Autism Spectrum Disorder and Mental Health Challenges · PDF fileAutism Spectrum Disorder and Mental Health Challenges in Youth. ... • Important element of intervention ......

Management in the Primary Care Setting

Autism Spectrum Disorder and Mental Health Challenges in Youth

February 13, 2016 Rebecca Marshal l , MD, MPH

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Outline DSM V Criteria Comorbidities Behavioral treatments Pharmacologic treatments Resources

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Autism Spectrum Disorder DSM IV DSM V Autistic Disorder, Aspergers Disorder, and PDD-NOS replaced with Autism

Spectrum Disorder (ASD). Three core domains of impairment (communication, social interaction, and

restricted interests and repetitive behaviors) changed to two domains of impairment: social/communication deficits and restricted interests and repetitive behaviors.

Also, a delay in language development is no longer necessary for a diagnosis.

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DSM V Autism Spectrum Disorder CriteriaA. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by:

1. Deficits in social-emotional reciprocity, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.

2. Deficits in nonverbal communicative behaviors used for social interaction, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.

3. Deficits in developing, maintaining, and understanding relationships, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

Specify current severity. Severity is based on social communication impairments and restricted repetitive patterns of behavior.

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DSM V Autism Spectrum Disorder CriteriaB. Restricted, repetitive patterns of behavior, interests, or activities:

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day).

3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest).

4. Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling ortouching of objects, visual fascination with lights or movement).

Specify current severity: Severity is based on social communication impairments and restricted, repetitive patterns of behavior (see Table 2).

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DSM V Autism Spectrum Disorder CriteriaC. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.E. These disturbances are not better explained by intellectual disability or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Aspergers disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder.

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ASD and Comorbid Psychiatric Disorders 2008 prevalence study in JAACAP 112 children with ASD ages 10-14

were assessed for other psychiatric disorders.

70% had at least one comorbid disorder

41% had two or more. Emily Simonoff, Andrew Pickles, Tony Charman, Susie Chandler, Tom Loucas, Gillian Baird, Psychiatric Disorders in Children With Autism Spectrum Disorders: Prevalence, Comorbidity, and Associated Factors in a Population-Derived Sample, Journal of the American Academy of Child & Adolescent Psychiatry, Volume 47, Issue 8, August 2008, Pages 921-929.

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ASD and Comorbid Psychiatric Disorders Most common diagnoses:

social anxiety disorder (29.2%) attention-deficit/hyperactivity disorder (28.2%) Oppositional defiant disorder (28.1 %) Generalized anxiety disorder (13.4%) Panic disorder (10.1%) Enuresis (11%) Low rates of major depressive disorder (0.9%), dysthymic

disorder (0.5%), and conduct disorder (3.2%)

84% of those with ADHD had a second comorbid diagnosis.

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Fig. 1. Weighted rates of comorbidity are shown for all of the disorders and for all of the main disorders, in which the latter includes ADHD, oppositional defiant or conduct disorder, and any emotional disorder

Emily Simonoff, Andrew Pickles, Tony Charman, Susie Chandler, Tom Loucas, Gillian Baird, Psychiatric Disorders in Children With Autism Spectrum Disorders: Prevalence, Comorbidity, and Associated Factors in a Population-Derived Sample, Journal of the American Academy of Child & Adolescent Psychiatry, Volume 47, Issue 8, August 2008, Pages 921-929.

Psychiatric comorbidity with ASD

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Intellectual disability in those with ASD approximately 50% exhibit severe or

profound intellectual disability 35% exhibit mild to moderate

intellectual disability, and the remaining

20% have IQs in the normal range.18 Fred Volkmar, Matthew Siegel, Marc Woodbury-Smith, Bryan King, James McCracken, Matthew State, and the AACAP Committee on Quality Issues. Practice Parameter for the Assessment and Treatment of Children and Adolescents With Autism Spectrum Disorder. JAACAP, 53 (2) 2014.

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Behavioral difficulties in those with ASD A range of behavioral difficulties can be observed in

ASD: hyperactivity obsessive-compulsive phenomena self-injury aggression stereotypies Tics affective symptoms (lability, inappropriate affective

responses, anxiety, and depression)

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Behavioral Treatments for ASD Core feature of ASD is

difficulty with social interactions.

Therapy / behavioral treatments therefore critical with strong evidence base for improved outcomes.

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Applied Behavior Analysis Based on concept of understanding how events influence and change

behavior. Requires assessment of how events influence an individuals behavior.

Includes: contextual factors such as the setting in which a behavior occurs; motivational variables such as the need to attain something; antecedent events, such as a request to do something from another person; Consequences following the behavior

Progress is measured by direct observations over time. Early Intensive Behavioral Intervention (EIBI) -- comprehensive ABA

program for young children Intensive and highly individualized Up to 40 hours per week of one-to-one direct teaching

Reichow, B. & Volkmar, F.R. Social skills interventions for individuals with autism: evaluation for evidence-based practices within a best evidence synthesis framework. Autism Dev Disord (2010) 40: 149.

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Naturalistic treatment Used to structure parent child interactions or

to teach imitation and/or joint attention behaviors

Intervening in the natural environment with natural reinforcers during interactions guided by the child

Evidence strongest for use with young children

Reichow, B. & Volkmar, F.R. Social skills interventions for individuals with autism: evaluation for evidence-based practices within a best evidence synthesis framework. Autism Dev Disord (2010) 40: 149.

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Parent Training

Reichow, B. & Volkmar, F.R. Social skills interventions for individuals with autism: evaluation for evidence-based practices within a best evidence synthesis framework. Autism Dev Disord (2010) 40: 149.

Important element of intervention programs for children with autism

Accumulating evidence that parent training is an effective method for increasing the social skills of young children

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Peer training The use of peers to help teach children with autism

has been a commonly used method that has significant research support

Used for both preschool and school-aged children Like-aged individuals with and without individuals Peers taught to provide specific elements of therapy

including visual supports and prompting

Reichow, B. & Volkmar, F.R. Social skills interventions for individuals with autism: evaluation for evidence-based practices within a best evidence synthesis framework. Autism Dev Disord (2010) 40: 149.

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Other modalities Visual supports (social stories, visual

schedules) Social skills groups Video modeling Occupational / physical therapy

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Communication Typically addressed in the childs IEP in

coordination with the speech-language pathologist.

Nonverbal children: alternative communication modalities, i.e., sign langu