April is Autism Awareness Month, a perfect time to review what you need to know about Autism as a pediatrician, and how to treat your patients with Autism. Brush up on the must-know information in the Autism Spectrum Disorder section of the Behavioral Medicine & Substance Abuse book pulled from our Pediatrics Core five-book set and laid out for you below.
Brush up on your knowledge of Autism with these pearls from the Pediatrics Video Board Review.
Overview
Autism is a biologically based, life-long, neurodevelopmental disorder characterized by impaired social communication and repetitive and restricted behaviors and interests. The most recent studies (CDC's Morbidity and Mortality Weekly Report [MMWR]; 2020) estimate the prevalence of autism spectrum disorder at 1 in 59 children in the U.S.
Males are approximately 4x more commonly affected than females. The prevalence of autism spectrum disorder has increased during the past several decades due to both increased awareness and changes in case definition. The pathogenesis of autism is not completely understood but appears, at least in part, to be caused by genetically altered brain development, resulting in the neurobehavioral phenotype. Environmental factors can also play a role. Overwhelming research evidence supports no causal relationship with vaccines.
Patients with this disorder demonstrate impaired social interaction and communication characterized by limited, repetitive, and stereotyped patterns of behavior or interests. Hyper- or hypersensitivity to sensory input is another core symptom of autism. Specific sensory sensitivity to foods, clothing, clothing tags, and certain surfaces is common. Affected individuals can be extraordinarily knowledgeable about a particular topic (e.g., train schedules, airplanes). Prognosis is variable among children with autism. Almost 50% of children with autism have normal intelligence. Autism is more common among children with certain genetic conditions (e.g., tuberous sclerosis, fragile X syndrome, untreated phenylketonuria).
Risperidone and aripiprazole are used for children with autism. Risperidone is approved in children ≥ 5 years of age, and aripiprazole is approved for children ≥ 6 years of age. Both are atypical antipsychotics. They are indicated for the treatment of maladaptive behaviors, such as irritability, aggression, explosive outbursts (temper tantrums), quickly changing moods, and/or deliberate self-injurious behavior.
Adverse effects of risperidone include increased appetite and weight gain, constipation, and hyperprolactinemia with resultant galactorrhea. Central nervous system (CNS) side effects can occur and include somnolence, fatigue, drooling, tremor, dystonia, and akathisia. Endocrine effects are liver function abnormalities and insulin resistance leading to hyperglycemia. Most adverse effects are mild and resolve over several weeks.
Adverse effects of aripiprazole include lethargy, vomiting, rapid weight gain, tremor, and extrapyramidal signs and symptoms.
DSM-5 diagnostic criteria for autism spectrum disorder are outlined in Table 6-3. Autism spectrum disorder is now applied as the diagnosis for children and adolescents with a previously established DSM-4 diagnosis of autistic disorder, Asperger disorder, or pervasive developmental disorder not otherwise specified.
Table 6-3 from the Behavioral Medicine section of the 10th Edition Peds Core.
For individuals who have marked deficits in social communication but whose symptoms do not otherwise meet the criteria for autism spectrum disorder, evaluate for social (pragmatic) communication disorder.
The AAP recommendations for routine screening with the M-CHAT questionnaire at 18 and 24 months of age are discussed in the Growth & Development section.
Treatment
Although ASD has no cure, a comprehensive multidisciplinary treatment approach helps diminish symptoms while promoting social and academic functioning. Patients have varying degrees of impairment, so management must be individualized. The sooner treatment begins (preferably in infancy), the better the outcome.
Early intensive behavioral and educational interventions focusing on communication, social, and cognitive skill development are central to management and are the initial treatment of choice. Applied behavior analysis (ABA), a prominent behavioral approach, discourages negative behavior while reinforcing positive behavior through a reward-based motivation system. It also teaches new skills and how to apply them in particular situations. Children with ASD benefit from highly structured educational programs taught by experienced educators in the field. Other interventions include speech therapy, occupational therapy, and physical therapy.
Some patients require psychotropic drugs to treat targeted symptoms of ASD. Stimulants (e.g., methylphenidate) are used for symptoms of hyperactivity and inattention. Antipsychotics (e.g., risperidone, aripiprazole) treat symptoms of aggression, irritability, and self-injurious behaviors.
Comorbidities may exist with ASD, so surveillance is imperative. Provide appropriate treatment or referral for medical (e.g., genetic disorder, seizure disorder,) and mental health (e.g., anxiety, depression) concerns as indicated.
This is just a couple of pages from the Core out of 30 more pages on Behavioral Medicine & Substance Use Disorders (and 1,014 others in the entire set of five books). Get your copy of the printed or online Core to efficiently review every topic on ABP/AOBP boards with our crisp, conversational writing style.
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