Autism Spectrum Disorder (ASD) is a complicated condition that is rapidly increasing due to pesticide and other chemical exposures during pregnancy and early in life. This article provides a brief introduction to it diagnosis and treatment for families, primary care providers and mental health students. You can watch the video or read an abridged version of the talk below.
1. What is Autism Spectrum Disorder (ASD)
ASD is a complex neurodevelopmental disorder characterized by difficulties in social interaction, verbal and non-verbal communication, obsessive interests, sensory sensitivity, rigid/repetitive behaviors and severe/prolonged tantrums.
ASD is new to the DSM 5, which came out in 2013 and replaced 4 separate disorders in the DSM IV by combining the symptoms of all 4 disorders:
– Autism Disorder
– Asperger’s Disorder
– Pervasive Development Disorder Not Otherwise Specified (NOS)
– Childhood Disintegrative Disorder
2. What is the History of Autism
Autism like behavior was described as early as the 1700’s in reference to “feral” children. In the early 1900’s it was associated with schizophrenia and was also falsely attributed to “refrigerator mothers”. In the 1960’s, Autism and childhood schizophrenia were separated and established as different disorders.
Asperger’s Disorder was named for Hans Asperger who described the condition in the late 1930’s. It was officially included in the DSM IV in 1994 and in ICD 9 in 1992, but it was previously described by Grunya Sukhareva, a Russian psychiatrist, in 1925. Asperger’s Disorder correlates with what is now unofficially call “High Functioning ASD” and refers to ASD where the IQ is normal to highly elevated. Bill Gates, the founder of Microsoft has publicly admitted to having Asperger’s Disorder (High Functioning ASD).
3. How are High Functioning and Low Functioning ASD Similar?
Similarities between high and low functioning ASD include: difficulties with transitioning or switching activities; tactile defensiveness and intolerance of temp/pain/hunger; ridged adherence to systems/patterns/routines; difficulty adapting to new/different environments, explosive aggression/prolonged tantrums when triggered; repetitive behavior – rocking, head banging and hand flapping; treatment is very similar, especially with psych meds.
4. How are High Functioning and Low Functioning ASD Different?
Differences between low and high functioning ASD include lack of eye contact in low functioning where as high functioning often has excessive eye contact. Speech is delayed in low functioning, but is normal to elevated in high functioning. Visio-spacial skills are preserved in low functioning, but is often delayed or impaired in high functioning. Low functioning individual are often obsessed with objects, especially things that spin or flip while high functioning individuals tend to be obsessed with topics and activities (like computer programing with Bill Gates).
5. How Common is ASD and Why Has It Increased So Much?
Recent studies suggest up to 2% of males and up to 0.5% of females in developed countries have ASD (much lower in 3rd world countries). ASD rates have increased 1000% over the last 40 years with almost all of the grow occurring in high functioning ASD. Recent research has linked the increase to pesticide levels in mothers prior to birth, not just due to improved diagnosis and screening. That said, ASD rates are likely to continue to grow due to improved screening and diagnosis in females where the symptoms are more subtle.
6. What Causes ASD?
The top two causes are genetics (inherited and due to genetic mutations) and being male. Other causes include early brain damage from certain viral infections during pregnancy, inadequate Folate during pregnancy, being deprived of oxygen in the womb or a birth and even epilepsy. Immune system dysfunction, especially in the brain likely plays a role, but this very complicated and we are just beginning to understand.
Prenatal pollution and pesticide exposure in moms prior to and during pregnancy explain much of the recent growth in ASD. Vaccines have been ABSOLUTELY DISPROVEN as a cause of ASD. The researcher that “found” the connection falsified the data and is currently in prison for fraud related to selling a medicine he invented to “protect” kids who were vaccinated.
7. How is ASD Diagnosed?
ASD is diagnosed with specialized neuropsycholigical testing by certified agency/tester. ASD is screened for with the M-CHAT-R starting a 18 to 24 months of age. Local and state Autism societies often have the best list of local agencies that do ASD testing.
8. Which Disorders Can Mimic ASD?
- Severe shyness and selective mutism (social avoidance with being non-verbal).
- Early deprivation leads to Inhibited Reactive Attachment Disorder (avoidance of touch and social interaction).
- Developmental delay with low IQ (rocking and head banging).
- ADHD with Oppositional Defiance Disorder can cause poor social skills and severe aggression.
- Bipolar Disorder and PTSD can both produce explosive tantrums that mimic ASD tantrums.
- Pediatric Autoimmune Neuropsychiatric Syndrome (AKA PANDAS) causes severe tics and sudden onset OCD.
- Autoimmune encephalitis (like Brain on Fire ) can cause a sudden loss of language and repetitive movements.
9. How Do You Treat ASD?
Early diagnosis is critical in ASD since early behavioral therapy can alter neurological development and the improve outcome. Applied Behavior Analysis (ABA) and Early Start Denver Model are the two best validated behavioral treatments. Treating associated medical problems, especially gastro-intestine issues; ear, nose and throat disorders and epilepsy also help. Social skills training is also critical. Medications have a limited role and are mostly used for aggression, anxiety, depression and ADHD symptoms.
10. What Medications are Used in ASD?
Risperidone (Risperdal) and aripiprazole (Abilify) are FDA approved for irritability and aggression in ASD down to 5 and 6 years old respectively. Risperidone seems to work a little better than aripiprazole, but it causes more severe weight gain and can cause boys to grow breasts (gynecomastia).
Alpha 2 agonist and beta blockers are often used for explosive aggression, which can decreased the dose of risperidone or aripiprazole needed. Certain antidepressants (SSRI and SNRI’s) can be helpful for anxiety and depression, especially in high functioning ASD.
Standard ADHD meds are used for ADHD symptoms, but ASD kids seem to do better with Adderall than with methylphenidate products (Ritalin, Concerta, Metadate). Sleep is often a problem so typical pediatric sleep medications are used as necessary (melatonin, Benedryl, clonidine, etc).
11. How are Medications Used in ASD?
Medications don’t help that much, 20 to 30% at best. ABA is the primary treatment and proves 70 to 80% of the benefit. Most outbursts and tantrums are due to changes in the routine or in their environment. It can take up to 4 weeks for a child with ASD to adapt to a new caregiver, a new teacher or a new classroom.
The key is to avoid or work around the triggers that cause the outbursts. Given the limited benefits of medication, it is important to always ask if the benefits are worth the side effects. It is also important to watch for seizures, anorexia, mania and psychosis in children and teens with ASD.
Always remember that ASD kids do much better as adults so don’t lose hope. When starting medication is is important to start at a low dose and to go up slowly. Unusual reactions to medications are more common in ASD kids.
12. What Psychiatric and Medical Disorders Commonly Co-Occur with ASD?
ADHD frequently c0-occurs in high functioning ASD, possibly 80% of the time. ADHD is less common in low functioning ASD, but still seems to occur 30 to 40% of the time. Severe anxiety and Obsessive Compulsive Disorder are also extremely common in ASD. Anorexia Nervosa is also quite common in ASD, especially high functioning ASD.
Teens and young adults with high functioning ASD are at high risk of become depressed due to the social rejection and bullying they often face. Bipolar Disorder can occur with ASD, but it mostly happens when there is also epilepsy or brain damage.
Interestingly, bisexuality, homosexuality and transsexuality are more common in high functioning ASD than in the general population. It is also possible to have ASD with a genetic or neuro-developmental syndrome such as Downs, Fragile X or Fetal Alcohol Syndromes.
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