ken pittman, md agape youth behavioral health child and adolescent psychiatrist board certified in...
TRANSCRIPT
Ken Pittman, MDAgape Youth Behavioral HealthChild and Adolescent PsychiatristBoard Certified in C&A Psychiatry, Adult Psychiatry, and Pediatrics
Autism as a Multidimensional Spectrum
• Identify Domains of Symptoms That Can Present in a Spectrum with ASDs
• Discuss Potential Subgroups Based on Combinations of These Symptoms
• Identify Treatment Options Based on Subgroups of Symptoms
Objectives
• DSM-IV• Autistic Disorder – 6 from a list of symptoms including social interaction
impairment, communication impairment, and repetitive/stereotypic behaviors
• Asperger’s Disorder - 6 from a list of symptoms including social interaction impairment, repetitive/stereotypic behaviors, and LACK of communication impairment
• Childhood Disintegrative Disorder – Normal development for 2 years, then loss of previously acquired skills
• PDD-NOS – Presence of Autistic-like social interaction impairment, but not fully meeting criteria for any of the above
• DSM-5• Autism Spectrum Disorder – Deficits in Social Communication/Interaction
combined with at least two repetitive behaviors (including sensory issues)
• Many specifiers including severity, with/without intellectual impairment, with/without language impairment, with catatonia, and associated with other conditions
• Social (Pragmatic) Communication Disorder – Listed a separate Neurodevelopmental Disorder, but basically an ASD without repetitive behaviors
What is Autism Spectrum Disorder?
• Why have we all heard the saying “If you’ve met one child with autism, you’ve met one child with autism?”
• Is Social Communication Disorder really that separate from ASD?
• Are sensory issues really a repetitive behavior?
• Are symptoms really “black and white” or are their many shades of gray?
• What about other associated symptoms? ADHD? Anxiety? Depression?
• Could having a more defined way of grouping ASD’s lead to better research and treatment?
So if the Criteria are More Basic…
• My thoughts on “the Spectrum”
• Symptoms that May Present as a Spectrum in Autism Spectrum Disorder• Social Communication/Interaction
• Repetitive Behaviors
• Sensory Issues
• Intellectual Impairment
• Language Impairment
• Inattention
• Hyperactivity/Impulsivity
• Irritability/Aggression
• Anxiety
• Depression
• Sleep
Putting the Spectrum back in ASD
• Complete Lack of Social Communication
• Very Impaired Social Communication Skills
• Somewhat Impaired Social Communication Skills
• Mildly Impaired Social Communication Skills
• No Impairment of Social Communication Skills (Not a Traditional ASD)
Social Communication/Interaction
• Significant repetitive behaviors in all areas
• Significant isolated repetitive behaviors
• Moderate repetitive behaviors
• Mild repetitive behaviors
• Very limited to no repetitive behaviors (Not a Traditional ASD, may include Social Communication Disorder)
Repetitive Behaviors
• Significant Hypersensitivity in Multiple Areas
• Moderate Hypersensitivity in Multiple Areas or Isolated Severe Hypersensitivity in one Sensory Area
• Very Mild to No Significant Hypersensitivity or Hyposensitivity
• Moderate Hyposensitivity in Multiple Areas or Isolated Severe Hyposensitivity in one Sensory Area
• Significant Hyposensitivity in Multiple Areas
Sensory Issues
• Significant Intellectual Impairment (IQ<60)
• Borderline to Mild Intellectual Impairment (IQ 60-80)
• Average or Near-Average Intellectual Functioning (IQ 80-120)
• Moderate Intellectual Giftedness (IQ 120-140)
• Significant Intellectual Giftedness (IQ>140)
Intellectual Impairment
• No Significant Verbal/Language Skills
• Significant Verbal/Language Impairment
• Mild to Moderate Language Impairment or Delay
• No Significant Language Impairment or Delay
• Elevated Language Skills and Vocabulary
Language Impairment
• Profound Inattention (9/9 Inattentive Symptoms)
• Significant Inattention (7-8/9 Inattentive Symptoms)
• Moderate Inattention (6/9 Inattentive Symptoms)
• Mild Inattention (4-5/9 Inattentive Symptoms)
• No Significant Inattention (<4 Inattentive Symptoms)
Inattention
• Significant Hyperactivity AND Impulsivity
• Moderate Hyperactivity AND Impulsivity or Severe Impulsivity alone
• Mild-Moderate Hyperactivity OR Impulsivity
• Average Level of Hyperactivity/Impulsivity
• Moderate to Severe Hypoactivity
Hyperactivity/Impulsivity
• Severe Irritability/Aggression with unclear triggers
• Severe Irritability/Aggression when triggered
• Moderate Irritability/Aggression when triggered
• Mild Irritability/Aggression when triggered
• Average Levels of Irritability
Irritability/Aggression
• Significant Anxiety in Many Domains that Leads to Limited Functioning
• Significant Anxiety in Social Situations Only that Leads to Limited Functioning
• Moderate Anxiety in Many Domains with Some Limited Functioning
• Moderate Anxiety in Social Situations Only that Leads to Some Limited Functioning
• Mild/Average to No Significant Anxiety
Anxiety
• Chronic/Recurrent Severe Depression
• Episodic Severe Depression
• Episodic Moderate Depression
• Episodic Mild Depression or Chronic Dysthymia
• No Clinically Significant Depression or Dysthymia
Depression
• Near Complete Lack of Sleep with Decreased Need for Sleep (Mania)
• Very Limited Sleep with Associated Drowsiness/Irritability/Lack of Energy
• Moderately Impaired Sleep
• Delayed Sleep Onset
• No Recurrent Sleep Issues
Sleep
“Jeremy”
• Diagnosed with Asperger’s Under DSM-IV, Now 16
• Mildly Impaired Social Skills
• Mild Repetitive Behaviors as a Child, Now Mostly Resolved
• History of Moderate Hypersensitivity to Sounds and Tags in Clothing
• Significantly Intellectually Gifted (IQ 147)
• Elevated Language Skills and Vocabulary
• No Significant Inattention
• No Significant Hyperactivity/Impulsivity
• Mild Irritability/Aggression when Triggered
• Moderate Anxiety in Many Domains
• Episodic Moderate Depression, particularly when in Middle School
• Delayed Sleep Onset
Clinical Examples of Symptom Clusters
“Patricia”
• Diagnosed with Autistic Disorder under DSM-IV, Now 9
• Complete Lack of Social Communication
• Significant Repetitive Behaviors in All Areas
• Significant Hyposensitivity in All Areas
• Significant Intellectual Impairment (Nonverbal IQ Estimated to be 53)
• No Significant Verbal/Language Skills
• Profound Inattention
• Mild Hyperactivity/Impulsivity
• Severe Irritability/Aggression with Unclear Triggers
• Mild/Average Anxiety
• No Known Depression or Dysthymia
• Very Limited Sleep with Associated Drowsiness/Irritability/Lack of Energy
Clinical Examples of Symptom Clusters
“Bobby”
• Diagnosed with Autistic Disorder under DSM-IV, now 12
• Somewhat Impaired Social Skills
• Significant Isolated Repetitive Behavioral
• Moderate Hypersensitivity to Sounds, Smells, and Tactile Stimulation
• Average Intellectual Functioning (IQ 94)
• History of Mild Language Delay, now normalized
• Significant Inattention
• Significant Hyperactivity AND Impulsivity
• Severe Irritability/Aggression when Triggered
• Moderate Anxiety in Social Situations
• Episodic Mild Depression with Recent Dysthymia
• Moderately Impaired Sleep
Clinical Examples of Symptom Clusters
• Could Patterns in Combinations of Symptoms Lead to Better Subgroups?
• Does response to stimulants vary based on intellectual functioning and/or degree of preexisting irritability/aggression?
• Could depression be better predicted/prevented based on the combination of other symptoms (such as degree of social impairment and intellectual functioning)?
• Do highly impulsive children with aggression respond differently to medication than those without significant hyperactivity/impulsivity?
• Should children with anxiety and aggression together have different treatment than children with aggression in the absence of anxiety?
• What about other domains? Autoimmune diseases? Known Genetic Issues? Dietary Issues?
Potential Impacts on Research/Treatment
