Asperger Webinar.txt

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Update: Asperger�s 
Disorder 

W.David Lohr, M.D. 
Assistant Professor Child Psychiatry 
Co-Clinical Director University of Louisville Autism 
Center 
University of Louisville School of Medicine 
wdlohr01@louisville.edu 
502-852-6941 

Objectives 

Provide introduction to Aspergers disorder 
Medical update 
Forum for further discussion 



Diagnosis of Asperger�s 
Disorder 

Hans Asperger 1944 
4 boys with difficulties relating to peers 
Fritz V. 




Lorna Wing 1981 
34 cases aged 5 to 35 years with no 
imaginative play and speech differences 







DSM-IV criteria for 
Asperger�s Disorder 

Impaired social interaction, with at least two of the below: 
marked impairment in communication by nonverbal 
behaviors such as eye contact, facial expression, body 
posture 
failure to develop appropriate peer relationships 
lack of spontaneous sharing of enjoyments and 
interests with others 
lack of social or emotional interaction 







DSM-IV criteria for 
Asperger�s Disorder 

Restricted, repetitive, and stereotypical behaviors and 
interests with at least one of the below: 
intense and focused preoccupation with unusual, 
restricted interests 
rituals and routines which are inflexible and non-
functional 
motor mannerisms which are unusual and repetitive 
such as hand-flapping, dances, etc. 
persistent preoccupation with parts of objects 







DSM-IV criteria for 
Asperger�s Disorder 

significant impairment in important areas of 
function 
no overall delay in language 
no significant delay in cognitive development, 
(mental retardation), or in adaptive skills 
criteria are not met for autism or schizophrenia 



Diagnostic problems 

How is Asperger�s Disorder different from 
autism? 
continuum of social impairment 
SRS scale 




language 
higher verbal IQ and increased fixated 
interests 
May have onset after 3 years of age 







DSM-5 

replaces categorical model with dimensional approach 
replaces Aspergers disorder and pervasive 
developmental disorder with autistic spectrum disorder 
social/communications development 
core feature with continuous distribution in 
population 
Where�s the cut-off? 




fixated interests/repetitive behaviors set 







DSM-5 

Social Communication Disorder 
impaired pragmatic use of language 
impaired social use of verbal and 
nonverbal communication 
is this mild autism? 







Clinical features of 
Asperger�s Disorder 

impaired social interaction 
one-sided, less interactive 
awareness of non-verbal communication 
impaired group play 
poor ability to recognize and understand 
thoughts of others 







Clinical features of 
Asperger�s Disorder 

impaired pragmatic language 
formality in volume, tone, rhythm of speech 
(prosody) 
verbosity and tangential (lectures) 




restricted and repetitive interests 
found in 82% of cases with Aspergers 
animals, science, technology 
dominates social activities 







Clinical features of 
Asperger�s Disorder 

resistance to change 
schedules, habits, order 




sensory processing dysfunction 
sound, smells, touch, heat 
impairments associated with social 
impairment -Hilton 2010 





Comorbid conditions seen in 
Aspergers Disorder 

Depression 
Anxiety 
Seizures 
Sleeping Disorders 
ADHD 
oppositional defiant disorder 
Overall rate of psychiatric conditions 74% 



Asperger�s disorder and 
depression 

�Up to 30% of children with ASD have 
depression 
�Changes in sleep and appetite 
�Changes in core autistic symptoms 
�Irritability or aggression 
�Self-injurious behavior, suicidal ideation 







Asperger�s disorder and 
anxiety 

�Seen in 43% to 84% of children with autism 
�Anxiety symptoms may be more common in 
Asperger�s disorder 
�Link to sensory hypersensitivity 



Epidemiology 

prevalence of Aspergers est. 2.6 per 10,000 
as of 2003 
estimated prevalence of 2.6% of autistic 
spectrum disorders in recent South Korea 
study, Kim 2011 
Family risk of autism, Ozonoff 2011 
19% chance of repeat child with autism 
32% risk if two older siblings have autism 




male:female ratio 9:1 



Etiologies of Aspergers 
Disorder 

Genetics 
linkage studies looking at specific genes 
in utero activation for autism, Kang 2011 
genetic/environmental interaction 








Neuroimaging 
frontal lobe, temporal lobe, amygdala 
enlarged brains and increased neurons in 
prefrontal cortex in autism, Courchesne 2011 







Etiologies of Aspergers 
Disorder 

in utero maternal autoimmune attack on fetal brain 
proteins, Van de Water 2011 
9% of mothers with ASD 
variant MET gene 




mitochondrial dysfunction, Rossignol 2011 
seen in 5% of children with autism 
associated with seizures and GI dysfunction 




Reduced blood antioxidant capacity 



Neuropsychological 
findings in Asperger�s 
disorder 

�Poor theory of mind 
�Executive dysfunction 
�Poor central coherence 
�Typically verbal IQ > performance IQ 



How is the diagnosis 
made? 

clinical interview 
Autism Diagnostic Interview, ADI-R 
Autism Diagnostic Observation Schedule, 
ADOS 
Social Responsiveness Scale, SRS 
Parent scales include ASDS, CATS, ASQ 



Psychological testing 

verbal, performance, and full-scale IQ 
measures of educational achievement 
measures of language 
measures of autistic symptoms 
measures of social functioning 
global child rating scales 



Further evaluation 

Speech Pathology 
language and vocabulary 
pragmatic measures 




Occupational Therapy 
sensory processing difficulties 
motor tone, balance, posture 







Treatment 

supportive and rehabilitative 
multi-disciplinary 
behavioral, social, educational, medical 



Behavioral Therapies 

teach social rules 
social skills groups 




teach adaptive behavior 
organizational strategies 
derived from ABA, cognitive behavioral 
therapy 



Speech Therapy 

not just pronunciation and articulation 
pragmatics 
social aspects of verbal and nonverbal 
communication 







Occupational Therapy 

sensory integration 
decreases irritability, improves flexibility 




improve tone, posture, core strength 
improve functional attention 







Educational support 

IEP and 504 plan 
awareness of psychological testing 
step-wise teaching approaches 
smaller classes with more 1:1 help 
opportunities for social integration 
increased time and prompting 







Cognitive-behavioral 
treatment 

�Studied for treatment of anxiety and 
depression in ASD 
�Group therapy 
�Social skills elements 
�Goal to reduce fixated interests 
�Parent training 







Pharmacotherapy 

core symptoms vs target symptoms 
target symptoms 
aggression, self-injurious behaviors 
hyperactivity 
mood or anxiety symptoms 







atypical antipsychotics 

risperidone (risperdal) and aripiprazole 
(abilify) are FDA approved for irritability and 
aggression in autistic disorders 
block dopamine 
associated with weight increases, lipid 
metabolism, sedation, movement 
abnormalities, hormonal changes 
require careful monitoring 



psychostimulants 

FDA approved for treatment of Attention-
Deficit/Hyperactivity Disorder, ADHD 
lower response rates and higher side effects in 
autistic spectrum 
multiple choices in short vs. long term effects 
but only two different chemicals 
monitor weight, growth, sleep 



selective serotonin 
reuptake inhibitors, SSRI 

widely used for anxiety and depression in 
autistic children 
limited display of effectiveness 
high incidence of side effects, (King 2009) 
activation, stereotypical movements, 
impulsiveness 







other medications 

guanfacine (tenex, intuniv) 
atomoxetine (strattera) 
anticonvulsants 



Parental support 

Autism Speaks 
parent support groups, FEAT 
louisville.edu/education/kyautismtraining/resources/family-guide 
Asperger�s Syndrome, Guide for Parents, 
Tony Attwood 
A Parent�s Guide to Asperger�s Syndrome, 
Ozonoff 



Social Skills Groups at University of 
Louisville Autism Center: STAR 

Eureka Group for those with ASD between ages of 12 to 18 
includes focus on depression and anxiety 




Middle school and elementary ages 
targets initiations, emotional regulation, problem solving 




Early Childhood 
targets social interactions and parent training 




Intensive summer social skills groups 



Research opportunities 
at University of Louisville 

�rTMS 
�Prism lenses 
�Face recognition 



Forum 

Questions 
What do you as teachers need? 
Advocacy 



Update: Asperger�s 
Disorder 

W.David Lohr, M.D. 
Assistant Professor Child Psychiatry 
Co-Clinical Director University of Louisville Autism 
Center 
University of Louisville School of Medicine 
wdlohr01@louisville.edu 
502-852-6941