Rutgers, The State University of New Jersey Liberty Plaza, 335 George Street, New Brunswick, NJ 08901

rwjms.rutgers.edu/boggscenter p. 732-235-9300 f. 732-235-9330

Eric Courchesne, PhD Professor and Co-Director, Autism Center of Excellence

University of California San Diego San Diego, CA

Autism Research: Prenatal Beginnings to Early Childhood Clinical Outcome

April 20, 2017 APA Hotel Woodbridge, Iselin, NJ

The attached handouts are provided as part of The Boggs Center’s continuing education and dissemination activities. Please note that these items are reprinted by permission from the author. If you desire to reproduce them, please obtain permission from the originator.

4/12/2017

1

Eric Courchesne and Karen Pierce

Visit us at

https://autism-center.ucsd.edu

Neurosciences

UC San Diego

Autism Center

of Excellence

Thank you:NFARNIMH

Simons FoundationEmch Family Foundation

Autism Speaks NICHD-UMB Brain BankATP/Harvard Brain Bank

Taran

Sierra

Karen Pierce

WHAT ARE THE EARLY BRAIN

BASES OF AUTISM?

4/12/2017

2

200

400

600

800

1000

1200

1400

1600

0 2 4 6 8 10 12 14 16

BR

AIN

VO

LU

ME

(m

l)

AGE

Normal Autism

Early Brain Overgrowth in Majority of Autism

Toddlers

Courchesne et al., Neurology 2001, JAMA 2003

Overgrowth

Hypothesized Due to an

Excess of Neurons

Courchesne et al Neurology2001, JAMA 2003, Neuron2007 Courchesne & Pierce

2005 CONB 2005

80% of ASD 2-16 Year Old Males Have Brain Weight

Above Normative Mean for Age

Redcay &

Courchesne,

Biological

Psychiatry, 2005

Shen, Amaral et al.

Brain, 2013

ASD

Controls

4/12/2017

3

SIZ

E

AGE

NORMAL

ASD

Overgrowth

Brain Growth Pathology in ASD

LARGEST META-ANALYSIS STUDY OF BRAIN SIZE IN ASDSacco, Gabriele, Persico 2015

44 MRI brain size studies, 3,085 subjects

significant brain overgrowth in ASD, P = 1.21 x 10-21

27 head circumference studies, 5225 subjects

significant enlargement in ASD P = 5.20 x 10-50

and 15.7% macrencephaly

*

*n.s.

n.s.

n.s. n.s.

1. Carper et al. 2002 Age 3.4 years

*

*

OccipitalParietalTemporalFrontal

Stan

dard

dev

iati

ons

from

nor

mal

*p<0.05

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

**

*

*

*

*

*

çç

2. Bloss & Courchesne, 2007 3.8 years

3. Kates et al. 2004 7.6 years

4. Palmen et al. 2005 11.1 years

5. Hazlett et al. 2005 19.1 years

(left cerebrum only)

*

Courchesne, Pierce et al

NEURON, 2007

2) Non-Uniform Gray Matter Overgrowth:

Frontal > Posterior

Excess Frontal Connections

But Small Axons

Solso et al

Bio. Psychiatry2016

4/12/2017

4

‐‐ p  < 0.1* p < 0.05

Differences in Age‐Related FA Changes in ASD and TD

Superior Longitudinal Fasciculus

Uncinate Fasciculus

Forceps Minor

Abnormal Laterality to Language

in ASD Infants & ToddlersEyler, Pierce and Courchesne

BRAIN, 2012

R

RTemporal

cortex

ASD14 to 47 months

Fw FwFw Bw Fw Bw Bw Bw

L Temporal

cortex

0.0

1.0

Effect

Size

(Eta2)

‐0.04

‐0.03

‐0.02

‐0.01

0.00

0.01

0.02

0.03

0 10 20 30 40 50 60

Left ‐Right Difference in

 Mean

 Amplitude of Response

Age in Months

TypicalL > R

ASDR > L

TYPICAL13 to 45 months

Pramparo Courchesne et al

Molecular Systems Biology, 2015

BRAIN SIZE AND

GENE EXPRESSION IN CELL CYCLE NETWORK

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WHEN DOES AUTISM BEGIN?

Schematic of Dorsolateral and Mesial Prefrontal Cortex

Courchesne, E. et al. JAMA 2011;306:2001-2010

Copyright restrictions may apply.

SIZ

E

AGE

NORMAL

ASD

Overgrowth: PRENATAL CAUSE

Autistic vs Control Males

Ages 2 to 16 years

79% more

neurons

29% more

neurons

Courchesne et al,

JAMA, 2011

4/12/2017

6

Abnormally Small Neurons at Young Ages in Autism

ASD and Typical

Child or Adult

4/12/2017

7

79% more DL-

PFC neurons

What is the

Cause of

Excess Cells?

What are the Resulting Cortical Defects?

Gene

expression

and CNV

analyses of

DNAAnatomic

Microstructure

Normal

mouse

Reelermouse

mSorLA RORB ER81 TBR1

I

II-III

IV

V

VI

Dispersion of the neurons expressing layer specific

markers in the reeler mouse brain

Dekimoto et al., Development, Growth and Differentiation, 2010

Layer ILayers

II-IIILayer IV Layers

V-VI

diffuse

layer 1

layer 5/6

layer 4

layer 5

layer 2/3

Layer 1

Layer 4

Layer 2/3 Layer 5/6

Layer 5Patches of

Disorganization in the

Neocortex of Children

with Autism

Rich Stoner and Eric

Courchesne at UCSD and

Ed Lein at the Allen

Institute

New England Journal of Medicine, 2014

4/12/2017

8

Focal Patches of

Disorganized

Cortical Layers,

Abnormal Migration,

and Clusters of

Disoriented Neurons

Stoner et alNEJM, 2014

79% more DL-

PFC neurons

What is the

Cause of

Excess Cells?

What are the

Resulting Cortical

Defects?

Gene expression

Anatomic

Microstructure

Dysregulation of Pathways Governing

Cell Numbers and Functional Integrity in

Frontal Cortex at Young Ages

Chow, Pramparo et al

PLoS Genetics, 2012

Cell cycle regulation

DNA damage responses

Apoptosis and survival

Cell differentiation

Immune

Abnormal Down-Regulation of Several

Neural Patterning GenesFGF1, HOXD1, NDE1, NODAL, PCSK6

4/12/2017

9

Activated Microglia in

ASD

See RED ARROWS

Morgan, Courchesne

Biological Psychiatry, 2010

Birth

Willsey et al

Cell,2013

High Confidence ASD Genes Active in

Neurodevelopment in PreFrontal Cortex

in 2nd Trimester

4/12/2017

10

0.5

0.9

1.3

1.7

‐9 ‐6 ‐3 0 3 6 9

Number of Neurons

ASD PATHOLOGY:Overabundance of Neurons 

in Fetal Development

ASD

Control

Mid 2nd

Trimester 30 yrs

Excess Proliferation

Birth

Prenatal Life

Kathleen Campbell

Eric Courchesne

Perinatal

4/12/2017

11

Infants to Toddlers

WHAT CAUSES THESE EARLY BRAIN

ABNORMALITIES IN AUTISM?

ANY INCREASE IN NEURON NUMBERS

SEEMS TO BE SUFFICIENT

TO CAUSE ASD

NO MUTATION

OR

ENVIRONMENTAL TRIGGER REQUIRED

4/12/2017

12

Overproduction of Upper-Layer Neurons in the

Neocortex Leads to Autism-like Features in Mice

Fang et al.,

Cell Reports2014

GENE-DISRUPTING

DE NOVO MUTATIONS:

CAN CAUSE INCREASE NEURON

NUMBERS AND BRAIN

OVERGROWTH AS WELL AS OTHER

ASD-KNOWN ABNORMALITIES

Evidence of Genetic Causes of Fetal  Brain Maldevelopmentand Early Brian Overgrowth: Mutation of WDFY3 Gene in 

Mouse Model of Autism

1) Early Brain Overgrowth

2) Greatest Growth Abnormality is Frontal, Least Occipital

3) Abnormal Cell Cycle Function 

4) Abnormal Cell Proliferation

5) Patches of Laminar DisorganizationAnd Nearby Clusters of Abnormal Neuron Migration

Orosco et alNature Communications, 2014

4/12/2017

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Patches of Laminar Disorganization & Abnormal Neuron Migration

Orosco et alNature  Comm., 2014

O’Roark, Eichler and

colleagues, Science 2012

Recurrent Gene Mutations in Small Subset of ASD

From Sugathan et al 2014

4/12/2017

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NON-GENETIC:

MATERNAL IMMUNE ACTIVATION

IN PRENATAL LIFE

Increased brain sizeUpregulation of cell cycle gene expressionShortening of cell cycleExcess neuronsIncreased cortical thicknessDisruption of genes involved in neuronal migrationFocal patches of disorganized cortexMicroglia abnormalities and enhanced microglia primingCerebellar vermis defects Defects of prefrontal dendritic morphology

Courchesne, Lombardo,

Pramparo

MIA

Le Belle et al 2014, Stem Cell Reports

Prenatal Maternal Immune Activation (MIA) Via LPS Amplifies Effects of Genetic Mutations in Mouse Models of Autism

4/12/2017

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Cortical Phenotype

Autism Patch of Cortical Malformation and Neural Dysplasia

Choi et al., Science 2016Stoner et al., NEJM 2014

MIA Animal Model of ASD

ASD Protrusions

ASD Intrusions

ASD Intrusion

MIA Animal Model of ASD

Choi et al., Science 2016

4/12/2017

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HOW CAN THIS KNOWLEDGE IMPACT

CLINICAL PRACTICE AND CARE?

Autism Is Present Already By Birth

Early Clinical BioMarkers Must Exist

Vastly Different BioTypes Exist

Different BioTypes Need Different Tx-Types

Some BioTypes May be Preventable; Others Not

Normal Outcomes Might Occur in Some BioTypes

Early Tx Is Essential

Frontal Cortical Neuronal Development in Humans

4/12/2017

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• Parent Anxiety• Parent Stress• Family Cohesion• Family Routines• Caregiver Strains• Community

Engagement and Integration

Family Functioning

• IQ• Executive

Function• Daily Living Skills• Attention

The Child’s Cognitive and

Adaptive Functioning

• Social Interaction• Eye Contact• Joint Attention• Language Ability• Gestures• Imitation• Functional Play• Symbolic Play

The Child’s Social

Communication & Interaction

• School Readiness• School Placement• Job Placement• Independence

The Child’s

Long Term Outcomes

Pierce, Courchesne, Bacon 2016

Importance of Early

Screening, Detection,

Diagnosis and

Treatment

THE NEED:

NEW APPROACHES TO

UNIVERSAL SCREENING FOR

AUTISM

IN 1-2 YEAR OLDS:

EXAMPLE #1:

The 1 Year Well-Baby Check-Up Approach

And the Get S.E.T. Early Model

Get S.E.T. Early Model

Screen and Refer Early

Evaluate and Refer Early

Treat Early

Pierce & Courchesne

4/12/2017

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The Get S.E.T. Early Model for Autism

1 Yr Well-Baby Check-Up Approach Using CSBS

• Fast • Easy

• Can be done by anyone,

anywhere NOW in community

pediatric settings

Karen Pierce et al., 2011J. Pediatrics

• Results in early risk detection

at ages 1-2 years, and early

diagnosis & early treatment in

community clinical settings

• Detects risk for other

developmental delays as well

as autism

• Improves standard-of-care

for all babies

• Inexpensive

Wetherby & Prizant, 2002

CSBS DP Infant-Toddler Checklist

DD LD ASD

ASDLDDD

“Other”

The Get S.E.T. Early Model for Autism

1 Yr Well-Baby Check-Up Approach Using CSBS

Benefit to Research

on Autism

• Enables prospective

research on autism as it

occurs in general pediatric

population

• Babies who do not end up

with autism serve as important

contrast groups showing how

autism looks as compared to

other disorders during early

developmentKaren Pierce et al., 2011J. Pediatrics

4/12/2017

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UCSD ACE   PEDIATRICIAN    NETWORK     N=170Dr. Robert Bjork, Dr. Michael Nelson, Dr. Cheryl Jennett

Dr. Dr. John Kafa, Dr. Douglas Wilson, Dr. Crystal De Freitas

Dr. Martin Gilboa, Dr. Patricia Juarez, Dr. George Madany,

Dr. Seven Brody, Dr. Ingrid Martinez-Andree, Dr. Irene Chang

Dr. Stephanie Powell, Dr. Adam Breslow, Dr. Patricia Pisinger

Dr. Isabel Baratta, Dr. Sheila Cason, Dr. Thomas Neglia

Dr. Stephen Balch, Dr. Randall Metsch, Dr. David Schmottlach

Dr. Sonja Brion, Dr. Anna Mendenhall, Dr. Nancy Clementino

Dr. Marshall Littman, Dr. Leslie McCormick, Dr. Sharon Sternfeld

Dr. Cara Cohen, Dr. Nicholas Tsoulos, Dr. Elena Fishman

Dr. Hilary Bowers, Dr. Albert Martinez, Dr. Genevieve Minka

Dr. Wendy Chacon, Dr. Leon Kelley, Dr. Victor Lipps, Dr. Jeffrey Selzer, Dr. Lynn Herring, Dr. Teresa O’dea, Dr. Richard Walls, Dr. Vivian Tung, Dr. Christian Archambault, Dr. Veronique James, Dr. Stuart Cohen, Dr. Nancy Shiau, Dr. Linda Smith, Dr. Tevor Henderson, Dr. Cheryl Morrell, Dr. Josef Zwass, Dr. Lon Dubeye, Dr. Andrea Siano, Dr. Aida Martinez, Dr. Rachel Ireland, Dr. Louis Luevanos Dr. Laurie Tyrrell, Dr. John Cella, Dr. Jill Gustafson, Dr. Rosemary Page, Dr. David Steele, Dr. Carlos Quiros, Dr. Brian Chu, Dr. Kathleen Jones, Dr. James Moseman, Dr. Laurence Ashbacher, Dr. Theresa Dailey, Dr. Frederick Frumin,Dr. Nicholas Levy, Dr. Julie Snyder Block, Dr. Lori Taylor, Dr. Rosalind Dockweiler, Dr. Christine Wood, Dr. William Hitchcock, Dr. Robert Warner, Dr. Sheetal Gandhi, Dr. Suzanne Mills, Dr. Mona Sobel, Dr. Craig Duck, Dr. James Hay, Dr. GeorgineJorgensen, Dr. Richard Payne, Dr. James Quigley, Dr. Richard Buchta, Dr. Ann Marie Engfelt, Dr. Benjamin Siegel, Dr. Lori Gould, Dr. Micelle Sanford Dr. Annie Kupelian, Dr. Paula Grayson, Dr. Raha Shaw, Dr. Gary Chun, Dr. Matilda Remba, Dr. Janna Cataldo, Dr. Nicole Gorton, Dr. Bret Gerber, Dr. Denise Brownlee, Dr. Stuart Rubenstein, Dr. Peggy Manuel, Dr. Veda Wu, Dr. Michael Berent, Dr. Gargi Kubal, Dr. Norman Gollub, Dr. Teresa Hardisty, Dr. Jeanne Montal, Dr. Katrina Durkee, Dr. Kamei Tolba, Dr. Carol Hart, Dr. Dennis Butler, Dr. Howard Mehl, Dr. Marta Awdykovych, Dr. Uma Narayan, Dr. Richard McNeal, Dr. Marta Awdykovych Dr. Richard McNeal, Dr. Jennie Ou, Dr. Howard Smart, Dr. Neethi Ratnesar, Dr. Fujii, Dr. Mattson, Dr. Norman, Dr. Sauer, Dr. Gabriela Mogrovejo, Dr. Julie Keeler, Dr. Liz Hourihan, Dr. Dania Lindenberg, Dr. Dori Mortimer, Dr. Marvin Zaguli and more…

To Date> 60,000 babies screened!

Karen Pierce

Triple Screen

12 months

18 months

24 months

Improve Screening Process

Screening and referral App

Ensure few, if any, ASD toddlers are missed

Automatic Score Automatic Referral

Track pediatrician reason if non referral

Track pediatrician clinical impression for later dx trackingKaren Pierce

• Autism can be detected by 12-24 months in most cases.

• Treatment can start by 14-16 months.

• Pediatricians from different groups can work together

to form a network to detect ASD at the earliest possible

ages

• The mean age of ASD detection can drop considerably

in any city with systematic effort

HIGHLIGHTS OF 2011 STUDY

4/12/2017

20

THE NEED:

NEW APPROACHES TO

UNIVERSAL SCREENING FOR

AUTISM

IN 1-2 YEAR OLDS:

EXAMPLE #2:

RNA Gene Expression Classifier

Metacore Pathway Enrichment

of Classifier GenesLeukocyte Microarray-Based

Gene Expression Autism

Screening & Diagnostic

Classifier in 1-2 Years Olds

Tiziano Pramparo,

Karen Pierce et al

JAMA Psychiatry2015

THE NEED:

NEW APPROACHES TO EARLY

DIAGNOSIS & PROGNOSIS IN AUTISM

AT AGES 1-2 YEARS:

EXAMPLE:GEO-PREFERENCE:

A DIAGNOSTIC & PROGNOSTIC MARKER OF A

SUBTYPE OF ASD

IN 1 TO 2 YEAR OLDS

Karen Pierce et al.,

Biological Psychiatry, 2016

4/12/2017

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ASD 15-Month Old

THE GeoPref TEST FOR AUTISMDetects 23% of ASD Cases with

98% SpecificityKaren Pierce

Archives of General Psychiatry 2011

Biological Psychiatry 2016

In preparation

Sample Size = 917

Ages 1-3 years

Autism Diagnostic Observation Schedule (ADOS)

4/12/2017

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THE NEED:

TREATMENT-RELEVANT

BIOLOGICAL SUBTYPES OF

AUTISM IN 1-2 YEAR OLDS:

EXAMPLE:

fMRI Language Activation

Lombardo et al

Neuron 2016

WHY DO SOME INFANTS WITH ASD GET

BETTER?

ARE THERE BIOMARKERS OF

PROGNOSIS?

4/12/2017

23

TIME FOR

Brain Activation in the Story Language Paradigm

Reveal ASD Outcome Subtypes

Lombardo et al

Neuron, 2015

THE NEXT MAJOR ADVANCE:

BIOTYPE SPECIFIC TREATMENTS

FOR AUTISM

AT AGES 1 TO 2 YEARS

4/12/2017

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Developmental Disabilities Lecture Series Suggested Reading List

Prepared by Eric Courchesne, PhD

Courchesne, E., Karns, C.M., Davis, H.R., Ziccardi, R., Carper, R.A., Tigue, Z.D., Chisum, H.J., Moses, P., Pierce, K., Lord, C., Lincoln, A.J., Pizzo, S., Schreibman, L., Haas, R.H., Akshoomoff, N.A., Courchesne, R.Y. (2001). Unusual brain growth patterns in early life in patients with autistic disorder: an MRI study. Neurology, 57(2):245-254.

Courchesne, E. & Pierce, K. (2005). Why the frontal cortex in autism might be talking only to itself: local

over-connectivity but long-distance disconnection. Current Opinion in Neurobiology 15(2):225-30.

Courchesne, E., Mouton P.R., Calhoun, M.E., Semendeferi, K., Ahrens-Barbeau, C., Carter-Barnes, C., Pierce, K. (2011). Prefrontal cortex neuron number and size in autism. JAMA. 306(18):2001-10.

Dinstein, I., Pierce, K., Eyler, L., Solso, S., Malach, R., Behrmann, M., Courchesne, E. Disrupted neural

synchronization in toddlers with autism. Neuron, 70(6):1218-25. PMID: 21689606. 2011. Lombardo, M., Pierce, K., Eyler,

L., Carter-Barnes, C., Ahrens-Barbeau, C., Solso, S., Campbell, K., & Courchesne,

E. (2015). Different functional neural substrates for good and poor language outcome in autism. Neuron, 86(2):567-77. PMID: 25864635

Marchetto MC, Belinson H, Tian Y, Freitas BC, Fu C, Vadodaria KC, Beltrao-Braga PC, Trujillo CA,

Mendes AP, Padmanabhan K, Nunez Y, Ou J, Ghosh H, Wright R, Brennand KJ, Pierce K, Eichenfield L, Pramparo T, Eyler LT, Barnes CC, Courchesne E, Geschwind DH, Gage FH, Wynshaw-Boris A, Muotri AR. Altered proliferation and networks in neural cells derived from idiopathic autistic individuals. Molecular Psychiatry. 2016 Jul 5. doi: 10.1038/mp.2016.95.

Pierce K, Carter C., Weinfeld, M., Desmond, J., Hazin, R., Bjork R. & Gallagher, N. (2011). Detecting,

studying and treating autism early: The 1-Year Well-Baby Check-Up Approach. Journal of Pediatrics, 159(3):458-465.e1-6, e-pub ahead of print. PubMed Central PMCID: PMC3157595.

Pierce, K., Marinero, S., Hazin, R., McKenna, B., Carter Barnes, C., Malije, A. (2016). Eyetracking

Reveals Abnormal Visual Attention to Geometric Images as a Biomarker of an ASD Subtype Associated with Increased Symptom Severity. Biological Psychiatry, 79(8):657-66. PMID:25981170. PMCID: PMC4600640

Pramparo, T., Pierce, K., Lombardo, M.V., Carter Barnes, C., Marinero, S., Lopez, L., Xu, R., & Courchesne, E. (2015). Prediction of Autism by Translation and Immune/Inflammation Coexpressed Genes in Toddlers from Pediatric Community Practices. JAMA Psychiatry, 72(4):386-94. PMID: 25739104.

Pramparo, T., Campbell, K., Carter Barnes, C., Marinero, S., Solso, S., Young, J., Mayo, M., Dale, A.,

Ahrens-Barbeau, C., Murray, S., Lopez, L., Lewis, N., Pierce, K., & Courchesne, E. (2015). Cell Cycle Networks link Gene Expression Dysregulation, Mutation and Brain Maldevelopment in Autistic Toddlers. Molecular Systems Biology. Dec 14;11(12):841. PMID: 26668231

Redcay, E. & Courchesne, E. Deviant functional magnetic resonance imaging patterns of brain activity to

speech in 2-3-year-old children with autism spectrum disorder. Biological Psychiatry, 64(7):589-598. PMCID: PMC2879340. 2008.

Solso, S., Xu, R., Proudfoot, J., Hagler, D., Campbell, K., Venkatraman, V., Carter, C., Ahrens-Barbeau,

C., Pierce, K., Dale, A., Eyler, L. & Courchesne, E. (2016). DTI provides evidence of possible axonal over-connectivity in frontal lobes in ASD toddlers. Biological Psychiatry, 79(8):676-84. PMID:26300272

Stoner R, Chow ML, Boyle MP, Sunkin SM, Mouton PR, Roy S, Wynshaw-Boris A, Colamarino SA, Lein

ES, Courchesne E. (2014). Patches of disorganization in the neocortex of children with autism. New England Journal of Medicine, 370: 1209-1219.

Notes

Notes

Notes

Notes