Autism Spectrum Disorders

1. Autism Spectrum Disorders Judith Miller, Ph.D. Department of Psychiatry University of Utah judith.miller@hsc.utah.edu

2. Educational Objectives • Overview of ASD characteristics • Discuss diagnostic issues • Briefly touch on: • Early identification • Adult outcomes • Causes and treatments

3. What is ASD? What is PDD? • PDD = Pervasive Developmental Disorder • the general diagnostic category in which autism, Asperger Disorder, and PDDNOS fall • all involve deficits in social relatedness, communication, and behaviors & interests • Terms ASD and PDD are largely synonymous

4. DSM-IV Classification System

5. Autism Spectrum Disorders

6. Terms that might be used interchangeably • Autism, Autistic Disorder • High functioning autism (i.e., a diagnosis of autism made in a verbal individual with normal IQ) • Asperger Disorder • PDDNOS • Autism spectrum disorder • “autistic features”

7. Symptoms of ASD • Social difficulties • Difficulty using or understanding nonverbal communication (eye contact, facial expression, body language) • Difficulty making friends • Difficulty sharing their interests with others appropriately • Difficulty with emotional reciprocity

8. Symptoms of ASD (cont.) • Communication Impairments • Delayed speech development • Difficulty with reciprocal conversations • Unusual language (repeats dialogue from movies, uses rote phrases) • Difficulty with imaginary or social play

9. Symptoms of ASD (cont.) • Restricted or Repetitive Interests or Behaviors • Preoccupation or narrow interests (e.g., memorizes facts about train schedules or dinosaur habits) • Repetitive hand or body movements • Difficulty with change/insistence on nonessential routines • Overly drawn to sensory activities

10. Diagnostic Differentiations • Autistic Disorder • 6 or more of the 12 possible symptoms, can include individuals of any intellectual or verbal level • “High functioning autism” means Autistic Disorder in a person who is verbal and not intellectually impaired • Asperger Disorder • 5 or fewer symptoms, must not have had delays in language or cognitive development (High functioning by definition) • PDDNOS • ASD symptoms but full criteria for autism or Asperger not met (fewer symptoms, atypical presentation, or developmental course not yet clear)

11. Reliability of diagnosis • ASD v. non ASD is reliable • Distinctions between forms of ASD (autism, HFA, AS, PDDNOS) are not as reliable • If the diagnoses cannot be reliably distinguished from each other by “autism experts,” validity of the proposed differences is called into question • ASD v. non ASD may be a more helpful distinction

12. hearing impaired general DD/MR speech-language disorders Specific Language Impairment Central Auditory Processing Disorder ADHD learning disabled psychotic/early schizophrenia OCD selective mutism abuse/neglect oppositional-defiant disorder personality disorders (in adults) Differential Diagnosis

13. Common Comorbidities • MR • ADHD • mood disorders • anxiety disorders • ASD generally makes other comorbidities more difficult to manage

14. Diagnostic measures • Best information comes from clinical observations and developmental history • Autism Diagnostic Observation Schedule (Western Psychological Services) • Autism Diagnostic Interview – Revised (Western Psychological Services) • Screeners are available, but have significant limitations and should be used with caution • Be sure that the test is appropriate for the individual’s verbal and cognitive level • Be aware that most screeners underidentify • Practice parameters referenced below

15. Early Identification • Recent emphasis on identifying autism as early as possible (i.e. at onset if possible) • Research includes: • Retrospective studies of home videos • Prospective studies of infant siblings • Toddler screening studies • Clinical experience suggests: • Brief evaluation is insufficient; some children look quite interactive in first 10-20 minutes

16. Early Warning Signs • Not responding to name • Limited imitation skills • Difficulty with pretend play • Difficulty with joint attention (pointing things out to people just to share a social interaction) • Library of early signs at www.autismspeaks.org

17. Adult Outcomes • Individuals with IQ <70 generally have poor adult outcomes • Individuals with IQ>70 have variable outcomes, from poor to very good • For HFA/AS, outcome does not necessarily improve as IQ gets higher • Individuals who were verbal at age 5 are more likely to have a good outcome, but not guaranteed

18. What Causes Autism? • Short answer: We don’t know • Long history of hypothesized causes, including poor parenting, vaccines, yeast, vitamin deficiency, etc. • Strong evidence for a genetic component • Probably poly-genetic, with variable penetrance

19. What treatment is effective? • Short answer: Behavioral teaching (aka “Applied Behavioral Analyses”) has been shown to improve IQ scores, reduce behavior problems, and increase functional living skills • Other ways of teaching skills and addressing problems can be effective • Many biomedical or alternative treatments have become available, often based on anecdotal evidence not supported by larger studies

20. Resources for further information • General information • www.autismspeaks.org • www.aspergersyndrome.org • www.cdc.gov

21. Resources (cont.) • Practice Parameters • Volkmar et al., (1999). Practice parameters for the assessment and treatment of children, adolescents, and adults with autism and other pervasive developmental disorders. J Am Acad Child Adolesc Psychiatry 38 (suppl 12) 32S-54S. • Filipek et al., (2000). Practice parameter: Screening and diagnosis of autism. Neurology 55:468-479. • CA Dept of Developmental Services (2002). Autistic spectrum disorders: Best practice guidelines for screening, diagnosis, and assessment. Available at: www.ddhealthinfo.org/asd.asp