ASD & Tic Disorders
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1 in 68 children will have ASD; ASD reported in all racial, ethnic and SES backgrounds; the risk is much higher in identical twins; the risk is five-fold higher in males; no genetic biomarkers found; half of people with ASD will experience intellectual disability
Early intervention (i.e. before the age of 5 years) are the most effective
ASD was first described in 1943 and not added and differentiated from psychosis until 1980
PCPs are critical to improving recognition; most children are not diagnosed until around age 4. Higher functioning children are not diagnosed until school age around 7 years
Differences in frontal brain regions, limbic system anomalies, increased brain size, differences in white matter and increased serotonin impact the presentation of ASD
ASD is more common than cancer, diabetes or Down’s syndrome, but children with ASD are less likely receive primary care consistent with the American Academy of Pediatrics medical home model
IACAPAP & LECTURE
Many children with ASD experience sensory processing difficulties including: touch, movement, body positioning, sight/vision, sound and smell/taste
Most parents realize something unusual about their child before the age of one. Many parents feel that their providers do not take their concerns seriously which is concerning because early intervention is the most effective intervention available
Delay in reaching social skill milestones, language impairment, repetitive behaviors and restricted interests
Screening and surveillance should happen at every well child checkup
Genetic/Medical rule outs: dysmorphology, staring spells, infections (encephalopathy or meningitis), endocrine (hypothyroidism), TBI, family history, G-banded karyotype, Fragile X, chromosomal microarray. Roughly 33% of children will come up positive and require follow up with a geneticist
IACAPAP & LECTURE
Address core deficits, incorporate parent education, specialized programs for children with limited or no language
Applied Behavioral Analysis, Early Start Denver Model, Social Skills Programs. There is little research supporting the efficacy these programs and they require substantial patient and family involvement for best results
The multidisciplinary team can be large and the involvement of each specialist should be guided by the child’s symptomatology
Traditional speech and language interventions, behaviorally based strategies, augmentative communication strategies for non-verbal group, visual supports
No pharmacologic treatment for ASD; limited research on ASD contributes to the lack of pharmacological treatment
Case by case basis, target symptoms, treating comorbid conditions. The goal is to facilitate remaining in the least restrictive environment with the greatest independence
50% response rate to stimulants
Marginal evidence from RCTs, consider benefits vs risks of different interventions, SSRIs may be helpful in extreme cases in which children are highly obsessive and rigid with their routine
Aggression, severe tantrums and self-injurious behaviors. Risperidone and aripiprazole are the only FDA approved medications for management of the maladaptive behaviors associated with ASD. Lower doses appear to be more effective in children with ASD than is considered normal for children without ASD
Adverse effects: weight gain, increased appetite, fatigue, drowsiness, dizziness, drooling, tremor, constipation. Relapse rates high without medication. Monitor: weight at each visit, CBC, CMP, LFTs and lipid panel on initiation, 3 months after starting, and at least every 6-12 months once stable. TSH as indicated by clinical profile. Prolactin if symptomatic with risperidone
Many families of children with ASD use some form of complimentary medicine to help manage symptoms. There is little supporting evidence for the efficacy of complementary evidence, but no evidence suggesting harmful side effects. Common treatments include: gluten free diets, omega-3 fatty acids, probiotics
Utilize available consultation such as Psychiatric Access Line for Kids (OPAL-K), consider simultaneous referral to a specialist. Start medication doses lower than normal and titrate slowly. Be clear about what symptoms are being targeted.
Children with ASD take longer to fall asleep, wake up more throughout the night and have total less sleep time than their peers without ASD. Supplementation with melatonin can help with sleep in children with ASD
Offer support for the number of emotions the family will experience after an ASD diagnosis. Encourage connection with other families who have experience with ASD. Refer parents and or siblings for treatment as indicated. Celebrate the child with the family. Treatment plan together.
IACAPAP & DSM
Frequency is lower among African Americans and Hispanic Americans, which may be related to differences in access to care
ADHD and obsessive compulsive and related disorders are common co-occurring disorders
Prevalence is estimated to be between 3-8 children per 1,000 in school age children. Males are more commonly affected than females, with the ratio varying from 2:1 to 4:1
Psychoeducation and psychotherapy (e.g. habit reversal training, exposure and response training, massed practice, relaxation training, contingency management and family therapy are effective interventions.
Sudden rapid, recurrent nonrhythmic motor movement or vocalization; onset is before age of 18 years.
In extreme cases where medication is indicated, dosage should start low and slow. Tics are not expected to be completely eliminated by medication; the aim is to decrease the severity of the symptoms with the least risk for adverse side effects. There is some evidence of the efficacy of medications such as haloperidol (in Europe), tiapride, risperidone and aripiprazole for the treatment of the disorder