Recommendations of the American Academy of Child and Adolescent Psychiatry for the Evaluation and Treatment of Autism Spectrum Disorder
Joaquín Díaz Atienza (translation)
In 2014, in response to changes in the diagnostic criteria for Autism Spectrum Disorder introduced by the DSM-IV-TR and DSM-5, the AAPCA proposed a modification of the previous recommendations.1 . In it, she provides very interesting data to consider in order to obtain good clinical information and implement treatments with the strongest scientific evidence.
In this post, we present the first part of the most important recommendations contained in the aforementioned document.
- Clinical presentation and evolution.
- Epidemiology.
- Etiology.
- Differential diagnosis.
- Evidence base for practice.
- Evaluation.
CLINICAL PRESENTATION AND EVOLUTION
The DSM-IV-TR required alterations in three domains: social behavior, communication/play, restriction of interests and activities with a start around age 3.
The disorders related to sociability They are especially striking and include a significant impact on nonverbal communication, peer relationships, and socio-emotional reciprocity. communication disorders This includes a delay, or total absence, of verbal language (without initiatives to compensate through other means) or individual verbal codes, marked difficulty in the skills to initiate or maintain a conversation, stereotyped, repetitive, or idiosyncratic language, and an absence of symbolic or social play. changes in interests and activitiesThese include reduced concerns, adherence to seemingly non-functional routines or rituals, stereotypies, motor mannerisms, and persistent preoccupation with specific parts of objects.
There is great variability in the presentation of the symptoms we have described. Preschool ageMost frequently, we find a lack of interest in interacting with peers, a lack of empathy, a significant delay in language and communication, considerable resistance to change, restricted interests, and stereotyped movements. During the school stageIn some cases, social skills improve, although other new problems may also arise, such as some self-harming behaviors. During adolescence, Some patients with autism may experience significant positive changes, while others may even experience deterioration (temper tantrums, self-harm, or aggression). A good prognostic indicator is the presence of functional language by age five.
Although in the DSM IV-TR, In the category of Pervasive Developmental Disorders, the following were described: autistic disorder, Rett syndrome, Asperger's disorder, disintegrative disorder y Unspecified TGDs, with the edition from DSM 5Very important changes occur. It is reduced to the category of Autism Spectrum Disorder (299.00) (TEASpecifying the severity based on the intensity of the impairment in social communication, restricted and repetitive behavior patterns. It is also necessary to indicate if there is intellectual disability, language impairment, if it is associated with a medical or genetic condition or a known environmental factor, or with another neurodevelopmental, mental, or behavioral disorder, with or without catatonia.
EPIDEMIOLOGY
There are approximately 36 epidemiological studies that reflect a wide variability in the estimated prevalence of ASD. According to the research, rates range from 0,7 cases per 10.000 to 72,6 per 10.000. This variability is explained by changes in diagnostic criteria over time. Rates using DSM-IV ranged from 10 per 10,000 to 16 per 10,000. The results published by the CDC in 2012 report rates of 11,3 by 1000The prevalence of Asperger's disorder was 2,6 per 10,000.
The most recent data suggest that the prevalence of ASD is increasing. Factors cited include changes in diagnosis, the age at which children are evaluated, and the location of the study.
Autism is usually four times more common in boys than in girls, although girls tend to have greater intellectual impairment than boys.
ETIOLOGY
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Neurobiology
The well-established fact that approximately 20–25% of patients with autism exhibit EEG abnormalities with epilepsy suggests the existence of neurobiological factors. A wide variety of brain abnormalities have been suggested. Postmortem studies have revealed limbic alterations; MRI studies have discovered abnormalities in brain areas involved in language/communication, social and affective processing, and the processing of familiar and unfamiliar faces; increased brain volume and alterations in white matter tracts have also been observed. One of the most frequently found findings is hyperserotoninemia, although its significance remains unclear. Dopamine is associated with stereotyped movements, hyperactivity, and a positive response to neuroleptics.
The possible causes related to the use of the vaccine due to its thimerosal content have not been demonstrated, although a possible role of the immune system is still being investigated in specific cases of autism.
Alleged neuropsychological correlates include impairments in executive functions, information integration, and theory of mind.
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Family patterns and genetic factors
There is evidence that genetic factors play a role in autism, supported by the high concordance rate among identical twins. In non-twin siblings, the concordance rate is typically between 2% and 10%, and up to 18% when considering a broad spectrum of autism spectrum disorders.
Other factors mentioned include the time between pregnancies, advanced maternal or paternal age, and extreme prematurity (< 26 weeks). High rates of mood disorders and anxiety have been found among family members.
Currently there is no doubt about the involvement in autism of a wide variety of genes that have modified not only clinical practice, but also diagnostic evaluation protocols.
DIFFERENTIAL DIAGNOSIS
First, we must rule out the specific developmental disorders, especially language, and sensory impairments such as deafness, although also the treactive attachment disorder, obsessive-compulsive disorder, the mental deficiency and anxiety disorders, including the selective mutism, childhood-onset schizophrenia and other organic conditions.
To diagnose autism spectrum disorder (ASD), all DSM-5 criteria must be met, and other disorders must be ruled out. In autism, parents often report that there was no period of normal development or that there was a history of unusual behavior, such as the child being very well-behaved and undemanding. Less frequently, parents report a period of normal development before a regression of acquired skills occurs. This issue of regression remains an area of research. Regression is typical in Rett syndrome, childhood schizophrenia, disintegrative disorder, and other degenerative diseases of the nervous system.
Language development disorders They may exhibit significant socialization difficulties and be misdiagnosed with ASD, which is especially challenging in preschoolers. However, two symptoms have been proposed as indicators of a language disorder: children showing an interest in communicating with peers between 20 and 42 months of age, and the use of nonverbal (gestural) language. Other aspects include the presence or absence of response to verbal cues and attentional direction.
At 36 months there are four items that all children with ASD should present: using other people's bodies, not responding when called, pointing, and finger mannerisms.
Social (pragmatic) communication disorder It differs from ASD in that it does not usually present restricted interests or stereotyped behaviors, which are common in ASD.
Differential diagnosis would also be necessary. with ADHD with significant attention deficit, sometimes making diagnosis difficult.
As to reactive attachment disorderChildren will present difficulties in attachment and inappropriate social response, although it usually improves significantly when an appropriate caregiver is established.
El Obsessive Compulsive Disorder It usually has a later onset, is not usually associated with difficulties in socialization/communication, is characterized by repetitive behavior patterns and is usually ego-dystonic (although not always in children).
As for the anxiety disordersChildren with anxiety disorders often exhibit excessive worry, a need for reassurance, an inability to relax, and feelings of insecurity. These symptoms are also common in some children with autism spectrum disorder (ASD), especially high-functioning children. A key difference is that children with anxiety disorders typically do not show difficulties with socialization or communication.
The differences with the childhood-onset schizophrenia It is often difficult to diagnose, as both are characterized by difficulties in social interaction and thought processes. However, hallucinations and delusions are not common in autism spectrum disorder (ASD).
COMORBIDITIES
Diagnosing potential comorbidities in autism spectrum disorder (ASD) is often very difficult because the severity of its symptoms can cause them to go unnoticed. Attempts to identify possible comorbidities have been hampered by the diagnostic methods used, although most research agrees on finding high rates. anxiety and attention disorders.
Some epidemiological studies have shown that 50% present cognitive delay 35% are profoundly affected, 35% are moderate to moderate, and 20% have a normal IQ. In children with Asperger's syndrome, unlike those with autism, verbal skills are not impaired, although motor skills are. It is always recommended to assess cognitive abilities in autism spectrum disorder (ASD).
In ASD we often encounter a wide range of difficulties: hyperactivity, obsessive-compulsive disorders, self-harm, aggression, stereotypies, tics y affective symptoms. All of them present a great difficulty in being able to consider them as comorbidity or not.
We also observed affective disorders These include emotional lability, inappropriate affective responses, anxiety, and depression. Difficulties in emotional regulation processes can lead to hypo- or hyper-reactivity. Depression is especially common in adolescents with Asperger's syndrome. Some studies have suggested an association in certain cases with bipolar disorder, tics, and Tourette syndrome. Bullying, including victimization. Sometimes aggravated by sexual orientation that does not match biological sex.
The DSM-5 allows for comorbid diagnosis with ADHD. Around 45% of those with ADHD usually respond to methylphenidate (although I personally believe that more methodologically sound clinical trials are needed)
NEXT POST:
https://diazatienza.es/2018/02/14/parametros-la-evaluacion-tratamiento-del-trastorno-del-espectro-autista-2-2/
– Evidence-based practice.
-Assessment.
- Treatment
- Fred Volkmar et al. Practice Parameter for the Assessment and Treatment of Children and Adolescents With Autism Spectrum Disorder. J. Am. Acad.Child Adolesc. Psychiatry, 2014;53(2):237–257 [↩]
