AAAP Today

A new study looking at data from the U.S. Centers for Disease Control and Prevention suggests that autism rates could drop off using the new DSM-5 criteria for Autism Spectrum Disorder (ASD) released by the American Psychiatric Association in 2013.

The DSM-5 changed the diagnostic label from Pervasive Developmental Disorder in DSM-IV and DSM-IV-TR to Autism Spectrum Disorder, doing away with Asperger´s syndrome, childhood disintegrative disorder and pervasive developmental disorder, not otherwise specified. The former definition by categories was changed in DSM-5 to a dimensional measure indicating level of severity.

In an effort to assess how this change could impact autism prevalence going forward, researchers looked at medical and educational records for 6,577 8 year old kids diagnosed with autism under using criteria in DSM-IV-TR, who were part of the CDC´s surveillance efforts. They found that only 81 % of the children, originally diagnosed with ASD using DSM-IV-TR, would qualify for an autism diagnosis under the DSM-5 definition.

Many of the kids who no longer appeared to qualify were missing just one criteria for the diagnosis.

According to Matthew J. Maenner of the CDC´s National Center on Birth Defects and Developmental Disabilities who led the study, “it is important to point out that we cannot predict what will happen in the future with how individuals with ASD are diagnosed, or how (or when) professionals will adapt to the new diagnostic criteria."

Reference: Maenner JJ, Rice CE, Arneson CL et al, Potential impact of DSM-5 criteria on Autism Spectrum Disorder Prevalence Estimates. JAMA Psychiatry, Published online, January 22, 2014.

Comment:

Lirio S Covey, Ph.D., AAAP President.

Previous research had shown decreased sensitivity but improved specificity of the DSM-5 criteria. In other words, DSM-5 criteria would result in fewer persons diagnosed to have ASD, but the error rate (a false diagnosis) would be lower.

If these criteria are strictly followed, future prevalence estimates of Autism Spectrum Disorders may be lower than past estimates. Access to treatment services for persons with ASD may be affected. In countries where financial assistance is provided to persons with autism, for example, through insurance payments for medical bills, fewer persons with ASD symptoms may qualify. This may reduce the number of persons, children or adults, who seek evaluation and treatment.

These labeling changes and consequences bring added importance to expert training of professionals and diagnostic teams placed in positions of determining the presence or not of ASD among persons presenting with ASD symptoms.

Experiencing major difficulties in social interaction is one of the two core symptoms of autism spectrum disorder (ASD). Given this centrality of social competence, social skills groups are a commonly used intervention for people with ASD, especial those with average to high functioning.

A meta-analysis of five randomized clinical trials was conducted to assess the effectiveness of social skills groups and training for individuals with ASD.

The subjects in the reviewed studies totaled 196 individuals with ASD aged 6 to 21 years. The range of mean full scale IQ scores fell in the average range (84.8 to 106.9). Treatment groups received social skills training in emotional recognition and regulation, social competence, social problem solving, and social communication. The comparison groups did not partake in social skills training activities.

The social skills intervention, as examined in the meta-analysis, is characterized by participation of between two and six individuals with ASD, usually at least aged six years, led by one to three therapists. The group typically meets once per week for 12+ weeks, with each session lasting 60 to 90 minutes. A social skills group session typically includes a structured lesson on a specific skill, modeling of the skill, role playing with rehearsal/practice of the modeled skill, discussion, and individualized performance feedback. Common topics for the groups vary with respect to the age and functioning level of the group members, but often include emotional recognition and regulation, social competence, social problem solving, and social communication.

The meta-analysis found significant improvements in social competence (for example, saying sorry after hurting someone else’s feelings, meeting with friends regularly, asking permission before using objects belonging to someone else) and in decreased loneliness in the social skills treatment group. No differences were found between treatment and comparison groups in emotional recognition, social communication as related to recognizing idioms, nor in child or parental depression.

Limitations of the study were: the small number of studies (5) and of subjects (196); possible bias due to awareness by group leaders, participants, and parents that they were in the treatment or the comparison group. The authors suggest caution in interpreting the study findings.

Reference: Reichow B, Steiner AM, Volkmar F. (2012) Social skills groups for people aged 6 to 21 with autism spectrum disorders (ASD). Cochrane Database System Review. July 11;7:CD008511.

Comment:

Lirio S Covey – The positive findings described are encouraging since to date no effective treatment for either of the core symptoms of ASD exist. The findings from the meta-analysis warrant further study. Persons with ASD, of all ages, should be encouraged to participate in social, sports, and recreational activities that will promote their engagement in social interactions with and those without autism. In looking towards vocational/occupational and residential settings for their loved one with ASD, families and guardians of persons with ASD should consider the availability of opportunities for frequent interpersonal and social interactions.

Gastrointestinal (GI) disorders are frequently seen in persons with autism spectrum disorder (ASD).

Using a mice-model, a team of researchers at the California Institute of Technology (Caltech) conducted a study to investigate if changes in the GI tract through probiotic therapy in can influence autism-like behaviors.

Having a severe viral infection during pregnancy raises the risk of having a child with ASD. The researchers mimicked this immune-suppressed condition by inducing an infection-like response in pregnant mice mothers.

The researchers found that the mice offspring who exhibited autistic-like behaviors also exhibited GI abnormalities. The GI tracts of the autistic-like mice were “leaky” which means they allowed material to pass through the intestinal wall and into the bloodstream, a GI characteristic that has been observed in some individuals with ASD.

The GI-disordered and autistic-like mice were treated with an experimental probiotic therapy (bacteroides fragilis) that had been used in animal models of GI disorders. With the treatment, the “leaky” GI tracts of the mice were corrected, and some of the main behavioral autism symptoms improved.

As a result of these findings, the researchers plan to develop and test an effective and reliable probiotic therapy for ASD in humans.

The authors offer a word of caution – "Autism is such a heterogeneous disorder that the ratio between genetic and environmental contributions could be different in each individual. Even if B. fragilis ameliorates some of the symptoms associated with autism, I would be surprised if it’s a universal therapy — it probably won’t work for every single case." Nevertheless, the study authors suggest that “these results may someday transform the way people view possible causes and potential treatments for autism”.

From an article by Jessica Stoller-Conrad, Probiotic Therapy Alleviates Autism-like Behaviors in Mice. ScienceDaily, Dec 5, 2013. Reference: Hsiao E et al, Microbiota Modulate Behavioral and Physiological Abnormalities Associated with Neurodevelopmental Disorders. Cell, 2013.

Comment:

Lirio S Covey – genetic and environmental factors are involved in the etiology of ASD. The study suggests that the immune-challenged condition of the mother during pregnancy is an autism-risk enhancing environmental factor, possibly an important one among many. The findings suggest a mode of post-natal treatment , i.e., probiotic treatment (as in live culture yogurt) that would be administered when autistic-like behaviors and GI symptoms are identified in the child. A further implication is careful monitoring and care of the mother during pregnancy to prevent, and (if it occurs) reduce the severity of immune-suppressive conditions such as a viral infection. The study indicates that the developmental path towards autism could begin during conception. How this process interacts with heritable genetic factors awaits further scientific inquiry.