AUTISM—PRESENTATION,

DIAGNOSIS, AND
MANAGEMENT
Steven G. Sugden, Blythe A. Corbett

ABSTRACT
Autism spectrum disorders (ASDs) represent a cluster of symptoms with core deficits
in social, communication, and behavioral domains, which develop by the age of 3.
Recent epidemiological reports estimate the overall prevalence of ASD to be ap-
proximately 59 per 10,000. ASD affects males more often than females (ratio 4:1).
Although ASD is conceptualized as a neurodevelopmental disorder, the symptoms
and associated comorbid conditions (eg, anxiety, depression, inattention) are often
lifelong. The precise neuropathology of ASD is unknown; however, a number of
brain regions have been implicated, including the frontal cortex, cerebellum, and
amygdala. Optimal treatment often combines intensive early-intervention behav-
ioral strategies and pharmacological interventions.

INTRODUCTION (eg, a standard score of less than 70).

Currently, autism is considered part of Conversely, a child with high-functioning
a spectrum of disorders with variable autism (HFA) is one who meets autistic
language and cognitive impairment. disorder criteria and has an IQ in the
However, the distinguishing feature average or above-average range of func-
across the spectrum is impaired recip- tioning (eg, a standard score greater
rocal social interaction. Autism spec- than 70).
trum disorders (ASDs) are complex Children with Asperger syndrome
neurodevelopmental disorders that rep- have poor social reciprocity, restricted
resent a broad range of severe and interests and/or repetitive behaviors,
pervasive symptoms. These consist of and behavioral deficits that have
social, communication, and behavioral onset prior to the age of 3. However, 47
deficits, which have an onset prior to they do not demonstrate significant
the age of 3. Autistic disorder (AD) rep- language delay or communication defi-
resents the most debilitating symptom cits, are often considered less im-
cluster within ASD, and, as such, these paired, and have an IQ that generally
children’s symptoms are the most falls within the average to above-
difficult to treat clinically. Autism is a average range. Since children diag-
heterogeneous disorder, with symp- nosed with both HFA and Asperger
toms often clustered based on cogni- syndrome tend to be more verbal and
tive functioning and with a division less impaired symptomatically, the dis-
based on intelligence quotient (IQ). tinction between HFA and Asperger
Specifically, a child with low-functioning syndrome may be difficult (Ozonoff
autism is one who meets the autistic et al, 2000). Finally, pervasive devel-
disorder criteria and has an IQ at least opmental disorder not otherwise speci-
2 standard deviations below the mean fied (PDD-NOS) represents a diagnosis

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 " AUTISM

KEY POINTS:
for children who either meet the crite- stricted patterns of interest that
A Autism
ria for autistic disorder with onset of is abnormal either in intensity or
spectrum
disorders symptoms after the age of 3 or have less- focus
represent a impairing social, communication, and o Apparently inflexible adherence to
cluster of behavioral deficits, or atypical symp- specific, nonfunctional routines or
symptoms with tomatology (American Psychiatric Asso- rituals
core deficits ciation, 2000). o Stereotyped and repetitive motor
in social, mannerisms
communication, DEFINITION OF AUTISM o Persistent preoccupation with parts
and behavioral SPECTRUM DISORDERS of objects
domains that According to the Diagnostic and Statis- In addition to the specific require-
develop by the
tical Manual of Mental Disorders, ments, a total of six symptoms in any
age of 3.
Fourth Edition, Text Revision (DSM-IV- of the categories needs to be evident
A The autism TR) (American Psychiatric Association, before the age of 3 (American Psychiat-
spectrum 2000), a child meets the criteria for au- ric Association, 2000).
consists of tistic disorder when he or she presents Children are diagnosed with Asperger
autistic disorder, with core deficits in social interactions, syndrome when they meet the fol-
Asperger
and verbal and nonverbal communica- lowing DSM-IV-TR criteria. First, they
syndrome,
tion, and has a repertoire of repetitive, need to have social impairment in at
and pervasive
developmental
stereotyped, or restricted interests. Spe- least two of the following ways:
disorder not cifically, a child must develop at least o Marked impairment in the use of
otherwise two of the following social deficits: multiple nonverbal behaviors such
specified. o Marked impairment in the use of as eye-to-eye gaze, facial expression,
A Children meet multiple nonverbal behaviors such body postures, and gestures neces-
the criteria as eye-to-eye gaze, facial expression, sary to regulate social interaction
for autistic body posture, and gestures neces- o Failure to develop peer relation-
disorder when sary to regulate social interaction ships appropriate to developmen-
they develop o Failure to develop peer relationships tal level
at least six o Lack of spontaneous seeking to o Lack of spontaneous seeking to
deficits in social, share enjoyment, interests, or achieve- share enjoyment, interests, or achieve-
communication, ment with other people ments with other people
and behavioral o Lack of social or emotional reciprocity o Lack of social or emotional reciprocity
domains
before age 3.
Additionally, a child needs to mani- Additionally, children need to have
fest one of the following communica- one of the restricted behaviors:
48 A Children tion impairments:
with Asperger o Encompassing preoccupation with
syndrome have
o Delay in, or total lack of, the devel- one or more stereotyped and re-
similar social opment of spoken language stricted patterns of interest that is
and behavioral o In individuals with adequate speech, abnormal either in intensity or
deficits as those marked impairment in the ability focus
with autistic to initiate or sustain a conversation o Apparently inflexible adherence to
disorder. with others specific, nonfunctional routines or
o Stereotyped and repetitive use of rituals
language or idiosyncratic language o Stereotyped and repetitive motor
o Lack of varied, spontaneous make- mannerisms
believe play or social imitative play o Preoccupation with parts of objects
Finally, a child needs to demon- Unlike autism, there is no clinically
strate one of the following behaviors: significant general delay in language or
o Encompassing preoccupation with cognitive development (American Psy-
one or more stereotyped and re- chiatric Association, 2000).

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 KEY POINTS:
PDD-NOS represents the class of brain regions may mediate autistic
children with severe and pervasive
A Unlike those with
symptoms (Brambilla et al, 2003).
autistic disorder,
impairment of reciprocal social skills
children with
with or without communication skills Frontal Cortex Asperger
or stereotyped behaviors. Additionally, syndrome
By monitoring glial activation, migra-
this category includes ‘‘atypical autism’’ develop without
tion defects, and excessive cerebral mi-
when autistic symptoms (deficits in com- general delay
gration, Vargas and colleagues (2005)
munication, social skills, and behavior) in language
were the first to identify an active neuro-
develop after the age of 3 (American or cognitive
Psychiatric Association, 2000). inflammatory process in autism within development.
the white matter of the frontal cortex.
Hypothetically, this process may be re- A Pervasive
EPIDEMIOLOGY developmental
sponsible for the enlarged frontal cor-
disorder not
ASDs affect significantly more males tex size noted in autistic toddlers,
otherwise
than females by a 4:1 ratio (American which declines during adolescent de- specified
Psychiatric Association, 2000). In the velopment (Courchesne et al, 2005). (PDD-NOS)
most recent epidemiological survey con- Additionally, cognitive neuroscience represents
ducted by Chakrabarti and Fombonne studies of autism have shown hypo- children with
(2005), the overall prevalence of functionality within the frontal cortex impaired social
ASD was measured at 58.7 per 10,000, (Courchesne and Pierce 2005). This skills with
(95% confidence interval [CI] of 45.2– finding led Courchesne and Pierce to or without
74.9). The overall prevalence for AD suggest that the neuroinflammatory pro- communication
was 22.0 per 10,000 (95% CI=14.1– cess noted by Vargas and colleagues or behavioral
32.7), and 36.7 per 10,000 (95% CI= (2005) may lead to dysfunction in the deficits.
26.2–49.9) for either Asperger syn- neurocircuitry resulting in impaired A PDD-NOS
drome or PDD-NOS. These results are integration of brain regions and lead- also includes
consistent with a previous report, ing to many of the emotional, lan- ‘‘atypical
which estimated the prevalence for guage, and sensory deficits within autism,’’ which
ASD near 60 per 10,000 (Fombonne, autism. describes
2003). PDD-NOS was the most fre- symptoms that
occur after
quent subtype within ASD, and it oc- Cerebellum the age of 3.
curred at about 1.7 times the rate of
Multiple studies have noted a reduc- A
AD. Consistent with previous stud- Autism spectrum
tion of the number of Purkinje neu- disorders affect
ies, Asperger syndrome occurred less
rons within the autistic cerebellum and males more
frequently than the two other sub-
a reduction of Purkinje neuron size
types (Chakrabarti and Fombonne,
within the cerebellar hemispheres (see
than females
(ratio 4:1).
49
2005; Fombonne and Tidmarsh, 2003).
Allen et al, 2004; Brambilla et al, 2003,
for a review). Although the cerebellum
PATHOPHYSIOLOGY has been considered mostly a motor
Although the exact neuropathology of structure, it contributes to other cogni-
autism remains unclear, a correlation tive processes. For example, cerebellar
exists between the development of dysfunction has been linked to slower
higher-order brain structures (eg, frontal or inaccurate attentional adjustments,
lobe, temporal lobe, and cerebellum) which may in turn impact the ability
and the onset of autistic symptoms (eg, to follow the natural sequential flow of
speech and language impairments, conversations or events (Allen et al,
emotional and social deficits, attention 2004). As autistic spectrum individuals
and cognitive dysfunction) (for a com- are unable to follow external conver-
plete review see Courchesne et al, sations or events (cerebellar pathol-
2005). As such, multiple higher-order ogy), they may attempt to compensate

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 " AUTISM

KEY POINTS:
by naturally restricting behaviors or in- contribute to variable and increased
A The precise
terests (Allen et al, 2004). stress, as measured by elevations in
neuropathology
is unknown salivary cortisol (Corbett et al, 2006).
Amygdala
in autism
spectrum Bauman and Kemper (1985) initially de- DIAGNOSIS
disorders. scribed abnormally small and densely
Since the 1940s and Kanner’s initial
packed cells within the medial portion
A Neuroinflam- description of autism, significant ad-
of the amygdala. Currently, no pub-
matory vancement has occurred in understand-
processes within lished studies have replicated this find-
ing the prevalence and developmental
the frontal cortex ing. However, Sparks and colleagues
course of ASD. In the process, the
may impair (2002), using magnetic resonance volu-
diagnostic criteria have become more
connections and metric studies of 45 young children
clearly defined and established. Initially,
interpretation with ASD (aged 3 to 4 years), showed
epidemiological surveys conducted be-
of stimuli from that children with autism had larger
other regions
tween 1966 and 1986 used diagnos-
bilateral amygdala volume when com-
within the brain, tic criteria based on the descriptive
pared with typically developing and
leading to works of Kanner, Lotter, and Rutter
developmentally delayed children. Simi-
emotional, (Fombonne, 2003; Kanner, 1943; Lotter,
larly, Schumann and colleagues (2004)
sensory, and 1966; Rutter, 1970). Now, the diagnos-
noted children with ASD, aged be-
language tic criteria for the major epidemiologi-
tween 7.5 and 12.5 years, to have larger
deficits within cal surveys have been based on the In-
autism. left amygdala volume compared with
ternational Classification of Diseases,
age-matched controls. These differ-
A Cerebellum ences were not present in the adoles-
10th Revision (ICD-10) and DSM-IV man-
neuropathology uals, which rely upon the judgment
cent population (aged 12.75 to 18.5
may affect of clinical experts (Fombonne, 2003).
years).
attentional Currently, the diagnostic gold stan-
A number of studies have indicated
processing, dard involves completing the Autism
leading to that the amygdala in ASD may actu-
Diagnostic Interview—Revisited (ADI-R)
restricted ally be hypoactive (see Baron-Cohen
(Lord et al, 1994), which consists of a
behaviors et al, 2000, for a complete review).
semi-structured interview conducted
within autism. However, this may be due to inade-
with the child’s parent or primary care
quate control of attention rather than
A Amygdala provider, and completing the Autism
hyperfunction
a fundamental functional impairment
Diagnostic Observation Schedule—
may be involved in autism. Recently, Dalton and col-
Generic (ADOS-G) (Lord et al, 2000),
in abnormal leagues (2005) used images of faces as
which is a semi-structured interview
stress-producing stimuli for subjects
50 fears/anxiety/
stress seen with HFA. Functional brain activity re-
and interactive assessment conducted
with the child suspected of having ASD.
in autism. vealed hyperactivity within the amyg-
Each instrument provides a diagnostic
dala region when eye movements
algorithm for the disorders within ASD,
were controlled and fixated on the
which correlates with ICD-10 and DSM-
eye region. Evidence increasingly sug-
IV classification (de Bildt et al, 2004).
gests that an important role for the
amygdala is in detecting threats and
mobilizing an appropriate behavioral PRESENTATION RED FLAGS
response, part of which is fear (Amaral To date, no genetic markers or screen-
and Corbett, 2003). If the amygdala is ing tests successfully predict onset of
pathological in autism, it may con- autistic symptoms for a given individual.
tribute to the abnormal fears and in- Nevertheless, some symptoms or ‘‘red
creased anxiety in children and adults flags’’ may be more indicative of au-
with autism (Amaral and Corbett, 2003). tistic pathology, and parents or pro-
Further, a hyperactive amygdala may viders who observe these symptoms in

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 KEY POINTS:

Presentation Red Flags

A The current
TABLE 4-1 diagnostic
standard for
" Communication: Red Flags autism spectrum
disorder involves
1 Year: no babble, no gesture
structured
18 Months: no words evaluation
(Autism
2 Years: abnormal voice quality (flat or sing-song prosody), reduced gesture
Diagnostic
21/2 Years: only a few single words Interview—
3 Years: speech largely unintelligible, echolalia, no phrases, and short sentences Revisited) with
a parent or
4 Years: skills inadequate for interaction caregiver and
5 Years: persistent fluency problems an observational
evaluation
Any age: loss of previously mastered communication skills
(Autism
" Social: Red Flags Diagnostic
1 Year: reduced eye contact, emotionally remote, absent social smile, Observation
no social referencing, less attention to other babies, no response to own Schedule—
name, no pointing response Generic).

2 Years: reduced or absent social attention (pointing, showing, gaze), reduced A Both the Autism
understanding of others’ emotions Diagnostic
Interview—
Any age: significant loss of previously attained social-relatedness skills
Revisited and
" Adaptive Skills: Red Flags the Autism
1 Year: short attention span; passive, reduced intentional activity; less sleep Diagnostic
and frequent waking; irritability Observation
Schedule—
2 Years: absence of symbolic play; repetitive, nonfunctional play
Generic correlate
" Motor Behavior: Red Flags with ICD-10
and DSM-IV
Before 1 year: motor abnormalities—approximately 6 to 8 months—such as
muscle tone asymmetries, dyscoordination, crawling abnormalities classification of
autism spectrum
1 Year: hand flapping, finger twiddling, object twiddling, rocking, hypotonia disorder.
2 Years: toe walking
" Sensory Behavior: Red Flags
1st Year: reduced reaction to sounds, intolerance to certain sounds
51
1 to 2 Years: has empty gaze, ignores cold, gets overexcited when tickled,
refuses certain textures or food
2 Years: lines up objects

children should be encouraged to seek orders, or anxiety disorders in the pre-

further workup (Table 4-1) (Case 4-1). sence of any of the ASDs. The rationale
for this hierarchical relationship is that
PSYCHIATRIC COMORBIDITIES features of anxiety, mood, and hyperac-
The DSM-IV-TR (American Psychiatric tivity disorders are so much a part of
Association, 2000) specifically prohibits ASD that it would be redundant to offer
making the diagnoses of attention multiple diagnoses. Caron and Rutter
deficit hyperactivity disorder, mood dis- (1991) explained that:

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 " AUTISM

KEY POINT:
. . . psychiatry has many non- MANAGEMENT
A Autism pathology
specific symptoms such as anxi- Nonpharmacological
manifests as
core deficits ety, depressed mood, poor con- Intervention
within social, centration, and restlessness. Of
course a dilemma arises from Expert committees recommend at least
behavioral, and
the fact that many of the non- 25 hours per week of educational pro-
communication
gramming for preschool children with
domains. specific symptoms also constitute
pervasive developmental disorders (Na-
Key warning the hallmarks of specific diag-
symptoms or red tional Research Council, 2001). As
nostic entities. The problem lies
flags include no such, children with autism generally
in deciding when depression is
babble talk by require a well-sequenced, highly struc-
an indicator of major depression
12 months; no tured teaching format in which skills
and when it is just an indication
hand gesture by are broken down and taught in a sys-
that psychopathologically some-
12 months; no tematic, step-by-step format as pre-
thing is the matter.
single words by sented through a comprehensive be-
16 months; havioral program. A central theme in
no two-word Nevertheless, individuals with ASD autism treatment is the notion that
phrases by 24 remain impaired, both from core au- early intervention is critical in order
months; and any tistic symptoms and from aggres- for the child to have the best possible
loss of language sive, self-injurious, hyperactive, hyper- outcome (Birnbrauer and Leach, 1993;
or social skills. arousal, and/or anxious symptoms (des Lovaas, 1987).
Portes et al, 2003). Failure of these Various reports indicate that fac-
symptoms to meet diagnostic criteria tors such as age at time of symptom
for a particular psychiatric disorder onset, IQ level, language function-
does not minimize their impact on ing (Smith, 1999), or diagnostic symp-
the specific individual (Cases 4-2, 4-3, tom severity (Smith et al, 2000) may
and 4-4). Recent literature has shown be predictors of outcome. Research in
that individuals with ASD experience ASDs has consistently reported bene-
more severe attention (Corbett and fit from early intervention behavioral
Constantine, in press), anxiety, and de- techniques (eg, Birnbrauer and Leach,
pressive symptoms (Kim et al, 2000) 1993; Lovaas, 1987). Autism strikes
compared with healthy controls. very early in development; treatment

52 Case 4-1
A 3-year-old boy is brought in by his mother because she is concerned that he is not developing
language skills. Although she has talked to her pediatrician on several occasions, the doctor
keeps insisting that he is just a ‘‘late talker’’ and will ‘‘catch up.’’ She reports that he has only
two or three words, which he uses inconsistently. Mostly, he will just repeat what he hears from
other people or on television, but it is usually out of context. When he wants something, he will
grab his mother by the hand and pull her to what he wants. His mother insists that he seems
to prefer being in his own world, and he not does appear to be interested in other children.
The mother reports that her son shows low frustration tolerance but a high tolerance to physical
pain. On examination, the child demonstrates poor eye contact and engages in repetitive
hand flapping, especially during periods of increased arousal. The child is referred to a
psychologist specializing in applied behavior analysis, who implements an individualized and
comprehensive behavioral program to enhance the child’s receptive and expressive language
and improve his reciprocal social skills.
Comment. This patient is diagnosed with autistic disorder with severe receptive and expressive
language delays. He is a good candidate for an intensive applied behavior analysis program.

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 KEY POINT:
A Children with
Case 4-2 autism generally
An 8-year-old boy presents with a history of precocious language require a
development, difficulty establishing friendships with peers, and poor well-sequenced,
school performance despite above-average intelligence. His parents report highly
that some of his behaviors started in infancy with his not wanting to be structured
swaddled. His development has also been marked by persistent difficulty teaching format.
establishing and maintaining his attention and engaging in impulsive
behavior. There have also been indications of obsessive and compulsive
behavior (eg, lining up his cars and having them all point in a particular
direction, having to watch a particular television show at a specific
hour), especially during his younger years. During the evaluation, he
demonstrates good eye contact but a poor sense of personal space and
boundaries and impulsive responding. His affect is generally flat, exhibited
by rather limited facial expressions directed to others.
Comment. This case represents Asperger syndrome with attention
deficit/hyperactivity disorder symptoms. Treatment with a stimulant is
prescribed. In addition, behavioral and educational strategies are offered
to address his impulsive responding, difficulty sustaining attention in
class, and poor organizational skills.

strategies therefore appear to be most lar behaviors (eg, language, social

effective when they begin early to development) are forming.
capture sensitive periods of develop- The past 30 years have generated
ment when the acquisition of particu- considerable empirical evidence that

Case 4-3
An 11-year-old boy presents with a history of language delay, poor social
skills, repetitive hand-flapping behaviors, and mild mental retardation.
He has a long-standing need for predictability and sameness, and he can be
quite rigid in his thought processes. The child becomes quite anxious and
exhibits very low frustration tolerance for benign changes in preferred
activity or schedule. Regarding socialization, he has shown difficulty
making friends, despite effort, and he has periodically engaged in
53
threatening behavior toward peers on the playground. His parents report
that he has made a lot of progress with his language development
but that his anxiety symptoms have worsened as he has developed.
He demonstrates heightened sensitivity to various sensory stimuli and
becomes particularly tense in noisy or crowded situations such as those
at a shopping mall.
Comment. Although the patient has been previously diagnosed with
autism, he demonstrates heightened sensitivity to external stimuli,
social rigidness, and a need for sameness. The nature of his symptoms
makes it difficult to interpret because his anxiety may have evolved from
his core autistic symptoms (eg, a need for sameness) or from a secondary
DSM-IV anxiety disorder. Regardless of the diagnostic challenge, he still
experiences routine anxiety symptoms that may be responsive to
psychotropic interventions.

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 " AUTISM

KEY POINTS:
A Treatment
strategies for Case 4-4
autism appear A 13-year-old boy is brought in by his parents because of concerns about
to be most his disruptive behavior at school and at home. He has had difficulties
effective when making friends throughout his education. He tends to spend free time
they begin early watching The History Channel. At school, he struggles with language arts
to capture and mathematics but excels in remembering historical dates, persons,
sensitive periods and places. He is easily provoked regarding issues about fairness or when
of development. his routine is disrupted at home. Lately, he has become more irritable
and aggressive. His parents describe episodes when he will go into a rage,
A Key components tear out every page from a book, throw everything out of a bookshelf,
of effective early and punch holes in walls. During the examination, he has limited direct
intervention interactions with the clinician. He is calm and indifferent, but his speech is
programs for mildly pressured.
autism generally
Comment. This is a case of Asperger syndrome with affective instability.
include early
He is started on an atypical antipsychotic, and special accommodations are
identification,
made at school to allow him to take a ‘‘time-out’’ when he feels
comprehensive
particularly angry or misunderstood.
programming,
individualization,
and a favorable
one-to-one,
early intervention behavior therapy tative, genetic and pharmacological
adult-to-child can result in significant, comprehensive, treatments are developed, behavior
teaching format. and lasting changes in children with au- modification will remain the most im-
tism (eg, Birnbrauer and Leach, 1993; portant treatment available.’’
A Aggressive,
Lovaas, 1987). Key components of ef-
self-injurious,
fective early intervention programs
hyperactive, Pharmacological Intervention
hyperarousing
generally include early identification,
and/or anxiety comprehensive programming, individ- Currently, there is no pharmacological
symptoms are ualization, and a favorable one-to-one, ‘‘cure’’ for ASDs, which causes frustra-
often associated adult-to-child teaching format (Newsom tion for the autistic individuals, families,
with autism and Rincover, 1989). A variety of unique and treating clinicians. With the recent
spectrum intervention strategies have shown ef- advances in psychotropic medications,
disorder and ficacy in teaching important skills to aggressive, self-injurious, hyperactive,
may cause a individuals with autism. One such tech- hyperarousing, and/or anxiety symptoms
significant level nique is video modeling, which involves have been targeted pharmacologically
of impairment. the presentation of brief video or DVD even though a paucity of large, double-
54 presentations that present a model blind, randomized control studies
showing a targeted behavior that the assessing and validating specific treat-
child watches and subsequently imi- ments are available (des Portes et al,
tates with a therapist or parent. Video 2003). Case study designs using serotonin
modeling has been used successfully to selective reuptake inhibitors (SSRIs) have
treat children with ASDs and, in some reported improvements in social in-
circumstances, has yielded better results teractions, mood and ritualistic behav-
for skill acquisition, maintenance, and ior, aggression, and depressive- and
generalization in individuals with au- obsessive-compulsive tendencies (Francis,
tism than in vivo participant modeling 2005). Nevertheless, the literature does
(eg, see Charlop-Christy et al, 2000; not support the use of one SSRI over
Corbett and Abdullah, 2005). another for impairments associated
Waterhouse and Fein (1998) under- with autism (Moore et al, 2004). Ad-
score the importance of behavior ther- ditionally, research from the Autism
apy stating, ‘‘Until effective preven- Network of the Research Units on

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 KEY POINTS:
Pediatric Psychopharmacology suggests The correlation between the devel-
opment of higher-order brain struc-
A There are no
an improvement in the autistic core
pharmacological
symptoms of restricted, repetitive, and tures (eg, frontal lobe, temporal lobe,
‘‘cures’’ for
stereotyped behavior with the use and cerebellum) and the onset of au- autism
of the atypical antipsychotic risperi- tistic symptoms, particularly speech, spectrum
done (McCracken et al, 2002). Limited emotional, social, language, attention, disorders.
literature supports the use of psycho- and cognition dysfunction, is integral
in understanding the neuropathology.
A Selective
stimulants for attention and hyperac-
serotonin
tive symptoms, particularly in higher- Neuroinflammatory processes within
reuptake
functioning ASD (Francis, 2005; Handen the frontal cortex may impair connec- inhibitors are
et al, 2000). Likewise, some pilot study tions and interpretation of stimuli from suggested to
data suggest an improvement in affec- other regions within the brain, leading target social
tive instability, impulsivity, and aggres- to emotional, sensory, and language interactions,
sive behaviors with valproate (Hollander deficits within autism. Cerebellar neu- mood,
et al, 2001). ropathology may affect attentional pro- ritualistic
cessing, leading to restricted behaviors behavior,
CONCLUSION within autism, whereas amygdala hy- aggression,
ASD, a complex neurodevelopmental perfunction may be involved in abnor- and depressive-
and obsessive-
illness, consists of core symptom deficits mal perception of fears or internalized
compulsive
in clusters of social reciprocity, commu- anxiety seen in autism.
tendencies.
nication, and stereotyped movements/ Currently, no pharmacological cures
restricted interests that manifest by exist for autism. Psychotropic medica- A Atypical
the age of 3. Warning signs include no tions are often used to target associated antipsychotics
babble talk by 12 months, no gestur- comorbid conditions (eg, SSRIs for are suggested
to target
ing movements by 12 months, no sin- social interactions, mood, ritualistic
aggression,
gle audible words by 16 months, no behavior, and aggression or atypical
irritability, and
two-word phrases by 24 months, and antipsychotics for restricted, repeti- restricted,
any loss of language or social skills. tive, and stereotyped behaviors, and repetitive, and
The current diagnostic standard for au- aggressive/irritability behaviors). Chil- stereotyped
tism involves a structured evaluation dren with autism tend to do better if behaviors.
(ADI-R) with a parent or caregiver and they are identified early and participate
an observational evaluation (ADOS-G). in structured teaching activities during A Stimulants
are suggested
Although ASD is viewed as a neuro- key developmental periods. As such, to target
developmental disorder, symptom clus- combining pharmacological and inten- hyperactive
ters and associated comorbid conditions sive early intervention behavioral strate-
(eg, anxiety, depression, inattention) are gies may enable children to be more
tendencies.
55
often lifelong. successful in learning effective living skills. A Mood stabilizers
are suggested to
target affective
instability,
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Review article from two prominent psychiatrists addressing comorbid symptom
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Case-report study endorsing video modeling over in vivo modeling in the teaching of
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This paper describes the use of video modeling and provides theoretical explanations
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A neuropsychological study of children with autism spectrum disorders, attention
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" Corbett BA, Mendoza S, Abdullah M, et al. Cortisol circadian rhythms and
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Novel study showing that the cortisol circadian rhythms in autism are altered when
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Review paper highlighting frontal cortex neuropathology within autism.

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Thorough review article highlighting multiple nodes that may be implicated in
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Excellent study showing that with corrected eye gaze the amygdala is hyperactive in
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Important paper demonstrating reliability between the Autism Diagnostic Observation
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Review paper by an international leader of epidemiology in autism.

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Review paper summarizing epidemiological data in Asperger disorder.

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Review of psychological and psychopharmacological interventions for autism.

Copyright @ American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

 " AUTISM

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Excellent review of the effectiveness of serotonergic agents for autism.

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" National Research Council. Educating children with autism. Washington, DC:
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Excellent review article explaining what it means to have autism from childhood
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Study showing the importance of early intense training for children with this disorder.

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A chapter discussing autism within evolutionary models of human social behavior.

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