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

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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

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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

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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

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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

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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

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