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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