Child and Adolescent Psychiatry for the General Psychiatrist, An Issue of Psychiatric Clinics (The Clinics: Internal Medicine)

222 Pages·2009·1.68 MB·English

by  Robert L. Hendren DO

ChildandAdolescentPsychiatryfortheGeneralPsychiatrist
Preface
MaliaMcCarthy,MD RobertL.Hendren,DO
GuestEditors
Because of a shortage and maldistribution of child and adolescent psychiatrists,
generalpsychiatristsincreasingly arebeingaskedtoevaluateandtreatchildrenand
adolescents who are suspected of having or who have mental disorders. Improved
recognitionoftheonsetofmanymentaldisordersearlyintheirtrajectory,increasing
initiation of pharmacologic treatment at younger ages, interest from parents and
teachers in getting the ‘‘best performance’’ from children who have behavioral,
emotional, and cognitive difficulties, and the availability of newer pharmacologic
agents with potentially fewer or less severe side effects are some of the reasons
commonlygivenforthisincreaseddemand.
In spite of excellent efforts to increase the number of child and adolescent
psychiatrists and to find better ways to share expertise with underserved areas,
the supply has not kept pace with demand. This issue of the Psychiatric Clinics
of North America is intended to deliver the latest information about some of the
mostcommonchildandadolescentmentalhealthissuesthatmightinvolveageneral
psychiatrist. We hope this compilation of articles will be a useful reference in the
offices of practitioners who have a background knowledge in general psychiatry
butwouldlikeaquickreviewofthelatestthinking andpracticeofchildandadoles-
cent psychiatry that is relevant to the general psychiatrist working in underserved
areas.
The first section of this issue addresses topics organized as disorders. The arti-
cles are sequenced in the approximate developmental order in which these disor-
ders might present in children. Autism spectrum disorders have increased
dramatically in prevalence in recent years. ‘‘New Developments in Autism’’
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xiv Preface
discusses some of the controversial issues pertaining to the pathophysiology of
autism and provides a balanced discussion of interventions, including alternative
treatments. ‘‘Psychiatric Issues in Genetic Syndromes’’ describes the current state
of knowledge pertaining to genetically based disorders with distinctive behavioral
phenotypes. ‘‘Review of Pediatric Attention Deficit/Hyperactivity Disorder for the
General Psychiatrist’’ is an especially readable review of the most clinically relevant
information pertaining to pediatric attention-deficit hyperactivity disorder. ‘‘Anxiety
Disorders and Posttraumatic Stress Disorder Update,’’ written by psychiatrists
from a subspecialty child anxiety disorders clinic, provides an up-to-date review
of the topic, highlighting differences across the lifespan. Because anxiety disorders
often persist into adulthood, this article provides a useful perspective even for
psychiatrists who do not treat children. Finally, perhaps one of the questions
most frequently asked by general psychiatrists is ‘‘What is childhood bipolar
disorder?’’ ‘‘Diagnostic Issues in Childhood Bipolar Disorder’’ addresses this
controversial topic, while ‘‘Very Early Interventions in Psychotic Disorders’’
describes the emerging data regarding prodromal psychotic patients and associ-
ated interventions. Clearly, the implications for understanding these early
processes are immense.
The next section, titled ‘‘Treatment,’’ involved difficult decisions on our part,
because the range of psychiatric interventions for children and adolescents is vast,
andourpageallotmentislimited.Ultimately,wedecidedtofocusontheinterventions
thatwebelievegeneralpsychiatristsinclinicalpracticetreatingchildrenaremostlikely
to use. ‘‘Cognitive-Behavior Therapy and Dialectical Behavior Therapy: Adaptations
Required to Treat Adolescents’’ addresses exactly what its title describes. ‘‘Child
and Adolescent Psychopharmacology Update’’ is as comprehensive and current
areviewasoneislikelytofindonthistopic.
Section three, ‘‘Service Delivery,’’ provides a context for the provision of child
psychiatric care and emphasizes some of the unique aspects of treating children
and adolescents. ‘‘The Wraparound Approach in Systems of Care’’ describes this
widely used and potentially highly effective approach to treating children who
have psychiatric disorders in community settings. ‘‘Disparities in Treating Cult-
urally Diverse Children and Adolescents’’ addresses the underutilization and
undertreatment of children from non-majority cultures. ‘‘The Psychiatrist as
Consultant: Working within Schools, the Courts, and Primary Care to Promote
Children’s Mental Health’’ illustrates this increasingly relevant role for child
psychiatrists.
Thefinalsection,‘‘ConceptualIssues,’’beginswith‘‘TowardsaNeurodevelopmen-
talModelofClinicalCaseFormulation.’’Caseformulationiscentraltochildpsychiatric
treatment,andmanyapproachesaredescribedintheliterature.Thisarticleproposes
anotherapproach thatwe mayfind ourselvesusing increasingly in thefutureasour
knowledge of the roles of and interactions between genes, environment, brain
development, pathophysiology, neuropsychology, and behavior, as they pertain to
child psychiatric disorders, grows. ‘‘Clinical Implications of Current Findings in
Neurodevelopment’’ describes some of the latest such findings. Finally, ‘‘Child and
Adolescent Psychiatry for the Future: Challenges and Opportunities’’ addresses
current challenges to providing psychiatric treatment to children and adolescents,
especiallyasrelatedtoworkforceissues,publicperception,andprofessionalidentity,
and proposes future directions, with an emphasis on the role of the general
psychiatrist.
Wehopethatthisissueprovesusefultoyou.WewouldliketothankSarahBarth
atElsevierPublishingforherexcellentguidanceandsupportthroughoutthisproject.
Preface xv
We direct an ongoing workshop based on this issue at the annual meeting of the
AmericanPsychiatricAssociationandwillappreciateknowingwhatishelpfultoyou
andwhatismissing.
MaliaMcCarthy,MD
Departmentof Psychiatry and BehavioralSciences
University ofCalifornia,Davis
MedicalInvestigation of Neurodevelopmental Disorders(M.I.N.D.)Institute
282550thStreet
Sacramento,CA 95817,USA
Robert L.Hendren,DO
Departmentof Psychiatry and BehavioralSciences
University ofCalifornia,Davis
MedicalInvestigation of Neurodevelopmental Disorders(M.I.N.D.)Institute
282550thStreet
Sacramento,CA 95817,USA
E-mail addresses:
[email protected](M. McCarthy)
[email protected] (R.L.Hendren)
New Developments
in Autism
KiahBertoglio,BSa,RobertL.Hendren,DOa,*
KEYWORDS
(cid:2)Autism (cid:2)Diagnosis (cid:2)Psychopharmacology (cid:2)Etiology
(cid:2)Treatment (cid:2)Epidemiology
Thedramatic increase in theprevalence ofautism withinthepast decade has been
accompaniedbyanabundanceofnewresearchandtreatmentstrategies.Although
thereisstillnoknowncauseorcure,thesubstantialprogressionofknowledgeabout
thedisorderinsuchashortperiodhasleftmanyprofessionalswithoutadequatetrain-
ing on how to recognize and deal with the many cases suddenly presenting in their
practice. This article is designed to provide basic information on the disorder to
helpequipthepracticingphysicianwithtoolsneededtoidentifyearlysignsofautism,
workwithfamiliesofaffectedindividuals,andimplementoptimaltreatments.
Autismischaracterizedbyaspectrumofabnormalbehaviorsthatincludemarked
impairmentinreciprocalsocialinteraction;communicationdifficulties;andrestricted,
repetitive,andstereotypedpatternsofinterestsandactivities.1Althoughtheprogno-
sisforchildrenwithautismisvariable,mostchildrenwithanearlydiagnosisofautism
are not completely independent as adults2 and the disorder generally has lifelong
effectsonachild’sabilitytobesocial,tocareforhimselforherself,andtoparticipate
inthecommunity.3Autismoftenhasadevastatingimpactontheaffectedchildandhis
orherfamilymembers,whomayexperienceassociatedanxiety,stress,mentalillness,
and lost productivity.4 There is no effective means of prevention, no fully effective
treatment, and no cure. Improved early diagnosis and a growing body of research
areleadingtothedevelopmentofpromisingtreatmentsandimprovedoutcomesfor
affectedindividuals,however.
Theincreaseintheprevalenceofautismfrom1in2500inthe1980sto1in150inthe
pastdecadehasraisedgreatconcern.5,6Substantialcontroversyexistsastowhether
thisisattributabletothemorefrequentemergenceofthedisorderfromanincreasein
potential triggers, such as environmental toxins, or is simply the result of evolving
Thisworkwaspartlysupportedbygrant3031fromAutismSpeaks,grant1R21MH080026-01A1
from the National Institutes of Health, grants CN138179 and CN138180 from Bristol Meyer
Squib,Inc.,andgrantNPL-2008-4-AUTUS-004fromNeuropharm,LTD.
Department of Psychiatry and Behavioral Sciences and The M.I.N.D. Institute, University of
California,DavisMedicalCenter,282550thStreet,Sacramento,CA95817,USA
*Correspondingauthor.
E-mailaddress:[email protected](R.L.Hendren).
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2 Bertoglio&Hendren
diagnosticpracticesandaheightenedattentiontothedisorderthathaveledtomore
sensitivediagnosticmeasuresandmorefrequentdiagnoses.7
Demographic findings on the disorder have been slim and varied. Autism is four
times more likely to emerge in boys compared with girls, although the reasons for
this are notfully understood.8 Although most studies have notidentified differences
in race among affected individuals,9 some have revealed variations. Most studies
reportahigherincidenceofautismamongimmigrantswhencomparedwithnatives.10
Additionally,arecentstudyidentifiedlowerratesofautisminLatinopopulationswhen
comparedwithnon-Latinopopulations,withcomparablysimilarratesinotherethnic-
ities. The same study also identified lower rates of autism in populations with lower
socioeconomicstatus.11Itisunclearwhetherthisrepresentsatruedifferenceinprev-
alence or whether it reflects fewer diagnoses being made in underserved and less
educatedpopulations,however.Nowell-establishedstudieshaveconsistentlyidenti-
fieddifferencesintheratesofautismacrossethnicitiesordemographicbackgrounds.
Therefore, most professionals maintain a belief that the occurrence of autism is not
influencedbyeconomic,social,racial,orethnicbackground.12
DIAGNOSIS
CharacteristicFeaturesofAutism
IntheDiagnosticandStatisticalManualofMentalDisorders,FourthEdition(DSM-IV),
autismisclassifiedasoneofthefivepervasivedevelopmentaldisorders(PDDs)andis
characterizedbyimpairmentsinthethreedomainsofsocialinteraction,communica-
tion,andrepetitivebehaviors.1Autismisoftenreferredtoasautismspectrumdisorder
(ASD),becausetheseverityandmanifestationofthesesymptomsvarywidely,ranging
frommodestsocialailmentstoseveredevelopmentalandbehavioralchallenges.13
Impairedsocialinteractionsmayincludebutarenotlimitedtopooreyecontact,dif-
ficultyinunderstandingandrelayingappropriatesocialgestures,troubleininterpret-
ing facial expressions, lack of joint attention, and limited or inappropriate facial
expressions.Poorlydevelopedempathyandlackofreciprocityarealsocharacteristic
traitsofthedisorder.Manychildrenwithautismexpressthedesiretohavefriendsbut
donotknowhowtoinitiateormaintainrelationships,andoftendonothaveaclearun-
derstandingofwhatfriendshipinvolves.14–16
Nonverbalandverbalcommunicationisoftenimpairedinautism.Thedevelopment
oflanguageisdelayedinmostaffectedchildren.Thirtypercentofchildrenwithautism
experienceregression,usuallybefore36monthsofage,whereintheyfrequentlylose
anypreviouslyacquiredlanguage.17Althoughmanyareabletoreacquireverbalskills,
some never develop language. Individuals with autism who do exhibit adequate
speechusuallyhavedifficultyininitiatingandsustainingconversationsoutsideoftheir
focusedinterests.Theirspeechisoftenrepetitiveandrote,echoingphrasesfromsur-
roundingindividuals,movies,videogames,orbooks.Childrenwithautismalsotypi-
cally have difficulty in understanding and integrating abstract concepts, focusing
theirdiscordonconcreteideas.Nonverbalcommunicationisalsoimpairedinautism,
becausethesechildrentypicallyuseinadequateorinappropriategestures,whichmay
includefailingtopointortoshaketheirheadfor‘‘yes’’or‘‘no’’.18
Inadditiontoimpairedsocialinteractionandcommunication,childrenonthespec-
trumdisplayrepetitivebehaviorsorstereotypedpatternsofinterests.Thismayinclude
awiderangeofbehaviorsinvolvingexcessivecircumscribedpreoccupations,inflex-
ible mannerisms, and preoccupation with parts of the whole. For example, children
whohaveautismmayhavetheirinterestoverlyfocusedonpartsoftoysasopposed
tothetoyasawholeormaybeinterestedinobjectsofamoreunusualnature,suchas
NewDevelopmentsinAutism 3
pipes,fans,orvents.Thesechildrenmayhaveastrongdesiretoreadthesamebook
incessantlyortowatchthesamemovie.Someofthesebehaviors,calledself-stimu-
latorybehaviorsor‘‘stimming,’’mayarisefromthechild’sunusualsensoryintegration,
which may be satisfied by behaviors, such as spinning, flapping arms, or repetitive
blinking.18
DifferentiatingAutismfromOtherPervasiveDevelopmentalDisorders
IntheDSM-IV,autisticdisorder,Asperger’sdisorder,andPDDnototherwisespecified
(PDD-NOS)arethemostcommonlydiagnoseddisorders,andperhapsthemostdif-
ficulttodifferentiatewithinthePDDcategory.Whenthesymptomsofautismarepres-
entwithoutsignificantlanguageorcognitivedelay,adiagnosisofAsperger’sdisorder
isoftenassigned.Thediagnosticassignmentofautismisalsooftenappropriate,how-
ever,becauselanguagedelayisusuallypresentbutnotrequiredforadiagnosisofau-
tism, although impairment is.19,20 Such extensive overlapping criteria between the
disorders have created substantial debate as to whether Asperger’s disorder is on
thecontinuumofASDasanequivalenttohigh-functioningautism(HFA)20orwhether
it represents a separate disorder.21 Individuals with Asperger’s disorder and those
withHFAmaybeobsessedwithcertaintopics;mayhavelearningdisabilitiesinread-
ing,writing,andmathematics;mayhaveanunusuallyaccuratememoryforcertainin-
formationandfacts;mayexhibitpeculiarreferencingduringconversations;andmay
behypersensitivetoloudsounds,lights,andodors.StudiesconductedbySzatmari
and colleagues22 and Fine and colleagues23 suggest that children who have HFA
havemorefrequentecholalia,pronounreversal,anddifficultywithconversationand
intonationcomparedwithchildrenwhohaveAsperger’sdisorder.Contradictorystud-
ieshavefoundnodifferenceinthefrequencyofthesesymptomsbetweenthetwodis-
orders,however.24Conversely,adiagnosisofPDD-NOSisoftenassignedtochildren
who exhibit subthreshold symptoms, when repetitive behaviors are not present, or
whenlanguagedevelopslate.Rett’ssyndromeandchildhooddisintegrativedisorder,
theothertwodiagnoseswithinthePDDcategory,aremuchlesscommonandareas-
sociatedwithcharacteristicneurologicregression,makingthemmoreeasilydifferen-
tiatedfromASDs.
DiagnosticTools
An autism diagnosis is best made by an experienced clinician using the DSM-IV. A
reliablediagnosismayalsorequiretheadditionoftheAutismDiagnosticObservation
Schedule(ADOS),aninteractiveassessmentwiththechildusingoneoffourmodules,
which is selected based on the amount of language the child has developed.25 The
AutismDiagnostic Interview, Revised(ADI-R) istheothermaindiagnostictool,con-
sistingofanextensiveinterviewwiththecaregiverthatfocusesondetailsofthechild’s
developmentbetweentheagesof3and4years.26Diagnosisismostaccuratelycon-
firmedwhenbothtestsareused,providinganextensiveparent-reportedhistoryofthe
childalongwithaclinician’sobjectiveevaluationthroughastandardizedtest.
AlthoughtheADOSandtheADI-Rarethemostreliableassessmentstodiagnose
autism, they require extensive training, certification, and time to administer and
were designed to be used for research studies. Other assessments that may be
usedincludetheSocialCommunicationQuestionnaire(SCQ),ChildhoodAutismRat-
ingScale(CARS),AutismBehaviorChecklist(ABC),ChecklistforAutisminToddlers
(CHAT),ModifiedChecklistforAutisminToddlers(M-CHAT),andPervasiveDevelop-
mentalDisorderScreeningTest(PDDST).Althoughtheseassessmentsdonotprovide
definitivediagnoses,theymayserveasvaluablescreeningtoolsthatmayhelpaclini-
ciantodeterminewhetherareferralformoreextensiveevaluationisindicated.
4 Bertoglio&Hendren
EarlyIdentification
Although periods of developmental delay may be observed in typically developing
children, they are often among the earliest presenting symptoms in children who
have ASDs. Primary care practitioners (PCPs) are often the first professionals to
whom parents turn when they are concerned about their child’s development. It is
therefore important that PCPs be sensitive to early diagnostic signs and that they
befamiliarwithreferralresourcesfordiagnosticconfirmationandbehavioral,speech,
andpharmacologictreatmentsoastoprovideaffectedchildrenwiththeearliestpos-
sibleintervention.
Characteristicemergingsymptomsofautismmaybeidentifiedinchildrenonlyafew
monthsold.Autismmaybereliablydiagnosedaroundtheageof2years.Thehallmark
symptomforevaluationisdelayedorabnormaldevelopmentofspeech.Manyother
characteristicsymptoms,includingabsentorimpairedjointattention,affectsharing,
eye contact, interest in other children, simple pretend play, and responding to
name,maypresentbeforeobviousdisturbancesinlanguagedevelopment,however.
Social referencing, the process of understanding others through observation and
changingone’sbehaviorsaccordingly,isalsolimitedinautism.Thesebehaviorsreli-
ablydistinguishchildrenwithearly-onsetautismfromthosewithotherdevelopmental
disorders.27,28Therefore,thefirstindicationofthesebehaviorswarrantsclosemoni-
toring, and the maintenance and progression of these symptoms necessitate
diagnosticevaluation.27,28Indicationsforanimmediateevaluationincludenobabbling
orgesturingby12monthsofage,nosinglewordby16monthsofage,notwo-word
phrasesby24monthsofage,andanylossoflanguageorsocialskillsatanyage.29
Otherred-flagconcernsincludesensoryissues,suchasbeinghyperreactiveorhypo-
reactive,inadditiontoproblemswithsleep,feeding,andcoordination.28
Before assigning a diagnosis of autism, other causes of developmental distur-
bancesoughttoberuledout.Ifpicaispresent,leadpoisoningshouldbeassessed,
which can present symptoms similar to those of autism. Genetic disorders that
needtoberuledoutincludefragileXsyndrome,neurofibromatosis,tuberoussclero-
sis,velocardiofacialsyndrome,15qduplications,andAngelman’ssyndrome.Audio-
logicandvisualexaminationsalsoneedtobeconducted,becausehearinglossmay
accountforthepresentationofsomeemergingautisticbehaviors.30
PATHOPHYSIOLOGY
GeneticSusceptibilitytoanEnvironmentalTrigger
Autismisthoughttoinvolveacomplexinteractionbetweenmultipleandvariablesus-
ceptibility genes,31 epigenetic effects,32 and environmental factors.33 Many believe
thatautismresultswhenageneticallysusceptiblechildisexposedtoanenvironmen-
tal trigger. Research into the pathophysiology of autism suggests multiple potential
mechanisms,furthersupportingthelikelihoodofdifferentgroupsofautisms.Although
no consistent biomarkers have been identified, results from these studies suggest
a role of inflammation, abnormal immunity, and neuronal disconnect in at least
sometypesofautism.
A genetic basis for autism is well accepted among most researchers in the field.
Thereisanincreasedriskforautismamongsiblings,witha4%to10%riskforsub-
sequentoffspringdevelopingthedisorder.1Identicaltwinssharea36%to96%likeli-
hood of having ASD compared with fraternal twins, who have up to a 30% risk for
sharing the disorder.34 In addition, one study reported that men 40 years of age or
olderarealmostsixtimesmorelikelytofatherachildwhohasautismthanmenyoun-
gerthan30yearsofage.35Althoughaspecificgeneforautismhasnotbeenidentified,
NewDevelopmentsinAutism 5
severalpotentialgeneticfactorshavebeenlinkedtoautism,suggestingthatsuscep-
tibilitytothedisordermayinvolveacombinationofvariousgenes.Specificgenesim-
plicated in ASD include genes at the loci 2q, 7q31 to 7q36, 15q11 to 15q13, and
16p13.34,36,37 One recent study showed a strong association of the mesenchymal-
epithelialtransitionfactor(MET)receptorgeneatthelocus7q31withASD,suggesting
an immune gut-brain connection.38 These studies and others provide compelling
evidenceforageneticcontributiontothedevelopmentofautism.
Thenatureoftheenvironmentaltrigger,proposedtobethenextstepinthedevel-
opmentofautism,ismorecontroversial.Documentedenvironmentalfactorsassoci-
ated with autism include prenatal or early postnatal exposure to viral infections,
valproicacid(Depakote),orthalidomide(Thalomid).39Thereissubstantialcontroversy
regarding the potential role of mercury, lead, and other heavy metals, in addition to
vaccinesandchemicals,intheetiologyofautism.Althoughsomestudieshavefound
high levels of heavy metals, such as mercury, in children with autism, it is unclear
whether or not they are etiologically related to the disorder. A potential mechanism
ofheavymetalinfluenceistheinductionofoxidativestress.40Similarly,theroleofvac-
cinesinthedisorderisheavilydebated,withmanyparentsreportingregressionintheir
childimmediatelyaftervaccination.Nocausativelinkhasbeenfoundbetweenvac-
cinesandautism,7anditisvastlyimportantforchildrentocontinuetobeimmunized
topreventtheemergenceofotherdiseases.Somestudieshaveshownahigherinci-
denceofautismwithincreasedexposuretomercuryfromThimerosal-containingvac-
cines, however, warranting the continued removal of Thimerosal from vaccines.41 A
safesuggestionforparentshesitanttovaccinatetheirchildmaybetospreadouttheir
vaccinesoveraperiodofseveralmonthsinsteadofadministeringallvaccinesduring
onevisit,especiallyifimmunedeficienciesaresuspected.
Researchtodatehasidentifiedimmune,oxidativestress,neurotransmitter,andep-
ileptiformabnormalitiesinmanyaffectedindividuals,althoughconsistentbiomarkers
for these potential pathogeneses have not been identified.34 Although there is evi-
dencefordepressedimmunityinsomeaffectedindividuals,assupportedbytheirfre-
quent infections and other findings, such as low lymphocyte numbers, substantial
research has also shown an overactive immune system in many individuals who
havethedisorder.Highlevelsofleukocytes,autoantibodies,andinflammatorycyto-
kinessupportahyperimmunityandanoverallinflammatoryprocessthatmaybeinflu-
ential in the development of ASD. An inflammatory process might also explain the
commongastrointestinalsymptomsandfrequentallergiesseeninmanyaffectedchil-
dren.42 Although approximately 30% ofchildren who have autism haveseizures, as
manyas65%haveabnormalelectroencephalographicactivity,suggestingpotential
dysfunctionalneuronalconnectivity.43,44Thisisfurthersupportedbyfindingsofhigh
levels of glutamate in children who have autism, creating an environment known to
cause excitoxicity.45 All these abnormalities can be antagonized by, and contribute
to, oxidative stress. This finding has been noted in many children with autism who
havebeenidentifiedashavinghighlevelsofreactiveoxidativespecies,suchasnitric
oxide, xanthine oxidase, and thiobarbituric acid reactive substances,46,47 and low
levelsofantioxidants,suchasglutathione(GSH)48andsuperoxidedismutase.49
Although brain abnormalities in autism are complex and not consistently identi-
fied,50studieshavediscoveredanintriguingpatternofbraingrowth.Thisresearchin-
dicates that infants with autism have the same or slightly smaller sized brains than
typicallydevelopingchildren,51whichthenrapidlyenlargeuntiltheage4years,after
whichgrowthslowsduringsubsequentstagesofdevelopment.52–54Byadolescence,
mostchildrenwithautismhaveasimilaroverallbrainsizeastypicallydevelopingchil-
dren but with varying abnormalities, which often include enlarged white matter and
6 Bertoglio&Hendren
decreased Purkinje cells.55,56 This pattern exemplifies one finding that is consistent
withthetheoriesofinflammation,oxidativestress,andunderconnectivity.Neverthe-
less, it is difficult to ascertain whether these abnormalities are primary mechanisms
inthepathogenesisofautismorwhethertheyaresecondarytothedisorder.
ManyDifferentAutisms?
Thespectrumofsymptomsandtheirseverity,varietyofassociatedsymptoms,incon-
sistentphysiologic findings, andvarying response to treatment strongly support the
presenceofsubgroupswithinthedisorder,eachofwhichmayhaveasomewhatdif-
ferentetiologyandresponsetotreatment.AnexcellentexampleofthisisfragileXsyn-
drome, a genetic mutation that accounts for approximately 2% of autism cases
throughauniqueetiology.ChildrenwithfragileXsyndromepossessclinicalfeatures
thataredistinctfromthoseofotherautisms(seethearticlebySolomonelsewherein
thisissue).57
Althoughwedonotyetknowthecausesoftheother‘‘autisms,’’manycliniciansclus-
tercasesintogroupsbasedoncommonlyassociatedsymptoms.Thirtypercentofchil-
drenwithautismexhibitregression.58Anadditional30%ofchildrenhaveseizures,and
upto65%displayabnormalelectroencephalograms.43,44Mentalretardationisfound
in70%ofchildrenwithautism,accordingtotheDSM-IVTextRevision(TR),whereas
few affected children possess savant skills.59 Frequent infections, allergies, and
chronicgastrointestinalsymptomsarealsooftenassociatedwiththedisorder.60–62
Commonlyassociatedbehaviorsincludeinattention,aggression,impulsivity,hyper-
activity, excessive compulsions, affective instability, and, occasionally, psychosis.
Studiesreportwidelyvaryingcomorbiditiesofautismwithattentiondeficithyperactiv-
itydisorder(ADHD),obsessivecompulsivedisorder,Tourette’sdisorder,bipolardis-
order,andschizophrenia,however.63Additionally,manychildrenexhibitsubthreshold
symptomsofthesedisorders,whichmakesitdifficulttodiscernwhetherornotthese
symptomsaresimplyvariationsintheautismspectrumorrepresentfullcomorbiddi-
agnoses. Regardless of whether the children are diagnosed with a full comorbidity,
treatmentneedstobetargetedtoaddresstheirsymptoms.
TREATMENT
The abundant anecdotal reports of promise with early intervention are increasingly
supportedbystudiesdemonstratingsubstantialcorticalplasticityduringearlydevel-
opment64 and positive outcomes from many early educational and behavioral inter-
vention programs.65 Therefore, routine screening and diagnostic evaluation of
children exhibiting early signs of the disorder, along with more studies focused on
earlyidentification,arecrucialinthepathtowardabetterprognosis.Betteroutcome
is associated with higher IQ, language ability and the ability to perform cognitive
shifts.66 Although core features of autism may not dramatically change, behavioral
and medical intervention often substantially improves adaptive skills, showing most
promisewhenimplementedinconjunctionwitheachother.
BehavioralInterventions
Applied behavior analysis (ABA),an in-home orschoolone-on-one behavioral inter-
ventionprogram,isoneofthemoststudiedtreatmentsforautismandisofteneffective
inhelpingthechildtodevelopadaptivefunctioningskills.65Suchbehavioralprograms
mayincludeupto40hoursperweekofintervention,withyoungerchildrenusuallyas-
signedmoretreatmenthours.TheDenverModelisapromisingexpansionofABAand
other more child-centered approaches, which integrate developmental, behavioral,