- Email: [email protected]
3.2 Evidenced-Based Behavioral and Pharmacological Interventions
INSTITUTES 3.1 — 3.3
Results: ASD is a heterogeneous disorder with diverse, yet overlapping, neurobiological underpinnings. As a consequence, the clinical presentation and course are often complex. The foundation for a sound assessment lies in a comprehensive clinical evaluation, paired with gold-standard autismdiagnostic assessments and measures of cognitive and adaptive function. Behavioral interventions are considered the cornerstone of treatment. Traditionally, pharmacological interventions have targeted specific symptom domains and comorbid psychiatric conditions. Recently, advances in neuroscience have opened a window into the neurobiological basis for the disorder, and novel treatments are being developed to target diseasespecific mechanisms. Next-generation genetic analyses have allowed us to identify hundreds of genetic variants, yielding an understanding of the functional pathways involved in the neurobiology of ASD. Model systems also allow us to identify neural processes and test hypotheses with genetic, electrophysiological, and pharmacological tools. In parallel, biomarker discovery will be critical to stratify variants, guide diagnosis, and predict treatment outcomes. The future of clinical management in ASD will integrate these findings to classify cases of ASD and optimize treatment outcomes. Conclusions: The proposed Institute will present an interdisciplinary and collaborative approach to ASD management that spans current clinical practice to translational research and delineates a conceptual model that shifts the paradigm of how we approach therapeutics in ASD.
EBP, GS, ASD http://dx.doi.org/10.1016/j.jaac.2017.07.522
3.1 CLINICAL DIAGNOSIS AND GOLD STANDARD ASSESSMENT David Grodberg, MD, Yale Child Study Center, david. [email protected] Objectives: The objective of this presentation is to familiarize participants with the components of an autism-focused psychiatric evaluation and to provide information on gold-standard diagnostic assessments in autism spectrum disorder (ASD). Special emphasis will be given to differential diagnoses, comorbidity, and complex symptom presentations. Methods: Diagnostic criteria and key aspects of the psychiatric evaluation will be presented, including the use of the Autism Mental Status Exam (AMSE), followed by a description of gold-standard assessment tools including: the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2); Autism Diagnostic Interview-Revised (ADI-R); Social Communication Questionnaire (SCQ); and Social Responsiveness Scale (SRS). Results: The foundation for a sound assessment in ASD is a comprehensive psychiatric evaluation to 1) identify core deficits; 2) characterize associated features; and 3) recognize comorbid psychiatric and medical conditions. Clinicians with specialized training in ASD use standardized assessments to clarify diagnosis and evaluate associated symptoms. Individuals with ASD often present with comorbid diagnoses, which can significantly impair social, academic, and adaptive functioning, and are often the target of pharmacological and behavioral interventions. Making treatment recommendations requires an understanding of the complexities of an ASD presentation. We will review the use of the Autism Mental Status Examination (AMSE), a brief diagnostic classification tool that structures the observation and recording of social, communicative, and behavioral functioning in ASD. In addition, gold-standard diagnostic assessments will be presented, including the ADOS-2 and ADI-R. The interpretation of standard scores obtained through measures of cognitive and adaptive skills will also be discussed. Case vignettes and questions will be used to establish proof of concept and solidify knowledge. Conclusions: At the conclusion of this presentation, attendees will: 1) recognize the core features and associated symptoms of ASD; 2) appreciate the usefulness of the AMSE; 3) understand the purpose of gold-standard assessment tools in ASD; 4) know what referral questions and tests to request in the assessment of ASD; and 5) learn a framework for the psychiatric formulation in ASD with a focus on treatment recommendations.
DIAG, MDM, PSP http://dx.doi.org/10.1016/j.jaac.2017.07.523
JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT P SYCHIATRY VOLUME 56 NUMBER 10S OCTOBER 2017
3.2 EVIDENCED-BASED BEHAVIORAL AND PHARMACOLOGICAL INTERVENTIONS Pilar Trelles, MD, Icahn School of Medicine at Mount Sinai, [email protected] Objectives: This presentation will provide attendees with a framework in the treatment of autism spectrum disorder (ASD) by reviewing evidence-based behavioral and pharmacological therapies in the management of core symptoms and associated features. Methods: A review of the literature was conducted to 1) identify therapies; and 2) define core and associated symptoms that have been targeted as outcomes in clinical trials. Behavioral interventions will focus on educational programs for children with ASD, modular treatments to target social skills in children and adolescents with ASD, and treatments to manage behavioral problems. Pharmacological treatments will use a symptomdomain approach. Results: The foundation of treatment for ASD relies on psychosocial treatments, whereas pharmacological interventions target associated features. Early intervention programs aim to alter developmental trajectories in young children with ASD. In later development, psychosocial interventions are used to manage problem behaviors and associated psychiatric disorders. We will review several evidence-based educational programs, social skills programs, and behavioral strategies. Pharmacological approaches will be reviewed using a dimensional approach. We will focus on providing information on the following families of medications: neuroleptic drugs, mood stabilizers, serotonergic medications, and medications used in the treatment of irritability and aggression, ADHD, restrictive and repetitive behaviors, and anxiety. For each intervention, we will review the theoretical neurobiological framework, as well as the latest research regarding effectiveness. Videos and case vignettes will be used to highlight central topics. Conclusions: At the conclusion of this presentation, attendees will gain knowledge of the following: 1) behavioral models used in early childhood; 2) key aspects of social skills programs for school-aged children and adolescents; 3) positive behavioral support and functional behavioral assessment strategies for problem behaviors; and 4) pharmacological interventions, with an emphasis on clinical trials and expert recommendations.
EBP, PPC, P http://dx.doi.org/10.1016/j.jaac.2017.07.524
3.3 NOVEL PHARMACOLOGICAL INTERVENTIONS Roberto Canitano, MD, University Hospital of Siena, [email protected] Objectives: The goal of this presentation is to provide an overview of novel pharmacological treatments in autism spectrum disorder (ASD). This presentation will focus on evidence from clinical trials using novel treatments targeting disease-specific mechanisms. Methods: A review of the literature was conducted to identify the following: 1) ASD disease-specific mechanism and 2) novel pharmacological therapies in ASD. Treatments will be presented by pharmacological action. Results: Excitation/inhibition (E/I) imbalance in neural circuits has been implicated in the etiology of ASD and, as such, is a target of novel treatments. Clinical trials have focused on reducing excessive glutamatergic and increasing GABAergic transmission to normalize E/I imbalance. A large RCT of memantine, a noncompetitive N-methyl-D-aspartate receptor antagonist, did not yield positive results. N-Acetylcysteine (NAC), a glutamate modulator, has been found to be effective in the management of irritability in ASD in two RCTs. Arbaclofen, a GABAergic agonist, was found to improve socialization in ASD in an open-label study and one RCT. Loop diuretics have gained interest as they are thought to modulate GABAergic signaling. Bumetanide was found to improve prosocial behaviors in one RCT, but results have yet to be reproduced. Oxytocin and vasopressin, involved in social behavior, offer a venue for intervention. Acute oxytocin administration improves emphatic accuracy in healthy adults and social deficits in ASD. RCTs of oxytocin show promise in enhancing socialization; however, evidence is limited. Therefore, larger, more rigorous clinical trials are needed. Interestingly, oxytocin has been found to improve GABAergic transmission. Finally, melatonin’s role in the establishment and synchronization of circadian rhythms has been linked to synchrony in motor,
www.jaacap.org
S139
Results: ASD is a heterogeneous disorder with diverse, yet overlapping, neurobiological underpinnings. As a consequence, the clinical presentation and course are often complex. The foundation for a sound assessment lies in a comprehensive clinical evaluation, paired with gold-standard autismdiagnostic assessments and measures of cognitive and adaptive function. Behavioral interventions are considered the cornerstone of treatment. Traditionally, pharmacological interventions have targeted specific symptom domains and comorbid psychiatric conditions. Recently, advances in neuroscience have opened a window into the neurobiological basis for the disorder, and novel treatments are being developed to target diseasespecific mechanisms. Next-generation genetic analyses have allowed us to identify hundreds of genetic variants, yielding an understanding of the functional pathways involved in the neurobiology of ASD. Model systems also allow us to identify neural processes and test hypotheses with genetic, electrophysiological, and pharmacological tools. In parallel, biomarker discovery will be critical to stratify variants, guide diagnosis, and predict treatment outcomes. The future of clinical management in ASD will integrate these findings to classify cases of ASD and optimize treatment outcomes. Conclusions: The proposed Institute will present an interdisciplinary and collaborative approach to ASD management that spans current clinical practice to translational research and delineates a conceptual model that shifts the paradigm of how we approach therapeutics in ASD.
EBP, GS, ASD http://dx.doi.org/10.1016/j.jaac.2017.07.522
3.1 CLINICAL DIAGNOSIS AND GOLD STANDARD ASSESSMENT David Grodberg, MD, Yale Child Study Center, david. [email protected] Objectives: The objective of this presentation is to familiarize participants with the components of an autism-focused psychiatric evaluation and to provide information on gold-standard diagnostic assessments in autism spectrum disorder (ASD). Special emphasis will be given to differential diagnoses, comorbidity, and complex symptom presentations. Methods: Diagnostic criteria and key aspects of the psychiatric evaluation will be presented, including the use of the Autism Mental Status Exam (AMSE), followed by a description of gold-standard assessment tools including: the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2); Autism Diagnostic Interview-Revised (ADI-R); Social Communication Questionnaire (SCQ); and Social Responsiveness Scale (SRS). Results: The foundation for a sound assessment in ASD is a comprehensive psychiatric evaluation to 1) identify core deficits; 2) characterize associated features; and 3) recognize comorbid psychiatric and medical conditions. Clinicians with specialized training in ASD use standardized assessments to clarify diagnosis and evaluate associated symptoms. Individuals with ASD often present with comorbid diagnoses, which can significantly impair social, academic, and adaptive functioning, and are often the target of pharmacological and behavioral interventions. Making treatment recommendations requires an understanding of the complexities of an ASD presentation. We will review the use of the Autism Mental Status Examination (AMSE), a brief diagnostic classification tool that structures the observation and recording of social, communicative, and behavioral functioning in ASD. In addition, gold-standard diagnostic assessments will be presented, including the ADOS-2 and ADI-R. The interpretation of standard scores obtained through measures of cognitive and adaptive skills will also be discussed. Case vignettes and questions will be used to establish proof of concept and solidify knowledge. Conclusions: At the conclusion of this presentation, attendees will: 1) recognize the core features and associated symptoms of ASD; 2) appreciate the usefulness of the AMSE; 3) understand the purpose of gold-standard assessment tools in ASD; 4) know what referral questions and tests to request in the assessment of ASD; and 5) learn a framework for the psychiatric formulation in ASD with a focus on treatment recommendations.
DIAG, MDM, PSP http://dx.doi.org/10.1016/j.jaac.2017.07.523
JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT P SYCHIATRY VOLUME 56 NUMBER 10S OCTOBER 2017
3.2 EVIDENCED-BASED BEHAVIORAL AND PHARMACOLOGICAL INTERVENTIONS Pilar Trelles, MD, Icahn School of Medicine at Mount Sinai, [email protected] Objectives: This presentation will provide attendees with a framework in the treatment of autism spectrum disorder (ASD) by reviewing evidence-based behavioral and pharmacological therapies in the management of core symptoms and associated features. Methods: A review of the literature was conducted to 1) identify therapies; and 2) define core and associated symptoms that have been targeted as outcomes in clinical trials. Behavioral interventions will focus on educational programs for children with ASD, modular treatments to target social skills in children and adolescents with ASD, and treatments to manage behavioral problems. Pharmacological treatments will use a symptomdomain approach. Results: The foundation of treatment for ASD relies on psychosocial treatments, whereas pharmacological interventions target associated features. Early intervention programs aim to alter developmental trajectories in young children with ASD. In later development, psychosocial interventions are used to manage problem behaviors and associated psychiatric disorders. We will review several evidence-based educational programs, social skills programs, and behavioral strategies. Pharmacological approaches will be reviewed using a dimensional approach. We will focus on providing information on the following families of medications: neuroleptic drugs, mood stabilizers, serotonergic medications, and medications used in the treatment of irritability and aggression, ADHD, restrictive and repetitive behaviors, and anxiety. For each intervention, we will review the theoretical neurobiological framework, as well as the latest research regarding effectiveness. Videos and case vignettes will be used to highlight central topics. Conclusions: At the conclusion of this presentation, attendees will gain knowledge of the following: 1) behavioral models used in early childhood; 2) key aspects of social skills programs for school-aged children and adolescents; 3) positive behavioral support and functional behavioral assessment strategies for problem behaviors; and 4) pharmacological interventions, with an emphasis on clinical trials and expert recommendations.
EBP, PPC, P http://dx.doi.org/10.1016/j.jaac.2017.07.524
3.3 NOVEL PHARMACOLOGICAL INTERVENTIONS Roberto Canitano, MD, University Hospital of Siena, [email protected] Objectives: The goal of this presentation is to provide an overview of novel pharmacological treatments in autism spectrum disorder (ASD). This presentation will focus on evidence from clinical trials using novel treatments targeting disease-specific mechanisms. Methods: A review of the literature was conducted to identify the following: 1) ASD disease-specific mechanism and 2) novel pharmacological therapies in ASD. Treatments will be presented by pharmacological action. Results: Excitation/inhibition (E/I) imbalance in neural circuits has been implicated in the etiology of ASD and, as such, is a target of novel treatments. Clinical trials have focused on reducing excessive glutamatergic and increasing GABAergic transmission to normalize E/I imbalance. A large RCT of memantine, a noncompetitive N-methyl-D-aspartate receptor antagonist, did not yield positive results. N-Acetylcysteine (NAC), a glutamate modulator, has been found to be effective in the management of irritability in ASD in two RCTs. Arbaclofen, a GABAergic agonist, was found to improve socialization in ASD in an open-label study and one RCT. Loop diuretics have gained interest as they are thought to modulate GABAergic signaling. Bumetanide was found to improve prosocial behaviors in one RCT, but results have yet to be reproduced. Oxytocin and vasopressin, involved in social behavior, offer a venue for intervention. Acute oxytocin administration improves emphatic accuracy in healthy adults and social deficits in ASD. RCTs of oxytocin show promise in enhancing socialization; however, evidence is limited. Therefore, larger, more rigorous clinical trials are needed. Interestingly, oxytocin has been found to improve GABAergic transmission. Finally, melatonin’s role in the establishment and synchronization of circadian rhythms has been linked to synchrony in motor,
www.jaacap.org
S139