the abc’s of autism

THE ABC’S OF AUTISM: A MULTIDISCIPLINARY TEAM APPROACH TO UNDERSTANDING AUTISM SPECTRUM DISORDERS

Semel Institute for Neuroscience and Human Behavior

University of California, Los Angeles

Who we are:• UCLA Center for Autism Research and Treatment (CART)

• Our research goals:• To understand the origins of the social, communicative, and language

deficits demonstrated by individuals with autism• To develop new and more effective treatment for autism spectrum

disorders

• UCLA Child and Adult Neurodevelopmental (CAN) Clinic • Our clinical service goals:

• To provide comprehensive diagnostic evaluations and treatment recommendations utilizing a multidisciplinary team approach

• To expand treatment service options across the lifespan from infancy to adulthood

Our Team Tonight (in order of appearance):

• Amanda Gulsrud, PhD: Clinical psychologist• Shafali Jeste, MD: Neurologist• Sunil Mehta, MD: Psychiatrist• Connie Kasari, PhD: Educational psychologist• Enjey Lin, PhD: Clinical psychologist

Contact information:

•For more information about CART and to participate in research:▫Website: http://www.semel.ucla.edu/autism▫Phone: 310-825-9041▫Email: [email protected]

▫For more information about CAN and our menu of service options:▫Website: http://www.semel.ucla.edu/autism/clinic▫Phone: 310-794-4008▫Email: [email protected]

THE ABC’S OF AUTISM: EARLY RISK AND DIAGNOSIS

Amanda Gulsrud, PhD



Neurodevelopmental disorders

•Autism spectrum disorder (ASD)•Intellectual disability (ID)•Global developmental delay (GDD)•Attention Deficit Hyperactivity Disorder (ADHD)•Social Communication Disorder

• Heterogeneous conditions characterized by a delay or disturbance in the acquisition of skills in a variety of developmental domains: motor, social, language, cognition (APA, 2013)

• Highly comorbid

• Severity quantified by level of adaptive/functional impairment

Diagnoses based on “Best clinical estimate”

(1)clinical evaluation combined with (2)standardized testing as needed--combination of caregiver report and child evaluation

(1) Clinical evaluation guided by theDiagnostic and Statistical Manual of

Mental Disorders (DSM): DSM-5 published May 2013

*Classification of mental disorders, provides criteria sets to guide the

process of diagnosis

*Revised periodically based on new knowledge about disorders

(2) Standardized tests:

Autism Diagnostic Observation Schedule (ADOS)—structured play based assessment

Autism Diagnostic Interview (ADI)—structured caregiver interview

Vineland Adaptive Behavior Scales – caregiver questionnaire about adaptive function (activities of daily living)

Impaired Communication

Repetitive behaviors and

restricted interests

Impaired social interaction

Impaired Social

Communication

DSM-5: Autism Spectrum DisorderA. Persistent deficits in social communication and

social interaction across contexts

A. Restricted, repetitive patterns of behavior, interests, or activities

A. Symptoms present in early developmental period

A. Symptoms limit/impair everyday functioning

B. Symptoms not better explained by ID or GDD.

Changes from DSM-IV:1. ASD replaces categorical diagnoses of autistic disorder, PDD-NOS, Asperger2. Social and communication combined into one domain3. RRB category includes sensory aversions and atypicalities4. No strict age minimum for symptom presentation

Early identification of risk/screening

Studies report some behavioral differences as early as 12 months of age (less initiating and responding to joint attention, less requesting, more object focused)

AAP recommends developmental surveillance and use of screening measures at the child’s 12, 18 and 24 month office visits

Screening tools validated at age 18 months M-CHAT PDDST-II Autism Screening Questionnaire

Early identification Early intervention Improved outcomes

Red Flags• No big smiles by six months • No back-and-forth sharing of sounds, smiles or other

facial expressions by nine months • No babbling or communicative gestures by 12 months • No words by 16 months • No meaningful, two-word phrases (not including

imitating or repeating) by 24 months • Any loss of speech, babbling or social skills at any age

Referrals

• Contact your family doctor or pediatrician for further evaluation and referral

• Contact your local regional center• http://www.dds.ca.gov/RC/

• Autism Speaks website for further resources• www.autismspeaks.org

Behavioral Interventions can begin early!• Community-based programs are seeing children as young

as 18 months of age

• UCLA Clinical Services and Research:• The Early Childhood Partial Hospitalizations Program (ECPHP)• Early Intervention Study for children 12-22 months of age at-risk for

ASD

THE ABC’s of Autism:Medical Workup and Neurological Comorbidities of Autism Spectrum Disorders

Shafali Spurling Jeste, MD



Recommended medical workup for ASD

• Genetics: karyotype, fragile X, MECP2 mutation testing, chromosomal microarray analysis (soon: whole exome sequencing!)

• MRI only if abnormal neurological exam or global developmental delay

• EEG only if concern for seizures or language regression

Why Genetics?

(1) Several single gene disorders show high rates of autism:

-Fragile X syndrome: 1-2%-Tuberous Sclerosis: <1% (30-50% have autism)-Rett syndrome: <1%

(2) Now finding more copy number variants (CNVs)-small duplications or deletions in the chromosomes-at least 20% of ASD associated with a CNV

Epilepsy• More than one unprovoked seizure in a lifetime• Diagnosed by clinical events and also by EEG

(electroencephalogram)• EEG picks up brain activity (firing of neurons) at the surface of the

scalp

Epilepsy in ASD• Known since the first reported case of autism• Abnormal EEG’s reported in up to 50%• Epilepsy reported in around 30%• No primary seizure type• Two peaks: early childhood and adolescence• Many genetic disorders associated with both ASD and

epilepsy• More common in girls with ASD

Epilepsy in ASD: Workup & Treatment• If any concern obtain 24 hour EEG:

• Abnormal spells (staring, involuntary movements)• Developmental regression (especially language regression)• Major change in behavior or sleep patterns

• Medications depend upon type of seizure• There are no medications that are specifically better for

children with ASD• However, side effects do exist that need to be considered

for each child

Sleep impairment in ASD is COMMON

Most common complaint is insomnia (=not enough sleep)>80% of children with ASDDiagnosed with parent questionnaires and sleep studies

Delayed sleep onsetNighttime awakeningsEarly morning awakeningsReduced “need” for sleep

“Good sleepers” show less: affective problems, inattention/hyperactivity, restricted/repetitive behaviors and better social interaction than “bad sleepers.”

Diagnosis of sleep impairment• Gold standard for identifying sleep problems is overnight

sleep study (actigraphy)• Polysomnogram (PSG): records EEG, eye movements, heart

rate, blood pressure, blood oxygenation, respirations• Can be challenging to obtain in children with ASD• Thus, studies often rely on questionnaires and reports

Treatment for insomnia

• Behavioral intervention is the first line treatment:• Establish a regular sleep routine• Set realistic goals and make gradual changes

• Medications:• Melatonin is most well studied• Clonidine• Mirtazapine• Anti-epileptics can be sedating• Lavender, chamomile, valerian root

• produced exclusively by pineal gland

• Effective for some patients

• Mechanisms of action are unclear

• NOT regulated by the FDA

Melatonin

When should you see a neurologist?

• Concerns about developmental regression• Concerns about seizures• Autism plus global developmental delay• Motor problems• Sleep problems (at least for consultation)• Need for a thorough neurological examination• Known genetic syndrome or variant associated with ASD

THE ABC’S OF AUTISM:PSYCHIATRIC CO-MORBIDITIES AND THE ROLE OF MEDICATION IN ASD

Sunil Mehta, MD

Semel Institute for Neuroscience and Human

Behavior


Financial Disclosures• None

As if Autism wasn’t enough…..• Psychiatric diagnoses are collections of symptoms• Intellectual Disability• Attention Deficit/Hyperactivity Disorder; Learning

Disorders• Depression/Bipolar Disorder• OCD/Anxiety disorder

What medication can and can’t do• No medication, so far, has been able to change the core

symptoms of ASD• The FDA has approved 2 medications for use in ASD,

Risperidone and Aripiprazole.• The one behavioral symptom that these medications

improve is self-injurious behavior/violence or aggression towards others.

• Commonly used psychiatric medications can be effective in treating co-morbidities, but…..

Be prepared for a bumpy ride• People with ASD are more likely to have side effects from

commonly used psychiatric medications and these side effects happen at lower doses than in neurotypical children.

• For mood symptoms/anxiety, people with ASD are less likely to respond to the first medication they try, so they will probably need to try multiple medications.

Supplements and Herbal medications• Vitamin E, Omega-3 fatty acids, fish oil have been

studied, data is inconclusive. Hyperbaric oxygen, heavy metal chelation, gluten-free diets have been studied and were found to have no effect.

• Mega-doses (>5 times USDA recommended daily allowance) of vitamins has never been proven to help in any disease.

• PLEASE tell your doctor about supplements and herbals, even if you think he/she won’t agree with you.

THE ABC’S OF AUTISM: Interventions for Children with ASD

Connie Kasari, PhD



Going to school with ASD

▫Most children spend 5-6 hours per day in school

▫Treatments for ASD are often incorporated in school

▫Disconnect between ‘therapy’ and ‘school’

▫Goal is that all therapies can be under one umbrella (e.g., school) but this may not always be possible

Early Intervention Models• There are multiple evidence-based models of early intervention for autism

• Most programs are based on behavioral principles

• Therapists work on behaviors that are important to individual’s functioning, such as:• Reducing behaviors such as tantrums, aggression, self-

stimulation, perseverative behaviors• Increasing language, social skills, play skills, joint

attention and emotional recognition

Preschool

Minimally verbal 5 – 8 year olds

Communication Interventions in Schools with iPad

Results positive for SGD in addition to behavioral intervention

Kasari et al, JAACAP, 2014

Older children need social skills

Develop friendships at school Working on peer relationships

Materials for Teachers/Playground AssistantsSpecific playground intervention: Remaking Recess

Social menus to encourage chatting at lunch time

Paraprofessionals can improve child engagement on the playground (6 weeks)

(Kretzmann, Shih & Kasari, 2014)

THE ABC’S OF AUTISM:INTERVENTIONS FOR ADOLESCENTS AND ADULTS WITH ASD

C. Enjey Lin, PhD, BCBA-D



Unique and Ongoing Needs

• Transition between adolescence to young adulthood is recognized as a crucial period • Slowing of improvement post-high school (particularly those without ID)

• Change in educational structure and resources after high school • +50% low rates of engagement in vocational or educational activities

• Co-occurring psychiatric conditions are common in ASD (e.g., anxiety or depressive disorders) • Complicates outcomes (e.g., quality of life, engagement in daily activities,

employment)• Greater cognitive and verbal abilities can be risk-factor

• Across all ability levels, teens and adults with ASD struggle • Under- or un-involved in education or work = 30% attended college and only up to

50% had regular employment-- lower rates compared to other disabilities (e.g., language delays)

(Hallett et al., 2013; Taylor et al., 2012; Shattuck et al., 2014; Smith et al., 2012; White et al., 2014)

Types of Interventions• Development is life-long process & environment makes a difference

• Disconnect, lack of treatments and resources

• Behavioral interventions: • Across the age-span• Areas-- communication, behavioral concerns, daily living, & social functioning

• Cognitive behavioral interventions: • Reduce anxiety & depressive disorder (high verbal and cognitive abilities)• Skill-building in core ASD areas & coping skills

• Social skills group interventions: • Focus on building and practicing skills• Friendships and interpersonal skills* in the work setting

(Bonete et al., 2014; Dawson & Burner, 2011; McGillivray & Evert, 2014; White et al., 2014; Lin & Wood, 2010; Valenti et al., 2010; Wood et al., in press; Yoo, Laugeson, et al., 2014)

Interventions (continued)

• Independent/adaptive living skills treatment: •Housekeeping, personal care, community living & social skills•Poorer skills = Poorer outcomes

• Vocational training: •Vocational engagement & independence = reduced ASD symptoms & challenging behaviors, and increased adaptive functioning

•Supported work/integrated programs (job coach) vs sheltered work setting programs = quality of life and cognitive functioning

•Room for improvement

(Garcia-Villamisar et al., 2002 & 2007; Shattuck et al., 2014; Taylor et al., 2013)

Some Available Resources • Behavior agencies in the community

• Autism Spectrum Therapies• STAR of California

• Vocational Training/Independent Living Programs• Department of Rehabilitation Services & Regional Centers

• Supported employment services vs work activity program services• Advance LA• FACT in Los Angeles

• Child and Adult Neurodevelopmental Clinic• Individual treatment, group treatment for enhancing independence and treating

anxiety/mood, medication treatment

• Social Skills Intervention• UCLA PEERS Social Skills Program for Adolescents and Young Adults

• Educational Programs• UCLA Pathways Program

Thank you