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Autism Spectrum Disorder and Co-Existing Neuropsychiatric Disorders:

Autism Spectrum Disorder and Co-Existing Neuropsychiatric Disorders: Medication and Treatment Luke Tsai, M.D., F.A.A.C.A.P. Professor Emeritus of Psychiatry and Pediatrics Research Scientist Emeritus University of Michigan Medical School.

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Autism Spectrum Disorder and Co-Existing Neuropsychiatric Disorders:

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  1. Autism Spectrum Disorder and Co-Existing Neuropsychiatric Disorders: Medication and Treatment Luke Tsai, M.D., F.A.A.C.A.P. Professor Emeritus of Psychiatry and Pediatrics Research Scientist Emeritus University of Michigan Medical School

  2. Autism Spectrum Disorder and Co-Existing Neuropsychiatric Disorders: Medication and Treatment Part I Evolution of Concept of Autism and Targets for Medication Treatments

  3. Evolution of Diagnosis of Autism • 1906 DeSanctisDementialPrecocissima • Heller Dementia Infantilis • Kanner Infantile Autism • Asperger Autistic Psychopathy • 1947 Bender Childhood Schozophrenia • 1955 Mahler Symbiotic Psychosis • 1967 Rutter Early Onset Psychosis

  4. Evolution of Diagnosis of Autism 1968 APA DSM-II Schizophrenia, Childhood Type WHO ICD-9Childhood Psychosis - Infantile Autism Subtype 1980 APA DSM-III Pervasive Developmental Disorders 1) Infantile Autism, full syndrome present 2) Infantile Autism, residual state 3) Childhood onset PDD, full syndrome 4) Childhood Onset PDD, residual state 5) Atypical PDD 1987 APA DSM-III-R Pervasive Developmental Disorders 1) Autistic Disorder 2) Pervasive Developmental Disorder Not Otherwise Specified (PDDNOS)

  5. Evolution of Diagnosis of Autism 1994 APA DSM-IV Pervasive Developmental Disorders WHO ICD-10 1) Autistic Disorder 2) Asperger Disorder 3) Rett Disorder 4) Disintegrative Disorder 5) PDDNOS

  6. Ever Since the Term “Pervasive Developmental Disorders” was Adopted in 1980 NO! The Term Autism Spectrum Should Be Used The Term PDD Should Be Used

  7. Is it time to replace the term “Pervasive Developmental Disorder” With “Autism Spectrum Disorder”?

  8. Literature Review (1994-2010) • Entrez PubMed Database Search • National Library of Medicine (NLM), USA • Key Words: Asperger’s Disorder • Numbers of Published Studies Based on the Use of Diagnostic Term: • Pervasive Developmental Disorder: 52 • Autism Spectrum Disorder: 207 • Autism: 133 • Comment: It appears that professionals in the field of Autism • prefer to use “Autism Spectrum Disorder” or “Autism” • than use “PDD.”

  9. NEW CONCEPT of AUTISM – DSM-5 ASD * Remove from DSM 299.80 Rett’s Disorder  * Subsumed Under the Diagnostic Category of Autism Spectrum Disorder X 299.10 Childhood Disintegrative Disorder X 299.80 Asperger’s Disorder X 299.80 Pervasive Developmental Disorder Not Otherwise Specified (PDDNOS)

  10. Evolution of Diagnosis of Autism 1994 APA DSM-IV Pervasive Developmental Disorders WHO ICD-10 1) Autistic Disorder 2) Asperger Disorder 3) Rett Disorder 4) Disintegrative Disorder 5) PDDNOS 2013 APA DSM-5 Autism Spectrum Disorder

  11. DSM – IV (1994) – Autistic Disorder • Qualitative impairment in social interaction • Qualitative impairments in communication • Restricted repetitive and stereotyped patterns of • behavior, interests, & activities • ************************************************************************************ • DSM–5 (2013) Autism Spectrum Disorder • Persistent deficits in social communication and social interaction • across contexts, not accounted for by general developmental delays • B. Restricted, repetitive patterns of behavior, interests, or activities

  12. Evolution of Autism Diagnosis Diagnostic Criteria – 4a No specific requirement of minimal items DSM – 5 (2013) Autism Spectrum Disorder Must meet criteria A, B, C, and D: • Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays: 1. Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction, 2. Deficits in nonverbal communicative behaviors used for social interaction; ranging from poorly integrated- verbal and nonverbal communication, through abnormalities in eye contact and body- language, or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures. 3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers); ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play and in making friends to an apparent absence of interest in people

  13. Evolution of Autism Diagnosis Diagnostic Criteria – 4b DSM – 5 Autism Spectrum Disorder B. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following: 1. Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases). 2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes). 3. Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests). 4. Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects). C. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities) D. Symptoms together limit and impair everyday functioning.

  14. There are Problems with the DSM-5 ASD Diagnostic Rules

  15. The officially published DSM-5 ASD does not specifically require any minimal number of the symptom criteria under social-communication domain must be present to qualify for a diagnosis of DSM-5 ASD. • Although many clinicians and investigators assume that all three symptoms are required, but some have argued that this is unclear (Brock and Hart 2013). • Some professionals in the field of ASD even consider this as a “major” flaw of DSM-5 ASD (Frances 2013).

  16. The other decision by DSM-5 ASD that also has been considered as a “major” flaw is that at the end of the criteria set of ASD, a note is attached (Frances 2013) Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger's disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder.

  17. This statement may be interpreted by many clinicians/raters as “free to choose” how to define and diagnose ASD. Those cases with “mild end” autism who would not qualify for DSM-5 ASD under “all three symptom criteria” rule would qualify for DSM-5 ASD under the “Note” rule. • Some will require one item from criterion A; others two; yet others three; and some will chuck DSM-5 altogether and use the very different definitions that are contained in DSM-IV.”

  18. What is going to happen to WHO’s ICD-11 ASD? Interview to Professor Sir Michael Rutter Chair of the Child & Adolescent Psychiatry working party for ICD-11 - Feb 2012 Sir Michael Rutter: At the moment there are important differences between proposals for DSM-5 and ICD-11.

  19. May 2012 Open ICD-11 Beta to the public Autism Spectrum Disorder 1) Autism 2) Disintegrative Disorder 3) Social reciprocity disorder (Asperger syndrome) 4) Rett syndrome

  20. Currently Being Proposed ICD-11 Autism Spectrum Disorder (2017) • Autism spectrum disorder without disorder of intellectual development or impairment in functional language   • Autism spectrum disorder with disorder of intellectual development • Autism spectrum disorder with limitation in communication • Autism spectrum disorder with both disorder of intellectual development and structural language impairment  

  21. Currently Being Proposed ICD-11 Autism Spectrum Disorder (2017) • Autism spectrum disorder with limitation in communication * Autism spectrum disorder with mild impairment of functional language * Autism spectrum disorder with marked impairment of functional language * Autism spectrum disorder with pervasive impairment of functional language * Autism spectrum disorder with complete impairment of functional language

  22. Currently Being Proposed ICD-11 Autism Spectrum Disorder (2017) • Autism spectrum disorder with both disorder of intellectual development and structural language impairment * Autism spectrum disorder with disorder of intellectual development and mild impairment in functional language * Autism spectrum disorder with disorder of intellectual development and marked impairment of functional language     * Autism spectrum disorder with disorder of intellectual development and pervasive impairment of functional language * Autism spectrum disorder with disorder of intellectual development and complete impairment of functional language

  23. Impact of ICD-11 on ASD ?????

  24. Reason for still studying Autistic Disorder and Asperger’s Disorder • ICD-10 will still be used till 2017 • Autistic Disorder • Asperger’s Disorder • PDDNOS • Rett Disorder • Childhood Disintegrative Disorder • DSM-5 ASD Rule • Note: Individuals with a well-established DSM-IV • diagnosis of autistic disorder, Asperger's disorder, or • PDDNOS should be given the diagnosis of autism • spectrum disorder.

  25. Targets of Medication Treatments “Social Deficits” “Stereotypies/ Restricted Interests” “Communication Deficits” Features of “Autistic Disorder”

  26. Intelligence and Cognitive Deficits About 40% to 60% of autistic children have an IQ below 50; only 20% to 30% have an IQ of 70 or more. Follow-up studies have shown that retardation present at the time of initial diagnosis tends to persist. A Wechsler Intelligence Scale profile characterized by Verbal IQ lower than Performance IQ (VIQ < PIQ) with lowest subtest score on Comprehension and highest on Block Design.

  27. Targets of Medication Treatments “Social Deficits” Cognitive Impairment “Stereotypies/ Restricted Interests” “Communication Deficits” Features of “Autistic Disorder” and Co-existing Cognitive Impairment

  28. Targets of Medication Treatments Disturbance of Motility About 67% of autistic children showed a clinically significant level of motor impairment Using a standardized test, the Test of Motor Impairment-Henderson Revision (Manjiviona and Prior 1995).

  29. Features of “Autistic Disorder” and Co-existing Cognitive Impairment and Motor Deficits “Social Deficits” Mental Retardation Motor Deficits “Stereotypies/ Restricted Interests” “Communication Deficits”

  30. Treatment/Cure of Autism Spectrum Disorder: Targets of Treatment Mental Retardation Motor Function Deficit “Social Deficits” “Stereotypies/ Restricted Interests” Neuropsychiatric Disorders “Communication Deficits”

  31. Comprehensive Treatment Model____ General & Special Education Therapy Behavior Therapy Family Counseling Speech Therapy Music Therapy PDD/ASD Sensory Integration Social Skill Training Art/Craft Therapy Vocational Training Independent Living Training Recreation Therapy Diet Therapy Medical/Surgical Therapy

  32. Treatment/Cure of Autism Spectrum Disorder: Targets of Treatment ___________ Mental Retardation Motor Function Deficit “Social Deficits” “Stereotypies/ Restricted Interests” Neuropsychiatric Disorders “Communication Deficits”

  33. “Social Deficits” Medications No Medication Has been Specifically Investigated in this Aspect

  34. EVIDENCE - 1 • Ballaban-Gil K, Rapin I, Tuchman R, et al., • Longitudinal examination of the behavioral, language, and social changes in a population of adolescents and young adults with autistic disorder. • Pediatr Neurol. 1996 Oct;15(3):217-23. • Over 90% of 45 adults had persisting social deficits.

  35. EVIDENCE - 2 • Howlin P, Mawhood L, Rutter M. • Autism and developmental receptive language disorder--a comparative follow-up in early adult lifeII: Social, behavioural, and psychiatric outcomes. • J Child Psychol Psychiatry. 2000 Jul;41(5): 561-78 • First seen when aged 7 to 8 years of age, re-evaluated at average age of 23 to 24 years. • On a composite measure of social competence, 74% was assessed as having severe social difficulties • 25% were rated as being of near/normal social functioning.

  36. “Social Deficits” No Data Most Likely X Medications

  37. Treatment/Cure of Autism Spectrum Disorder: Targets of Treatment ___________ Mental Retardation Motor Function Deficit “Social Deficits” “Stereotypies/ Restricted Interests” Neuropsychiatric Disorders “Communication Deficits”

  38. “Communication Deficits” Medications No Medication Has been Specifically Investigated in this Aspect

  39. EVIDENCE • Ballaban-Gil K, Rapin I, Tuchman R, et al, • Longitudinal examination of the behavioral, language, and social changes in a population of adolescents and young adults with autistic disorder. • Pediatr Neurol. 1996 Oct;15(3):217-23. • Language improved with age, though only 35%achieved • normal or near-normal fluency. • Comprehension also improved, though only 29% of • subjects had achieved normal or near-normal comprehension • of oral language.

  40. No Data Most Likely X “Communication Deficits” Medications

  41. Treatment/Cure of Autism Spectrum Disorder: Targets of Treatment ___________ Mental Retardation Motor Function Deficit “Social Deficits” “Stereotypies/ Restricted Interests” Neuropsychiatric Disorders “Communication Deficits” Will be Discussed Later

  42. Treatment/Cure of Autism Spectrum Disorder: Targets of Treatment ___________ Mental Retardation Motor Function Deficit “Social Deficits” “Stereotypies/ Restricted Interests” Neuropsychiatric Disorders “Communication Deficits”

  43. Most Likely X Motor Function Deficit Medications No Medication Has been Specifically Investigated in this Aspect

  44. Treatment/Cure of Autism Spectrum Disorder: Targets of Treatment ___________ Mental Retardation/ Cognitive Impairment Motor Function Deficit “Social Deficits” “Stereotypies/ Restricted Interests” Neuropsychiatric Disorders “Communication Deficits”

  45. Mental Retardation / Cognitive Impairment Medications No Medication Has been Specifically Investigated in this Aspect

  46. EVIDENCE • Freeman BJ, Rahbar B, Ritvo ER, et al. • The stability of cognitive and behavioral parameters in autism: a twelve-year prospective study. • J Am Acad Child Adolesc Psychiatry. 1991 May;30(3):479-82. • 62 autistic patients enrolled in a prospective study an average of 12 years ago. • Retesting results indicate that 68% had scores within original IQ group; 9% moved down; 23% moved up IQ groups.

  47. Most Likely Mental Retardation/ Cognitive Impairment X Medications

  48. Treatment/Cure of Autism Spectrum Disorder: Targets of Treatment ___________ Mental Retardation Motor Function Deficit “Social Deficits” “Stereotypies/ Restricted Interests” Neuropsychiatric Disorders “Communication Deficits” Will be Discussed Later

  49. Impaired Communication Skills Impaired Motor Function X X Impaired Social Interactions ? Impaired Cognitive Function MEDICATIONS X Restrict, repetitive Interests &/or Activities Comorbid Neuropsychiatric Disorders

  50. Recognizing Co-Existing Neuropsychiatric Conditions of Autism Spectrum Disorder • Prevalence of Co-Existing • Neuropsychiatric Conditions

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