Posts Tagged ‘
autism spectrum disorder ’
Thursday, November 7th, 2013
Early diagnosis of autism spectrum disorders (ASD) offers the promise of early intervention – with the premise being the earlier, the better. New research suggests that we may be on the horizon of finding signs of ASD in the first 6 months of life. Here’s the breakdown of why this study – which examined attention to eyes in infants as a predictor of a diagnosis of ASD in toddlerhood – is so important.
Why Is This Study Design Powerful? This study – which builds on substantial prior research on eye contact in ASD – uses a powerful longitudinal design to search for the early signs of ASD in infants, including some at high risk (babies of older siblings with ASD). These design features give confidence in the results – the sampling frame goes from early infancy through the typical age of first diagnosis of ASD, and the high-risk component ensures enough cases to draw meaningful conclusions. And the construct of interest – attention to eyes – has been well-studied, is theoretically grounded, and can be measured with precision.
Why Are The Findings Provocative? Two reasons. First, while ASD (or the risk, or liability, to develop ASD) is assumed to be present at birth, early signs of ASD have been elusive. This study offers hope that by detecting a lack of attention to eyes in the first 6 months of life may offer one potentially powerful screen for risk for ASD. But there’s more. An especially novel finding is that infants later diagnosed with ASD started out in life attending to eyes – but that that ability declined over time. This may eventually be a clue in terms of underlying brain mechanisms – and it also suggests that if these fundamental mechanisms are “in tact” at birth and then decline, perhaps there is even more room for change with very early intervention. Either way, a strong signal of risk in the first 6 months of life may be translated – perhaps rapidly – into very early intervention strategies.
What’s The Take-Home Message? Parents have been encouraged to be mindful of some of the signals of risk for ASD in the early years – including 7 early signs of ASD. Although this study has not yet led to formal recommendations for parents, it does suggest how important face-to-face interaction is during infancy – and also highlights that parents should be vigilant about seeing how their baby reacts when eye contact is expected. The way a baby looks at the human face changes a lot over the first year in life – but the constant is that they spend a lot of time looking at it. The suggesting from this new research is that babies at risk for ASD show a decrease in their interest in the face during infancy. If this is happening, it is certainly worth bringing to the attention of a pediatrician, who will be positioned to look for other developmental milestones and indicators.
What’s The Future? Research studies are especially influential if they give a glimpse into the future. Here the hope is that a screening protocol can be developed to route infants into very early intervention – a developmental time that may hold promise for a lot of plasticity and response to intervention. Bear in mind that some of the most exciting findings to date about intervention – based on application of the Early Start Denver Model (ESDM) – demonstrated that one of the results of intensive intervention is changing the brain response to the human face, with normative patterns of brain activity achieved in some cases. Starting that process in infancy might lead to even more effective intervention programs for ASD.
Video Showing Early Signs of Autism
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Friday, August 30th, 2013
Not yet. But someday it may be a possibility.
Researchers are developing a technique that analyzes the placenta for troboblast inclusions (TIs) – which are folds and creases that can be observed at a microscopic level. Preliminary research is suggesting that a density of these may indicate risk for Autism Spectrum Disorder (ASD). Longitudinal studies will now track babies for a few years to determine the magnitude of that risk.
We often hear about exciting science that will not come to fruition for a long time. But what’s intriguing about this project is that the scientists argue that the biological screening will promote the earliest environmental intervention possible. This is a terrific perspective because we know early environmental intervention can have profound effects on the development of kids with ASD. So rather than waiting for biological cures that may never happen, it’s quite smart to think about using biological science to bolster our ability to deliver interventions that we know have positive and sometimes quite powerful benefits.
Scientist Using A Microscope Via Shutterstock.com
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Thursday, May 30th, 2013
While DSM-5 should be reflecting consensus, it has certainly spurred many reactions – from inside the ranks.
Consider that the National Institute of Mental Health – the primary funding agency for mental health research in the US – will essentially ignore the DSM-5 in favor of its own research-based criteria. In other words – the DSM-5 is not especially informative for those who do research on mental health.
Consider the serious critique of the process offered by Allen Frances, M.D., in his book Saving Normal: An Insider’s Revolt Against Out-Of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life. Dr. Frances was chair of the DSM-IV Task Force, and as such has an insider’s viewpoint on the whole process. The bottom line for him is that the DSM-5 not only does not improve on what we had before, it makes matters worse, primarily by introducing new disorders and making decisions about diagnostic criteria without sufficient evidence or grounding. The bigger point is that the diagnostic approach is losing the ability to discriminate behaviors that are part of the normal spectrum (and reflective of normative variation) and those that are truly problematic for individuals and deserving of diagnosis as a way of guiding treatment.
So what do we make of all this? I have two reactions.
I’m not all that concerned about the NIMH part of this. The reality is that researchers frequently look at “psychiatric disorders” in a number of ways – and not by following whatever clinical system is in place. That’s the point of research – to come up with something better. The problem, though, is that while there has been a lot of research that impacts our understanding of the various disorders, it has not yielded a radically different way of defining them clinically. It’s the goal, but it’s far from the reality.
That’s where “Saving Normal” comes into play. It’s hard to see that substantial progress was made at the research end to justify a whole new system. The choices made in DSM-5 are bringing more uncertainty to an already uncertain process. Let’s look at kids briefly. What’s especially troubling is that some kids who need treatment may no longer meet criteria for a disorder (like the estimated 10% reduction rate in diagnosing Autism Spectrum Disorder) – whereas others who exhibit potentially age-appropriate typical behaviors (like tantrum tantrums) may be diagnosed with the rather shaky Disruptive Mood Dysregulation Disorder.
So where are we at? Diagnoses need to be made. Kids (and adults of course) need treatment. A diagnostic system for psychiatric disorders is going to be very fuzzy at best. Wouldn’t the best approach be to introduce changes for a given disorder when the evidence suggests it is the time to do so – rather than arbitrarily replace one system with another at a designated time in the future? In this day and age, wouldn’t that be feasible?
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Wednesday, May 22nd, 2013
The DSM-5 has made major changes in the way that Autism Spectrum Disorder (ASD) is diagnosed. Here are 5 practical tips for parents based on these changes:
1) Understand the implications of eliminating Asperger’s Disorder. For most children, this change should not have much impact in the diagnostic process. It will impact some children who are higher functioning and who would have, in the past, been diagnosed with Asperger’s Disorder. The DSM-5 includes severity criteria which were designed in part to incorporate these types of kids into the new diagnostic framework. That said, many in the field think that some kids may no longer receive a diagnosis if their symptoms are less severe. Some of the initial studies demonstrate that some kids who would have been diagnosed in the prior DSM will not receive a diagnosis using DSM-5. As a parent, be ready to have this discussion with a clinical provider – and be ready to ask questions like “If the old system was in place, would my child have been diagnosed as Asperger’s?” You may need to advocate more strongly than before for your child. Focus on the need for services that could make a difference for your child’s development and collaborate with your practitioners to make sure your child has every opportunity to benefit from intervention.
2) Understand the implications of eliminating other alternate diagnoses. DSM-5 does away with other diagnostic options like Pervasive Developmental Disorder Not Otherwise Specified. The impact may be felt for kids who have many symptoms of ASD but not necessarily the exact profile. There may be no alternative diagnosis despite the fact that they have many developmental issues that need attention. Make sure your practitioners seem savvy about DSM-V and know how to make sure a kid with this kind of mixed presentation doesn’t get lost in the transition to the new diagnostic framework. Have that discussion with them and be satisfied – or seek out another opinion.
3) Beware of the severity criteria and insurance. Many clinicians have told me that they are concerned that insurers may balk at covering services for some children who are rated to show less severe symptoms. We don’t know this yet. Make sure your clinician is on top of these issues and that the team is ready to take on battles if necessary. You want to have confidence in your providers because this is all new and it is not clear how it will all unfold.
4) Remain vigilant about the early signs of autism. Just because the way ASD is diagnosed has changed in DSM-5, that doesn’t mean the warning signs have changed. They remain the same and you should be aware of the 7 early signs of autism.
5) Remember that early intervention still matters. If you suspect that your child may have ASD, it is better to get started as early as possible with the evaluation process – and if necessary intervention. Intervention helps any child, no matter what the severity, and early intervention is, right now, the best we have to offer kids with ASD. The fact that we have switched to DSM-5 does not alter the importance of early intervention – though, again, you need to be aware that you might need to fight harder to get intervention. It’s a fight worth taking on.
Autism Awareness via Shutterstock.com
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Tuesday, May 21st, 2013
As a parent, you may be wondering why such a fuss is being made about the release of the DSM-5 (the 5th edition of the Diagnostic and Statistical Manual of the American Psychiatric Association). Here is a brief overview of why it may be (0r become) relevant to you – and why it’s important to learn about the issues that are being debated.
Many Kids Will Experience A Mental Disorder
The primary reason parents need to know about DSM-5 is that many psychiatric disorders that originate in childhood are not uncommon. Consider some rough numbers:
- Around 1 in 50 kids are being diagnosed with Autism Spectrum Disorder
- Around 1 in 10 kids are being diagnosed with Attention Deficit Hyperactivity Disorder
- Around 1 in 10 kids are being diagnosed with Conduct Disorder
- Around 1 in 10 kids are being diagnosed with an Anxiety Disorder
- Around 1 in 10 kids are being diagnosed with a Mood Disorder
- Around 1 in 2 teens have reported meeting diagnostic criteria for at least 1 disorder in their lifetime
Having a good look at these numbers means that lots of parents will be faced at some point in time with the possibility of having their child evaluated for a disorder – and will need to consider treatment options. That’s where the DSM-5 comes in.
DSM-5 Is The Primary Guide For Clinical Diagnosis
The DSM-5 is the handbook used by a broad range of health care professionals who evaluate individuals (youth and adults) for potential psychiatric disorders. It’s an authoritative guide that reflects a consensus statement on the best way to categorize disorders along with the specific symptoms and rules to be used to make a diagnosis. The intention is to make it reflect current clinical thinking that is supported by research. It is not perfect, it reflects a particular point of view by those charged with generating the guidelines, and there is much debate (and criticism) of the diagnostic approach taken by the DSM-5.
All that said, the fact remains that the DSM-5 will be used if you bring your child to a health care professional for evaluation. The clinician will consider lots of information during this process – the DSM-5 does not dictate what information they use and how they get it. It’s intended to serve as a guide to the endpoint of making (or not making) a diagnosis. And it serves as the template for a health care provider to request reimbursement from insurance companies to support treatment.
Why All The Controversy Now?
The DSM-5 is a revision of the prior version which was released in 2000. As such, it includes a number of changes – some of which are minor, some of which are major. Beyond the more general discussions about what’s “normal” and what isn’t, the key things that parents need to know are the practical implications of the changes. As a parent, you should be aware of the changes to disorders that are especially relevant for youth. Here’s a brief overview:
Autism Spectrum Disorder: Major changes have occurred. In the prior version, a spectrum of disorders were available to clinicians, reflecting important variations in symptom profile. Four disorders were listed: Autistic Disorder, Asperger’s Disorder, Childhood Disintegration Disorder, and Pervasive Developmental Disorder Not Otherwise Specified. The key change is that there is now just one diagnosis made of Autism Spectrum Disorder (ASD) – and the other diagnostic categories will no longer be used. Proponents of this change suggest that it is more accurate by defining the core features of ASD that were common to all of the disorders in the spectrum and allowing for differences in severity level under one diagnostic umbrella. Critics suggest that a number of youth who require diagnosis and treatment will not be diagnosed – and that the reliance on severity levels may make it harder for kids with more mild symptoms to receive treatments they need. There’s no answer to these issues yet – they will unfold over time as data are collected. But if your child is evaluated for ASD, it’s in your best interests to be up on the debates and have informed discussions with your clinician in order to make sure you are advocating for the best care for your child.
Attention Deficit Hyperactivity Disorder (ADHD): Minor changes have occurred. In the past, there had to be evidence that a child showed symptoms of ADHD before age 7. That has been extended to age 12 in the DSM-5. There is also more attention to making diagnoses in adults more manageable. All of these changes mean that if you have an older child who has never been diagnosed with ADHD, they might now be evaluated differently. It’s also important to know what isn’t in the DSM-5 – a lower limit on age. That is, there are no guidelines in terms of how young a child may be when making a diagnosis. This is relevant as there have been (controversial) suggestions that kids as young as 4 years of age could be diagnosed (and many in fact have). Know that DSM-5 does not offer guidance here and you will need to make up your own mind if this makes sense for your child – hopefully with the appropriate guidance of a well-trained clinician. Overall, the worry here is that kids of all ages may be overdiagnosed.
Conduct Disorder (CD): Minor changes have occurred. Conduct disorder represents a persistent pattern of rule breaking behavior and behavior that violates the rights of others. It can be diagnosed in young children as well as teens. The primary change has been to incorporate symptoms indicating a callous and unemotional interpersonal style. The thinking here is kids with this profile may be especially prone to experience problems in the future – and require more intensive management and treatment. Be aware that these symptoms will receive more attention now in the diagnostic process.
Disruptive Mood Dysregulation Disorder (DMDD): This diagnosis reflects a major change – it is a new diagnostic category. The idea was to provide a diagnostic option for kids who show persistent irritability and extreme emotional and behavioral outbursts. The rationale for developing the DMDD criteria was to make sure kids who show these symptoms do not get mislabeled as having pediatric bipolar disorder – but still may qualify for treatment. The controversy is that many feel that there is not sufficient evidence to support this new diagnosis – and in the worst case scenario kids who do not have psychiatric problems will be diagnosed with a disorder and get treatment that they don’t need.
Over the next few days, I will publish blog posts that consider each of these four disorders in greater detail, and provide some guidance for parents to help sort through these complex issues. There are no straightforward answers to be found – rather parents need to know about DSM-5 so they can be prepared to navigate the best decisions for their child.
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