Prof. Dr. Vladimir Trajkovski presented this presentation on Erasmus International week at Laane Viru College in Rakvere, Estonia, March 12, 2019

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AUTISM SPECTRUM DISORDERS AUTISM SPECTRUM DISORDERS ––
COMPLEX SOCIAL PROBLEMCOMPLEX SOCIAL PROBLEM
Prof. Dr. Vladimir Trajkovski
Estonia, March 12, 2019

2. 2
DefinitionDefinition
Autism Spectrum Disorders are developmental
neurological conditions characterized by:
»Delays in social interaction
»Delays in the development of expressive and
receptive language
»Restrictive interests (dinosaurs, computers)
»Repetitive or stereotypical behaviors (rocking,
hand flapping, pacing, echolalia)
»May have difficulty with the acquisition of
motor skills.

3. 3
History
• Described in 1943 by Dr. Leo Kanner
– Study of 11 children
– Early infantile autism
• Characterized by social differences
• Dr. Hans Asperger
– Described milder form of disorder
– Asperger syndrome

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What We Know About Autism
• Autism is a biological disorder with multiple
etiologies.
• No single cause, no single cure.
• No biological marker.
• No evidence of parenting defects or emotionally
induced autism (e.g., the “refrigerator mother”).
• Currently, the view is that some factor(s) act
through one or more mechanism to produced a
final common pathway of CNS insult that results
in the behavioral syndrome of autism.

5. 5
StatisticsStatistics
• The prevalence of ASD is currently estimated to be 1 in
59 children in the USA (Baio et al., 2018).
• This figure represents a 151% increase since (CDC) first
began to monitor the prevalence of ASD in 2000
(Christensen et al., 2016).
• Increased prevalence can be explained, in part, by
changes in diagnostic criteria, diagnostic substitution,
improved awareness in the general public, and increased
recognition by clinicians.
• Boys are nearly 4-5 times more likely than girls to have
autism.
• There is no medical detection or cure for autism.
• Over 1.5 million people in the US.

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EpidemiologyEpidemiology

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77
Social impairments
Verbal and non-
verbal
communication
impairments
Repetitive and
stereotyped
patterns of
behaviours
Autism
Neurodevelopmental disorder characterised
by impairments in 3 domains:
General characteristicsGeneral characteristics (1)(1)
Onset before 3 years of age
75% of autistic people have intellectual disability
~30% of cases have epilepsy

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• Sibs affected in 3%: core syndrome
• Sibs affected in 10-20%: spectrum disorder
• Identical twins affected in 60-90%
• Non-identical twins affected in 0-10%
• First-degree relatives increased rates of affective
disorders (depression, bipolar), social phobia, obsessive-
compulsive phenomena, and ”broader phenotype
symptoms”.
• First-degree relatives also show possibly increased
rates of learning disorders including ID, dyslexia and SLI.
• A high heritability (90%) relative to diabetes, asthma,
schizophrenia, hypertension, etc.
General characteristicsGeneral characteristics (2)(2)

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EtiologyEtiology
Unknown
– Initially described as a disorder of
parenting/“refrigerator mothers”
Neurobiologic disorder
Gene/environment interaction
Role of other systems
– Immune
– Gastrointestinal (GI)

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•• Polygenic disorderPolygenic disorder
•• There are many theories as to theThere are many theories as to the cause of Autismcause of Autism suchsuch
asas…………
•• abnormal cerebral blood flow to areas of the brain,abnormal cerebral blood flow to areas of the brain,
•• high fevers,high fevers,
•• birth trauma,birth trauma,
•• brain injury,brain injury,
•• infections,infections,
•• reactions to vaccinesreactions to vaccines,,
•• lack of oxygen before, during or after delivery.lack of oxygen before, during or after delivery.
• chromosomal -fragile X syndrome, tuberous sclerosis
• genetic -increased risk in twins, sibs
• structural -anatomic, cellular.
Possible cPossible causes ofauses of aautismutism

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Risk FactorsRisk Factors
• Males
• Monozygotic twins
– 60% for DSM-IV autistic disorder
– 71% for ASD phenotype
– 92% broader phenotype of social and communication
deficits
• Siblings 3-20% (50-100x)
• Increasing maternal age
• Intrauterine infections
– rubella, CMV, herpes, HIV - probably additive brain
trauma rather than distinct ASD etiology.
• Neurotoxin exposure during pregnancy including
(FAS/ARND)

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Risk Factors / Family HistoryRisk Factors / Family History
Genetic loading or genetic etiologiesGenetic loading or genetic etiologies
Dimensional DisorderDimensional Disorder
•• Within families Within families –– broader autistic phenotypebroader autistic phenotype
–– More social difficultiesMore social difficulties
–– Higher cognitive, and executive function deficitsHigher cognitive, and executive function deficits
–– Increased stereotypic behaviorIncreased stereotypic behavior
–– Language and pragmatic disordersLanguage and pragmatic disorders
–– Social problemsSocial problems
–– Anxiety and OCDAnxiety and OCD
–– Affect disordersAffect disorders
–– Schizophrenia, anxiety, bipolar disorderSchizophrenia, anxiety, bipolar disorder
–– LDLD
–– Cognitive Adaptive DisorderCognitive Adaptive Disorder

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Genetic inheritance of ASD
• Susceptibility genes
• Genetic heterogeneity – very likely to be more than one
complex genetic form of autism
• Males are about 4 times more likely than females to develop
ASD.
• Serotonin transporter (5‐HT) gene, SLC6A4, is seen to be
disrupted with autistic brains.
• No genetic test yet – possible susceptibility test in following
years.
• Need environmental interaction.

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• Chromosomal and gene disorders
– Fragile‐X anomaly occurs in 3‐5% of children with
ASD.
– ASD individuals have a 5% elevated risk for
chromosomal anomalies.
– About 50% of children with tuberous sclerosis
have ASD.
Genetic Influences

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• 15‐20% of siblings of individuals with ASD
have the disorder
– Broader autism phenotype
• Concordance rates
– 70‐90% in identical twins
– Near 0% for fraternal twins
– Heritability of an underlying liability for ASD is
90%
Family and Twin Studies

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• Points to particular areas on many different
chromosomes as possible locations for genes
for ASD
– Causally implicated but not a direct cause
– ASD is likely to be a complex genetic disorder
– Expression of ASD genes may be influenced by
environmental factors occurring primarily during
fetal brain development
– Epigenetic dysregulation may be a factor.
Molecular Genetics

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The chances of recurrence
• Parents more likely to exhibit mild autistic phenotypes
• 15% of fathers of children with ASD have Asperger Syndrome
(often diagnosed later)
• Fathers and grandfathers of children with autism are twice as
likely to be engineers
• Brothers of a child with autism have a 7% risk for autism and
an additional risk of 7% for milder autistic spectrum
symptoms
• Sisters have a 1% risk, risk for milder symptoms is unknown.

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Studies SuggestStudies Suggest
Larger Environmental RoleLarger Environmental Role
Previous studies suggested strong genetic rolePrevious studies suggested strong genetic role
One study looked at 192 twin pairsOne study looked at 192 twin pairs
–– 54 identical, 138 fraternal54 identical, 138 fraternal
–– Identical twins with 60Identical twins with 60––70% chance of dual70% chance of dual
diagnosesdiagnoses
–– Fraternal twins with 20Fraternal twins with 20––30% chance of dual30% chance of dual
diagnosesdiagnoses
TwoTwo--fold increase risk for ASD when mother on afold increase risk for ASD when mother on a
selective serotonin reuptake inhibitor (SSRI)selective serotonin reuptake inhibitor (SSRI)
Hallmayer J, Cleveland B, Torres A, et al. Genetic heritability and shared environmental factors among twins with autism. Arch
Gen Psychiatry. Online July 2011; Croen LA, Grether JK, Yoshida CK, et al. Antidepressant use during pregnancy and childhood
autism spectrum disorders. Arch Gen Psychiatry. Online July 2011.

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Some Genetic Disorders associatedSome Genetic Disorders associated
with Autismwith Autism
•• Fragile X Fragile X ~~ 5%5%
•• Tuberous Sclerosis Tuberous Sclerosis ~25%~25%
•• Down syndrome Down syndrome ~10%~10%
•• AngelmanAngelman syndrome syndrome ~40%~40%
•• PraderPrader‐‐WilliWilli syndromesyndrome ~25%~25%
•• San San FilippoFilippo syndromesyndrome ~90%~90%
•• SmithSmith‐‐MagenisMagenis (del 17p11.2) (del 17p11.2) ~90%~90%
•• VCF/ VCF/ DiGeorgeDiGeorge (del 22q11)(del 22q11) ~25%~25%

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2020
ChromosomalChromosomal ““Hot SpotsHot Spots”” in ASDin ASD
Most commonMost common OthersOthers
15q1115q11‐‐1313 XpXp
7q227q22‐‐3131 18q18q
22q1122q11 17p17p
22q1322q13 17q17q
2q372q37 16p16p
Shaefer and Mendelson, Genet Med 10 (1), 4-12, (2008)

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2121
PossiblePossible aautismutism ssusceptibilityusceptibility
ggenesenes
GENEGENE
•• Immune (HLA)Immune (HLA)
•• Glutamate receptor (GluR6)Glutamate receptor (GluR6)
•• HomeoboxHomeobox (HOXA1)(HOXA1)
•• ReelinReelin (RELN)(RELN)
•• Speech1 (FOXP2) & METSpeech1 (FOXP2) & MET
•• WNT2 & EN2WNT2 & EN2
•• Serotonin Receptor (5Serotonin Receptor (5‐‐HTRHTR‐‐7)7)
•• GABA Receptors (GABRB3)GABA Receptors (GABRB3)
•• UbiquitinUbiquitin‐‐P P LigaseLigase (UBE3A/E6(UBE3A/E6‐‐AP)AP)
•• Serotonin Transporter (5Serotonin Transporter (5‐‐HTR7)HTR7)
•• NeuroliginsNeuroligins (NLGN3 & 4)(NLGN3 & 4)
LOCATIONLOCATION
6p6p
6q6q
7p7p
7q227q22
7q317q31
7q327q32
10q10q
15q15q
15q15q
17q17q
XX

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Characteristics of Autism Characteristics of Autism (1)(1)
•• Social interaction Social interaction
differencesdifferences
•• Communication Communication
differencesdifferences
•• Unusual behaviors / Unusual behaviors /
interestsinterests
•• Sensory DifferencesSensory Differences
•• Need for structure, Need for structure,
rules, & predictability rules, & predictability
•• Motor differencesMotor differences
•• Attention differencesAttention differences
•• Cognitive style Cognitive style
differencesdifferences

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Characteristics of Autism (2)(2)
• Persons with autism may exhibit some of the
following traits.
– Insistence on sameness; resistance to change
– Difficulty in expressing needs; uses gestures or
pointing instead of words
– Repeating words or phrases in place of normal,
responsive language
– Laughing, crying, showing distress for reasons not
apparent to others
– Prefers to be alone; aloof manner
– Tantrums
– Difficulty in mixing with others
– May not want to cuddle or be cuddled
– Little or no eye contact

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– Unresponsive to normal teaching methods
– Sustained odd play
– Spins objects
– Inappropriate attachments to objects
– Apparent over‐sensitivity or under‐sensitivity to
pain
– No real fears of danger
– Noticeable physical over‐activity or extreme
under‐activity
– Uneven gross/fine motor skills
– Not responsive to verbal cues; acts as if deaf
although hearing tests in normal range.
Characteristics of Autism (3)(3)

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Characteristics lead to:Characteristics lead to:
• Resistance to environmental change.
• Resistance to changes in routine.
• Unusual response to sensory stimuli,
hypersensitive or hyposensitive.
• Transition difficulty from one activity to the next.
• Few friendships with peers.
• Difficulty taking turns.
• Takes statement literally.

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Language development
• delayed and deviant
• peculiar use of sounds and words
• Echolalia
• Pronominal reversal - use 'i' where 'you' is
meant and vice-versa
– e.g. 'do you want a drink' instead of 'i want a drink'
• denial of personal identity?
• or just related to echoing
• Use of '-ing'
– 'daddy piping', 'boy bubbling' (boy blowing bubbles)
- 9 yr old autistic girl (Wing, 1976).

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Development of social
communication
• Within the first and second year of life
children develop:
– Sense of self
– Capacity to judge form evidence
– Ability to integrate ideas from past experience
– Ability to appreciate psychological state of
another person.

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Social communication
• Teasing
• Helping
• Comforting

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Development of social
communication
During the first and second year of life
children
– Show interest in other people
– Show curiosity about feelings and thoughts.

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Social Communication requires:
• Joint attention
• Effective reciprocity or emotional sharing
• The ability to realize that another person
has thoughts and ideas similar to you.

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Theory of Mind
• Understanding the desires of another
• Understanding the emotional state of
another person
• Having the ability to figure out what a
person’s intentions are
• Knowledge that what you are thinking can be
conveyed to others through nonverbal
means.

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Intellectual development
• poor on verbal ability
• may perform above average on memory or
spatial tasks
• may be talented in music or drawing
• 1/4 have IQ>70.

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Children with autismChildren with autism
•• DonDon’’t have the basic presupposition that they t have the basic presupposition that they
are like other people and others are like themare like other people and others are like them
•• Trouble imitating facial expressionsTrouble imitating facial expressions
•• DonDon’’t point or follow objectst point or follow objects
•• DonDon’’t understand false beliefs.t understand false beliefs.

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ImitationImitation

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Fit Faces with EmotionsFit Faces with Emotions
Social CognitionSocial Cognition

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Joint AttentionJoint Attention

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If you know one person with autism, you
don’t know them all
•• They may have different combinations of They may have different combinations of
characteristics.characteristics.
•• They may have the same characteristics, They may have the same characteristics,
but in different degrees.but in different degrees.

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Neuropathology
What developmental processes might lead to a larger brain?
-Increased neurogenesis
-Increased gliogenesis, myelination
-Increased synaptogenesis
-Disturbed migration
-Decreased apoptosis
-Decreased dendritic pruning

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Other brain regions
Cerebellum
-Decreased Purkinje cell number (Kemper and Bauman)
-Decreased Purkinje cell size (Fatemi)
-Decreased neuron size in deep cerebellar nuclei in older, but not young
autistic subjects
Cerebral cortex
-Course, poorly laminated cingulate cortex in 5/6 subjects (Bauman)
-No difference in neuron counts in frontal cortex (Bailey)
But other alterations were visible
-thickened cortices
-high neuronal densities
-irregular laminar patterns
-poor gray-white matter boundries
-Changes in laminar patterns could suggest defects in migration

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Cortical minicolumns in cortical area 4
lamina III in autism vs control brain
Normal
control brain
ASD brain
Casanova
2006

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Neurotransmitters
Alterations in many neurotransmitter systems in autism
-Glutamate
-GABA
-Serotonin
-Catecholamines (norepinephrine, dopamine)
-Neuropeptides

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Biological impairments in autismBiological impairments in autism
•• Chronic diarrhea/constipationChronic diarrhea/constipation
•• Yeast/bacterial overgrowth of Yeast/bacterial overgrowth of
bowelsbowels
•• Inability to clear heavy metalsInability to clear heavy metals
•• Impaired Impaired sulfationsulfation
•• Leaky gut syndromeLeaky gut syndrome
•• Imbalance immune systemImbalance immune system
•• Mineral deficienciesMineral deficiencies‐‐zinc, zinc,
magnesium, seleniummagnesium, selenium
•• MalabsorptionMalabsorption/malnutrition/malnutrition
•• Impaired neuronal Impaired neuronal
developmentdevelopment
•• Disrupted Disrupted
hippocampus/hippocampus/amygdalaamygdala
•• Gluten/casein sensitivityGluten/casein sensitivity
•• Impaired Impaired secretinsecretin signalingsignaling
•• Impaired detoxificationImpaired detoxification
•• Impaired Impaired antioxidationantioxidation
•• OmegaOmega‐‐3 fatty acid 3 fatty acid
deficiencydeficiency
•• Significant food allergiesSignificant food allergies
•• Impaired pancreatic Impaired pancreatic
functionfunction
•• Frequent viral and bacterial Frequent viral and bacterial
infectionsinfections
•• Vitamin deficienciesVitamin deficiencies
•• AutoimmunityAutoimmunity
•• Neurotransmitter Neurotransmitter
imbalance/dysfunctionimbalance/dysfunction
•• Sensitivity to vaccinationsSensitivity to vaccinations
•• SeizuresSeizures

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Metabolic conditions in association withMetabolic conditions in association with
autism phenotypeautism phenotype
1.1. Disorders of purine metabolismDisorders of purine metabolism
•• Adenylosuccinate lyase (ADSL) deficiency Adenylosuccinate lyase (ADSL) deficiency
•• Phosphoribosylpyroposhate (PRPP) synthetase superactivityPhosphoribosylpyroposhate (PRPP) synthetase superactivity
2.2. Disorders of pDisorders of pyrimidineyrimidine metabolismmetabolism
•• Dihydropyriminidase (DPD) deficiencyDihydropyriminidase (DPD) deficiency
•• Cytosolic 5Cytosolic 5’’ nucleotidase (NT) superactivitynucleotidase (NT) superactivity
3.3. Unknown sulfatation defectUnknown sulfatation defect
•• UrinUrinee SS‐‐sulfocsulfocyysteinstein
4.4. Disorders of GABA metabolismDisorders of GABA metabolism
•• Succinic semialdehyde dehydrogenase (SSADH) deficiencySuccinic semialdehyde dehydrogenase (SSADH) deficiency
5.5. Disorders of Disorders of creatinecreatine metabolismmetabolism
•• Guanidinoacetate methyltransferase (GAMT) deficiencyGuanidinoacetate methyltransferase (GAMT) deficiency
•• XX‐‐linked creatine transporter defectlinked creatine transporter defect
6.6. Conditions that infer susceptibility to autism phenotypeConditions that infer susceptibility to autism phenotype
•• MonoaminMonoamine e ooxxsidasidasese A (MOA) A (MOA) andand GlGlyyooxxilailasese A (GLYA)A (GLYA)

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Common Psychiatric
Comorbidities seen with ASD
• ADHD
• Aggression
• Self injurious behaviors 24 – 43%,
• Anxiety Disorders
• Depressive Disorders 9 – 44%
• Obsessive Compulsive Behaviors >40%
• Sleep disturbances
• Sexualized behaviors
• Psychosis
• Tics

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Learning Disabilities
• Some children with autism have
diagnosable learning disabilities such as
dyslexia, while others have unusual abilities
such as hyperlexia (the ability to read at an
extremely young age).
• Some have a very tough time gaining basic
math skills; others are mathematical
"savants,“ achieving far beyond their grade
level.

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ADHD symptoms in ASD
Inattention
• difficulty in shifting their attention from one task
to another
• Focused on object of interest
Over activity
• Anxiety
• stereotypic behavior
• agitated depression or even mania
Aggression:
• sometimes incorrectly attributed to hyperactivity

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ADHD symptoms in ASD
In early childhood
• hyperactivity
• stereotyped behaviors
• irritability and temper tantrums
Later
• aggressiveness/self injurious behavior
• stereotypic behaviors
In adolescence and adulthood:
• esp. in higher functioning individuals depression or OCD
may develop and interfere with functioning.

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Serious Emotional Disturbances
• It can also be tough to distinguish
between mood disorders and bipolar
disorder, schizophrenia, and autistic
behaviors.
• It is not unusual for a person with autism
to also have a mental health diagnosis of
bipolar disorder, clinical depression,
obsessive compulsive disorder or
schizophrenia.

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Behavioral Issues
• Common reason for presentation to
mental health services
• 20% with severe intellectual disability
have some form of severe behavioral
disorder
• Problem behaviors: self harm/aggression
to others
• Significantly disabling/ not responding to
other measures.

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Sleep problems
• The cause of sleep problems in autistic
children is unknown.
• Social cues may be important in addition to
the light dark cycle.
• A perseveration of thoughts and anxieties
at bedtime or during night awakenings may
be important.
• There is some evidence that melatonin
levels are lower in autistic children.

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Epilepsy
• Most common medical disorder is intellectual disability.
• 20% of autistic children between the ages of 1 and 18
years suffer some kind of epileptic seizures.
(Munoz‐Yuna et al., 2003)
Incidence
• 8 – 18% of mild cases
• 30 – 36% of severe cases
• 25% of all children with intellectual disability and epilepsy
have autism.
• In more severe cases, stereotypes and involuntary
movements may be difficult to distinguish from epilepsy.

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Epilepsy
• Combination medication regimens address
both seizures and behavioral emotional
difficulties.
• Anticonvulsants suppress seizures,
aggressive behavior & impulsivity in
children with PDD.
• Initiated as monotherapy often not
sufficient.
• Combination of neuroleptic &
anticonvulsant preparations needed for
better symptom control.

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Autism assessment‐testing
• speech, language, communication
• developmental
• genetics
• hearing
• cognitive, psychoeducational
• neuropsychological
• psychiatric

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Assessment for ASDAssessment for ASD
•• Should include direct assessment of cognitive Should include direct assessment of cognitive
skills/ development, language, adaptive skills/ development, language, adaptive
functioning, and behavior whenever possible.functioning, and behavior whenever possible.
•• Diagnosis should be based on parent Diagnosis should be based on parent
interview, direct observation (Autism interview, direct observation (Autism
Diagnostic Observation Schedule) and, if Diagnostic Observation Schedule) and, if
possible, teacher observations.possible, teacher observations.

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Autism assessment‐instruments (1)
•parent report –
• Modified Checklist for Autism in Toddlers [M‐CHAT] ‐
screening
• Childhood Autism Rating Scale [CARS]
• Gilliam Autism Rating Scale [GARS‐2]
• Social Communication Questionnaire [SCQ]
•parent history –
• Autism Diagnostic Interview [ADI‐R]

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Autism assessment‐instruments (2)
•behavioral data –
• Functional Analysis of Behavior, menu of
reinforcers/ motivators
•observation/ interview –
• Autism Diagnostic Observation Schedule
[ADOS] modules 1‐4
Lord et al., 2000

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DiagnosisDiagnosis
•• Diagnosis in young childrenDiagnosis in young children
–– Autism can be reliably diagnosed as young as 2 Autism can be reliably diagnosed as young as 2
yearsyears
–– More variability with children with early diagnoses More variability with children with early diagnoses
of PDD NOSof PDD NOS
–– Repetitive behaviors are less common in both Repetitive behaviors are less common in both
very young children and highvery young children and high‐‐functioning functioning
adolescents and adultsadolescents and adults

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DSMDSM‐‐5 Criteria: Social Communication5 Criteria: Social Communication
Persistent deficits in social communication and social
interaction across contexts, not accounted for by
general developmental delays, manifested by all of
the following:
– Deficits in social‐emotional reciprocity
– Deficits in nonverbal communicative behaviors
– Deficits in developing and maintaining relationships
appropriate to the developmental level.

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DSMDSM‐‐5 Criteria:5 Criteria:
Restricted/Repetitive BehaviorsRestricted/Repetitive Behaviors
Restricted, repetitive patterns of behavior, interests,
or activities as manifested by at least 2 of the
following:
– Stereotyped or repetitive speech, motor movements, or
use of objects
– Excessive adherence to routines
– Highly restricted, fixated interests that are abnormal in
intensity or focus
– Hyper‐ or hypo‐reactivity to sensory input or unusual
sensory interests

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Adolescents
• Continued difficulty with social and pragmatic
language
• Some seek to develop social skills
• Refinement of special interests
• Increased anxiety, some have deterioration
but regain later.

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Adults
• Vastly differing outcomes
• 1/3 able to care for self, achieve some
independence, have some friends, live
independently or with support, work
• Nearly 70% have fair to good language
• Marriage is rare.

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Adults continued
• About 45% have poor outcome
• Dependent on family or living in residential
setting
• Major seizures, behavioral problems,
continued dependency
• Increased rates of depression and anxiety

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Intervention
• Early identification
• Speech‐Language Therapy
• Occupational Therapy
• Physical Therapy
• Interaction with same aged normal peers.

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Intervention
• Development of a communication system
• Picture Exchange Communication System (PECS)
• Visual schedules
• Visual cues
• Social skills training
• Social stories
• Play groups

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Intervention
• Analysis of behavior for appropriate behavioral
intervention (e.g., ABA)
– Intensive behavioral approach
– Goal is to teach children how to learn by focusing on
building blocks of development
• Developmental, individual‐difference, relationship‐
based (DIR) / Floortime
– Use of play to build relatedness (e.g., warmth, pleasure,
meaningful communication, creativity)

67. 67

68. 68
Educational Intervention (1)
• Teachers need specific training in the education of
children with Autism
• Intensive Speech‐Language therapy
– Collaboration between therapist, parents, and teacher is
critical
• Promote behaviors with positive behavioral
strategies
• Use of visual and manipulative educational
materials.

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Educational Intervention (2)
• Visual communication aids
– Visual schedule, chart of daily activities
• Social skills training
– Social stories
– Positive reinforcement for positive behaviors.

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Key Issues for Intervention
• Early intervention is critical
• Communication
• Social Skills Development
• Gradual increase in prosocial behaviors
• Development of self & awareness of others.

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Medication
• There are no medications that “cure” Autism.
• Medication should be used for specific
symptoms.

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Specific symptoms for
medication
• Anxiety
• Obsessive‐Compulsive behaviors
• Depression
• Self abusive behaviors
• Aggression
• Sleep deprivation

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Medications Used
• Selective Sertonin Reuptake Inhibitors (SSRI)
• Prozac (Fluoxetine)
• Zoloft (Sertraline)
• Celexa (Citalopram)
• Neuroleptics
• Risperdal (Risperidone)
• Zyprexa (Olanzapine)
• Geodon (Ziprasidone)
• Abilify (Aripiprazole)

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Medications Used Continued
• Alpha adrenergic agonists
• Clonidine
• Guanfacine
• Mood stabilizers
• Depakote (Valproic acid)
• Tegretol (Carbamazepine)
• Antiopiod
• Naltrexone

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Complementary and Alternative Therapies
• Gluten‐Casein Free Diet
• Based on toxicologic opioid hypothesis
• Nutritional Supplements
• Based on hypothesis that minerals and/or vitamins improve
“autistic behaviors”
• Immune globulin therapy
• Based on assumption Autism is an autoimmune
abnormality
• Secretin
• Intravenous hormone that stimulates pancreas and liver to
manage “autistic behaviors”
• Chelation
• Based on hypothesis that mercury exposure is cause of
Autism

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Prognosis and Course (1)
• Prognosis is highly dependent upon the level of
functioning
• By school age, autistic children can be divided into
three groups:
1. Low Functioning
*Verbal and non‐verbal IQ < 70
(about 50% of affected children)
2. Mid‐Functioning
*Non‐verbal IQ > 70 but verbal IQ < 70
(about 25% of affected children)
3. High Functioning
*Verbal and non‐verbal IQ > 70
(about 25% of affected children)

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Prognosis and Course (2)
• Some children with autism show improvement in
adolescence which is related to good adult outcome:
– Activity level usually decreases
– Behavior becomes more manageable
– Self‐help skills improve
– Communication continues to develop
– IQ usually remains stable
– Usually become more social
• A large percentage (10 – 25%?) of children will develop
seizures (all types) as they age.

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Prognosis and Course (3)
• Anxiety and depression are the most commonly
co‐occurring psychiatric disorders in adults with
autism
• Factors known to be related to outcome:
– IQ by age 5 – 6 years
– Communication skills by age 5 years
– Early educational intervention
• Factors not known to be related to outcome:
– Family history of neuropsychiatric disorders
– Adequacy of parenting
– Family atmosphere.

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Conclusions Conclusions (1)(1)
•• Autism is a complex neurodevelopment disorder which is Autism is a complex neurodevelopment disorder which is
serious social, medical and mental health problem.serious social, medical and mental health problem.
•• Autism is characterized by: social deficits; communication Autism is characterized by: social deficits; communication
deficits; repetitive behaviorsdeficits; repetitive behaviors
•• Evidence for autism as executive disorder at cognitive & Evidence for autism as executive disorder at cognitive &
biological levels.biological levels.
•• Genetic basis plus environmental events.Genetic basis plus environmental events.
•• Autism has epidemic prevalence.Autism has epidemic prevalence.
•• ComorbidComorbid disorders are very frequent in ASD.disorders are very frequent in ASD.
•• Authorities who create social policy must establish services Authorities who create social policy must establish services
and should take better social care for them.and should take better social care for them.

80. 80
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Conclusions (2)(2)
Currently, diagnosable medical conditions, cytogeneticCurrently, diagnosable medical conditions, cytogenetic
abnormalities, and singleabnormalities, and single--gene defects together accountgene defects together account
around 10%around 10%--15% of cases.15% of cases.
A wealth of linkage, and cytogenetic and candidate gene
studies have implicated several regions of the genome that
may harbor autism susceptibility genes.
Identifying and mapping homologous genes in different
species will also aid in the prediction of likely gene
function.
There is still no prenatal diagnosis of autism.
Parents who have one child with idiopathic autism have aParents who have one child with idiopathic autism have a
7%7% to have another child with autism.to have another child with autism.