The first workshop of the FCP 2017 Series was presented by Roma A. Vasa, M.D., and entitled “Co-Occurring Psychiatric Conditions in Youth with Autism Spectrum Disorder.”

With a calm and professional style, Dr. Vasa provided a very attentive audience with a wealth of information on her topic. She answered questions and accepted comments during her presentation, but managed to effortlessly complete all of her material. There was not the rushed feeling toward the end of the workshop that is typical of some presenters who do not limit questions. Dr. Vasa’s competent command of her topic was evident throughout the workshop.

Workshop Objectives included:

• List the DSM-5 diagnostic criteria for autism spectrum disorders (ASD)
• Discuss the prevalence and impact of psychopathology in ASD
• Explain the clinical characteristics and treatments for several common psychiatric conditions in youth with ASD

All goals were met. As promised, this informative workshop covered common mental health conditions that occur in youth with autism spectrum disorder (ASD). The prevalence, clinical characteristics, and general treatment recommendations for each were discussed and 5 case examples were provided.

Dr. Vasa also did a very nice job of clearly identifying each of her three goals, making them an integral part of a linear sequence in her presentation. The audience did not have to search for these topics, since they were embedded in the flow of her remarks.

Prior to addressing her goals, Dr. Vasa provided a brief, but satisfactory description of the history and evolving definition of Autism and Autism Spectrum Disorders (ASD). She then placed ASD within the context of other neurodevelopmental disorders, emphasizing that ASD is usually much more complex because of a large number of associated co-occurring disorders. She also emphasized that the presentation of ASD is different with each child. As Dr. Vasa stated, “If you have seen one child with ASD, then you have seen one child with ASD.” She made it clear that ASD is a multisystem disorder requiring a multi-informant/multi-method input for a complete assessment, and multiple disciplines for effective treatment. She stressed that medication is only one of many interdisciplinary treatments for ASD symptoms, and should only be used if symptoms are moderate to severe.

Dr. Vasa began discussing her first goal, “List the DSM-5 diagnostic criteria for autism spectrum disorders (ASD),” by providing a short history of ASD in the Psychiatry Diagnostic and Statistical Manual DSM). She said that Autism first appeared in 1980 in “DSM-II” as Infantile Autism. Since then ASD has evolved to the current, 2014 DSM (DSM-5), which she described as a “Live Document,” meaning that the definition is currently evolving with new research. Dr. Vasa pointed out the etiology for 95% of ASD is still unknown.

The DSM-5 describes two areas of deficits that define ASD:

1. Social Communication and Social Interaction (3 of 3 required)

• Deficits in Social-Emotional Reciprocity.
• Deficits in non-verbal communicative behaviors used for social interaction.
• Deficits in developing, maintaining, and understanding relationships.

2. Restrictive Repetitive Patterns of Behavior (2 of 4 required)

• Sterotyped/repetitive speech, motor movements, or use of objects.
• Excessive adherence to routines, ritualized patterns of behavior, excessive resistance to change.
• Restricted/fixated interests that are abnormal in intensity or focus.
• Hyper- or Hypo- reactivity to sensory input

Goal number two, “Discuss the prevalence and impact of psychopathology in ASD,” was begun with a list of 16 co-occurring psychiatric diagnoses common with ASD. Dr. Vasa said that these were considered part of ASD in the original concept. Over the years, the research discovered that none of these 16 described ,or always occurred with ASD. Each of the 16 co-occurring disorders represent a treatable, but separate disorder associated with ASD.

Dr. Vasa stated that psychopathology is extremely prevalent in ASD throughout the lifespan.

• Population cohort: 70% of youth with one and 40% of youth with 2 co-occurring psychiatric disorders.
• Clinic Sample: 95% of youth had 3 or more psychiatric disorders.
• High Rates of anxiety and depression in adults with ASD.

Regarding the impact of psychopathology with ASD, Dr. Vasa stated that these co-occurring disorders typically, aggravate, underlying ASD symptoms, increase educational and social impairment, interfere with treatment and transition planning, increase medical visits and lead to caregiver burnout.

Goal three, “Explain the clinical characteristics and treatments for several common psychiatric conditions in youth with ASD,” was addressed using research examples, and a discussion of treatment methods with case examples. Dr. Vasa discussed overlapping symptoms between ASD and some psychiatric disorders. She said that sometimes anxiety symptoms with ASD such as social avoidance can be confused with social anxiety. The difference being that social avoidance with ASD may be due to a lack of skills, despite a desire to engage with peers and treatable with skill training, rather than a social anxiety, treatable with medication. Dr. Vasa also said that depression may be confused with social avoidance, or repetitive behaviors may be viewed as ADHD. She said that without a careful diagnosis, a treatable disorder may be missed.

Dr. Vasa described a hierarchy of treatment options for co-occurring psychopathology symptoms with ASD psychosocial treatments, such as social-skills training or modified Cognitive-Behavioral-Therapy (M-CBT) for symptoms that are low to moderate, and medication for symptoms that are moderate to severe. Dr. Vasa cautioned that there are very few medications that have been approved for youth with ASD. Some antidepressants have been approved.  Other medications such as risperidone (Risperdal) and arapiprazole (Abilify) are atypical antipsychotics that are sometimes used off-label. Research shows that they reduce irritability in ASD. Also, methylphenidate has had some success in reducing symptoms of ADHD in youth with ASD.

Dr. Vasa emphasized that medications, even when effective, all have serious side-effects. The risk-to-benefit ratio must be considered before they are used. Her own philosophy when medications are indicated is, “Start low and go very slow.” As before, Dr. Vasa repeated that non-medication treatments should be tried first, and continued along with the medications.

Overall, this was another winner! In her workshop today, Dr. Vasa packed many hours of information into a very satisfying three-hour presentation. Those around me echoed my own pleasure at the extent of the knowledge that she shared. As with all good workshops, during the break, comments were positive and most participants appeared eager to return for the second half.

Any other thoughts?