6/15/2017
“Autism in Adults: Changing the Brain to Improve Behavior” Bureau of Autism Services June 7, 2017
Nancy J. Minshew, MD Professor of Psychiatry & Neurology Director of Autism Research Program University of Pittsburgh www.pittautismresearch.org
Teaching Objectives
• Adult brain in autism is plastic and changes with treatment- treatment effects are not “skin deep” • New treatments address challenging behavior and improve function- also change brain circuitry • New treatments focus on active learning: a lesson, practice, report, and repeat (Think Toast Masters) • Visual supports important • Direct brain stimulation from scalp has considerable promise for changing treatment in the next decade- delivered in combination with effective cognitive program
1 6/15/2017
Learning Objectives
• Recognize cognitive components of behavior that are obstacles but can mediate change • Understand the wide disconnect in ASD between facts they recite and their capacity to use them to understand themselves and the world • Critical importance of environment and staff in bridging the gap • Appreciate high rate of anxiety, intolerance of uncertainty, depression, suicidality and psychosis • Become familiar with interventions • Become aware of trauma and PTSD
Autism Spectrum Disorder (DSM-5)
• Autism Spectrum Disorder is defined by underdevelopment (child-like state) of skills for being social, communicating, recognizing and regulating emotions, understanding concepts, and problem solving.
• And a major impairment in functioning in a dynamic world, e.g., adaptive function.
2 6/15/2017
65 y.o. man with ASD • Diagnosed with schizophrenia until age 47 despite no psychosis and preschool onset • Hospitalized at age 4 for 6 years for temper tantrums; state hospital from age 14-18 • Looks his age, speaks in sentences, loud, funny, pleasant, agreeable, polite, friendly (sort of), super memory, endearing because he is childlike • Never lived independently • Repeated admissions for verbal and physical aggression
• RC Video
• ADOS Video
3 6/15/2017
Not Obvious But Critical Facts • Mental age: concepts below preschool level- he recognizes certain simple rules; no insight or judgement; cannot problem solve; just agrees or says what he thinks you want to hear • Social contact is brief, superficial, one-sided, and he is solitary and sound sensitive; polite but no interpersonal social skills: does not do well in social settings • His language is confined to repeated stereotyped sentences- comprehension poor • Life long history of poor emotion regulation
What did not work
• Diagnosis of schizophrenia or bipolarism • Crowded residences with disruptive clients • Escalating medications • Repeated hospitalizations • Telling him he had to accept the way things were- accept what to him was intolerable but others did not see that- they did not see him
4 6/15/2017
What Worked: Success at 62 years old • Passavant Memorial Homes- 3 residents with ASD all in retirement range, calm, go their own way during day, home by 4 pm • ASD calm, savy stable staff, communication among team goes through 2 staff; • They have learned about him + my long experience with him (his suit list) and twice yearly input (crime shows/sports) • Understanding what his behavior means about his thinking to determine a reasonable response • Leaving situation and self-calming approaches
Match Services to Needs
• We really don’t know most clients well enough to define their needs • Test scores provide limited insight • Look at Vineland Adaptive Behavior Scores, sentence and paragraph comprehension, & processing speed
5 6/15/2017
Begins With Identifing Functioning Level • Close your eyes so you are not confused by the person’s age or appearance, ignore language level, and ask yourself how old is a child when they act, think, or say things like this? • Watch how they function to figure out what they understand and what their words mean • Think about the emotions they display and what triggers them • Revise your estimate, repeat above • Requires a team- many eyes & much reflection
Think About Behavior In Components: Then figure where they derail • Content inappropriate (context, age) • Emotionally inappropriate • Lacks empathy, perspective taking • Impulsive, speak/act without thinking • Not understanding, not getting the big picture • Not thinking ahead/ no capacity for delay of gratification for longer term gains • Disorganized • Lack of motivation or incentive
6 6/15/2017
Adaptive Function Is A Cognitive Deficit in Its Own Right in ASD • Highlighted by ASD cases with IQ> 70 and unremarkable neuropsychological test results except for very low Vineland Adaptive Behavior Scores and perhaps slow processing speed • Sum of identified deficits does not explain limitations- there is an added dimension to their deficits • Its about how to use information to understand oneself and the world • This is why new treatments focus on learning by doing and listening to what peers think
Neural Representation of Adaptive Behavior
• It has its own brain circuitry • Beginning to image it • Objective measure of response to treatment
7 6/15/2017
Representation of Self in the Brain
8 6/15/2017
PLoS One. 2014; 9(12) Published online 2014 Dec 2
PLoS ONE 9(12): e113879. doi:10.1371/journal.pone.0113879
9 6/15/2017
Self Esteem, Adult Identity, Values • All underdeveloped and not addressed • Bullying is extreme • Focus is on their behavior and more treatment • Good and bad character traits never discussed • No one says what they like about the person w/ ASD • Often never feel valued or comfortable • Need affirmation, safe places, recreation • Volunteering can be affirming • Sense of competence and self-determination- “I can do this” “I am seen as a person”
Reduced Speed of Processing Also a Major Contributor to Impairments • May or may not be apparent in test scores • All are slow processors • Limited capacity to process larger amounts of information and multiple inputs (complexity) • Most obvious in novel, unrehearsed settings • Result of functional underconnectivity between brain regions
10 6/15/2017
Adding Electrical Wiring This Way Decreases Available Electricity
Abundance of white matter tracts: to an even greater extent in left than right hemisphere
Left Right Left Right
Autism Matched typical Male Male Aged 20 Aged 23
11 6/15/2017
Impaired Face Processing As Another Often Unrecognized Deficit
• Face identity • Face emotion recognition and expression • Most common brain abnormality in ASD is FFA • Essential to perspective taking, and thus to social interactions • Very impairing
John Robison Switched On • Sudden acquisition of face processing skills after rTMS brain stimulation in Harvard study • Finally understood what people were feeling, and then could respond empathetically • Went from so unable to work in groups to a faculty position, membership on numerous federal committees, international advocate- successful positive contributor and influence
12 6/15/2017
The brain as the origin of symptoms in autism
And therefore the ultimate target for treatment.
Activation During Spatial Working Memory Task Shows Absence of Higher Order Brain Circuits
Front of head & brain Notice absence Red is of brain decision activity making during wiring in decision autism making
Back of head & brain Healthy Autistic Individuals Individuals
13 6/15/2017
Reliably lower functional connectivity for autism participants between pairs of key areas during sentence comprehension (red denotes lower connectivity)
Imaging Insights About the Brain in ASD Processes Information (Thinks) • Rely on word processing v. integrative sentence processing • Rely on visual system to code language symbols v. language system • Rely on visual imagery in language comprehension • Likewise see faces with visual system but not social and emotion systems
14 6/15/2017
Brain Circuitry Changes In ASD With Treatment
Brain Systems Are Plastic in ASD, But Not in All and Not Enough • Several interventions repair cortical systems in toddlers, preschoolers, and adults. • Hence, behavioral and cognitive interventions have biological/brain effects. • Is plasticity measureable to predict intervention outcome and can plasticity be amplified to shorten treatment time?
15 6/15/2017
Progress in Understanding Mechanisms Has Led to Advances in Treatment • Interactional treatments for infants, toddlers, and preschoolers (Early Start Denver Model, PRT) • Cognitive rehabilitation treatments for those with language and IQ scores in normal range (PEERS, Mindfulness Meditation, CET, EST, UOT, JASPER) • Brain stimulation methods- “emerging” • Combinations of the above, individualized, likely to be most effective • Neurobiologically driven drug approaches to change brain development- greatly needed for those severely affected- disappointing so far
16 6/15/2017
54% & 70% of those with ASD have one or more other mental health conditions
• ADHD 30-61% • Anxiety Disorder 11-42% • Depression 7-26% • Bipolar Disorder 6-27% • Schizophrenia 4-35%
Differentiating Comorbidity From Autism is Key
• Substantial overlap between ASD symptoms and symptoms of these disorders • Major problem historically has been over treatment with medications that do not work • Medications should be third line, started at low dose, and stopped if don’t clearly work • Best resource: an ASD expert who can tell the difference
17 6/15/2017
Sondra Williams Autism Speaks Website
“My anxiety can be so profound because of the fear of social expectations, sensory violations and unexpected changes.
These are all so unbearable that I can feel frozen and unable to move forward.
A simple request of me can sometimes be the core trigger of a meltdown.”
Addressing Anxiety
• Decompose into contributing components • Modify environment & staff expectations • Repeat again and again • CBT modified for ASD • Work on regulating emotional responses • Work on cognitive framing and strategies • Start low, go slow for exposure to stressors • Low dose SSRIs • Do not rely on medications!
18 6/15/2017
Traumatic Experiences & PTSD
• Not surprising • Probably universal • Rarely considered in differential diagnosis • Sondra Williams could easily have PTSD
19 6/15/2017
Cognitive Behavioral Therapy Techniques
• Identify motivations for change- theirs & yours • Identify situations that are problematic • Identify their negative thoughts and find positive thoughts and a logic that makes sense to them • Find examples of positive behavior • Role-play • Gradual exposure to feared situations
Depression & Suicide
• Depression rates rise with age and intellectual ability suggesting a painful awareness of autism’s social challenges and isolation. • Screen for depression as a routine part of care. • Screen for suicidal ideation routinely • Attempts are occurring
20 6/15/2017
Recognizing Depression: Any Unexplained Regression in Function or Behavior • Signs and symptoms include chronic feelings of sadness, hopelessness, worthlessness, emptiness and/or irritability. • Also common: social isolation, moving or talking slowly, feeling restless, and having trouble sitting still or concentrating. • Can include frequent thoughts about death and/or suicide.
Schizophrenia, Psychosis • Described with 22q syndrome • SZ does occur but definitely Work in Progress • Important to differentiate concrete thinking in ASD that gets looser under stress but reintegrates with structure v. true thought disorder in SZ • Be aware those with ASD can copy symptoms of those around them with schizophrenia • Safeguard: Ask them what they mean by the words they use wrt hallucinations & suicidal thoughts (don’t tell them the definitions)
21 6/15/2017
Bipolar Disorder Diagnosis in ASD
• Actually rare but often diagnosed in ASD • Affect lability reflects the emotion dysregulation that is typical of autism and • Their developmental immaturity • No training/teaching to build this vital skill
22 6/15/2017
http://well.blogs.nytimes.com/2016/06/02/usi ng-meditation-to-help-close-the-achievement- gap/?smprod=nytcore-iphone&smid=nytcore- iphone-share
23