Autism and Psychiatric Management

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Autism and Psychiatric Management

• By
• Faisal Ahmed, M.D

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Classical Autism typical presentation

• A three year old boy
• Pays little attention to his parents or other
  adults
• Repeats certain words in a stereotyped manner
• Fascinated with running water
• Watches fans and rotating wheels

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Autism

• Part of pervasive developmental disorders
• Children with autism generally have problems in
  three crucial areas of development
• 1. social interaction
• 2. language
• 3. behavior
• Subnormal intelligence in two third of the
  patients

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Social skills

• Fails to respond to his or her name
• Has poor eye contact
• Appears not to hear you at times
• Resists cuddling and holding
• Appears unaware of others' feelings
• Seems to prefer playing alone retreats into his
  or her "own world

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Language

• Starts talking later than other children
• Loses previously acquired ability to say words or
  sentences
• Does not make eye contact when making requests
• Speaks with an abnormal tone or rhythm may use
  a singsong voice or robot-like speech
• Can't start a conversation or keep one going
• May repeat words or phrases verbatim, but doesn't
  understand how to use them

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Behavior

• Performs repetitive movements, such as rocking,
  spinning or hand-flapping
• Develops specific routines or rituals
• Becomes disturbed at the slightest change in
  routines or rituals
• Moves constantly
• May be fascinated by parts of an object, such as
  the spinning wheels of a toy car
• May be unusually sensitive to light, sound and
  touch and yet oblivious to pain

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Causes

• No single cause.
• May include
• - Genetic Errors
• - Environmental factors
• - Other causes

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NEUROBIOLOGICAL FINDINGS IN AUTISM

• Increased (peripheral) serotonin levels.
• Persistent primitive reflexes.
• Increased head size (macrocephaly).
• Changes in brain morphology/cytoarchitecture.
• Failure to activate fusiform face region.
• High rates of EEG abnormality/seizure disorder

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Differential Diagnosis of Autism

• Hearing loss/ congenital deafness
• Childhood onset schizophrenia
• Mixed receptive/expressive language disorder
• Psychosocial deprivation

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Age of Onset

• In most cases, the apparent onset of autism
  occurs within the first or second year of life.

Age of onset (cases with clinical diagnosis of
autism in DSM-IV field trial). (F Volkmar and A
Klin, Issues in the classification of autism and
related conditions, . New York Wiley, vol. 1, p.
20.)
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EVALUATION PROCEDURES

• Historical information
• Developmental and psychological
• assessment ( CHAT scale, etc)
• Psychiatric examination
• Medical evaluations

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Commonly used instruments include

• Childhood Autism Rating Scales (CARS) (Schopler,
  et al., 1988) - an instrument in which
  individuals of different ages are rated, some
  training is required,
• Autism Behavior Checklist (Krug, Arick, and
  Almond, 1980) - a screening instrument completed
  by teachers,
• Autism Diagnostic Interview - Revised (ADI-R)
  (Lord, Rutter Le Couteur, 1994), a
  semistructured interview for parents,
• Autism Diagnostic Observation Scale (ADOS)
  (DiLavore, Lord Rutter, 1995) an observational
  scale for children and adults.

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Prevalence of Autism

• More common in boys 3 to 51
• 1 to 2 per thousand to 1 in 500

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Treatment in Autism

• Educational therapies
• Behavior and communication therapies
• Medications for self-injurious behavior and
  repetitive behavior
• Atypical antipsychotics
• Stimulants
• SSRIs

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Prognosis

• Most are severely impaired as adults and need
  assistance with living

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Bad Parenting Skills
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Aspergers Disorder case presentation

• Three year old can communicate verbally
• Few hand gestures
• Poor eye contact
• Little social interest
• Odd behavior patterns
• Age appropriate cognitive and self care skills

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Aspergers Disorder

• At the milder end of this Autism spectrum.
• Different from Autism.

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AUTOBIOGRAPHICAL STATEMENT OF A 10 YEAR OLD BOY
WITH ASPERGER DISORDER

• My name is Robert Edwards. I am an intelligent,
  unsociable but adaptable person. I would like to
  dispel any untrue rumors about me. I cannot fly.
  I cannot use telekinesis. My brain is not large
  enough to destroy the entire world when unfolded.
  I did not teach my long haired guinea pig,
  Chronos, to eat everything in sight (that is the
  nature of the long haired guinea pig).Name
  changed.
• Volkmar, Klin, Schultz, Rubin, Bronen,
  Asperger's disorder Clinical case conference.
  American Journal of Psychiatry, 157(2), 26267,
  2000.

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Age of onset

• Noticed between 3 to 5 years of age or even later
• More common in boys
• Incidence as high as 1 in 500

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Differential Diagnosis

• Autistic Disorder (language developed)
• Schizophrenia of childhood onset
• Retts disorder (in girls)
• Obsessive Compulsive Disorder
• Schizoid Personality Disorder

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Prognosis

• Better than autism
• Likely to hold a job where socialization is not
  required
• Computers programmers, mathematicians,
  engineering
• One study reported more than twice the of first
  degree relatives of children with Asperger's in
  these fields.

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Retts Disorder case presentation

• Infant girl
• Six months of normal development
• Losing her acquired skills
• By 18 months little social interaction, ataxic
  gait, odd finger tapping and hand wringing
  gestures

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Retts Disorder

• Decreased social interest and skills
• Brief period of normal functioning
• Stereotyped hand-wringing movements
• Psychomotor retardation
• Mental retardation
• Associated with a specific genetic defect in
  MECP2, a regulator gene on the X chromosome.

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Rett Syndrome
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Onset and Occurrence

• Before 4 years of age
• Usual onset between 5 and 48 months
• Only in girls.
• Prevelance between 1 in 15,000 and 1 in 22,000
  females

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Treatment Prognosis

• Progressive and lifelong
• At this time there are no specific treatments.
  Various supportive treatments are used, including
  special education, occupational, physical and
  respiratory therapies

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Childhood Disintegrative Disorder-case
presentation

• Three year old boy
• Previous normal functioning
• Stops speaking and interacting with others
• Can no longer dress himself
• Begins to wet and soil himself
• Mental retardation

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Onset Occurrence

• Two to ten years of age when skills are lost
• Very rare
• More common in boys

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Prognosis

• Chronic and lifelong

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Pervasive Developmental Disorders Treatments

• The multiple developmental and behavioral
  problems associated with these conditions often
  require the care of multiple providers
  coordination of services and advocacy for
  individuals and their families is important.
• Early, sustained intervention is indicated as is
  the use of various treatment modalities (e.g.,
  pharmacotherapy, special education,
  speech-communication therapy, and behavior
  modification).

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Treatment plan

• Establishing goals for educational
  intervention.
• Establishing target symptoms for intervention.
• Prioritizing target symptoms/co-morbid
  conditions.
• Monitoring multiple domains of functioning
  (including behavioral adjustment, adaptive
  skills, academic skills, social-communicative
  skills, and social interaction with family
  members and peers).
• Monitoring medication for efficacy and side
  effects, as appropriate.

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Pervasive Developmental Disorders Treatments

• Intensive behavioral intervention
• Goals
• Decrease behavioral symptoms
• Aid in development of delayed, rudimentary, or
  nonexistent functions (i.E. Language and
  self-care skills)

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Pervasive Developmental Disorders Treatments

• Intensive behavioral intervention
• Components
• Intensive one on one tutoring utilizing positive
  reinforcement
• Ex reward appropriate behaviors with food or
  praise (waving bye-bye)
• Parent training
• Show parents how to shape appropriate behaviors
  using reward system

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Pharmacotherapy

• Increase the ability of persons with PDD to
  profit from educational and other intervention
  (McDougle, 1997).
• interventions should be focused on the target
  symptom without losing sight of the larger
  clinical picture,
• Since individuals with autism/PDD are often
  nonverbal, reliance typically is made on reports
  and observation of specific behaviors.

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Neuroleptics

• intensively investigated in individuals with
  autism
• fundamental mode of action appears to be dopamine
  receptor blockade
• Haldol, Risperdal, Abilify
• The results of numerous controlled clinical
  trials in children with autism suggest the
  potential for significant benefit in terms of
  reduced stereotype and withdrawal thus
  facilitating learning (Campbell, Anderson
  Small, 1990a).
• In the US, risperidone and abilify are approved
  by FDA for the treatment of irritability
  associated with autistic disorder in children and
  adolescents .
• The most frequent side effects include sedation
  and irritability but in general are dose related
• Longer-term administration can be associated with
  other side effects such as drug related
  dyskinesias including tardive dyskinesia , weight
  gain, Risk of Diabetes, Abnormal Cholesterol
  levels.
• the long-term safety of neurolpetics in children
  and adolescents with autistic disorder remains to
  be fully determined

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Selective Serotonin Reuptake Inhibitors.

• potent inhibitors of the serotonin transporter
  and were initially of interest in autism given
  the observation of high peripheral serotonin
  levels in autism.
• Fluvoxamine, Fluoxetine, Clomipramine
• Target Symptoms Depression, Anxiety,
  obsessive-compulsive-like behaviors
• Cook et al. (1992) found that fluoxetine (in
  doses ranging from 20 mg every other day to 80 mg
  daily) was associated with improved levels of
  functioning in individuals with autism and with
  mental retardation without autism
• Side effects insomnia, hyperactivity,
  restlessness, agitation, and decreased appetite,
  Seizure and heart conduction delays with
  Clomipramine.

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Mood Stabilizers

• Valproic Acid, Lithium, Carbamazapine,
  Oxycarbamazapine
• Most effective in comorbid Bipolar disorder or
  other mood disorders.
• Mixed results in studies.
• Side effect Burdon

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Anxiolytics
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Question

• Children with autism generally have problems in
  three crucial areas
• Social interaction, anxiety, aggression
• Conduct, humor, expressed language
• Social interaction, behaviors, language
• Impulse control, Mood and affect, cognitive
  ability.

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Answer

• C Social interaction, behaviors, language

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Question

• Autism is known to be caused by a single gene
  located on Chromosome 14?
• True
• False

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Answer

• False
• Causes include
• - Genetic Errors
• - Environmental factors
• - Other causes

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Question

• Asperger disorder is another form of autism with
  a difference of mood unstability.
• True
• False

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Answer

• False
• Only difference is language and Age appropriate
  cognitive and self care skills