Asd intervention vienna oct 07.ppt

The Autism Spectrum
Disorders: Interventions
Vienna, October 2007
Definitions
Autism = Autism Spectrum Disorders (ASM) =Pervasive Developmental Disorders (PDD) v The ASM encompass the entire range of severityv The ASM diagnosis applies irrespective of etiologiesv Dimensional, not dichotomous Dx ’ fuzzy margins, DSM IV PDD
PDD = pervasive developmental disorder, 1. Autistic disorder2. Asperger disorder3. PDD-NOS (PDD not otherwise specified) 4. Disintegrative disorder5. (Rett disorder) Etiologies of Autism
§ In ~ 80-90% of cases, etiology unknown but genetically (and environmentally?) influenced § Diagnosable causes multiple but each exceedingly Potential targets of intervention
v Not available because many putative etiologies v Multiple ’ even if known, no one Rx applies to all v Main neuropathologic evidence: prenatal processv Pharmacology: targets putative monoamines, etc.
v Education, i.e., influence brain development/ Needs to be addressed
v Core deficits: educational/behavioral intervention v Associated symptoms (e.g., epilepsy, apraxia, ADHD, etc.) that need medical or other Rx v Education about autism and how to deal with it v Emotional support for all family members Problems with the evidence
studies of the effectiveness of behavioral or medical interventions comparing the effectiveness of different treatment approaches children, ill-defined selection criteria, short-term studies Symptoms to be remediated
§ Troublesome social behaviors, especially aggressivity, joint inattention, tantrums § Troublesome stereotypies & rigidity v functional MRI in amputees, blindness, deafness § But efficacy of intervention is constrained by the severity of the underlying brain dysfunction addresses some troublesome symptoms, not core deficits Age at intervention
§ The brain is most plastic while brain § The earlier targeted education starts, crucial (even though controlled studies not available to show this in autism) Characteristics of early
intervention
§ Must be individualized to each child’s Educational management
§ No cure! – the goal is optimal functional outcome -
within the constraints of individual brain biology!
’ less severely affected children do better…
§ Child needs to be taught specific social & other
skills that other children “pick up” on their own
§ Parents need training in behavior management
§ Address needs of all family members!
§ Discourage unproven therapies
Needs of other family
§ All need to be aware of goals/strategies of § All need to learn what autism is & is not v Personal support, on-going individual helpv Training in management strategiesv Respite & practical assistancev Opportunity to fulfill their own needs v Must not to be sacrificed to autistic sibv Need to learn to be tolerant helpers and advocates Treatments of unproven
specificity / efficacy
Chelation of heavy metals (mercury, lead) Sensory integration, vestibular stimulation Anticonvulsants in the absence of clinical epilepsy? OK for their psychotropic effects Approaches to behavioral
remediation
§ All require preliminary and on-going functional behavioral § Developmental Individual Differences (Floor Time) (Greenspan) (one on one - encourages interaction and progress through developmental milestones) § Individual operant conditioning: Applied Behavior Analysis - ABA (Loovas), pivotal response training (Koegel) etc. - effective to develop compliance, but not panacea (one on one, no peers, may not generalize) § Structured teaching: Treatment & Education of Autistic and Related Communication Handicapped Children (TEACCH) (Schopler) (addresses needs of family & child) § Integrated education: normal peers (± individual coach): provide role models, supplemented with individual training § Mixed models (including parents in the classroom) Remediation of social
problems
§ Bring child under adult control (compliance)§ Train joint attention, sitting§ Teach/pactice social interactions (with § Teach how to read social cues§ Teach how to react to frustration§ Teach that temper tantrums are no longer Remediation of social
problems
§ Provide varied & graded opportunities to v interact with small, then larger, groups of peers (e.g., well supervised nursery school, play dates, v participate in community activities (school, In schoolage children
§ Ongoing social skills training in dyadic or triadic groups of specific & realistic interactions, with feedback and practice between training sessions § Use of visual organizers to provide visual frameworks that demonstrate paths of interactions § Training teachers & parents to do the Communication deficits
§ Focus on meaningful communication through any channel (pragmatics are universally and persistently impaired) § Operant conditioning often useful to get language started, but inadequate to train spontaneous/ conversational language use § Visual language (pictures, Sign): does not retard/ inhibit Rigidity
§ Written/drawn schedules to minimize
surprises
§ Announce changes in advance
§ Gradually practice flexibility –
deliberate schedule deviances
Stereotypies
§ Ignore stereotypies that are not too
frequent unless they preclude more
meaningful activities
§ Operant conditioning to minimize
troublesome stereotypies
§ Medication?
Atypical sensory responses
§ Effectiveness of intervention is limited
§ Ignore those that are not too troublesome
§ Choose those stimuli to which to attempt
desensitization
§ Try to avoid the most troublesome stimuli
§ No effective drug known
Self-injury
§ Extremely difficult to treat
§ Analyze circumstances of its occurrence
to avoid them
§ No truly effective medication, including
naltrexone
§ Anafranil, SSRIs? – may be useful for
obsessive/compulsive picking at sores
Sleep disorders
§ Goal: consolidate night sleep§ Avoid daytime naps§ Have regular sleep time § Institute going to bed routine, resist (chloral hydrate, clonidine, guanfacin, welbutrin?) Pharmacotherapy: role and
limitations
§ Adjunctive to behavioral interventions § Questionable use of multiple medications Attention deficit
§ Poor joint attention or real ADD?
§ Use same behavioral approaches as for ADD. May/may
not need medication
§ Try stimulants: help some children, and effect ~
immediate and short-lived (methylphenidate,
atomoxetine?)
§ Other drugs: clonidine, guanfacine, paroxetine?
§ Avoid risperidone unless there are other troublesome
symptoms like aggressivity
Aggression, irritability
§ Dopamine blockers (haloperidol etc.) effective but major side-effects (sedation, dystonic & tardivedyskinesias, weight gain, etc.) § Atypical neuroleptics, specific serotonin reuptake inhibitors - SSRIs (risperidone, paroxetine, fluvoxamine, fluoxetine, etc) § Anxiolytics (SSRIs, propranolol, benzodiazepines)§ Antidepressants (clomipramine, desipramine)§ Anticonvulsants as mood stabilizers (valproate, Autism: Epilepsy
Ø Cumulative risk: 30% by adulthoodØ Onset peaks: toddler/preschool, Ø Linked to severity of MR and other signs Risk Factors for Seizures
in Children with Autism
Epilepsy in children without severe
MR classified by language subtype
Epilepsy
§ Clinical seizures are treated to achieve
control as they would in any child
§ Choice of medication: avoid sedative or
other behavioral side-effects
§ No evidence to date that medication is
effective for subclinical epilepsy/EEG
epileptiform activity, even in the face of
language/autistic regression or ESES
(dissenting opinion in selected cases: Deonna/Roulet-Perez,
2005)
Autistic Regression
Ø Regression of language, sociability, playØ Mean age: 21 monthsØ Reported by 1/3 of parentsØ Improvement but not full recovery after a Ø Trigger?Ø Role of subclinical epilepsy? Treatment of autistic
regression
anticonvulsants effective for subclinical epileptiform activity, even in the face of language/autistic regression! § Only anecdotal reports of effectiveness AUTISM: PROGNOSIS
v Symptoms change with agev Improve with early intensive educationv Prognosis unreliable in early childhoodv So do not “hang crepe” too early Autism: Prognosis
v Prognosis variable, by no means hopeless, unreliable in very young v Depends in part on the adequacy of family’s and v Supplement auditory by visual inputsv Provide a structured predictable environmentv Train social skills throughout childhood

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