the school system unless comorbid condi- tions such as ... As the leader of the medical home, .... sor in Child Psychiatry at the University of Louisville School.
Guest Editorial Leading specialists review current developments in pediatrics.
Case Challenges in Autism Spectrum Disorder: The Role of the Pediatrician W. David Lohr, MD; and Peter Tanguay, MD
P
ediatricians play a crucial role in the evaluation and management of autism spectrum disorders. This role has grown in importance as the prevalence of autism has increased by 78% since 2002, according to the Centers for Disease Control and Prevention.1 Pediatricians are charged with developmental screening and thus with the detection of cases of autism by using tools such as the Modified Checklist for Autism in Toddlers at 18 and 24 months. Algorithms exist to direct pediatricians to refer suspected cases for full multidisciplinary evaluation and treatment.2 To help with when the diagnosis and severity of the condition is not so clear, we have chosen case challenges that reflect important guide posts for the pediatrician treating children with autism spectrum disorders (ASD). These cases focus on higherfunctioning autism to provide help to the practicing clinician who may find little information on how to manage these patients situated at the boundary between disease and typical development. Often, fewer clinical services are available for children with ASD who may not qualify for educational services through the school system unless comorbid conditions such as attention-deficit/hyperactivity (ADHD) disorder exist. In autism treatment centers, in an effort to minimize lifelong disability, priority is rightly placed on delivering intense levels of services to those patients with critical deficits in speech and occupational functioning. It can be challenging to find speech and 408 | Healio.com/Pediatrics
language pathologists experienced and willing to work with children who have intact speech basics but have deficits in the “pragmatic nature” and social interactive elements of speech. Children with milder levels of autistic symptoms also generally do not qualify for intense waiver-based state services, which allow for case management and focused behavioral therapies. Pediatricians should remain aware of grass roots efforts and parent organizations such as Families for Early Autism Treatment (FEAT) and Autism Speaks, which offer important support and directions for parents exhausted by the needs presented by these children. The outpatient diagnosis of higher-functioning ASD can be difficult because the deficits of social interaction are milder and harder to identify. The case challenge addressing this question (see page 411) offers information on common clinical symptoms and clinical scales to help make a diagnosis. PROPOSED CHANGES TO DIAGNOSTIC CRITERIA Proposed revisions in the criteria for autism in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, see page 412) will change how the diagnosis of autism is made. The case challenge we offer discusses how these revisions will alter the way clinicians diagnose autism. Concerns have been raised that DSM-5 may be less sensitive in diagnosing ASD in high-functioning individuals.3,4 If these concerns prove true, it will be harder for these individuals and families to obtain
coverage for needed services. Others point out DSM-5 offers much needed progress in specificity and validity in ASD.5-7 A recent multisite study has questioned how reliably even experts in the field can apply DSM-IV-TR criteria to ASD.8 Also, some believe there is no difference between high-functioning autism and Asperger’s disorder.9 The bottom line for the clinician is that current DSM-5 criteria will result in a more specific diagnosis and homogenous population to treat and study. PEDIATRICIAN’S ROLE IN ASD TREATMENT As the leader of the medical home, pediatricians have the advantage of longterm relationships with patients and families and play a central role in referral and coordination of care delivered to the patient with Asperger’s disorder or ASD. Pediatricians will function as a member of a multidisciplinary team, which includes therapists, teachers, speech pathologists, and occupational therapists providing targeted care to these individuals. The case challenge that discusses the treatment plan in a patient with Asperger’s disorder (see page 413) points out the multidisciplinary aspect of evaluation and treatment necessary to address multiple deficits. Pediatricians will need to provide advice, guidance, and support to families utilizing multipronged but often fragmented delivery of services. Many pediatricians may also find themselves offering advice to families on transition planning into adulthood, as a recent study shows only 34.7% youth with
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Guest Editorial ASD will attend college and only about 55% will have paid employment in the first 6 years after high school, the lowest rates of youths in any disability categories.10 Pediatricians who treat patients with ASD in the outpatient setting will confront comorbid medical and mental conditions. ADHD, mood disorders, and anxiety are described in the population, and the overall rate of comorbid psychiatric conditions has been estimated to be as high as 74%.11,12 The case by Jennifer F. Le, MD (see page 414) illustrates the decision process necessary when patients with ASD require pharmacologic management. The case illustrates guidelines for the clinician, as medication should not be the only modality of treatment involved and should be directed at targeted symptoms and not core symptoms of autism. Overall, the responses are more modest and side effects are greater for this population. Our case challenge describing a patient with tantrums (see page 415) illustrates the difficulties faced with trying to understand how symptoms of underlying anxiety interface with core symptoms of autism. Routine evaluation for psychiatric conditions in patients with autism is an important aspect of their care and is a role pediatricians will need to fulfill. Children with autism often have medical and psychiatric comorbidities leading to complicated behavioral and pharmacologic
interventions. In some situations, it may be necessary to hospitalize the patient in order to safely evaluate and treat the various processes which may lead to aggression. The second case by Dr. Le (see page 416) guides the pediatrician on when it may be appropriate to refer a child with autism for inpatient care and the benefits one might expect. CONCLUSION Pediatricians play a central and crucial role in the evaluation and management of ASD throughout its dimensional spectrum of severity. The patient’s medical home can provide connections between families and the various multidisciplinary specialists required to effectively combat this illness. For further information and resources, the American Academy of Pediatrics offers the publication entitled Autism: Caring for Children with Autism Spectrum Disorders: A Resource Toolkit for Clinicians, second edition. doi: 10.3928/00904481-20120924-07
REFERENCES 1. Prevalence of autism spectrum disorders — Autism and Developmental Disabilities Monitoring Network, 14 sites, United States, 2008. MMWR Surveillance Summaries. 2012;61(3):1-19. 2. Johnson CP, Myers SM. Identification and evaluation of children with autism spectrum disorders. Pediatrics. 2007;120(5):1183-1215. 3. Mattila ML, Kielinen M, Linna SL, et al. Autism
spectrum disorders according to DSM-IV-TR and comparison with DSM-5 draft criteria: an epidemiological study. J Am Acad Child Adolesc Psychiatry. 2011;50(6):583-592 e511. 4. McPartland JC, Reichow B, Volkmar FR. Sensitivity and specificity of proposed DSM-5 diagnostic criteria for autism spectrum disorder. J Am Acad Child Adolesc Psychiatry. 2012;51(4):368383. 5. Swedo SE, Baird G, Cook EH Jr., et al. Commentary from the DSM-5 Workgroup on neurodevelopmental disorders. J Am Acad Child Adolesc Psychiatry. 2012;51(4):347-349. 6. Ozonoff S. Editorial: DSM-5 and autism spectrum disorders — two decades of perspectives from the JCPP. J Child Psychol Psychiatry. 2012, in press. 7. Frazier TW, Youngstrom EA, Speer L, et al. Validation of proposed DSM-5 criteria for autism spectrum disorder. J Am Acad Child Adolesc Psychiatry. 2012;51(1):28-40.e3. 8. Lord C, Petkova E, Hus V, et al. A multisite study of the clinical diagnosis of different autism spectrum disorders. Arch Gen Psychiatry. 2012;69(3):306-313. 9. Happe F. Criteria, categories, and continua: autism and related disorders in DSM-5. J Am Acad Child Adolesc Psychiatry. 2011;50(6):540-542. 10. Shattuck PT, Narendorf SC, Cooper B, Sterzing PR, Wagner M, Taylor JL. Postsecondary education and employment among youth with an autism spectrum disorder. Pediatrics. 2012;129(6):1042-1049. 11. Simonoff E, Pickles A, Charman T, Chandler S, Loucas T, Baird G. Psychiatric disorders in children with autism spectrum disorders: prevalence, comorbidity, and associated factors in a population-derived sample. J Am Acad Child Adolesc Psychiatry. 2008;47(8):921-929. 12. Mattila ML, Hurtig T, Haapsamo H, et al. Comorbid psychiatric disorders associated with Asperger syndrome/high-functioning autism: a community- and clinic-based study. J Autism Dev Disord. 2010;40(9):1080-1093.
About the Guest Editors W. David Lohr, MD, is is the Clinical Co-Director of the University of Louisville Autism Center, and Assistant Professor in Child Psychiatry at the University of Louisville School of Medicine. Dr. Lohr obtained his MD from Johns Hopkins University. He completed his psychiatry residency at Washington University in St. Louis, and child psychiatry fellowship at Western Psychiatric Institute and Clinic. Dr. Lohr is presidentelect of the Kentucky Chapter of the American Academy of Child and Adolescent Psychiatry. His areas of educational and research interest include the identification and treatment of psychiatric comorbidity of autistic spectrum disorders.
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Peter E. Tanguay, MD, is the Spafford Ackerly Endowed Professor of Child and Adolescent Psychiatry (Emeritus) in the Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Louisville. Dr. Tanguay is the author of many articles in leading journals on the subject of autism, and has presented lectures and workshops in the United States, Europe, Japan and, most recently, in China. He is a Fellow of the American College of Psychiatrists, and is currently Editor-inChief of the Psychiatric Residents in Training Exam (PRITE) sponsored by the American College of Psychiatrists.
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