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Ilana Slaff, M.D. Special effects by Joelle Galatan 1 Slide 2 DSM-IV-Diagnostic Criteria for Autistic Disorder (I) A total of six (or more) items from (A), (B), and (C), with at least two from (A), and one each from (B) and (C) (A) qualitative impairment in social interaction, as manifested by at least two of the following: 1. marked impairments in the use of multiple nonverbal behaviors such as eye- to-eye gaze, facial expression, body posture, and gestures to regulate social interaction 2. failure to develop peer relationships appropriate to developmental level 3. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people, (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people) 4. lack of social or emotional reciprocity ( note: in the description, it gives the following as examples: not actively participating in simple social play or games, preferring solitary activities, or involving others in activities only as tools or "mechanical" aids ) 2 Slide 3 DSM-IV-Diagnostic Criteria for Autistic Disorder (B) qualitative impairments in communication as manifested by at least one of the following: 1. delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime) 2. in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others 3. stereotyped and repetitive use of language or idiosyncratic language 4. lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level 3 Slide 4 DSM-IV-Diagnostic Criteria for Autistic Disorder (C) restricted repetitive and stereotyped patterns of behavior, interests and activities, as manifested by at least two of the following: 1. encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus 2. apparently inflexible adherence to specific, nonfunctional routines or rituals 3. stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex whole-body movements) 4. persistent preoccupation with parts of objects (II) Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (A) social interaction (B) language as used in social communication (C) symbolic or imaginative play (III) The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder. 4 Slide 5 DSM-IV-Diagnostic Criteria for Aspergers Disorder The individual needs to have at least two of the criteria for impairment in social interaction and at least one criteria for restricted repetitive and stereotyped patterns of behavior. (III) The disturbance causes clinically significant impairments in social, occupational, or other important areas of functioning. (IV) There is no clinically significant general delay in language (E.G. single words used by age 2 years, communicative phrases used by age 3 years). (V) There is no clinically significant delay in cognitive development or in the development of age-appropriate self help skills, adaptive behavior (other than in social interaction) and curiosity about the environment in childhood. (VI) Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia. 5 Slide 6 DSM-IV-Diagnostic Criteria for Aspergers Disorder Although not part of criteria, some individuals can have difficulty sustaining a conversation with others. An individual with Aspergers disorder may not be able to read the other individual and may overly focus on their own special interest. 6 Slide 7 Pervasive Developmental Disorder (PDD-NOS) This category is used when there is a severe and pervasive impairment in the development of reciprocal social interaction associated with impairment in either verbal or nonverbal communication skills or with the presence of stereotyped behavior, interests and activities but the criteria are not met for a specific pervasive developmental disorder, schizophrenia, schizotypal personality disorder or avoidant personality disorder. 7 Slide 8 Diagnostic Rating Scales The Checklist for Autism in Toddlers (CHAT) identifies children who are at risk of developing social-communication disorders. It is administered at the 18 and 24 month check up and takes five minutes to complete. This rating scale has high specificity and low sensitivity, but a good positive predictive value. The Modified Checklist for Autism in Toddlers (M-CHAT) can be used 16 months to 30 months and was developed to have a higher sensitivity. The Childhood Autism Rating Scale (CARS) can help diagnose autism in children and professionals can be easily trained to administer in five to ten minutes. CARS2 can help diagnose high functioning autism and Aspergers disorder. 8 Slide 9 Diagnostic Rating Scales An ADOS (Autism Diagnostic Observation Schedule) can be helpful to diagnose autism. There are different modules for different ages and levels of functioning and administration time is 30 to 45 minutes. This is used for research as well as clinical use. An ADI-R (Autism Diagnostic Interview-Revised) takes hours to administer and is used for research in conjunction with the ADOS. However, a study of the ADI-R can assist with clinical interviewing. The Gilliam Aspergers Disorder Scale is designed to evaluate individuals for Asperger's disorder. 9 Slide 10 10 Educational and Behavioral Treatments Applied Behavior Analysis (ABA) Floortime TEACCH Treatment and Education of Autistic and Communication Handicapped Children Aversives Slide 11 Applied Behavior Analysis (ABA) ABA shapes behavior through reinforcement of successes, prompting and fading procedures. Edible or non-edible reinforces are used for desired responses or a reinforcer may be taken away for an undesired response. This was studied with 19 children each in the intervention and control groups and about 47% of children who received ABA 40 hours per week were mainstreamed in a regular education program without further need for support services. In a follow-up study, gains were maintained at a mean age of 11.5 years. 11 Slide 12 Applied Behavior Analysis (ABA) The New York State Department of Health in 1999 concluded that ABA programs were the only form if intervention that met the burden of demonstrating significantly positive outcomes under rigorous scientifically controlled circumstances. Replications of this study found benefits although not as dramatic. A recent meta-analysis of 26 studies in 323 subjects found that long-term, comprehensive ABA intervention leads to (positive) medium to large effects in terms of intellectual functioning, language development, acquisition of daily living skills and social functioning in children with autism. 12 Slide 13 Applied Behavior Analysis (ABA) Parent training and support is necessary and part of New York State Education Department guidelines. There are also ABA models for older children and adults with autism. 13 Slide 14 14 Applied Behavior Analysis A functional behavior analysis (FBA) can be useful to determine why an individual has a problem behavior and how the individuals behavior relates to the antecedents or consequences. Slide 15 Floortime: A Development Individual Difference Relationship (DIR) Based Approach This appears to be an intensive and directed extension of play therapy. The DIR approach focuses on helping children master the building blocks of relating, communicating and thinking rather than on symptoms alone. The childs stage of social/emotional development is assessed, as well as how the child takes in the world through sight, sound and touch and responds to it. Building relationships with primary caregivers is a critical element in helping a child return to a healthy developmental path. 15 Slide 16 Floortime: A Development Individual Difference Relationship (DIR) Based Approach There is a retrospective 200 case-chart review to support the efficacy of this therapy. In a study of 68 children given the therapy 15 hours a week by parents for 8-12 months, 45.5% of children showed significant improvement on the functional emotional assessment scale, but children had other interventions, and results may not be able to be generalized to other caretakers. 16 Slide 17 17 Treatment and Education of Autistic and Communication Handicapped Children TEACCH was developed in the 1970s by Eric Schopler and includes a focus on the person with autism and the development of a program around this persons skills, interests and needs. This structured teaching approach includes: Organizing the physical environment Developing work skills and schedules Explicitly clarifying expectations using visual materials to function as independently as possible in a given environment without adult prompts Slide 18 18 Treatment and Education of Autistic and Communication Handicapped Children The therapy is also placed on cultivating strengths and interests versus a sole focus on remediation of deficits. TEACCH also attempts to work at a systems level, aiming to integrate services and provider networks over the lifespan. Picture or word activity schedules are used which help with structure, predictability to assist with transitions and to compensate for problems with auditory processing (processing spoken language). Work stations are used to facilitate independence. Slide 19 19 Treatment and Education of Autistic and Communication Handicapped Children There is also programming for communication, social skills and employment. A number of studies have shown positive outcomes when comparing TEACCH to standard special education programs. TEACCH in NC has a legislative mandate and when implemented it is a lifelong, integrated and comprehensive program. Outside NC TEACCH programs may not be comparable (not providing multiagency integrated services, implementation in the home and community outside of school and follow-up past the specific school program). Slide 20 Visual Schedule Materials 20 Slide 21 Visual Schedule Materials 21 Slide 22 Visual Schedule Materials 22 Slide 23 Visual Schedule Materials 23 Slide 24 Object Activity Schedule 24 Slide 25 Alternative and Augmentative Communication One example is the Picture Exchange Communication System (PECS) developed by Andy Bondy and Lori Frost. Children are first taught to point to symbols (photos or drawings) of objects or activities that they prefer or desire and then the child is taught to hand the symbols to the trainer. Children can be then taught to put the symbols together and/or add vocalizations as approximations to words while speech is emerging. 25 Slide 26 Alternative and Augmentative Communication Almost half of children taught to communicate using PECS develop spontaneous speech and most of these children discontinue using PECS. However, of eight single-subject experiments (18 participants) and three group studies (95 PECS participants, 65 in other intervention/control) indicated that PECS is a promising but not yet established evidence-based intervention for facilitating communication in children with ASD. Small to moderate gains in communication were demonstrated following training. Gains in speech were small to negative. One study showed adults can also derive benefit from learning PECS.. 26 Slide 27 PECS Book 27 Slide 28 Picture Exchange Book with Token Board on Front 28 Slide 29 Examples of Alternative and Augmentative Communication 29 Slide 30 Examples of Alternative and Augmentative Communication Object Communication Board 30 Slide 31 Examples of Alternative and Augmentative Communication 31 Slide 32 32 Aversives What is aversive conditioning? learning in which punishment or other unpleasant stimulation is used to reduce the frequency of an undesirable response (medical- dictionary.thefreedictionary.com/aversive+condi tioning) Positive behavior modification programs and psychotropic medications are not sufficiently effective in all cases to treat life threatening behaviors. Slide 33 33 Aversives Behavioral skin shock has been the most studied alternative treatment with at least 113 peer reviewed articles. One study on a child using food aversion resulted in near zero levels of pica (distasteful food was placed on objects the child was consuming). One study assessed the use of behavioral skin shock in nine students ages 8-30 (three with autism/PDD NOS) with high frequency and severe forms of self-injurious and aggressive behavior. Positive verbal and non verbal utterances and time off work either significantly improved or there was no change and there were no negative side effects. Slide 34 Pharmacological Treatments with Large Placebo Controlled Trials Risperidone Aripiprazole Citalopram Methylphenidate 34 Slide 35 Aberrant Behavior Checklist (ABC) Five subscale items Irritability, Agitation Lethargy and Social Withdrawal Stereotypic Behavior Hyperactivity, Noncompliance Inappropriate Speech 35 Slide 36 ABC Irritability Subscale Items Injures self on purpose Aggressive to others (verbal or physical) Screams inappropriately Temper tantrums/outbursts Irritable and whiny Yells at inappropriate times Depressed mood Demands must be met immediately Cries over minor annoyances/hurts Mood changes quickly Cries and screams inappropriately Stamps feet or bangs objects/slams doors Deliberately hurts self Does physical violence to self Has temper outbursts/tantrums when does not get own way 36 Slide 37 Risperidone (Risperdal) Risperidone is Food and Drug Administration (FDA) approved as a treatment for irritability in children and adolescents with autism. One placebo controlled study involving 101 children ages 5-17 found help with irritability, hyperactivity and stereotypic behavior according to the respective ABC subscales and (Clinical Global Impressions-Improvement) CGI-I. 37 Slide 38 Risperidone (Risperdal) Another placebo controlled trial with 79 children ages 5-12 showed significant improvements on all the subscales on the ABC and on the CGI-C (Clinical Global Impressions- Change). However, these studies did not publish data on the individual components of the ABC-Irritability subscale which may make it difficult to determine for which specific behaviors it was helpful. 38 Slide 39 Risperidone with Parent Training A randomized parallel group with 124 children ages 4-13 with frequent tantrums, self-injury and aggression were randomized to receive medication (risperidone and if not effective aripiprazole) with or without parent training. The combined group showed significant decreases on the ABC-Irritability, Stereotypic behavior and Hyperactivity/Noncompliance subscales. The combined group had a lower risperidone dose than the medication only group. 39 Slide 40 Aripiprazole (Abilify) One placebo controlled study of 98 children ages 6-17 years with autistic disorder with tantrums, aggression, or self-injurious behavior or a combination showed improvement on the ABC irritability subscale and the CGI-I after being given aripiprazole with flexible dosing. 40 Slide 41 Aripiprazole (Abilify) Another placebo controlled trial with 218 children ages 6-17 years with autistic disorder with tantrums, aggression, or self- injurious behavior or a combination showed improvement on the ABC irritability subscale and the CGI-I with fixed dosing of aripiprazole. However, the specific subcategories (injures self on purpose, deliberately hurts self and physical violence to self) of the ABC irritability subscale showed no significant difference between the treatment groups and placebo except for injures self on the flexible dose trial but only to a p