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Click Here to Download 7th Annual ECMH Conference 2016 Charmi Patel Rao, MD Outline Two Sides of the Same Coin: How Autism and Trauma are Similar Explanation of the Title My Background Charmi Patel Rao, MD History of Overlap Theories AUTISM Child & Adolescent Psychiatrist TRAUMA Key Areas of Overlap September 23, 2016 Bringing it all Together Future Areas of Research Case Presentation Explanation of the Title 4yo boy living in his biological home who Two different disorders presents with aggression, poor frustration Autism represents other developmental disorders tolerance, inability to self‐regulate, and poor Two different etiologies peer interactions leading to being kicked out Areas of overlap and similarities? of two preschool settings. Differential Diagnosis? My Professional Background Child with both Trauma and Autism Board Certified Child & Adolescent Psychiatrist Complicated picture Clinical expertise in ECMH and Won’t be talking too much about this today Developmental Disabilities Rady Children’s KidSTART Clinic If differential diagnosis includes both, start Vista Hill Stein Education Center with trauma but keep autism close in mind Common themes I have seen in clinical because practice ……early intervention is KEY! Disclaimer: not a basic science researcher 1 7th Annual ECMH Conference 2016 Charmi Patel Rao, MD History of Overlap Theories Areas of Overlap Genetics Autism caused by emotionally detached mother Neurobiology (Kanner 1950s) Brain regions Autism caused by poor parenting (Bettelheim Brain pathways 1960s) Neuroendocrine factors Autism caused by intrauterine trauma Clinical presentation Infections, environmental agents, maternal conditions Attachment/Attunement Sensory processing Mostly discounted Treatment Genetics Brain Regions Anxiety disorders, particularly those involving Cerebellum social phobia, occur more often in families with autism Amygdala Compared with Down syndrome Hippocampus Particularly in children without cognitive delays Seen with MDD, OCD and other anxiety disorders too but highest association with social phobia Cerebellum Amygdala Function: Function: Motor planning, balance, coordination Formation and storage of memories associated Attention/memory tasks with emotional events Complex reasoning and problem solving Fight or flight response Abnormality seen in trauma and autism: Abnormality seen in trauma and autism: Smaller volume Higher activation in both 2 7th Annual ECMH Conference 2016 Charmi Patel Rao, MD Hippocampus Brain Pathways Function: Sympathetic Nervous System Long term memory formation Behavior regulation Abnormality seen in trauma and autism: Hypothalamic‐Pituitary‐Adrenal (HPA) Axis Dysfunction seen in both Different mechanisms Atrophy seen in trauma Abnormal shape seen in autism Sympathetic Nervous System HPA Axis Environmental Stress Hormonal Signals Neural Signals Signals from sensory receptors Sympathetic impulses Hypothalamus CRH Adrenal Medulla Anterior Pituitary Norepinephrine Epinephrine & ACTH Norepinephrine Adrenal Cortex Short‐term “fight or flight” response Cortisol Long‐term adjustment to stress Sympathetic Arousal Neuroendocrine Factors Aggression Neuropeptides: Impulsivity Oxytocin Hyperarousal Vasopressin Emotional reactivity Both involved in social behavior and communication Oxytoxin has a role in stress buffering Exaggerated startle response Hyperfocus Enzymes: Rigidity Prolyl endopeptidase (PEP) Repetitive behavior and stimming (autism) ….symptoms seen in both trauma and autism Hormones: Cortisol 3 7th Annual ECMH Conference 2016 Charmi Patel Rao, MD Cortisol Elevation Clinical Presentation Emotional dysregulation TRAUMA AUTISM Tantrums/meltdowns Re‐traumatization Play interactions Aggression Hyperactivity, impulsivity Memories of trauma Novel environments Sleep disturbance Feeding difficulties Environmental triggers Eye contact Difficult peer interactions/difficulty with social engagement Flashbacks Social interactions in general Difficulty with transitions Kicked out of preschool/daycare setting Developmental Delays PuttingSensory it Processingall together Underlying Etiology / Genetics Speech and language delay Fine motor delay Gross motor delay Trigger Cognitive delay Sensory Processing Brain Pathway And of course… Social‐emotional delay Clinical Presentation Definitions Sensory Processing and Trauma/Autism Sensory processing: how the nervous system Some but not all children with trauma have manages incoming sensory information and Sensory Processing Disorder generates responses Some but not all children with autism have Sensory integration: how the body’s 8 senses Sensory Processing Disorder work together to create the body’s responses Sensory processing disorders: difficulty MOST children with trauma or autism have taking in and interpreting sensory information some challenges with sensory processing so that an appropriate response can be generated 4 7th Annual ECMH Conference 2016 Charmi Patel Rao, MD Attunement and Attachment Attunement and Attachment (continued) Attunement = how reactive a caregiver is to a Disconnect in the child’s emotional needs and moods development of attunement Attachment = emotional bond that typically and attachment in both cases forms between infant and caregiver by which the Interestingly, children with infant gets primary needs met autism are shown to have the ability for secure attachment, Engine of subsequent social, emotional and cognitive especially if no cognitive development delays Development of many neural pathways dependent on a Strongly based on caregiver’s child’s attachment relationship attunement Good attunement helps establish good attachment Treatment: General Points Common Goals of Treatment Some treatments overlap Diminish autonomic arousal Makes sense when looking at the underlying Improve emotional regulation neurobiology and involvement of sensory Increase emotional expression processing Engage cognition Obviously there is a need for treatment to be different because the underlying etiology is still different Non‐medication and medication approaches Therapy: Common Themes Treatments (medication) Dyadic therapy approach Alpha‐2 agonists (guanfacine, clonidine) Calming physiological reaction to stress can calm the ASD: less so for ABA, seen in RDI and DIR Floortime psychological reaction to stress Helpful for impulsivity, anxiety, hyperarousal Emphasis on co‐regulation Sensory strategies Antidepressants (SSRIs) Can be helpful for anxiety and mood symptoms and possible Movement tools impulse control issues Mindfulness Side effects: akathisia, worsening agitation, anxiety Referral for other developmental services as Stimulants needed Not particularly useful for hyperarousal state Can cause worsening of anxiety symptoms 5 7th Annual ECMH Conference 2016 Charmi Patel Rao, MD Future Areas of Research HPA Axis Sympathetic Nervous Better understanding of the genetics of autism Better understanding of a genetic link between System trauma and autism TRAUMAAUTISMSummary Better understanding of the early parts of the cascade that leads to abnormal activation of the Sensory Processing HPA axis and sympathetic NS Role of epigenetics for both trauma and autism Acknowledgements Questions Professional Mentors/Colleagues My patients Family 6.
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