1. Continuity Clinic Autism Spectrum Disorders Modified from a conference by Dr. Chuck Conlin

2. Continuity Clinic 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

3. Continuity Clinic Background Prevalence –Estimated anywhere from 1 to 6 per 1,000 children 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

4. Continuity Clinic Background 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

5. Continuity Clinic Classification Autistic Disorder Rett’s Disorder Childhood Disintegrative Disorder Asperger’s Disorder Pervasive Developmental Disorder. Not Otherwise Specified

6. Continuity Clinic 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)

7. Continuity Clinic 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

8. Continuity Clinic 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

9. Continuity Clinic 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

10. Continuity Clinic 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 reach@kennedykrieger.org

11. Continuity Clinic ASD: Published Guidelines AAP; Committee on Children with Disabilites 2001 (Pediatrics, 107(5): 1221- 26) 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.

12. Continuity Clinic 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

13. Continuity Clinic 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

14. Continuity Clinic 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

15. Continuity Clinic 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

16. Continuity Clinic 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)

17. Continuity Clinic 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

18. Continuity Clinic 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: www.autism-society.orgwww.autism-society.org –Families for Early Autism Tx: www.feat.orgwww.feat.org –Yale Child Center: info.med.yale.edu/chldstdy/autism –www.aspergersyndrome.org

19. Continuity Clinic 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

20. Continuity Clinic 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

21. Continuity Clinic 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

22. Continuity Clinic 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

23. Continuity Clinic 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

24. Continuity Clinic 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

25. Continuity Clinic 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

26. Continuity Clinic 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 stereotypies Vit A – improve immune function

27. Continuity Clinic ASD: Complimentary Interventions II Casein and gluten free diets i.e., “Special Diets for Special Kids by Lisa Lewis; http://members.aol.com/autismndi http://members.aol.com/autismndi Secretin – 6 clincal trials, PC – no effect Chelation – DSMA has liver & kidney potential toxicities Auditory integration therapy MMR