2017/04/12 A CHALLENGING TRANSITION: MANAGING YOUNG ADULTS WITH AUTISM SPECTRUM DISORDER B Y : D R . C E L I A R O B I C H A U D B . S C . , M . D . P G Y 4 R E S I D E N T , D E P A R T M E N T O F P S Y C H I A T R Y D A L H O U S I E U N I V E R S I T Y OBJECTIVES • Review Re w the diagno nosis is of Autis ism Spectrum um Disorder der (ASD), , etiol ology ogy, epidemiol emiology ogy, and major or psychi hiat atric ic comor orbid idit itie ies (specif ific ical ally ly with h attention ention to trans nsit ition ion aged youth) h) • Present ent cases es of a young g adult lts with h ASD preparing ng for trans nsit ition ion to adult lt services es • Review Re w the basic ic compon onents ents of the trans nsit ition ion from adolesc escence ence to adult ltho hood, od, as they apply to youth h with h ASD • Re Review w an approach h to manag aging ing psychia hiatric comor orbid idit itie ies in young g adult lts with h ASD in the e adult lt mental al healt lth h system em 2 1
2017/04/12 WHEN YOU THINK OF “YOUNG ADULTS WITH AUTISM”… 3 AUTISM SPECTRUM DISORDER • Lifelong ong neurod odevelop opme mental tal disor order er with detrim imen ental tal imp mpact act on funct ction oning ing • A triad of sympt mptom om domains ins that t represen esent t imp mpairmen irments ts in: • Quality of reciprocal social/emotional interactions • Verbal and non verbal communication • Repetitive stereotyped behaviors and interests • Re Represen esent t ~1% of the e genera eral populati tion on • Herita tabil ilit ity y ~90% • Sex ex ratio io 4:1 (male:f e:female emale) • 2:1 with comorbid intellectual disability 4 2
2017/04/12 5 THREE MAJOR DOMAINS OF IMPAIRMENT 6 3
2017/04/12 AUTISM: A HIGHLY HERITABLE, HETEROGENEOUS, NEURODEVELOPMENTAL DISORDER Hans Asperger 1906-1980 7 Leo Kanner 1894-1981 HOW IS A DIAGNOSIS OF AUTISM MADE? • A behaviora oral diagn gnosis: osis: symp mptom oms s MUST begin in in early rly childhood ood developm evelopmen enta tal period iod (12-24mos), mos), but may become ome more e appa paren ent t with th increa eased sed socia ial demands • I.e. may not fully manifest until social demands exceed capacity • Later in life may be masked by learned strategies • Specif cifie iers: s: • With or without intellectual impairment • With or without language impairment • Associated with known medical or genetic factor (~15%) • Associated with another mental, neurodevelopmental or behavioral disorder • With or without catatonia 8 4
2017/04/12 TOOLS • Use of struc uctur ured ed diagn gnos ostic ic tool ol important ant • ADI-R: Autism diagnostic interview for caregivers or adults • ADOS: Autism Diagnostic Observation Schedule • Four modules tailored to age group and verbal ability • CARS: Childhood Autism Rating Scale • Ideall ally, coupled ed with h detaile iled develo lopmenta ental history from a caregi giver er 9 COMORBIDITIES: PHYSICAL Epilepsy • Higher rates of seizures • Estimates 2-46% Gastrointestinal • 3x more common to have complaints of abdominal pain, constipation and diarrhea • Feeding and eating Sleep problems • Sleep latency • Night awakening • ?abnormalities in melatonin production and circadian rhythm? Altere ered d sleep ep, anxiet ety, irritabi bility, and self f injury may y all be indicative e of a physi ysical health h probl roblem em! 10 5
2017/04/12 COMORBIDITIES: PSYCHIATRIC • Approximately 70% 70% of individuals with ASD meet criteria for one additional mental health disorder, 40% 40% have two or more • Higher rates of: • Depressio ion n (70% % in high h functionin oning g young g adult lts with h no comorbid id ID, , Lugenard et al 2011 11 ) • Anxiety (56%) • GAD and SAD • Intellectual disability (38%) • ADHD (30%) • OCD • Controversial, given symptom overlap. Estimates 7-20% • Schizophrenia, solitary auditory hallucinations, Bipolar I https://www.carautismroadmap.org/intellectual-disability-and-asd/ 11 DEPRESSION IN HIGH FUNCTIONING ASD • Individuals with normal intelligence and verbal ability still may have core difficulties in social interactions and communication • Vulnerable to negative life circumstances (bullying etc.) • High level of alertness is recommended in these individuals for decline in mental health and psychosocial functioning Lugnegård, Tove, Maria Unenge Hallerbäck, and Christopher Gillberg. "Psychiatric comorbidity in young adults with a clinical diagnosis of Asperger syndrome." Research in developmental disabilities 32.5 (2011): 1910-1917. 12 6
2017/04/12 LET’S RECAP • I N D I V I D U A L S W I T H A U T I S M H A V E D E F I C I T S I N C O M M U N I C A T I O N , S O C I A L I N T E R A C T I O N A N D R I G I D I T Y • M U L T I P L E P S Y C H I A T R I C C O M O R B I D I T I E S T H A T A R E D I F F I C U L T T O D I S T I N G U I S H F R O M T H E P R I M A R Y S Y M P T O M S O F A S D H O W M I G H T Y O U N G A D U L T S W I T H A S D F A R E • W I T H T R A N S I T I O N I N G F R O M A D O L E S C E N C E T O A D U L T H O O D ? 13 CASES • Joe is a 19 19 ye year r old male, e, lives ves at home e with his siblings ings and paren rents ts • Diagnosed with ASD as a toddler by pediatrics • Lower functioning, requiring substantial support with activities of daily living • First st conta tact ct with psych ychiatr iatry y at age 12, referr erred ed by pediatr iatrici ician for esca calati ting g aggr gress essiv ive e behavior ior, tics s and abnor orma mal repeti etiti tive e behavior ior • Also struggles with hyperactivity and impulsiveness in the classroom • When stressed: self-injurious, touching mouth to various surfaces around the house, walking in circles • Comor orbid medica cal conditi tion ons: s: Epilepsy epsy, GERD RD/int /intermitt ermitten ent vomit iting ing • Medica cati tion ons: risperidone, fluoxetine, lamotrigine 14 7
2017/04/12 CASES, CONT. • Robert is a 19 ye year r old male, adopt pted ed at age 2, lives indep epen endent ently ly in the basem ement ent of his paren ents home • Diagnos gnosed at age two with delayed speech ch, , ASD and ADHD • First seen n by psyc ychiatr iatry y at the IWK at age 14, seen n by out of of pr provinc ince e psyc ychiatr iatris ist prior or • Main symptoms are anger, aggression, hyperactivity/impulsivity and inflexibility • He has finished ed school ool and is working ing part time as a clean aner • His current clinician helps him with budgeting, meal planning etc. • Biologica ogical l famil ily y history y of schiz izop ophrenia, renia, bipolar lar and ADHD Comorb rbid id medica cal l cond ndit itions ions: Seizures ures • • Curren rent medica ications ions: atomoxet etine, ine, fluoxetine, ine, arip ipip ipraz razol ole 15 CASES, CONT. Joe and Ro Robert have been n followed ed by the e ASD clini nic at • the IWK from age 12/14 until l now ow What challe lleng nges es do you foresee ee them em fa facing ng with h a mov ove e • to the adult lt system? em? Will they be the same e for bot oth? h? • What challe lleng nges es do they ey fa face mov oving ing tow owar ard adult lthood hood in general al ? 16 8
2017/04/12 WHAT DOES IT MEAN TO BE AN ADULT? 17 TRANSITION FROM ADOLESCENCE TO ADULTHOOD • Eriks iksonian onian stages ges: identity v.s. role confusion, intimacy v.s. isolation • Acti tivit ities ies of trans nsit ition ion: completing school, gaining employment, post secondary education, contributing to a household, community engagement, satisfactory personal and social relationships 18 9
2017/04/12 FOR A TEEN WITH ASD • Schoo ool l planning ing might ht mean: n: • What services and supports are available to make post secondary goals attainable (such as assistive technology)? • Home planning ing might ht mean: • Becoming more integrated into the community and more independent with age, a continuum of living arrangements and outside support • Employ oyment ent planning ing might ht mean: n: • Segregated training workshops, day programs, supported employment programs or entering competitive workforce 19 WHAT ARE THE OUTCOMES FOR YOUNG ADULTS WITH ASD? • Canadi dian study dy of 48 indivi vidu duals s diagnos osed ed as pres eschoo hoolers ers with h ASD, followed ed up at mean age 6.8y, 11.4y y and 24y y • Average CARS score 34 at time 1, 31 at time 2 (mild autism) VERBAL IQ NON VERBAL IQ Average or above Mild Average or above Mild Moderate Severe to profound Moderate Severe 15% 15% 17% 17% 17% 17% 33% 33% 24% 24% 35% 35% 33% 33% 26% 26% Eaves, Linda C., and Helena H. Ho. "Young adult outcome of autism spectrum disorders." Journal of autism and developmental disorders 38.4 (2008): 739-747. 20 10
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