Overview 8/28 Flashcards
Leo Kanner 1894-1981
SC/RRB domains still used
But historical inaccuracies (ex. refrigerator mothers)
Hans Asperger 1906-1980
Was known for Aspergers
Lorna Wing 1928-2014
British, first to describe it in English
Assessed need for support
Ivar Lovaas 1927-2010
first to publish in 1987, paper on 47% of kids with early behavioral program have IQ leaps. Moved where ASD was on DSM. Axis 1 vs. Axis 2. (“lifelong” vs. treatable).
Prevalence of ASD
1%, CDC rates keep going up
about ____ of those with ASD function in ID range
1/3 (<70)
Boy Girl ASD ratio
4:1
Are outcomes in ASD uniform?
No they are variable
Why is ASD prevalence rising?
Rates vary on methodological factors
Studies after 2000 have higher rates of ASD
Rise can be attributed to change diagnostic standards, availability of services and greater public awareness.
One criteria and you stick to that criteria.
DSM-5 ASD critieria:
Social need all 3: Reciprocity, NV communication, developing and maintaining relationships
RRBs (Need 2): Stereotyped, Adherence to routines, restricted/fixated interests, hyper/hypo sensory sensitivity
ASD diagnosis depends on SUPPORT NEED
score high, but significant other and job no diagnosis.
______ is used for classification of ASD rather than genetic, psychological/neuro/biochem
Phenomenological DSM
Why nosology (classification of ASD)?
Necessary for communication, prognosticating, treating, and etiology
Meets patient/parent expectations: tame beast by naming it, eligibility for services
Main point of brain research in ASD
Different parts, different symptoms and problems (social, communication, RRB)
Monozygotic twins _____% concordance for ASD
Dizygotic twins ____% rates for ASD
At risk younger siblings _____% risk
What runs in families?
60-90%
0-30%
15-20%
Broader phenotype
What chromosomes have ASD risk genes?
7, 15, X, 11
Genetics in ASD: recent switch from focus on inherited genes control NT to
Rare de novo copy number variants that affect genes regulating synaptic and axonal development
Synaptic Scaffolding protein gene
SHANK3
Synapse formation gene
NLGN 3 and 4
Abnormal structure and function of synapse
PTEN
Neuronal Network gene
CNTN4
Synaptogenesis gene
NRXN1
Maternal risk factors
low/high age, smoking, high/low education, hypertension, diabetes, SSRI 1st t, immigration, breech, C-section, weighing more than 90 kg, epilepsy, preterm, etc.
ADHD CDC 2003 study asking parents for symptoms and looking at med usage.
Rates of clinicians across country vary.
Poor/low incomes States lower rates? Higher in South?
Cultural variables on who is identified and gets services.
Implications of Gene-Environment interaction
Match of genes & environment = health
* Desynchronization = Pathology
* Environment and genes can change
* Environment usually changes faster than genes
* The illusion of heritability
– Cannot subtract heritability from 100% and conclude
environmental percent
– The case of PKU (100% genetic and 100% environmental)
Do we know for sure what causes ASD?
It’s complicated
maybe course of brain development, maybe risk factors in maternal fetal environment, maybe environmental factors act in concert with inherited susceptibilities or inducing epigenetic changes
Diagnostic Instruments for ASD
ADOS, ADI-R, Rating Scales
When are the following time foci used to diagnose ASD on ADOS?
- Current
- Ever
- Most abnormal
- Occasionally/other
- Current- last 3 months
2 Ever-abnormal items - Most abnormal- 4-5 years (Maturational influenced)
- Occasionally/other- friendships
0, 1, 2, 3, 7 coding conventions on ADOS
0- not present
1- is present, not sufficiently severe enough for 2
2- present AND meets criteria
3- Behavior present and interferes with functioning or ordinary life
7- abnormality in area of coding but NOT type specified
ADI-R pointing to express interest
Focus on: Pointing to show (not request), pointing at distance (not proximal), coordination (head/eye movements, object to person), spontaneity/variety, social quality
ADI-R approach to social/vocalization “chat”
Requires: Reciprocity, turn taking, maintenance of interchange, social quality (not because you want something)
“0” (no impairment) code for ADI-R friendships
Own age group, sharing of non-stereotyped activities, seen outside prearranged group settings, definite reciprocity and mutual responsiveness
ADI-R code 3 for sharing suggests
No sharing
What is the ADOS goal?
to create a social
environment in which the child realizes
the expectation is for him/her to
interact with the examiner
What 3 things does the ADOS provide information about.
Social behavior, ability to communicate, play behavior
ADOS modules:
1
2
3
4
1- no speech-simple phrases
2- 3 word phrases/not yet fluent - verbally fluent
3- child/young teen, toys not helpful
4- verbally fluent teen/adult
Rating Scales are all about what?
ACCURACY
(determined by sensitivity, specificity, positive and negative predictive power)
What impacts sensitivity, specificity, positive and negative predictive power of rating scale?
development/content of the scale, comparison group, diagnostic ascertainment of ASD, age, ID level, language level.
Behavior problems: part of ASD?
Tricky. Part of clinical description according to APA, highly prevalent. BUT point prevalence varies on instrument used.
Behavior problems study: what are behavior problems associated with
Psychotropic medicine use
High caregiver stress
Behavior problems, not functioning level related to stress
Transactional model
Does it work? STudy of citalopram hyrobromide
No. Done to reduce stereotyped behavior. SSRI. Improve, but so does placebo.
Clinical reality of multiple meds, what is most helpful?
Stimulant + antipsychotic + parent training
Drug studies target what symptoms
irritability, RB, ADHD symptoms
Are there drugs for social behavior or RRB?
No
What are the 2 FDA drugs for Autism?
Risperidone and aripriprazole
Obstacles to psychopharmacology
great genetic & phenotypic heterogeneity
– large placebo responses
– positive publication bias
– low incidence disorder
RUPP Autism Network study of Risperidone found what?
Reduced irritability on ABC and CGI
Side effects of risperidone and anitpsychotics
Sedation first month
* Weight gain, metabolic syndrome
* Hormone changes
* Neurological (EPS)
* Constipation
* Photosensitivity
* Temperature regulation
* ECG changes
* Reduced white count
Parent Training vs. Parent education Paper (Luc is on it will be on exam)
1st study with large sample comparing people trained on behavior principles: Parent training (PT) vs. Parent education program (PEP)
Placebo: 12 session 24 week trial compare placebo (education with therapist)
Both improved and loved it.
Parent training was better by week 24, but still great. on CGI rating
What do good comprehensive intervention packages have?
Timing, intensity, direct provision of learning experiences, breadth, individual differences, environmental maintenance of development
