Autism for PCPs Sourav Sengupta, MD, MPH Child Fellow, Western Psychiatric Institute & Clinic February 14, 2012
Overview <ul><li>What is autism? </li></ul><ul><li>Who has autism? </li></ul><ul><li>How do we help people with autism? </...
What is autism? Social Interaction non-verbal shared play peer relationships social/emotional reciprocity Communication sp...
On the “spectrum”… <ul><li>Asperger’s Disorder </li></ul><ul><ul><li>Social Interaction </li></ul></ul><ul><ul><li>Repetit...
On the “spectrum”… <ul><li>Rett’s Disorder </li></ul><ul><ul><li>Normal prenatal, perinatal development </li></ul></ul><ul...
On the “spectrum”… <ul><li>Childhood Disintegrative Disorder </li></ul><ul><ul><li>Normal development until 2 yo </li></ul...
On the “spectrum”… <ul><li>Pervasive Developmental Disorder NOS </li></ul><ul><ul><li>Impairment in communication, social ...
What is  NOT  autism? <ul><li>Selective mutism (only in SELECT settings) </li></ul><ul><li>Anxiety/separation anxiety </li...
Biological Underpinnings <ul><li>10x increase in siblings </li></ul><ul><li>Increased concordance in monozygotic twins </l...
ASD prevalence increasing <ul><li>1 in 110 children in the US, increasing </li></ul><ul><li>Why? </li></ul><ul><ul><li>Imp...
Surveillance <ul><li>Ask parents about developmental and behavioral concerns </li></ul><ul><li>Observe for any ASD signs <...
Screen <ul><li>Test  all  children at 18- and 24-month visits </li></ul><ul><li>Numerous available – M-CHAT is free for cl...
Quick Clinical Screen - Social <ul><li>Joint attention – enjoying shared experiences </li></ul><ul><ul><li>“ Look at that ...
Quick Clinical Screen -  Language <ul><li>Diminished drive to communicate </li></ul><ul><li>No pointing, gestures, facial ...
Medical Work-up <ul><li>Need for medical genetics eval? </li></ul><ul><li>Wood’s light    tuberous sclerosis </li></ul><u...
Get help! <ul><li>Alliance for Infants and Toddlers! </li></ul><ul><li>Child Psychiatrist, Developmental Pediatrician, Chi...
Treatment <ul><li>Goals: </li></ul><ul><ul><li>Improve social and language skills (EARLY) </li></ul></ul><ul><ul><li>Decre...
Treatment <ul><li>Behavioral </li></ul><ul><ul><li>Intensive therapy (>25hrs/week)    improved cognitive, language, life ...
Treatment <ul><li>Treat co-morbid conditions, medical & psychiatric! </li></ul><ul><ul><li>Constipation </li></ul></ul><ul...
Treatment <ul><li>What about Complementary and Alternative Medicine in autism? </li></ul><ul><ul><li>Normalize </li></ul><...
Clinical Environment <ul><li>Parent/Caretaker must accompany! </li></ul><ul><li>Limit other children in office/exam room <...
Pearls from Temple <ul><li>Develop child’s strengths, teach from those! </li></ul><ul><li>Turn-taking! </li></ul><ul><li>B...
Thank you! <ul><li>Questions? </li></ul><ul><li>[email_address]   </li></ul>
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Autism Spectrum Disorders for Primary Care Providers

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Basics of Autism Spectrum Disorders for Primary Care Providers

Sourav Sengupta, MD, MPH

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  • PRIOR TO AGE 3 NOT RETT’s, CHILDHOOD DISINTEGRATIVE DISORDER
  • M-CHAT= modified checklist for autism in toddlers
  • M-CHAT= modified checklist for autism in toddlers
  • M-CHAT= modified checklist for autism in toddlers
  • Tss = Therapeutic Staff Support
  • Autism Spectrum Disorders for Primary Care Providers

    1. 1. Autism for PCPs Sourav Sengupta, MD, MPH Child Fellow, Western Psychiatric Institute & Clinic February 14, 2012
    2. 2. Overview <ul><li>What is autism? </li></ul><ul><li>Who has autism? </li></ul><ul><li>How do we help people with autism? </li></ul><ul><li>Social issues surrounding autism </li></ul><ul><li>Resources for PCPs, families in Western PA </li></ul>
    3. 3. What is autism? Social Interaction non-verbal shared play peer relationships social/emotional reciprocity Communication spoken language conversation repetition imaginative/imitative play Repetitive Behaviors intense, restricted interests inflexible routines, rituals motor stereotypies interest in parts > whole
    4. 4. On the “spectrum”… <ul><li>Asperger’s Disorder </li></ul><ul><ul><li>Social Interaction </li></ul></ul><ul><ul><li>Repetitive Behaviors </li></ul></ul><ul><ul><li>Not significant language, cognitive delays/deficits </li></ul></ul>
    5. 5. On the “spectrum”… <ul><li>Rett’s Disorder </li></ul><ul><ul><li>Normal prenatal, perinatal development </li></ul></ul><ul><ul><li>Normal psychomotor development through 5 months </li></ul></ul><ul><ul><li>Normal head circumference </li></ul></ul><ul><ul><li>Deceleration of head circumference growth b/t 5-48 mo </li></ul></ul><ul><ul><li>Loss of motor skills, replaced by stereotypies </li></ul></ul><ul><ul><li>Loss of social interaction </li></ul></ul><ul><ul><li>Gait/trunk motor deficits </li></ul></ul><ul><ul><li>Severe expressive/receptive language deficits </li></ul></ul>
    6. 6. On the “spectrum”… <ul><li>Childhood Disintegrative Disorder </li></ul><ul><ul><li>Normal development until 2 yo </li></ul></ul><ul><ul><li>Loss of in 2+ skills < 10 yo: </li></ul></ul><ul><ul><ul><li>Language </li></ul></ul></ul><ul><ul><ul><li>Social skills </li></ul></ul></ul><ul><ul><ul><li>Bowel/Bladder </li></ul></ul></ul><ul><ul><ul><li>Play </li></ul></ul></ul><ul><ul><ul><li>Motor </li></ul></ul></ul><ul><ul><li>Impaired in 2+: language, social, repetitive behaviors </li></ul></ul>
    7. 7. On the “spectrum”… <ul><li>Pervasive Developmental Disorder NOS </li></ul><ul><ul><li>Impairment in communication, social interaction, and/or repetitive behaviors </li></ul></ul><ul><ul><li>Specific criteria unmet </li></ul></ul><ul><ul><li>Subsyndromal? </li></ul></ul>
    8. 8. What is NOT autism? <ul><li>Selective mutism (only in SELECT settings) </li></ul><ul><li>Anxiety/separation anxiety </li></ul><ul><li>Sensory Processing/Integration Disorder (overlap) </li></ul>
    9. 9. Biological Underpinnings <ul><li>10x increase in siblings </li></ul><ul><li>Increased concordance in monozygotic twins </li></ul><ul><li>Multiple underlying genetic etiologic possibilities </li></ul><ul><li>Environment likely affects gene expression </li></ul><ul><li>No evidence for MMR relationship </li></ul><ul><li>ASD + dysmorphism +/- family hx  think genetic syndrome </li></ul>
    10. 10. ASD prevalence increasing <ul><li>1 in 110 children in the US, increasing </li></ul><ul><li>Why? </li></ul><ul><ul><li>Improved awareness, diagnosis? </li></ul></ul><ul><ul><li>Changes in diagnostic criteria? </li></ul></ul><ul><ul><li>Service delivery for children with ASD? </li></ul></ul><ul><ul><li>Pre-term births? </li></ul></ul><ul><ul><li>Environmental? </li></ul></ul>
    11. 11. Surveillance <ul><li>Ask parents about developmental and behavioral concerns </li></ul><ul><li>Observe for any ASD signs </li></ul><ul><li>Understand family hx of ASD </li></ul>
    12. 12. Screen <ul><li>Test all children at 18- and 24-month visits </li></ul><ul><li>Numerous available – M-CHAT is free for clinical use, well replicated </li></ul><ul><li>High sensitivity, low(er) specificity – follow-up interview to identify false positives </li></ul><ul><li>http://www.mchatscreen.com </li></ul>
    13. 13. Quick Clinical Screen - Social <ul><li>Joint attention – enjoying shared experiences </li></ul><ul><ul><li>“ Look at that picture/ball/duck/cool thing!” </li></ul></ul><ul><ul><li>Brings a toy to parent and smiles </li></ul></ul><ul><li>Social orienting </li></ul><ul><ul><li>Reponse to name </li></ul></ul><ul><li>Pretend play </li></ul><ul><ul><li>“ Someone’s calling you on the cellphone!” </li></ul></ul><ul><ul><li>“ Pour me a cup of tea!” </li></ul></ul>
    14. 14. Quick Clinical Screen - Language <ul><li>Diminished drive to communicate </li></ul><ul><li>No pointing, gestures, facial expressions </li></ul><ul><li>Echolalia </li></ul><ul><li>Cannot understand simple commands </li></ul>
    15. 15. Medical Work-up <ul><li>Need for medical genetics eval? </li></ul><ul><li>Wood’s light  tuberous sclerosis </li></ul><ul><li>Lead screening </li></ul><ul><li>Metabolic testing (vomiting, seizures) </li></ul><ul><li>Hearing evaluation </li></ul>
    16. 16. Get help! <ul><li>Alliance for Infants and Toddlers! </li></ul><ul><li>Child Psychiatrist, Developmental Pediatrician, Child Neurologist (get an ADOS!) </li></ul><ul><li>Specialized therapist (BS, TSS, OT, cognitive/social skills) </li></ul><ul><li>Case Management </li></ul><ul><li>School System </li></ul><ul><li>Speech pathologist </li></ul>
    17. 17. Treatment <ul><li>Goals: </li></ul><ul><ul><li>Improve social and language skills (EARLY) </li></ul></ul><ul><ul><li>Decrease challenging behaviors </li></ul></ul><ul><ul><li>Support families </li></ul></ul><ul><ul><li>Foster INDEPENDENCE </li></ul></ul>
    18. 18. Treatment <ul><li>Behavioral </li></ul><ul><ul><li>Intensive therapy (>25hrs/week)  improved cognitive, language, life skills </li></ul></ul><ul><ul><li>Applied Behavioral Analysis </li></ul></ul><ul><ul><li>Play therapy, Floortime </li></ul></ul><ul><ul><li>Social Skills </li></ul></ul>
    19. 19. Treatment <ul><li>Treat co-morbid conditions, medical & psychiatric! </li></ul><ul><ul><li>Constipation </li></ul></ul><ul><ul><li>Pain (dental, headache, ear) </li></ul></ul><ul><li>Medications (see handout) </li></ul><ul><ul><li>Please be careful with benzodiazepines! </li></ul></ul><ul><ul><li>Melatonin 0.05mg/kg 1-2 hours before bedtime </li></ul></ul>
    20. 20. Treatment <ul><li>What about Complementary and Alternative Medicine in autism? </li></ul><ul><ul><li>Normalize </li></ul></ul><ul><ul><li>Ask! </li></ul></ul><ul><ul><li>Don’t judge! </li></ul></ul><ul><ul><li>Respond based on risk to health of child </li></ul></ul><ul><ul><li>Assist in navigating studies, providers, resources </li></ul></ul>
    21. 21. Clinical Environment <ul><li>Parent/Caretaker must accompany! </li></ul><ul><li>Limit other children in office/exam room </li></ul><ul><li>Quiet, neutral environment (ask parent) </li></ul><ul><li>Developmentally- and ASD-appropriate expectations about level of interaction/participation </li></ul><ul><li>Allow self-soothing </li></ul><ul><li>Be flexible! </li></ul>
    22. 22. Pearls from Temple <ul><li>Develop child’s strengths, teach from those! </li></ul><ul><li>Turn-taking! </li></ul><ul><li>Be flexible around sensory issues </li></ul><ul><li>Simple, direct, calm, FREQUENT communication </li></ul><ul><li>Be wary of low expectations! </li></ul>
    23. 23. Thank you! <ul><li>Questions? </li></ul><ul><li>[email_address] </li></ul>
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