1. Ken Pittman, MD Agape Youth Behavioral Health Child and Adolescent Psychiatrist Board Certified in C&A Psychiatry, Adult Psychiatry, and Pediatrics

2. Identify Domains of Symptoms That Can Present in a Spectrum with ASDs Discuss Potential Subgroups Based on Combinations of These Symptoms Identify Treatment Options Based on Subgroups of Symptoms Objectives

3. DSM-IV Autistic Disorder – 6 from a list of symptoms including social interaction impairment, communication impairment, and repetitive/stereotypic behaviors Asperger’s Disorder - 6 from a list of symptoms including social interaction impairment, repetitive/stereotypic behaviors, and LACK of communication impairment Childhood Disintegrative Disorder – Normal development for 2 years, then loss of previously acquired skills PDD-NOS – Presence of Autistic-like social interaction impairment, but not fully meeting criteria for any of the above DSM-5 Autism Spectrum Disorder – Deficits in Social Communication/Interaction combined with at least two repetitive behaviors (including sensory issues) Many specifiers including severity, with/without intellectual impairment, with/without language impairment, with catatonia, and associated with other conditions Social (Pragmatic) Communication Disorder – Listed a separate Neurodevelopmental Disorder, but basically an ASD without repetitive behaviors What is Autism Spectrum Disorder?

4. Why have we all heard the saying “If you’ve met one child with autism, you’ve met one child with autism?” Is Social Communication Disorder really that separate from ASD? Are sensory issues really a repetitive behavior? Are symptoms really “black and white” or are their many shades of gray? What about other associated symptoms? ADHD? Anxiety? Depression? Could having a more defined way of grouping ASD’s lead to better research and treatment? So if the Criteria are More Basic…

5. My thoughts on “the Spectrum” Symptoms that May Present as a Spectrum in Autism Spectrum Disorder Social Communication/Interaction Repetitive Behaviors Sensory Issues Intellectual Impairment Language Impairment Inattention Hyperactivity/Impulsivity Irritability/Aggression Anxiety Depression Sleep Putting the Spectrum back in ASD

6. Complete Lack of Social Communication Very Impaired Social Communication Skills Somewhat Impaired Social Communication Skills Mildly Impaired Social Communication Skills No Impairment of Social Communication Skills (Not a Traditional ASD) Social Communication/Interaction

7. Significant repetitive behaviors in all areas Significant isolated repetitive behaviors Moderate repetitive behaviors Mild repetitive behaviors Very limited to no repetitive behaviors (Not a Traditional ASD, may include Social Communication Disorder) Repetitive Behaviors

8. Significant Hypersensitivity in Multiple Areas Moderate Hypersensitivity in Multiple Areas or Isolated Severe Hypersensitivity in one Sensory Area Very Mild to No Significant Hypersensitivity or Hyposensitivity Moderate Hyposensitivity in Multiple Areas or Isolated Severe Hyposensitivity in one Sensory Area Significant Hyposensitivity in Multiple Areas Sensory Issues

9. Significant Intellectual Impairment (IQ<60) Borderline to Mild Intellectual Impairment (IQ 60-80) Average or Near-Average Intellectual Functioning (IQ 80-120) Moderate Intellectual Giftedness (IQ 120-140) Significant Intellectual Giftedness (IQ>140) Intellectual Impairment

10. No Significant Verbal/Language Skills Significant Verbal/Language Impairment Mild to Moderate Language Impairment or Delay No Significant Language Impairment or Delay Elevated Language Skills and Vocabulary Language Impairment

11. Profound Inattention (9/9 Inattentive Symptoms) Significant Inattention (7-8/9 Inattentive Symptoms) Moderate Inattention (6/9 Inattentive Symptoms) Mild Inattention (4-5/9 Inattentive Symptoms) No Significant Inattention (<4 Inattentive Symptoms) Inattention

12. Significant Hyperactivity AND Impulsivity Moderate Hyperactivity AND Impulsivity or Severe Impulsivity alone Mild-Moderate Hyperactivity OR Impulsivity Average Level of Hyperactivity/Impulsivity Moderate to Severe Hypoactivity Hyperactivity/Impulsivity

13. Severe Irritability/Aggression with unclear triggers Severe Irritability/Aggression when triggered Moderate Irritability/Aggression when triggered Mild Irritability/Aggression when triggered Average Levels of Irritability Irritability/Aggression

14. Significant Anxiety in Many Domains that Leads to Limited Functioning Significant Anxiety in Social Situations Only that Leads to Limited Functioning Moderate Anxiety in Many Domains with Some Limited Functioning Moderate Anxiety in Social Situations Only that Leads to Some Limited Functioning Mild/Average to No Significant Anxiety Anxiety

15. Chronic/Recurrent Severe Depression Episodic Severe Depression Episodic Moderate Depression Episodic Mild Depression or Chronic Dysthymia No Clinically Significant Depression or Dysthymia Depression

16. Near Complete Lack of Sleep with Decreased Need for Sleep (Mania) Very Limited Sleep with Associated Drowsiness/Irritability/Lack of Energy Moderately Impaired Sleep Delayed Sleep Onset No Recurrent Sleep Issues Sleep

17. “Jeremy” Diagnosed with Asperger’s Under DSM-IV, Now 16 Mildly Impaired Social Skills Mild Repetitive Behaviors as a Child, Now Mostly Resolved History of Moderate Hypersensitivity to Sounds and Tags in Clothing Significantly Intellectually Gifted (IQ 147) Elevated Language Skills and Vocabulary No Significant Inattention No Significant Hyperactivity/Impulsivity Mild Irritability/Aggression when Triggered Moderate Anxiety in Many Domains Episodic Moderate Depression, particularly when in Middle School Delayed Sleep Onset Clinical Examples of Symptom Clusters

18. “Patricia” Diagnosed with Autistic Disorder under DSM-IV, Now 9 Complete Lack of Social Communication Significant Repetitive Behaviors in All Areas Significant Hyposensitivity in All Areas Significant Intellectual Impairment (Nonverbal IQ Estimated to be 53) No Significant Verbal/Language Skills Profound Inattention Mild Hyperactivity/Impulsivity Severe Irritability/Aggression with Unclear Triggers Mild/Average Anxiety No Known Depression or Dysthymia Very Limited Sleep with Associated Drowsiness/Irritability/Lack of Energy Clinical Examples of Symptom Clusters

19. “Bobby” Diagnosed with Autistic Disorder under DSM-IV, now 12 Somewhat Impaired Social Skills Significant Isolated Repetitive Behavioral Moderate Hypersensitivity to Sounds, Smells, and Tactile Stimulation Average Intellectual Functioning (IQ 94) History of Mild Language Delay, now normalized Significant Inattention Significant Hyperactivity AND Impulsivity Severe Irritability/Aggression when Triggered Moderate Anxiety in Social Situations Episodic Mild Depression with Recent Dysthymia Moderately Impaired Sleep Clinical Examples of Symptom Clusters

20. Could Patterns in Combinations of Symptoms Lead to Better Subgroups? Does response to stimulants vary based on intellectual functioning and/or degree of preexisting irritability/aggression? Could depression be better predicted/prevented based on the combination of other symptoms (such as degree of social impairment and intellectual functioning)? Do highly impulsive children with aggression respond differently to medication than those without significant hyperactivity/impulsivity? Should children with anxiety and aggression together have different treatment than children with aggression in the absence of anxiety? What about other domains? Autoimmune diseases? Known Genetic Issues? Dietary Issues? Potential Impacts on Research/Treatment

21. Ken Pittman, MD Agape Youth Behavioral Health 423-443-3336 drpittman@youthbehavior.com Questions?