Download Best Practices for People with Mild Autism Spectrum

Best Practices for People
with Mild Autism Spectrum
Disorder (aka Asperger’s
Syndrome)
Paul Glaser MD, PhD
Professor of Pediatrics and
Psychiatry
October 23, 2015
Disclosures of Potential Conflicts
Source
Consulta
nt
Advisor
y Board
Stock or
Equity
>$10,00
0
Speaker
s’
Bureau
Researc
h
Support
NIMH
Expenses
related to
this talk
or
meeting
X
NIDA
Shire
Honorariu
m for this
talk or
meeting
X
X
Objectives



Discuss the Diagnosis of Asperger
Syndrome (aka Autism Spectrum
Disorder, mild)
Discuss Best Medicines and Therapies
Discuss School and Behavioral Plans
1
DSM-IV Disease Overview
Pervasive Developmental Disorders (PDDs)
Childhood
Disintegrative
Disorder (CDD)
Autism Spectrum
Disorders* (ASDs)
Autistic
Disorder
Asperger’s
Disorder
Rett’s
Disorder
Pervasive
Developmental
Disorder Not Otherwise
Specified (PDD-NOS)
*ASD is not a DSM-IV TR definition but reflects categorization in the general public.
Tidmarsh L et al. Can J Psychiatry. 2003;48:517-525; DSM-IV TR. Washington, DC: American
Psychiatric Association; 2000.
DSM-5 Disease Overview
Autism Spectrum
Disorders* (ASDs)
Asperger’s Disorder



Similar criteria as DSM-IV Autistic
Disorder but with no clinically
significant delay in language, cognitive
delay, or curiosity about the
environment
Eliminated with DSM-5
Autism Spectrum Disorder without
intellectual impairment, with minimal
language impairment, requiring support
2
Autism Epidemiology

Prevalence
•
•
•
•
•
•

1 in 2000 (1966, Lotter)
1 in 500-1000 (1979-1996)
1 in 500 (1999, Osbahr)
1 in 250 (2004, CDC)
1 in 150 (2007, CDC)
1 in 68 (current CDC website) – increased
detection?, wider range being diagnosed?
Male:Female Ratio
• 2:1 with severe dysfunction
• 4:1 with average IQ
http://www.cdc.gov/ncbddd/autism/
Criteria For Autistic Disorder


DSM-IV - A Categorical System
Three Domains
• (1) Social Communication
• (2) Verbal and Non-Verbal Communication
• (3) Restrictive, Repetitive, Stereotypic
Behaviors

All or Nothing Diagnosis
3
DSM- 5 Criteria





DSM-5 - A Dimensional System
Two Domains
(1) Deficits in Social Interactions and
Social Communication
(2) Restrictive, Repetitive, Stereotypic
Behaviors
On a Spectrum of Disability
Autism Spectrum Disorder (A)


A. Persistent deficits in social communication and
social interaction across contexts, not accounted for
by general developmental delays, and manifest by
all 3 of the following:
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
Autism Spectrum Disorder (A)


2. Deficits in nonverbal communicative behaviors used
for social interaction; ranging from poorly integratedverbal 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
4
Autism Spectrum Disorder (B)


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)
Autism Spectrum Disorder (B)


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)
Autism Spectrum Disorder (C,D)


C. Symptoms must be present in
early childhood (but may not
become fully manifested until
social demands exceed limited
capacity)
D. Symptoms together limit and
impair everyday functioning
5
Differential Diagnosis


Mental Retardation
Specific Developmental Disorders
• Particularly language disorders




Selective Mutism
Reactive Attachment Disorder
Obsessive Compulsive Disorder
Childhood Schizophrenia (rare)
The M-CHAT
The Checklist for Autism in Toddlers
 Can be administered at 18, 24, 30, and
36 months of age
 Designed to take 5 minutes
 9 questions to ask the parent, 4 points
of observation
 Requires doll and toy cup
 http://www2.gsu.edu/~psydlr/Diana_L._
Robins,_Ph.D..html
W.U. Autism Clinical Center
A Missouri Autism Center of Excellence
• Diagnosis and Comprehensive Intervention Planning
• Child and Adolescent Psychiatric Care
• Expert Behavioral Planning for ABA and Positive
Behavior Supports
• Parent-Implemented Early Intensive Behavioral
Intervention (birth - 2 yrs.)
• Opportunity to participate in the discovery process
(research portfolio of the Intellectual and
Developmental Disabilities Research Ctr.)
Child and Family Development Center
Division of Child Psychiatry
• Clinical Genomic Characterization (via
4444 Forest Park Avenue, suite 2600
IDDRC@WUSTL)
St. Louis, MO 63108
(314) 286-1700
Email: [email protected]
6
Medicines for Aspergers



There are no medicines specifically for
Aspergers
There is no “cure” for Aspergers
But medicines can help some of the
symptoms
If attention is a problem

Stimulants usually don’t work
• Concerta,Metadate,Ritalin (methylphenidate)
• Adderall,Dexedrine (amphetamines)





Buproprion (Wellbutrin)
Atomoxetine (Strattera)
Clonidine (Catapres)
Guanfacine(Tenex, Intuniv)
Mementine (Namenda)
If aggression is severe


And threatens to put person in institution
or jail
Atypical Antipsychotics
•
•
•
•
•
Risperdal (risperidone) FDA approved
Zyprexa (olanzapine)
Seroquel (sertraline)
Geodon (ziprasidone)
Abilify (aripiprazole) FDA approved
7
If depression/anxiety is problem?

Try SSRI first
•
•
•
•
•
•

Zoloft (sertraline)
Paxil (paroxetine)
Prozac (fluoxetine)
Lexapro (escitalopram)
Celexa (citalopram)
Luvox (fluvoxamine)
Benefits/ Side Effects
Anti-seizure medications

Depakote (divalproic acid)
Tegretol (carbamazepine)
Trileptal (oxcarbazepine)
Neurontin (gabapentin)
Lamictal (lamotrigine)
Topomax (topiramate)

Benefits/side effects





Sleep Medications





Good sleep hygiene
Melatonin (3mg IR or extended release)
Diphenhydramine - Benadryl (some
children have reverse activation)
Clonidine (0.05, 0.1, or 0.2 mg qhs)
Trazodone
8
Regression in Aspergers





Vignette
Sickness?
Changes?
Behaviors?
Medications?
The Best Medications







Structure
Sameness
Predictability
Keeping Promises
Simplicity
Family Focus
Consistent Discipline
Stress Control






Occupational Therapy
Recreation Therapy
Appropriate “Self-Stim”
Cranial-Sacral Therapy
Swimming
Hippotherapy
9
Case Vignette

The mailman
Therapy Options




Supportive Therapy
CBT (Cognitive Behavioral Therapy)
Restricted Interest Therapy
Computer based Therapy
Therapy Options

Important Themes for Aspergers
• Learning to express emotions
• Affect – usually constricted
• Learning social cues

Common Problems
• Theory of Mind difficulties
• Getting nowhere feeling
10
Special Therapy Options


With PTSD: TF-CBT
With more dysfunction or younger
• Play therapy
• Floor time
• ABA therapy
Therapy Options

Social Skills group

Foreign Language concept
• Peer group invited is critical
At School


Can be a very overwhelming
environment with so much social stimuli
and sensory stimuli
Biggest target for bullies
11
School Options



Home Schooling (with or without
computer-based training)
Public School with resource rooms or
individualized educational plan (IEP)
Non-traditional school settings
• Horse farm

Mainstreamed (with or without one-onone aide)
School Interventions

504 Plan or IEP – (Individualized
Educational Plan)
•
•
•
•
•
•
One-on-one tutoring
Assistive technology for communication
Token economy system
Visual schedule for day
Half/Shortened Day
One-on-one aide for social skills or to prevent
bullying
Case Vignette

“I think I have what my son has.”
12
Bibliotherapy
Bibliotherapy
Apps





The Social Navigator
• Social skills guide and brain trainer
ReQall
• Record your reminders by voice and see them in text
IEP Checklist
• IEP Checklist for parents and educators
AutismXpress
• Can be helpful in creating self-awareness of moods
First Then Visual Schedule
• Behavioral supports for caregivers of ASD individuals
13
Conclusions


People with Mild Autism Spectrum
Disorder or Aspergers will be in
your practice
Therapy, school interventions, and
medications can help improve their
lives
14