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Case: “He’s about to be kicked out of school and I’m going to lose my job!”

What are you going to do to help Thomas?

What is Autism Spectrum Disorder?

ASD is a neurodevelopmental disorder that leads to difficulties with

1. Social communication and interactions;
2. Behaviours, with restricted repetitive behaviors and Interests.

Features of Autism Spectrum Disorder (ASD)

ASD is a heterogeneous condition that affects a person's ability to relate to others with the following features: 

Associated issues may include

Classic symptoms vs. less obvious symptoms of ASD

Most diagnostic criteria are based on the classic male with ASD. Many females with ASD have written about how they have less obvious symptoms of ASD, which has led to the realization that there is a wide spectrum of symptoms. It is now realized that these 'less obvious' symptoms can apply to males or females. 

Strengths of ASD

Despite the challenges in those who have ASD, note various strengths that those with high functioning ASD bring into their lives and workplaces such as:

• Being very good at following rules and laws, as well as trying to understand things according to rules and laws (Baron-Cohen, 2003).
• Being objective rather than people focused, which helps some individuals with ASD do very well in fields such as science, engineering, computers. In addition, many individuals with ASD have interests across other fields that include arts, music, drama, and social sciences, to name just a few.
• Being able to focus their attention for long periods of time, even on tasks which others may find boring or mundane.
• Being able to stay objective, and not be as affected by ‘peer pressure' or others opinions (e.g. children on the autism spectrum are far less influenced by peers when it comes to clothing trends or pressure to try drugs)
• Being visual. Many may have exceptional (even "photographic") visual memory (i.e. memory for things that they have seen). These strong visualization skills (the ability to think in pictures) may help in engineering, design and other visual fields.
• Being auditory and verbal. Rather than being visual however, individuals with ASD may have exceptional auditory memory (i.e. memory for things that they have heard.) Strong verbal skills in fact, can help in future professionals such as being a writer, editor, tour guide, or lecturer...
• Strong "analytical" or logical reasoning skills, which may help with accounting, engineering, and computers.
• Show great depth of knowledge in areas of interest, which can help them become experts in their fields of interest.
• Having a strong work ethic, as they tend to be punctual, reliable, dependable, accurate and follow rules closely.

Epidemiology

Prevalence

• Previously felt to be 1%
  • 1% (CDC 1/88) (Can. J. Psych. 55(11), 2010, 715-20; Arch Gen Psyc 2011, 68(5), 459-65)
• However, more recent data suggests it is more common ~ 1.5%
  • 1.5% or 1 in 66 Canadians aged 5 to 17 years (1 in 42 males, and 1 in 165 females) (Government of Canada, 2018)

Gender: M:F – 4:1

• Although males are diagnosed more frequently than males, evidence suggests that many females actually have missed diagnoses as they have more subtle signs than males (Kirkovski, 2013; Loomes, 2017).

Intellectual disability

• Most with ASD do not have intellectual disability (ID)
• <25% have ID

Age of diagnosis

• In some children with more obvious and severe ASD symptoms, it can be diagnosed as early as 2-years of age (Guthrie, 2013), though parents will often tell you, “I knew he was different from birth.”
• Mean age of diagnosis is age 4-5 (Daniels, 2014)

Morbidity and Burden of Disease

ASD causes significant morbidity to the child and family

• Severely affects many aspects of a child’s life
• Has emotional, behavioural, medical impacts on family
  • Causes more stress on the family than any other disorder of childhood
  • Leads to 1000 extra hours of care per year.

Etiology

Parents often ask “What causes ASD?” and it is helpful to help affirming explanations, as opposed to primarily pathological explanations, such as Baron-Cohen's Systematizing Theory, the ‘engineering hypothesis’:

• It has been noted anecdotally, that certain professions such as engineering and computer sciences have a disproportionately high percentage of individuals with ASD (Baron-Cohen, 2009). As modern societies become increasingly dependent on technology, it has been theorized that having ASD traits are adaptive and helpful, which is one theory which might possibly explain rising rates of autism spectrum disorders (CDC, 2012).
• This fits with the fact that in popular culture, there are more and more positive depictions, such as the characters on the TV series “Big Bang Theory”, or Dilbert.

Vaccines do not cause autism

• There are still some parents who worry that vaccines cause autism, but the good news is 1) research strongly shows vaccines do not cause autism and 2) earlier evidence suggesting vaccines cause autism have in fact been shown as being fraudulent

Screening

Indications for Screening

Are you doing a psychiatric assessment of a child/youth?

• Ask about ASD (“Psychiatric assessment of all children should routinely include questions about sign/symptoms of autism spectrum disorder”, JAACAP Practice Parameters for ASD, 2014).

Is there an older sibling diagnosed with ASD?

• If so, then consider screening for ASD in younger siblings and other first degree family members (e.g. parents)
• When an older sibling is diagnosed with ASD, the odds of a younger sibling having ASD is 10-20% (Szatmari, 2016).

Early Red Flags

Are there problems with social communication?

• Little social smiling
• Limited social eye contact
• Little comfort seeking
• Little separation anxiety
• Limited greeting
• Impaired joint attention
  • Joint attention is the ability to share interests, pleasurable experiences, or requests by using gestures or verbal communication in combination with eye contact with another person.

Are there problems with non-verbal communication?

• Speech delay, e.g. does not have spontaneous 2 word phrases with a verb by 24 months
• No pointing to indicate what you want to see
  • Instead of pointing, a child with ASD might grab your head to turn your head towards what they want you to see.
  • The child may drag the parent by the hand, treating other people as a tool or object
• No change in facial expression
• No gestures
• Difficult for parents to guess what the child wants due to the lack of communication

Red Flags for Ages 18 mos. and older

Are there problems with:

• Delayed or atypical language

• Regression or loss of communication skills (including words)
• Language comprehension and production (e.g. delayed or odd first words or unusually repetitive)
• Unusual tone of voice or unusual crying?
• Problems developing normal gestures (such as pointing, waving)?
• Play

• Differences in play, such as
  • Reduced or atypical: imitation of actions; functional/imaginative play
  • Excessive or unusual manipulation or visual exploration of toys and other objects
  • Repetitive actions with toys and other objects
    

• Visual or other sensory and motor skills
  • Atypical visual tracking, visual fixation (e.g. on lights)
  • Under- or over-reaction to sounds or other forms of sensory stimulation
  • Delayed fine and gross motor skills, atypical motor control (e.g., reduced muscle tone, reduced postural control for age)
  • Repetitive motor behaviors, atypical posturing of limbs or digits
    

Screening Instruments

• Modified Checklist of Autism in Toddlers (M-CHAT) (sensitivity 0.77-0.87, specificity: 0.38-0.99)
• Infant-Toddler Checklist (ITC) (sensitivity 0.86-0.89, specificity 0.75-0.77)
• Social communications Questionnaire (SCQ)
• ABC (Autism Behaviour Checklist)

Clinical Presentation

Children/youth may present with

• Difficulties with daily routines
  • Child may be rigid and insistent on certain daily routines
  • Aversion to change and sensory sensitivities:
  • Troubles following normal eating, sleep and routines (haircuts, nail cutting, dental care, dressing, etc)
  • Adaptive skills generally below measured IQ
    
• Social isolation and troubles communicating.
  
• Functional impairment
  • Troubles meeting normal developmental milestones that one would expected for their chronological age, e.g. having friends; moving out, etc.
    

• Academic problems, iIntellectual impairment and/or language impairment
  • Often large gap between intellectual and adaptive functional skills
  • Example:
    • May have good intellectual skills, yet in real life, has severe troubles with adaptive skills
    • Child/youth may have above-average intelligence, but marks may be lower than expected due to troubles with planning, organization and coping with change.
• Motor
  • Motor deficits often present: odd gait, clumsiness, walking on tiptoes, etc.
• Self-injury (head banging, biting)
• Disruptive/challenging behaviors
  

Typical Presentation

There are various ways in which adults with ASD may present to psychiatry:

• Patients with a diagnosis of ASD may present with ongoing mental health concerns.
  
• Patients without a prior diagnosis of ASD may also present for concerns such as
  • Mental health concerns
  • Specifically wondering if there is a diagnosis of ASD

Prior to the Appointment

Consider having materials that explain ahead of time what will happen during the appointment that parents can give to their child, such as a social story about “What to expect during your visit” (link to CHEO examples).

The Waiting Room

Given that many individuals with ASD are sensitive to sensory overload, try to have a waiting room that is sensory friendly without too much light, sound, smells, etc. This also helps people with other conditions such as anxiety and trauma. 

History

Therapeutic alliance and goals with patients with ASD

Developing therapeutic alliance includes finding mutually agreeable goals.  Try to see things from the perspective of the patient with ASD, as due to their difficulties with theory of mind, it is much harder for them to see your perspective. They are dragged in to see you. They are already feeling blamed and criticized by others. It is hard for them to see things from others’ perspectives, such as their parent(s), sibling(s) or teacher(s). Imagine yourself in the patient’s shoes, and how difficult that would be.

Examples of converting parent and other’s concerns into the patient’s concerns, with the hope of generating a mutual goal:

Start of the interview

Concrete, literal

• Individuals with ASD tend to be concrete and take things literally
• Example
  • Clinician: “What brought you here today?”
  • Person with ASD: “A car.” (providing a literal, concrete answer; as opposed to a more abstract answer, e.g. problems with school, stresses at home, etc.)

A comprehensive psychiatric assessment will include

• Identifying data
• Current services and supports
• Living situation
• Reason for referral
• HPI
  • Parent’s main concerns
  • What makes things worse, e.g. triggers and stressors
  • What makes things better
• Past mental health history
• Medications
  • Any side effects?
• Past medications
• Neurovegetative symptoms
  • Any sleep issues ?
• Safety
  • Aggression, self-injury to self?
  • Aggression, self-injury to others?

• Diet / Nutrition
  • Is the patient a picky eater? If so, there may be a higher risk of malnutrition
• MSE
  • Observation of child including play
  • Observe child in social settings

Diagnostic Questions Based on DSM-5 criteria

Diagnostic Tools

• Autism Diagnostic Interview-revised (ADI-R)
• The Autism Diagnostic Observation Schedule-Generic (ADOS-G), specificity 0.72-1.0, sensitivity 0.72-0.98
• Childhood Autism Rating Scale (CARS), sensitivity and specificity 0.82-0.95
• Diagnostic Interview for Social and Communication Disorders (DISCO)

While it can be helpful to have training in using standardized diagnostic tools, this is not always possible -- ultimately, the diagnosis is a clinical diagnosis.

DSM-5 Criteria for Autism Spectrum Disorder (ASD)

A. Persistent deficits in social communication and interaction across multiple context, as manifested by the following, currently or by history

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.

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least 2 of the following, currently or by history

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypes, 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 the same route or eat the 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 hypo reactivity 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).

C. Symptoms must be present in the early developmental period (however note that symptoms 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 areas of function such as social, occupational.

E. Symptoms are not better explained by intellectual disability (ID) or global developmental delay

Specify:

• Current severity of A and B

Specify:

• With or without intellectual impairment
• With or without language impairment
• Associated with a known medical or genetic condition or environmental factor
• Associated with another neurodevelopmental, mental, or behavioral disorder
• With catatonia

Differential Diagnosis: Medical Issues

Medical conditions can cause or worsen challenging behaviours in patients with ASD:

Differential Diagnosis: Psychiatric Conditions

Are there any other conditions (especially treatable conditions) with similar symptoms, such as:

Comorbidity

Comorbidity is common

• 70% will have one mental disorder
• 40% will have two or more mental disorders

Prognosis and Outcome

Most people with ASD improve over time

• Language increases, symptoms decrease; those with better social skills do better. 
• However, adaptive functioning remains poor for most. 

How many children lose their ASD diagnosis?

• Studies have followed children diagnosed with ASD from 3-years of age to middle childhood, and show that an ASD diagnosis is removed in 5.6-20% of children (Brian 20-16; Shephard, 2017).

Physical Exam

Especially if the patient has troubles expressing themselves verbally, ensure a physical exam to rule out physical contributor. If the psychiatrist is not doing a physical exam, then the psychiatrist should coordinate so that someone is doing a physical exam (JAACAP Practice Parameter for ASD, 2014).

Mental Status Exam (MSE)

General observations:

• Possible sensory overload, with signs of fight/flight or freeze.
• Technology overuse may be suggested by inability to put down an electronic device.

Communication / Language

• Tend to have poor eye contact
• May not recognize usual boundaries in social situations, e.g. make factually correct, but socially inappropriate comments about the interviewer’s appearance, ethnicity, etc.
• Tone of voice may be unusual
• May have their unique use of words, language, or made up words

Insight

• Due to troubles with perspective taking, tend to see any problems/issues from their own perspective, and have troubles seeing from other’s perspective, e.g. “everyone at school is being mean to me” without understanding that his/her own behaviours lead everyone to respond negatively.

Investigations

Based on clinical suspicion, consider:

• Genetic testing, such as G-banded karyotype, fragile X testing, chromosomal microarray
• EEG if history of seizure or history of significant regression in social or communication functioning.
  • EEG abnormal in 20 -25%.
• Neuroimaging
  • Referral for genetic or neurologic consultation

Additional assessments

• Psychoeducational testing to rule out comorbid learning disabilities or other conditions.
• Neuropsychological testing (include verbal skills, non-verbal skills, adaptive skills and overall function assessments)
• Guide future planning (e.g. educational needs)
• Adaptive skills
• Communication assessment
• Vision
• Hearing
• Speech Language Pathology
• Occupational Therapy
• Sleep assessment

Documenting the Diagnosis

Does the patient meet criteria for DSM-5 diagnosis of Autism Spectrum Disorder (ASD)? If so, then document the diagnosis, as this is important for many agencies in order to qualify for services.

How to Document Autism Spectrum Disorder (ASD) Diagnosis

State the diagnosis, e.g.  “I am writing this letter to confirm a diagnosis of autism spectrum disorder (ASD)

• With / without intellectual impairment. 
• With / without language impairment. 

State the ASD severity such as

• Level 1: Requiring support, due to issues such as
  • Social difficulties, e.g. May find it difficult to initiate conversations with others and may respond inappropriately or lose interest quickly. As a result, it can be challenging for them to make friends, especially without the right support.
  • Inflexible behavior, e.g. May be difficult for them to cope with changing situations or contexts, such as new environments; and may need help with organization and planning.
• Level 2: Requiring substantial support
  • People in this category need more support than those with a level 1 diagnosis. They have more severe social deficits that make holding a conversation very challenging.
  • Even with support, they may struggle to communicate coherently and are more likely to respond inappropriately to others. They may speak in short sentences or only discuss very specific topics.
  • These individuals may also have issues with nonverbal communication and might display behaviors such as facing away from the person with whom they are communicating.
  • People with a level 2 diagnosis may also have inflexible behaviors that can interfere with daily functioning. They typically do not cope very well with changes, which can cause them significant distress.
• Level 3: Requiring very substantial support
  • Level 3 is the most severe autism diagnosis, with people having significant impairments in their verbal
  • Will often avoid interactions with others, but they may interact in a limited way if they must respond to others or communicate a need.
  • Behaviors are highly inflexible and repetitive. They may react strongly to changes and become highly distressed in a situation that requires them to alter their focus or task.

Management / Treatment

Provide education about ASD

• Consider ASD handouts from eMentalHealth.ca
  https://www.ementalhealth.ca/index.php?m=article&ID=8887

Service navigation

Family support:

• Do the caregivers require any supports such as:
  • Financial supports
  • Respite
• Do siblings require any supports, such as
  • Sibling support

Establish goals for interventions such as:

• Language / communication
• Social skills
• Behaviours
• Self-regulation
• Addressing behaviours that challenge (BTC) such as repetitive, self-stimulatory behaviors, tantrums, aggression and self-injurious behaviors.

Establish target symptoms for intervention

• Ask the family what goals they would like to work on
  • E.g. less anger?
  • E.g. more independence?

Treat any treatable comorbid conditions

• E.g. ADHD

Monitor multiple domains of functioning

• Behavioral adjustment, adaptive skills, academic skills, social/communicative skills, social interactions) (case coordination)

Monitor pharmacological interventions for efficacy and side-effects.

Liaise with the school

• Telephone call / email with school
• Letter to school stating diagnosis of ASD
  https://docs.google.com/document/d/111vPe2r4krjkHjdGChnR-LvGZtxvo1R6SFZJ7-ilEqo/edit#heading=h.a3sxhvcasswb
• Letter to school requesting any additional supports such as accommodations, modifications

Management/Treatment: Behavioural Interventions

Applied Behavior Analysis (ABA).

• Uses the principles of operant conditioning to teach specific social, communicative, and behavioral skills to children with ASD. It involves teaching new behaviors by explicit reinforcement of these behaviors, problem behaviors are often addressed by carefully analyzing triggers or antecedents of the problem behavior in order to change the factors in the environment that are contributing to the problems behavior.

• Effective intervention includes a minimum of 20 hours per week of carefully organized services, preferably initiated when a child is younger than 4.
• Outcomes of ABA (effect size 0.3 to >1):
  • Gains in verbal intelligence quotient, language communication domains if treatment is started earlier, with greater intensity or duration of intervention
• ABC’s of ABA
  • ABA uses the following 3 step process to understand behaviour and teach new skills:
    • A: Antecedent/instruction
      • What happens right BEFORE the behavior?
    • B: Behavior/ the child’s response
      • What the child does.
    • C: Consequence/ teacher feedback
      • What happens right AFTER the behavior?

Intensive Behaviour Intervention (IBI)

• Intensive Behaviour Intervention (IBI) is a more intense form of ABA which consists of >25 hours per week, adult directed, 1:1
• IBI has good evidence:
• Most gains are seen if IBI is
  • High level of intervention (30-40hrs per week)
  • 1:1 (therapist or parent)
  • >2yrs
  • Starts before 5yrs

Management/Treatment: Developmental Treatments

Many families report that their children do not respond to ABA nor IBI approaches, particularly those with higher functioning ASD.

Developmental-based treatments are more child directed and focus on the child’s developmental level as well as social communication skills

Examples include:

• Early Start Denver Model,
• Pivotal response Training,
• Developmental Individual Difference Relationship-based approach (DIR or Floortime)

Evidence is weaker for developmental treatments compared to ABA treatments however.

Visual supports and strategies

Individuals with ASD benefit from visual supports and strategies which includes:

• Picture Exchange Communication Systems (PECS): Children are taught to select pictures of desired objects or activities as a way of requesting access to the object/activity. Examples of software include Proloquo on iPad.
• Visual schedules: Especially helpful for those who struggle with routines, a visual schedule helps the child know what to expect in their day.

Social skills training

Stories are a powerful and compelling way to teach many concepts. The Bible is an example of the use of stories to teach various concepts. Social stories (aka social scripts) can help individuals with ASD to function better by explaining various situations.

Examples might include:

• What to expect when I go to the dentist
• What does it mean when there are no more cookies
• How to introduce myself to someone
• And so on...

Sensory / Self-Regulation Interventions

Individuals with ASD tend to have sensory issues, motor issues, as well as self-regulation problems.

Professionals that can help include occupational therapy (OT) using: 

• Sensory assessment, and developing an appropriate sensory diet
  • Individuals with ASD tend to have various sensory sensitivities, e.g. sensitivity to sound, light, touch, etc.
  • An OT can assess a patient’s sensory profile using standardized tools, in order to develop an appropriate sensory diet, i.e. doing one’s best to ensure that the patient’s sensory environment is less overwhelming.
  • For example, if a patient with ASD is sensitive to sound, the OT can recommend accommodations/ modifications to the school to help the patient cope better, such as:
    • Instead of insisting the patient take a regular school bus to school, recommending that the patient be allowed to take special transportation, e.g. van
    • Accommodations for noisy school situations (such as noisy school assemblies, fire drills, etc.)
• Snoezelen room
  • A calming sensory environment that can often be found in schools or other organizations that work with children/youth on the spectrum.
• Safe and Sound Protocol (SSP)
  • Developed by Dr. Stephen Porges, this is a type of auditory desensitization to help children/youth tolerate frequencies of human interaction.

Management / Treatment: Behaviours that Challenge (BTC)

Terms

• Behaviours that Challenge (BTC)
• Challenging Behaviors (CB)

Etiology

• CB are largely due to environmental factors
• Causes of CB: gaining attention, escape from demands or undesired tasks, self-stimulation, seeking tangible items (food, toys), poor coping and social skills

Assess

• Method used to establish environmental causes: Functional Assessment
• Scatter plot: time of day that CB occurs across days/weeks
• Antecedent-behavior-consequence (ABC) charts
• Experimental functional analysis (EFA) research, time
• Questions about behavior function (QABF) reliab., valid

Behavioral Treatments

• Positive Behavioral Support (PBS): incorporate nonaversive behavioral interventions with increasing respect, improving interpersonal relationships and building personal competency

Differential Reinforcement (DR) :

• DRI (of incompatible behavior): reinforcing behavior that cannot be emitted simultaneously with the target behavior
• DRA (of alternate behavior): appropriate behavior are reinforced
• DRO (of other behavior) : reinforces specific time intervals during which the target behavior does not occur

Behavioral Treatments

• DR (solo or in combination) effective in reducing or eliminating CB: SIB, rumination, inappropriate vocalizations, aggression, pica, disruptive behaviors, hand mouthing, stripping, trichotillomania and property destruction
• Note if there is a skill deficit: need to teach an appropriate replacement behavior
• Anger management training or aggression with people with Mild-mod ID (capable of insight into their emotions and the connection to their target behaviors
• Relaxation training: use of the Snoezelen room (dark room with multiple form of sensory stimulation: music, light-up objects, vibrating objects, spinning lights). (careful not to reinforce CB)
• Restrictive interventions (restraints for ex): appropriate for crisis, dangerous situations

Management/Treatment: Address Stressors/Triggers

Stressors / triggers for problems:

• Transition/ phases: change of residence, new school, altered route to school/work, going into puberty, achieving majority.
• Interpersonal loss or rejection: Loss of parent, caregiver, friend, roommate; breakup of romantic attachment; being suspended from school.
• Environmental: excessive noise, reduced privacy, lack of satisfactory stimulation.
• Parenting/social support: lack of support, destabilizing visits, phone calls, letters, neglect, physical/sexual abuse.
• Illness or disability: chronic medical or psychiatric illness, acute illness, sensory deficits, seizures.
• Frustration: due to inability to communicate needs/wishes; due to lack of choice about residence, etc; because of realization of deficits

Strengths and Difficulties in Persons with ASD

Typical strengths of those with ASD

• Attention to details, memory (especially rote memory)
• Skilled in a particular area (have passion, conviction)
• Deep study resulting in encyclopedic knowledge on areas of interest
• Tendency to be logical, often very verbal (provide detailed descriptions, great if you are lost)
• Different way to look at things, ideas or concepts
• Visual processing (think in pictures or video)
• Communicate directly, loyal, honest, nonjudgmental listening

Difficulties

• Getting the “big” picture
• Uneven set of skills
• Difficulty to be motivated or interested to study areas not of interest
• Difficulty perceiving/understanding the emotional states of other
• Difficulty to perceive unwritten rules of social interactions.
• Sensory integration problems where input may register unevenly, difficulty screening out background noise
• Generalization of skills and concepts

Management/Treatment: Medications

What’s the evidence?

• There is no treatment for core symptoms of social and relationship problems in ASD.
• FDA-approved medications for “irritability in children and adolescents with autism” are:
  • Aripiprazole (Abilify) for age 6-17 y
    • Note that Aripiprazole theoretically has less metabolic effects than Risperidone
  • Risperidone (Risperdal) for age 5-16 y
• Periodic attempts to decrease or discontinue medication is prudent since most require long-term treatment.

Have non-medication strategies been tried without success?

• If so, consider medication options, along with behavioural interventions (Ip et al., 2019). Remember that medications do not address underlying issues. 

Symptom Targets for Medications

Findling R et al.: An update on pharmacotherapy for ASD in Child/Adolescents,Curr Opin Psychiatry 2015 28: 91-101.

Medication Dosage Charts 

Atypicals

SSRIs

ADHD medications

Alpha Adrenergics

* Clonidine is not listed here as it is not approved by Health Canada at the present time.

Management: Complementary and Alternative Medicine (CAM) Treatments

Does the family report using CAM?

• Discuss risks / benefits of CAM (Ip et al., 2019)
  • Risks include actual risks of the treatment, but also the family burden of paying for an ineffective treatment
• Does a family wish to use CAM?
  • Recommend that they use one at a time
  • Set a target symptom or goal, and monitor progress on that goal
    • E.g. if goal is “less anger”, then consider getting a baseline, e.g. “On a scale between 0 and 10, if 0 is no anger, and 10 is the worst, how much anger is there?”

A review by Brondino reviewed studies on various CAM treatments.

• Biologically based CAMs that have studies are:
  • Gluten/casein-free diet (Elder, 2006) -- inconclusive.
  • Omega 3 (Amminger, 2007; Bent, 2011) -- inconclusive.
  • Vitamin supplementation (vitB6, vitB12, and tetrahydrobiopterin) -- inconsistent results.
  • Hyperbaric Oxygen Therapy -- results promising, but not entirely consistent.
  • Elimination diet does not appear effective in treating ASD core symptoms in general, though individual patients who do have intolerance may benefit from elimination diet[111].
  • Omega 3 supplementation -- no evidence for recommendation in ASD: the only positive results come from a single open label trial [26].

Unfortunately,, there is no conclusive evidence supporting the efficacy of CAM therapies in ASD at this time (Brondino, 2015.)

Nonetheless, Brondino reported promising results for the following:

• Music therapy;
• Sensory integration therapy
• Acupuncture
• Massage

System Navigation in Ontario

Would you like a diagnostic assessment from an Autism Diagnostic Hub?

• In Ontario, there are five Autism Diagnostic Hubs where you can refer
  https://www.ontario.ca/page/autism-assessment-diagnosis#section-3

Have you seen a patient and confirmed a diagnosis of ASD? If so, then: 

• Write a letter confirming the diagnosis -- here is an example of such a letter
  https://docs.google.com/document/d/1eeZYWg-J3obVJ9SHelSjaHqNE8wEJKdVzdJ3w1C4h68/edit#heading=h.174yugffznrk
  
  
• Ask the family to apply to the Ontario Autism Program (OAP), using the letter you have written for confirmation of the diagnosis
  https://www.ontario.ca/page/ontario-autism-program

• Useful agencies
  • Autism Ontario

System Navigation in Ottawa

• Services and Supports
  • Private practice
  • CHEO Autism Program

References

Amminger G. P., Berger G. E., Schäfer M. R., Klier C., Friedrich M. H., Feucht M. Omega-3 fatty acids supplementation in children with autism: a double-blind randomized, placebo-controlled pilot study. Biological Psychiatry. 2007;61(4):551–553. doi: 10.1016/j.biopsych.2006.05.007.

Bent S., Bertoglio K., Ashwood P., Bostrom A., Hendren R. L. A pilot randomized controlled trial of omega-3 fatty acids for autism spectrum disorder. Journal of Autism and Developmental Disorders. 2011;41(5):545–554. doi: 10.1007/s10803-010-1078-8.

Brian J. et al. Stability and change in autism spectrum disorder diagnosis from age 3 to middle childhood in a high-risk sibling cohort. Autism Int. J. Res. Pract. 2016 Oct; 20(7): 888–892.

Daniels AM, Mandell DS. Explaining differences in age at autism spectrum disorder diagnosis: A critical review. Autism 2014;18(5):583–97.

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Kirkovski M, Enticott PG, Fitzgerald PB. A review of the role of female gender in autism spectrum disorders. J Autism Dev Disord 2013;43(11):2584–603.

Meng-Chuan L et al.: Prevalence of co-occurring mental health diagnoses in the autism population: a systematic review and meta-analysis. The Lancet Psychiatry. 2019 Oct 1, 6(10): P819-829.
https://doi.org/10.1016/S2215-...

Government of Canada. Autism Spectrum Disorder Among Children and Youth in Canada 2018: A Report of the National Autism Spectrum Disorder Surveillance System. 

https://www.canada.ca/en/publi... (Accessed Mar 7, 2020).

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4871151/

Review Articles

Autism spectrum disorder: advances in evidence-based practice 

Evdokia Anagnostou, Lonnie Zwaigenbaum, Peter Szatmari, Eric Fombonne, Bridget A. Fernandez, Marc Woodbury-Smith, Jessica Brian, Susan Bryson, Isabel M. Smith, Irene Drmic, Janet A. Buchanan, Wendy Roberts and Stephen W. Scherer

CMAJ April 15, 2014 186 (7) 509-519; DOI: https://doi.org/10.1503/cmaj.121756
http://www.cmaj.ca/content/186/7

Zwaigenbaum L, Brian JA, Ip A; Canadian Paediatric Society, Autism Spectrum Disorder Guidelines Task Force. Position statement. Early detection for autism spectrum disorder in young children. Paediatr Child Health 2019;24:424-32. https://www.cps.ca/en/documents/position/asd-early-detection (accessed October 31, 2019).

Brian JA, Zwaigenbaum L, Ip A; Canadian Paediatric Society, Autism Spectrum Disorder Guidelines Task Force. Position statement. Standards of diagnostic assessment for autism spectrum disorder. Paediatr Child Health 2019;24:444-51. https://www.cps.ca/en/documents/position/asd-diagnostic-assessment (accessed October 31, 2019).

Ip A, Zwaigenbaum L, Brian JA; Canadian Paediatric Society, Autism Spectrum Disorder Guidelines Task Force. Position statement. Post-diagnostic management and follow-up care for autism spectrum disorder. Paediatr Child Health 2019;24:461-8. https://www.cps.ca/en/documents/position/asd-post-diagnostic-management (accessed October 31, 2019).

Clinical Practice Guidelines

Volkmar F et al.: Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. J Am Acad Child Adolesc Psychiatry. 2014 Feb;53(2):237-57. doi: 10.1016/j.jaac.2013.10.013.
https://www.ncbi.nlm.nih.gov/pubmed/24472258

Addendum

Sample “To Whom It May Concern Letter” that confirms the child/youth’s diagnosis of ASD

DATE

To whom it may concern

This letter is to document that this youth meets criteria for a diagnosis of Autism Spectrum Disorder (ASD).

Date of Child’s Assessment: ____

This child meets DSM-5 Criteria which include the following:

Thank you for your support of this youth and family.

Feel free to contact me if you have any further questions,

YOUR NAME

YOUR ADDRESS

About this Document

Written by Dr's Michael Cheng, FRCP(C), Psychiatrist, CHEO, uOttawa; Dhiraj Aggarwal, Psychiatrist, CHEO, uOttawa.

Conflicts of Interest: No competing interests declared.

Disclaimer

This information is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a qualified expert or health professional. Always contact a qualified expert or health professional for further information in your specific situation or circumstance.

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