AUTISM SPECTRUM DISORDER

Timothy Jeider, MD
CAP Fellowship, UNLV 2018
 THE SPECTRUM

• Intellectual Disability
• Global Developmental Delay
• Communication Disorders; Language Disorder; Speech Sound Disorder,
Childhood-Onset Fluency Disorder (Stuttering)
• Social (Pragmatic) Communication Disorder
• Unspecified Communication Disorder
• Autism Spectrum Disorder
 INTELLECTUAL DISABILITY

A. Deficits in intellectual functions, such as reasoning, problem solving,

planning, abstract thinking, judgment, academic learning, and learning from
experience, confirmed by both clinical assessment and individualized,
standardized intelligence testing.
B. Deficits in adaptive functioning that result in failure to meet developmental
and sociocultural standards for personal independence and social
responsibility. Without ongoing support, the adaptive deficits limit functioning
in one or more activities of daily life, such as communication, social
participation, and independent living, across multiple environments, such as
home, school, work, and community.
C. Onset of intellectual and adaptive deficits during the developmental period.
Severity
level Conceptual domain
For preschool children, there may be no obvious conceptual
differences. For school-age children and adults, there are
difficulties in learning academic skills involving reading, writing,
arithmetic, time, or money, with support needed in one or more
areas to meet age-related expectations. In adults, abstract
Mild thinking, executive function (i.e., planning, strategizing, priority
317 (F70) setting, and cognitive flexibility), and short-term memory, as well
as functional use of academic skills (e.g., reading, money
management), are impaired. There is a somewhat concrete
approach to problems and solutions compared with age-mates.
All through development, the individual’s conceptual skills lag
markedly behind those of peers. For preschoolers, language
and pre-academic skills develop slowly. For school-age children,
progress in reading, writing, mathematics, and understanding of
time and money occurs slowly across the school years and is
markedly limited compared with that of peers. For adults,
academic skill development is typically at an elementary level,
Moderate
and support is required for all use of academic skills in work and
318.0 (F71)
personal life. Ongoing assistance on a daily basis is needed to
complete conceptual tasks of day-to-day life, and others may
take over these responsibilities fully for the individual.
Attainment of conceptual skills is limited. The individual
generally has little understanding of written language or of
concepts involving numbers, quantity, time, and money.
Caretakers provide extensive supports for problem solving
Severe throughout life.
318.1 (F72)
Conceptual skills generally involve the physical world rather
than symbolic processes. The individual may use objects in
goal-directed fashion for self-care, work, and recreation. Certain
visuospatial skills, such as matching and sorting based on
physical characteristics, may be acquired. However, co-
Profound occurring motor and sensory impairments may prevent
318.2 (F73) functional use of objects.
Social domain
Compared with typically developing age-mates, the
individual is immature in social interactions. For
example, there may be difficulty in accurately
perceiving peers’ social cues. Communication,
conversation, and language are more concrete or
immature than expected for age. There may be
difficulties regulating emotion and behavior in age-
appropriate fashion; these difficulties are noticed by
peers in social situations. There is limited
understanding of risk in social situations; social
judgment is immature for age, and the person is at risk
of being manipulated by others (gullibility).
The individual shows marked differences from peers in
social and communicative behavior across
development. Spoken language is typically a primary
tool for social communication but is much less complex
than that of peers. Capacity for relationships is evident
in ties to family and friends, and the individual may
have successful friendships across life and sometimes
romantic relations in adulthood. However, individuals
may not perceive or interpret social cues accurately.
Social judgment and decision-making abilities are
limited, and caretakers must assist the person with life
decisions. Friendships with typically developing peers
are often affected by communication or social
limitations. Significant social and communicative
support is needed in work settings for success.
Spoken language is quite limited in terms of vocabulary
and grammar. Speech may be single words or phrases
and may be supplemented through augmentative
means. Speech and communication are focused on the
here and now within everyday events. Language is
used for social communication more than for
explication. Individuals understand simple speech and
gestural communication. Relationships with family
members and familiar others are a source of pleasure
and help.
The individual has very limited understanding of
symbolic communication in speech or gesture. He or
she may understand some simple instructions or
gestures. The individual expresses his or her own
desires and emotions largely through nonverbal,
nonsymbolic communication. The individual enjoys
relationships with well-known family members,
caretakers, and familiar others, and initiates and
responds to social interactions through gestural and
Practical domain
The individual may function age-appropriately in personal care. Individuals
need some support with complex daily living tasks in comparison to peers. In
adulthood, supports typically involve grocery shopping, transportation, home
and child-care organizing, nutritious food preparation, and banking and money
management. Recreational skills resemble those of age-mates, although
judgment related to well-being and organization around recreation requires
support. In adulthood, competitive employment is often seen in jobs that do
not emphasize conceptual skills. Individuals generally need support to make
health care decisions and legal decisions, and to learn to perform a skilled
vocation competently. Support is typically needed to raise a family.
The individual can care for personal needs involving eating, dressing,
elimination, and hygiene as an adult, although an extended period of
teaching and time is needed for the individual to become independent in
these areas, and reminders may be needed. Similarly, participation in all
household tasks can be achieved by adulthood, although an extended period
of teaching is needed, and ongoing supports will typically occur for adult-
level performance. Independent employment in jobs that require limited
conceptual and communication skills can be achieved, but considerable
support from co-workers, supervisors, and others is needed to manage
social expectations, job complexities, and ancillary responsibilities such as
scheduling, transportation, health benefits, and money management. A
variety of recreational skills can be developed. These typically require
additional supports and learning opportunities over an extended period of
time. Maladaptive behavior is present in a significant minority and causes
social problems.
The individual requires support for all activities of daily living, including meals,
dressing, bathing, and elimination. The individual requires supervision at all
times. The individual cannot make responsible decisions regarding well-being
of self or others. In adulthood, participation in tasks at home, recreation, and
work requires ongoing support and assistance. Skill acquisition in all domains
involves long-term teaching and ongoing support. Maladaptive behavior,
including self-injury, is present in a significant minority. 
The individual is dependent on others for all aspects of daily physical care,
health, and safety, although he or she may be able to participate in some of
these activities as well. Individuals without severe physical impairments may
assist with some daily work tasks at home, like carrying dishes to the table.
Simple actions with objects may be the basis of participation in some
vocational activities with high levels of ongoing support. Recreational activities
may involve, for example, enjoyment in listening to music, watching movies,
going out for walks, or participating in water activities, all with the support of
others. Co-occurring physical and sensory impairments are frequent barriers
 GLOBAL DEVELOPMENTAL DELAY

• This diagnosis is reserved for individuals under the age of 5 years when

the clinical severity level cannot be reliably assessed during early
childhood.
• This category is diagnosed when an individual fails to meet expected
developmental milestones in several areas of intellectual functioning,
and applies to individuals who are unable to undergo systematic
assessments of intellectual functioning, including children who are too
young to participate in standardized testing.
• This category requires reassessment after a period of time.
 COMMUNICATION DISORDERS

• Language Disorder
• Vocab, Syntax, Content
• Speech Sound Disorder
• Sound Production
• Childhood-Onset Fluency Disorder (Stuttering)
 SOCIAL (PRAGMATIC)
COMMUNICATION DISORDER

A. Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following:
1. Deficits in using communication for social purposes, such as greeting and sharing information, in a manner that is appropriate for the social context.
2. Impairment of the ability to change communication to match context or the needs of the listener, such as speaking differently in a classroom than on a
playground, talking differently to a child than to an adult, and avoiding use of overly formal language.
3. Difficulties following rules for conversation and storytelling, such as taking turns in conversation, rephrasing when misunderstood, and knowing how
to use verbal and nonverbal signals to regulate interaction.
4. Difficulties understanding what is not explicitly stated (e.g., making inferences) and nonliteral or ambiguous meanings of language (e.g., idioms,
humor, metaphors, multiple meanings that depend on the context for interpretation).
B. The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement,
or occupational performance, individually or in combination.
C. The onset of the symptoms is in the early developmental period (but deficits may not become fully manifest until social communication
demands exceed limited capacities).
D. The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains of word structure and
grammar, and are not better explained by autism spectrum disorder, intellectual disability (intellectual developmental disorder), global
developmental delay, or another mental disorder.
 THE SPECTRUM
NEURODEVELOPMENTAL DISORDERS

• Intellectual Disability
• Global Developmental Delay
• Communication Disorders; Language Disorder; Speech Sound Disorder,
Childhood-Onset Fluency Disorder (Stuttering)
• Social (Pragmatic) Communication Disorder
• Unspecified Communication Disorder
• Autism Spectrum Disorder
OVERVIEW VIDEO OF ASD
WHAT CAUSES ASD?
 AUTISM SPECTRUM DISORDER

A. Persistent deficits in social communication and social interaction across multiple

contexts
1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach
and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or
affect; to failure to initiate or respond to social interactions.
2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for
example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye
contact and body language or deficits in understanding and use of gestures; to a total lack of
facial expressions and nonverbal communication.
3. Deficits in developing, maintaining, and understanding relationships, ranging, for example,
from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing
imaginative play or in making friends; to absence of interest in peers.
 AUTISM SPECTRUM DISORDER

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by

at least two of the following:
1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor
stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or
nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid
thinking patterns, greeting rituals, need to take same route or eat same food every day).
3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong
attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative
interests).
4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the
environment (e.g., apparent indifference to pain/temperature, adverse response to specific
sounds or textures, excessive smelling or touching of objects, visual fascination with lights or
movement).
 AUTISM SPECTRUM DISORDER

C. Symptoms must be present in the early developmental period (but may not
become fully manifest until social demands exceed limited capacities, or may be
masked by learned strategies in later life).
D. Symptoms cause clinically significant impairment in social, occupational, or
other important areas of current functioning.
E. These disturbances are not better explained by intellectual disability
(intellectual developmental disorder) or global developmental delay.
Intellectual disability and autism spectrum disorder frequently co-occur; to make
comorbid diagnoses of autism spectrum disorder and intellectual disability, social
communication should be below that expected for general developmental level.
Severity level Social communication Restricted, repetitive behaviors
Level 3 Severe deficits in verbal and nonverbal social communication Inflexibility of behavior, extreme difficulty coping with change,
“Requiring very substantial support” skills cause severe impairments in functioning, very limited or other restricted/repetitive behaviors markedly interfere with
initiation of social interactions, and minimal response to social functioning in all spheres. Great distress/difficulty changing focus
overtures from others. For example, a person with few words of or action.
intelligible speech who rarely initiates interaction and, when he or
she does, makes unusual approaches to meet needs only and
responds to only very direct social approaches.

Level 2 Marked deficits in verbal and nonverbal social communication
“Requiring substantial support” skills; social impairments apparent even with supports in place;
limited initiation of social interactions; and reduced or abnormal
responses to social overtures from others. For example, a person
who speaks simple sentences, whose interaction is limited to
narrow special interests, and who has markedly odd nonverbal
communication.
Inflexibility of behavior, difficulty coping with change, or other
restricted/repetitive behaviors appear frequently enough to be
obvious to the casual observer and interfere with functioning in a
variety of contexts. Distress and/or difficulty changing focus or
action.

Level 1 Without supports in place, deficits in social communication cause Inflexibility of behavior causes significant interference with
“Requiring support” noticeable impairments. Difficulty initiating social interactions, functioning in one or more contexts. Difficulty switching between
and clear examples of atypical or unsuccessful responses to social activities. Problems of organization and planning hamper
overtures of others. May appear to have decreased interest in independence.
social interactions. For example, a person who is able to speak in
full sentences and engages in communication but whose to-and-
fro conversation with others fails, and whose attempts to make
friends are odd and typically unsuccessful.
 GENERALIZED CHECKLIST

LANGUAGE SOCIAL BEHAVIOR

 Speech  Engages with  Tantrums/Aggression
others?
 Expression  Motor Flaps
 Eye Contact
 Receptive  Sensory Seeking
 Imaginative Play
 Echolalia  Restrictive/Repetitive Play
 Joint Attention
 Scripting  Sleep
 Responds to name
 Personal Space

THE BASIC QUESTION:

Has then been a loss of previously gained development?
VIDEO COVERING BASIC SIGNS
 WHAT TO DO ABOUT IT?

• No Cure.
• ABA Therapy
• Aggression Management
 APPLIED BEHAVIORAL ANALYSIS

• The process of systematically applying interventions based upon the principles

of learning theory to improve socially significant behaviors to a meaningful
degree, and to demonstrate that the interventions employed are responsible for
the improvement in behavior (Baer, Wolf & Risley, 1968; Sulzer-Azaroff & Mayer, 1991).
• Discrete trial training (DTT)
• a particular ABA teaching strategy which enables the learner to acquire complex skills
and behaviors by first mastering the subcomponents of the targeted skill. 
ABA THERAPY OVERVIEW VIDEO
AUTISM TANTRUM
 ROLE OF MEDICATIONS

• Aggressive / Self-Injurious Behavior

• Only two are FDA approved

• Abilify
• Risperdal
• Off label: alpha-Agonists
• Clonidine
• Guanfacine
 CASE INTRODUCTION

• You are working in the pediatric emergency room, and hear a child screaming loudly. You go to see what’s
happening, and find a child physically restrained to a gurney, screaming. You ask the child to tell you
what’s happening, but the child keeps screaming.
• A nurse nearby approaches you and asks for emergency medication orders and a psychiatric consultation.
You let her know you can’t proceed with orders until you have a basic understanding of the situation. It’s a
busy day in the ER, and the nurse hands you the triage notes she received:
• Jim is a 10 year old male referred via his school for extreme physical aggression. The school called 911
after Jim began screaming, turned over his desk, ripped up all nearby papers, kicked peers and began biting
himself. School staff attempted to restrain him, and he then bit the staff and head-butted them.
• You again approach Jim and attempt to engage. He keeps thrashing his head back and forth, and is
screaming.
• Vitals signs upon arrival: unable to obtain due to patient’s aggression and non-responsiveness to adults. No
labs have been obtained.
 DISCUSSION #1

• What do you do next?

 MORE INFORMATION

• You call the school and obtain the following information:

• Jim has been in their self contained special educational program for ‘emotional disturbance.’ He
has been involved in previous episodes of aggressive behavior, but none as severe as that
described above. The classroom teacher says that Jim began to escalate over the course of the
day, with his final flipping of the desk episode occurring shortly before lunch. She can’t figure
out why it occurred.
• The teacher tells you that Jim is relatively nonverbal and grunts in response to most questions.
He has no friends in class, and typically stays at his desk, picking at his fingers. He has an IEP
with goals including reduction of aggressive episodes and attainment of academic milestones
several grade levels below his chronological age.
• The school nurse tells you he has no documented allergies and is not prescribed medication that
he takes during the school day.
 MORE INFORMATION

• You call the school and obtain the following information:

• Jim has been in their self contained special educational program for ‘emotional disturbance.’
He has been involved in previous episodes of aggressive behavior, but none as severe as that
described above. The classroom teacher says that Jim began to escalate over the course of the
day, with his final flipping of the desk episode occurring shortly before lunch. She can’t figure
out why it occurred.
• The teacher tells you that Jim is relatively nonverbal and grunts in response to most questions.
He has no friends in class, and typically stays at his desk, picking at his fingers. He has an
IEP with goals including reduction of aggressive episodes and attainment of academic milestones
several grade levels below his chronological age.
• The school nurse tells you he has no documented allergies and is not prescribed medication
that he takes during the school day.
 DISCUSSION #2

• Based on the limited information you have, what do you suspect is going on?
• Physical manifestation of emotional distress from overwhelming stimulation.
• What do you imagine frustration/distress/panic/etc. would look like in a person who’s primary
means of communication is gesturing and grunting/noisemaking?

• What additional clinical or historical data do you need to move forward?

• Medical / Surgical History
• Established Diagnoses*
• Allergies
• Medications
 FURTHER DEVELOPMENTS

• Jim’s screaming is starting to die down, and he appears tired. You take the time to call his
parents, whose contact you were able to get from the school. Jim’s mom luckily answers the
phone and tells you the following:
• She doesn’t think the school treats Jim well.
• Jim has ‘fits’ when people don’t understand him.
• These ‘fits’ rarely happen at home, “because I know how to handle him.”
• She can’t recall his diagnosis.
• She gives him ‘that pill’ at night, before bed.
• Jim skipped breakfast this morning because his tummy didn’t feel well.
• Mom says she’s going to pick dad up from work and they’ll be at the ER right away.
 FURTHER DEVELOPMENTS

• Jim’s screaming is starting to die down, and he appears tired. You take the time to call his
parents, whose contact you were able to get from the school. Jim’s mom luckily answers the
phone and tells you the following:
• She doesn’t think the school treats Jim well.
• Jim has ‘fits’ when people don’t understand him.
• These ‘fits’ rarely happen at home, “because I know how to handle him.”
• She can’t recall his diagnosis.
• She gives him ‘that pill’ at night, before bed.
• Jim skipped breakfast this morning because his tummy didn’t feel well.
• Mom says she’s going to pick dad up from work and they’ll be at the ER right away.
 DISCUSSION #3

• Based on mom’s information, are you better able to determine an underlying

diagnosis? If so, what is it? And, if not, what else do you need?
A. Persistent deficits in social B. Restricted, repetitive patterns of behavior,
communication and social interaction: interests, or activities (at least two):
 Stereotyped or repetitive motor movements,
 Deficits in social-emotional use of objects, or speech
reciprocity:  Insistence on sameness, inflexible adherence
 Deficits in nonverbal to routines, or ritualized patterns of verbal or
communicative behaviors used for nonverbal
 Highly restricted, fixated interests that are
social interaction: abnormal in intensity or focus.
 Deficits in developing,  Hyper- or hyporeactivity to sensory input or
maintaining, and understanding unusual interest in sensory aspects of the
environment.
relationships:
 C. Symptoms must be present in the early developmental.
 D. Symptoms cause clinically significant impairment.
 E. ...not better explained by intellectual disability (intellectual developmental disorder) or global
developmental delay.
 DISCUSSION #3

• Based on mom’s information, are you better able to determine an underlying

diagnosis? If so, what is it? And, if not, what else do you need?
A. Persistent deficits in social communication and
social interaction:
 Deficits in social-emotional reciprocity:
• ”You again approach Jim and attempt
to engage. He keeps thrashing his
head back and forth, and is
screaming.”
 Deficits in nonverbal communicative
behaviors used for social interaction:
• “relatively nonverbal and grunts”
 Deficits in developing, maintaining, and
understanding relationships:
• “no friends”
B. Restricted, repetitive patterns of behavior, interests,
or activities (at least two):
 Stereotyped or repetitive motor movements, use of
objects, or speech
 Insistence on sameness, inflexible adherence to
routines, or ritualized patterns of verbal or nonverbal
• Based on his school “routine.”
• “stays at his desk, picking at his fingers”
 Highly restricted, fixated interests that are abnormal
in intensity or focus.
 Hyper- or hyporeactivity to sensory input or unusual
interest in sensory aspects of the environment.
• This is my theory of what’s happening.

 C. Symptoms must be present in the early developmental.

 D. Symptoms cause clinically significant impairment.
 E. ...not better explained by intellectual disability (intellectual developmental disorder) or global
developmental delay.
 FURTHER DEVELOPMENTS

• 30 minutes later, mom and dad arrive at the ER. You sense there’s a level of conflict between the parents.
Mom immediately goes to Jim’s bedside and begins speaking to him in a soft voice – he continues to calm
down and shortly thereafter falls asleep.
• While Mom is at Jim’s bedside, you meet with Dad. You summarize your findings to date and ask dad to
fill in the blanks. Dad says ‘she just won’t accept it.’
• Dad tells you that Jim was diagnosed with autism spectrum disorder by at least two different providers:
his pediatrician and a neuropsychologist. According to the most recent testing results, Jim has a full scale
IQ in the 60s. He is not verbal, but can use a PEX device to assist communication. At home, Jim
frequently has violent tantrums, biting and hitting mom, himself and the family dog. Dad is extremely
frustrated by mom’s lack of acceptance and ‘coddling’ of Jim – during and after tantrums she often gives
him M&Ms (his preferred food) which helps calm him down. Mom believes he’s been misdiagnosed and
is just a misunderstood boy. Over the past year, mom and dad have been fighting more related to Jim’s
frequent tantrums and mom’s lack of acceptance; it’s now to the point that dad sleeps in a separate room.
 FURTHER DEVELOPMENTS

• Jim and his parents live with the family dog. He is an only child. Mom became pregnant at 38 and had an uncomplicated
pregnancy – she did not smoke or drink. Jim was born at 37 weeks by emergency c-section due to decelerations
during labor. APGAR scores were 8/8. As an infant, Jim had difficulty latching on and was unable to breast feed. He
cried frequently and was difficult to soothe. He did not have a primary transitional object. (slide). As a toddler, he was
slow to learn to crawl and never seemed to develop expressive language skills, although he did seem to understand simple
commands. Dad remembers Jim rubbing his face on the carpet when he’d get upset. As Jim grew up, he always seemed
slower than the other kids, both in gross motor skill development and cognitive development. Mom always attributed his
slow developmental progress to food allergies (none of which were diagnostically confirmed) and other’s impatience with
understanding Jim.
• Mom and Dad married later in life (both were 35). Both are engineers and met at work. Neither have significant family or
personal psychiatric history. Dad did not want a child but mom did. She was elated to learn she was pregnant, and dad
slowly warmed to the idea of becoming a father. Mom worked throughout her pregnancy until the day she began going into
labor in the office. Throughout the pregnancy, mom would talk about her dream and aspirations for Jim, in a nearly
obsessive fashion (per dad’s description). Shortly after delivery, Mom developed post-partum depression. She did not seek
treatment for her depression until Jim turned 6 months; 3 months after starting antidepressants, her symptoms resolved, and
3 months after that she discontinued medication.
 PRIMARY TRANSITIONAL OBJECT

• Transitional Object is a term from developmental psychology specifically

relating to those objects of affection, which the child soothes itself and which
functions as a substitute for the mother. The TO, in proper terms, is a prop used
by the child in the early efforts to test reality.
 FURTHER DEVELOPMENTS

• Jim and his parents live with the family dog. He is an only child. Mom became pregnant at 38 and had an
uncomplicated pregnancy – she did not smoke or drink. Jim was born at 37 weeks by emergency c-section due to
decelerations during labor. APGAR scores were 8/8. As an infant, Jim had difficulty latching on and was unable to
breast feed. He cried frequently and was difficult to soothe. He did not have a primary transitional object. As a
toddler, he was slow to learn to crawl and never seemed to develop expressive language skills, although he did seem to
understand simple commands. Dad remembers Jim rubbing his face on the carpet when he’d get upset. As Jim grew
up, he always seemed slower than the other kids, both in gross motor skill development and cognitive development.
Mom always attributed his slow developmental progress to food allergies (none of which were diagnostically confirmed)
and other’s impatience with understanding Jim.
• Mom and Dad married later in life (both were 35). Both are engineers and met at work. Neither have significant
family or personal psychiatric history. Dad did not want a child but mom did. She was elated to learn she was
pregnant, and dad slowly warmed to the idea of becoming a father. Mom worked throughout her pregnancy until the day
she began going into labor in the office. Throughout the pregnancy, mom would talk about her dream and aspirations for
Jim, in a nearly obsessive fashion (per dad’s description). Shortly after delivery, Mom developed post-partum
depression. She did not seek treatment for her depression until Jim turned 6 months; 3 months after starting
antidepressants, her symptoms resolved, and 3 months after that she discontinued medication.
 DISCUSSION #4: BPS FORMULATION

BIOLOGY PSYCOLOGY
• Maternal Postpartum Depression • Limited ability to express (PECS).
• No other Psych History • Aggression
• Non-verbal • Difficult to soothe
• fsIQ – 60 • No PTOs
• Physical Delays • M&M’s

SOCIAL
• Parents fighting.
• Dad didn’t want child.
• Limited Support Network.
• Belief in medications........
• IEP
 ENCOUNTER WRAP UP

• You discharge the family from the ER now that Jim has calmed down. You
notice mom gives him a pack of M&Ms on the way out the door, which he
hungrily eats.
• His ER discharge plan includes follow up with you in the clinic. To make the
process easier, you obtain consent from the parents and get his pediatric and
psych testing records sent to you, as well as a copy of his IEP. Indeed, Jim was
identified as having autism spectrum symptoms by his pediatrician at the 18
month check up. His initial testing at 3 years of age demonstrated autism
spectrum disorder and comorbid intellectual delay.
 CLINIC FOLLOW UP
You have now completed your psychiatric intake of Jim and his family, and identify autism-related aggression
as a primary focus of treatment. There are no active medical problems according to the pediatrician’s note.

PSYCHOPHARMACOLOGY
• Targets for pharmacologic intervention
• Associated comorbid conditions (e.g., anxiety,
depression
• aggression / self-injurious behavior,
• hyperactivity, inattention,
PSYCHOTHERAPEUTIC
• Structured educational and behavioral interventions have been
shown to be effective for many children with ASD76 and are
associated with better outcome.
• ABA
• Early Intensive Behavioral Intervention
• Aka ABA for kids under 5 years old
• Picture Exchange Communication System

• compulsive-like behaviors, repetitive or • Structured Education Models

stereotypic behaviors • Early Start Denver Model

• Treatment and Education of Autism and related Communication
• sleep disturbances handicapped Children program

Combining medication with parent training is moderately more efficacious than medication alone for
decreasing serious behavioral disturbance and modestly more efficacious for adaptive functioning.
 PSYCHOPHARMACOLOGY

• FDA approved treatment of irritability, consisting primarily of physical aggression and severe tantrum behavior, associated with
autism:
• Risperidone
• 5 – 16 years old
• Dosing should be initiated at 0.25 mg per day for patients < 20 kg and 0.5 mg per day for patients ≥ 20 kg.
• After a minimum of four days from treatment initiation, the dose may be increased to the recommended dose of 0.5 mg per day for patients
< 20 kg and 1 mg per day for patients ≥ 20 kg.
• Dose increases may be considered at ≥ 2-week intervals in increments of 0.25 mg per day for patients < 20 kg or 0.5 mg per day for
patients ≥ 20 kg.
• If effective response not achieved at 3mg/day, consider alternate treatment.*
• Aripiprazole
• 6 – 17 years old
• Dosing should be initiated at 2 mg/day
• Dose adjustments of up to 5 mg/day should occur gradually, at intervals of no less than 1 week.
 PSYCHOPHARMACOLOGY

• Alpha-agonists
• Clonidine , guanfacine
• Norepinephrine Reuptake Inhibitor
• Straterra
• SSRIs/TCAs for OCD symptoms
• Fluoxetine, Clomipramine
• Other antipsychotics
• Haldol / Zyprexa
 PSYCHOPHARMACOLOGY

• Informed Consent.
 ADDITIONAL TREATMENT

• Additional providers to consider:

• Pediatrician
• +/- Geneticist
• Neuropsychologist
• OT / PT / SP / ABA Therapists
• Teachers
• Who else?
 ADDITIONAL TREATMENT

• What about Mom and Dad?

• Referral to Family and/or Couples therapy.

• Difference in discipline “beliefs” will impact therapy.
• Expectations.
• Quit points, respite, self-care.
• Complex treatment regiments will require working together.
• Divorce.
• Address these possible problems directly.
 PROGNOSIS

• The prognosis for children with ASD is governed by the joint impact of the
degree of expression of ASD and the degree of developmental delay, if any. [1]
• Autism carries a very variable prognosis; there might be a slight increase in
mortality in the first 30 years of life. A small, but not negligible, minority of
people with autism lead productive, self-supporting adult lives, but about two-
thirds will remain dependent on others throughout life. The risk of epilepsy is
very high, both in early childhood and adolescence. An important minority
deteriorate in adolescence. Outcome in autistic-like conditions is even more
variable, ranging from excellent in many cases of so-called Asperger syndrome
to gloomy in most cases of so-called disintegrative disorders. [2]

1. Coplan J. Counseling parents regarding prognosis in autistic spectrum disorder. Pediatrics. 2000 May 1;105(5):e65-.
2. Wenar C, Kerig P. Developmental psychopathology: From infancy through adolescence. McGraw-Hill; 2000.