiatry, 65(8), Juranek, J., Filipek, P.A., Berenji, G.R., Modahl, C., Osann, K., & Spench, M.aA. (2006). Association between amygdala volume and anxiety level: Magnetic resonance imaging (MRI) study in autistic children. Journal of Child Neurology, 21(12), Kaiser, M.D>, Hudac, C.M., Shultz, S., Lee, S.M., Cheung, C., Berken, A.M., … & Pelphrey, K.A. (2010). Neural signatures of autism. National Academy of Science, 107(49), Kim, S.H., & Lord, C. (2010). Restricted and repetitive behaviors in toddlers and preschoolers with autism spectrum disorders based on the Autism Diagnostic Observation Schedules (ADOS). Autism, 3(4), Kleinhans, N.M., Richards, T., Weaver, K., Johnson, L.C., Greenson, J., Dawson, G., & Aylward, E. (2010). Association between amygdala response to emotional faces and social anxiety in autism spectrum disroders. Neuropsychologia, 48(12), Lee, H., Marvin, A.R., Watson, T., Piggot, J., Law, J.K., Law, P.A., … & Nelson, S.F. (2010). Accuracy of phenotyping of autistic children based on Internet implemented parent report. American Journal of Medicine, 153B(6), Leekam, S. Tandos, j., McConachie, H., Meins, E., Parkinson, K., Wright, C., … & Le Couteur, A. (2007). Repetitive behaviours in typically developing 2-year-olds. Journal of Child Psychology and Psychiatry, 48(11), Lord, C., & Bishop, S.L. (2010). Autism spectrum disorders: Diagnosis, prevalence, and services for children and families, Social Policy Report. Society for Research in Child Development, 24(2), 1-21.

56 References Lord, C., Luyster, R., Ruthrie, W., & Pickles, A. (2012). Patterns of Developmental trajectories in toddlers with autism spectrum disorders. Journal of Consulting and Clinical Psychology. Lord, C., Petkova, E., Hus, V., Gan, W., Lu, F., Martin, D.M., … & Risi, S. (2012). A Multivariate Study of the Clinical Diagnosis of Different Autism Spectrum Disorders. Archives of General Psychiatry, 69(3), Lord, C., Risi, S., DiLavore, P.S., Shulman, C., Thurm, A., & Pickles, A. (2006). Autism from 2 to 9 years of age. Archives of General Psychiatry, 63(6), Luyster, R., Gotham, K., Guthrie, W., Coffing, M., Petrak, R., Pierce, K., & Lord, C. (2009). The Autism Diagnostic Observation Schedule – toddler module: A new module of a standardized diagnostic measure for autism spectrum disorders. Journal of Developmental Disorders39(9), Parsons, S., & Mitchell, S. (2002). The potential of virtual reality in social skills training for people with autistic spectrum disorders, Journal of Intellectual Disability Research, 46(5), Pelphrey, K.A., Shultz, S., Hudac, C.M., & Vander, B.C. (2011). Research review: Constraining heterogeneity: The social brain and its development in autism spectrum disorder. Journal of Child Psychologica Psychiatry, 52(6), Piven, J., Arndt., Bailey, J., & Andreasen, N. (1996). Regional brain enlargement in autism: A magnetic resonance imaging study. Journal of the American Academy of Child and Adolescent Psychiatry, 35(4), Piven, J., Gayle, J., Landa, R., Wzorek, M., & Folstein, S. (1911). The prevalence of fragile X in a sample of autistic invididuals diagnosed using a standardized interview. Journal of the American Academy of Child and Adolescent Psychiatry, 30(5), Regier, D.A.E., Narrow, W.E.E., Kuhl, E.A.E., & Kupfer, D.J.E. (2011). The conceptual evolution of DSM-5. Washington DC: American Psychiatric Publishing Inc. Richler, J., Huerta, M., Bishop, S.L., & Lord, C. (2010). Developmental trajectories of restricted and repetitive behaviors and interests in children with autism spectrum disorders. Developmental Psychopathology, 22(1), Sanders, S.J., Ercan-Sencicek, A.G>, Hus, V., Luo, R., Murtha, M.T., Moreno-De_Luca, D., … & State, M.W> (2011). Multiple recurrent de novo CNVs, including duplications of the 7q11.23 Williams syndrome region, are strongly associated with autism. Neurology, 70(5), Sparks, B.F., Friedman, S.D>, Shaw, D.W., Aylward, E.H., Echelard, D., Artru, A.A. … & Dager, S.R. (2002). Brain structural abnormalities in young children with autism spectrum disorders. Neurology, 59(2), Tanguay, P.E. (2000). Pervasive developmental disorders: A 10-year review, Journal of American Academy of Child Adolescent Psychiatry, 39(9), Veenstra-Vanderweele, J., Christian, S.L., & Cook, E.H., JR. (2004). Autism as a paradigmatic complex genetic disorder. Annual Review of Genomics Human Genetics, 5, Virtues-Ortega, J. (2010). Applied behavior analytic intervention for autism ine arly childhood: Meta-analysis, meta-regression, and dose-response meta-analysis of multiple outcomes, Clinical Psychology Review, 30, Walker, D.R., Thompson, A., Zwaigenbaum, L., Goldberg, J., Bryson, S.E., Mahoney, W.J., … & Szatmari, P. (2004). Specifying PDD-NOS: A comparison of PDD-NOS, Asperger syndrome and autism. Journal of American Academy of Cild and Adolescent Psyciatry, 42(2), Wood, J., Drahota, A., Sze, K., Har, K., Chiu, A., & Langer, D.A. (2009). Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: a randomized, controlled trial, Journal of Psychology and Psychiatry, 50(3),


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