1. Autism Spectrum Disorders (ASD): Identification & Management including “Co-Morbidities”
Chuck J. Conlon, MD, FAAP
Director of Developmental Pediatrics
Children’s National Medical Center

2. 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

3. 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

4. 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

5. Autism Spectrum Disorders: Classification
Autistic Disorder
Rett’s Disorder
Childhood Disintegrative Disorder
Asperger’s Disorder
Pervasive Developmental Disorder. Not Otherwise Specified

6. 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. 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. 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. 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

10. 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 or

11. ASD: Published Guidelines
AAP; Committee on Children with Disabilites 2001 (Pediatrics, 107(5): )
American Academy of Neurology & Child Neurology Society (Filipek et al., 2000 Neurology, 55: )
CAN Consensus Statement (Geschwind et al., 1998, CNS Spectrums, 3:

12. 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

13. 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

14. 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. 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. 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. 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. 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: info.med.yale.edu/chldstdy/autism

19. 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. 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. 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. 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. 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. 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. 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. 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. 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