Understanding Autism: Key Insights from DSM-5 to Intervention Strategies

Music. Let's listen in. Goals for today's presentation are to help understand the DSM-5 diagnostic criteria for ASD or autism spectrum disorder, differentiate the autism spectrum disorder from some of the neurodevelopmental disorders and the social communication disorders, look at some of the common commodities, how there is like an overlap of symptoms, and then we'll also briefly review the evidence-based behavioral and pharmacological interventions.

Right so autism spectrum disorder as probably most of your aware is a neurodevelopmental disorder that impacts people interact with other person social communication their learning and their behavior now it is a developmental disc it is described as a developmental disorder however it can be diagnosed at any age it is described as a developmental disorder because the symptoms generally appear in the first few years of life are noted or recognized in there.

A little bit about the prevalence in epidemiology. As per the 2023 data from CDC, 1 in 31 children aged 8 have been diagnosed with autism spectrum disorder. Globally, the prevalence in 2021 was around 1%, although it is still increasing with better evidence and improving access to cares. It is more commonly diagnosed in males compared to females, and it's about like four is to one ratio, three to four is to one ratio, depending on which study you look at.

The average age of diagnosis is about four years, although the symptoms and signs are recognized even earlier. Now, what causes autism? It appears to be a combination of several genetic and environmental factors. There definitely appears to be a very strong genetic predisposition. The current heritability estimate for autism spectrum disorder is about 0.83, which indicates it's a very strong genetic component.

Some of the environmental factors that's associated with higher risk of autism include like prenatal exposures to toxins, drugs, infections, and even some prescription medications. Increased parental age is another risk factor. There is also some association between untreated and undertreated mental illness during pregnancy and autism in the offsprings.

One thing that needs to be emphasized, because there is a very strong myth out there, is that there is no evidence to suggest any association between vaccines and autism. Several large studies done in multiple countries have confirmed the same. So this is a myth that needs to be broken. And talking about myths, there are several common myths about autism.

We already spoke about the vaccines. Now, there's another myth that autism is only a childhood condition. Adults do not have autism. That's not true. Once diagnosed with autism, they have autism for life. It cannot be cured. So far with the current treatments and the interventions, we do not have a cure for autism. We can only manage the symptoms with behavioral and pharmacological interventions. Some people learn coping skills and mask their symptoms, but it cannot be completely cured.

Not all autistic people have a special talent, or not all autistic people have learning disabilities. Autistic people are antisocial. This is another common myth.

The difference between people who have autism and antisocial personality disorder is that in autism, they have in the individual has a deficit in understanding the social norms of the social rules whereas an and whereas an antisocial person they understand the rules but they just disregard they don't care for the rules only boys are artistic again it is seen across all genders it's just that boys or males are more diagnosed with autism and it is not caused by bad parenting,

Now, the good parental support, kids or individuals can develop better coping skills, masking skills, but just autism is not the outcome of bad parenting.

Now, before we jump into the diagnostic criteria, I would like to emphasize that autism is a spectrum disorder. If you've met one person with autism, you've only met one person with autism because they're like, each individual is like highly unique and they exhibit different challenges and abilities. This course is to highlight the importance of recognizing the diversity within the autism community and avoiding generalizations.

Now, coming to the DSM-5 diagnostic criteria, which guides us in the diagnosis of ASD, the essential features of ASD are broadly organized into two sections. Part A, or criteria A, which discusses about the deficits in social communication and interaction. And then that criteria B, which discusses about the restricted repetitive patterns of behaviors, interests, or activities.

Now, for someone to be diagnosed with autism, They need to demonstrate the deficits or issues in all the three areas that's shown here, which is the social-emotional reciprocity, nonverbal communicative behaviors, developing, maintaining, and understanding relationships. What does that mean? We will look at them individually. So social-emotional reciprocity, it can be described as the ability to engage with others and share thoughts and feelings.

Now when someone has deficits in social emotional reciprocity and it it varies according to the age in young children it can manifest as like little or no showing no initiation of social interactions, no sharing of emotions they would probably like have a hard time approaching peers on the playground they are interested but they can they do not know how to approach they typically wait for others to approach and sometimes it can be as severe as even if someone else approaches,

they just ignore them. Now, in older kids and adults without intellectual disability or language deficits, it can manifest as difficulties processing and responding to complex social cues, like how to join a conversation, when to join, what to say, what not to say. Also, some individuals have deficits in understanding jokes or sargasm. They have a hard time understanding, and they take the very concrete content of what is said instead of applying to the situation.

They have difficulty with conversing with peers on a general basis. And this is not exclusively with peers. It can also be with family members. Some individuals who have developed compensation strategies for some of the social challenges, they still struggle when they're in a novel or a new or unsupported situation. And they can struggle with anxiety when that happens.

The second part, the nonverbal communicative behaviors, deficits in this can manifest as a typical use of eye contact, gestures, body language, speech and intonation. An early feature which depicts this of autism, how this manifests is like impaired joint attention. They typically do not point to things that they are interested in or they do not share their interest.

They have a hard time following someone's pointing or eye gaze they often fail to use expressive gestures spontaneously in communication among young people and adults with fluid language where there is no deficits the difficulty in coordinating non-verbal communication can be seen as like odd or like wooded or exaggerated body language not only do they have issues with showing appropriate body language, they also can represent,

misrepresent, or misinterpret other's facial expressions or their body language. And the third component of the social communication, developing, maintaining, and understanding relationships. This can manifest as absent, reduced, or atypical social interest.

It can manifest as light rejection by others A passivity or inappropriate approaches that seem aggressive or disruptive, In young children, there is often lack of social play, an imagination Older individuals, they must struggle to understand what behavior is considered appropriate in one situation but not to the other, Frequently, there is a desire to establish friendships Without a complete or realistic idea of what friendship entails,

Again, when considering all these social communication areas, we need to consider what is the norm for the age, gender, and the culture.

Moving on to criteria B, so the criteria A is the social deficits, and then the criteria B is the restricted repetitive patterns of behaviors, interests, or activities. Here, out of the four, you only need to meet the criteria at least for two of them.

Some of the features are stereotype repetitive movements or speech, insistence on sameness, inflexible adherence to routines or rigidity, highly restricted fixated interests and then the sensory issues which could be like hyper or hyper reactivity to sensory input, now what does stereotype repetitive movements or speech look like it can be like a simple more water stereotypy like hand flapping finger flicking or like rocking movements,

and what we usually call stemming repetitive use of objects like spinning coins lining up toys by color that can be another one Repetitive speech can present as echolalia, parroting of words, stereotype use of certain words or phrases that they see on TV. Individuals with limited language skills, it can present as high-pitched screeches or animal noises.

Then the rigidity or the inflexible entrance to routines and insistence on sameness, this can manifest as resistance to change there is like distress at like very small changes also like for example eating a different breakfast or like going to taking an alternative route to school or work they need to adhere to those strict strictly there is also rigidity in thinking they might need to wear the same clothes every day or they might need the same breakfast or same color

things every day there is ritualized patterns of verbal and non-verbal behavior like repetitive questioning or like pacing a perimeter that also is kind of like um inflexible at translate routine highly restricted and fixated interests here the emphasis is on the abnormal intensity. The focus of the interests. And it also can be a typical one, what is not normal for their age.

Now, as we know, in toddler age or sometimes even in school age, kids have fixation on certain objects, what we describe as transitional objects. The way to kind of differentiate them is that transitional objects offer comfort and security while hyperfixations are intense and take a lot of the individual's time and get in the way of their social interactions.

Okay and then the other common presentation is sensory issues they can either be hypersensitive to sensory input like very sensitive to loud noises certain textures foods or it could be hyper reactivity meaning like they have high very high point tolerance so you might see someone who comes to the emergency room or to your office with like a big injury to the head they don't care about it. You might be anxious or scared about it, but they don't really care about it.

Their pain tolerance can be high. Now, not everyone is the same, but they can either be hyper or hyper. Again, because of the sensory issues, we have a lot of challenges they can have because of, let's say, they're having sensitivity to food textures, then it can also lead to feeding disorders. So among the criteria B, again, you only need two out of the four to meet the criteria for autism spectrum.

Of the additional requirements the symptoms need to be present in early developmental period but they may not become fully manifested until the social demands exceed limited capabilities, or may be biased by learned strategies the symptoms should cause clinically significant impairment in functioning either in social occupational or other areas the disturbances are not better explained by just idd or global developmental delay now idd and autism they can frequently co-occur,

but to make a comorbid diagnosis of ASD and IDD, the social communication should be way below that expected for the general developmental level. And then, according to the DSFI, one of the specifiers is the level of support. So if you see level one, level two, level three, that basically indicates the level of support that they need.

Previously, it used to be called high functioning autism or low functioning autism but those are outdated and they're somewhat like dangerous because it doesn't truly depict the strengths and the challenges of an individual so instead of that the better way to kind of describe it is the level of support that they would need level one being like the minimal support that they would need and level three being the highest level of support they would need for

example in level one they might just need some therapy individual therapy or life skills coaching because they don't, their deficits are very subtle or the stress is like not as intense, when they're during transitions level two they require substantial support let's say because of their atypical social behaviors or like excessive interest in the specific topics or the distress is like much more noticeable when faced with the change,

This level would be like the accommodations that we talk in school, like help with their reading, their social skills support. They might need social skills training. Level three, requiring very substantial support. That means these individuals have severe problems with communication or severe stemming behaviors. The distress is too extreme when asked to switch tasks or with transitioning.

These individuals with level three they might need one-on-one aids and for communications they might need aac tools like augmentative and alternative tools picture symbols or like electronic devices to communicate so now we looked at the diagnostic criteria based on dsm-5 now let's say when should we screen and how do we diagnose autism so the screening tools more than me. Pediatricians in the group can definitely are more familiar with that.

I'm familiar with the MCHAT and the ASQs, but not with the other screening tools. The American Academy of Pediatrics suggests that autism screening should be a part of standard 18 and 24-month well visits. And the National Center on Birth Defects and Developmental Disabilities recommends that all children should be screened at ages 9, 18, 24, and 30. The MCHAT, which is the one that's frequently used is basically a modified checklist for autism in toddlers.

It's a specific screening tool for autism recommended by the AAB that should be administered around 18 and 24 months. It consists about 20 questions about the child behavior, and then the results will let one know if they need a further evaluation for autism.

The ASQs, on the other hand, they're not specifically designed for like autism screening but they can be used to identify children who may require further evaluation by especially if their communication domain score is like below the cutoff. Once the screening is done, then you can either administer the diagnostic tools or refer them to a psychologist or people who are trained to administer the diagnostic tools.

The CARS and the GARS, those are the Childhood Autism Rating Scale and the Gilliam Autism Rating Scale. They don't need very specific training to administer them. It usually takes input from the teachers or for the parents in the first and then some of the other caregivers or teachers. And they can kind of indicate the possibility of autism spectrum.

It was the autism diagnostic observation schedule that is kind of the gold standard for collecting objective information about social communication. And however, one of the major limitations is that it is more time consuming and it requires specialized training to administer the test. However, it has strong psychometric support and is widely used in clinical settings.

Often times insurance companies want the diagnosis to be made using an ADOS so that they can approve those services like the AV therapy. It's important to diagnose or catch the diagnosis of autism at an early age because there are several benefits.

At an individual level, because of the brain plasticity in early childhood, if there is early intervention, there is enhanced better outcomes with cognitive, language, and social-emotional functioning. This can reduce the child's frustration and also enhance the quality of life. It reduces the risk for developing psychiatric comorbidities like anxiety and depression later on in life.

At a family level, it provides them with the support, with the knowledge at an early time, which can kind of help them facilitate better coping mechanisms with the kids. And it also reduces parental stress, has improved better family outcomes. And from a society or the community point of view, it definitely has some significant long-term cost savings because there is reduced need for intensive interventions like crisis interventions in patient psychiatric hospitalizations.

There is also better social outcomes when we intervene early and because of that, they are easily integrated into the society and have greater independence in adulthood.

All right. Now, while there are benefits, there are also some dangers of early diagnosis. However, I believe the benefits definitely outweigh the risks. Some of the potential risks are like there is a danger for being labeled and stigmatization, which can again impact the self-esteem of the individual.

There is a risk for over diagnosis or misdiagnosis although it can provoke anxiety and high stress level in parents again the risks of that are like the benefits of that outweigh the risks because, with early intervention later on the stress levels and anxiety can be better. What are some of the challenges with making the diagnosis? We have the definitive diagnostic criteria. We have several diagnostic tables. What are the challenges or barriers for making a diagnosis?

One, as you already probably understand, we have to rely on the parent report a lot. And if the parents have their own biases or if they are not cognizant or not too aware of recognizing some of the subtle symptoms, it can be challenging.

They may not bring the it for like evaluations or even when they bring in for the evaluations their report could be biased or not sufficient now the individuals themselves or the patients they themselves can have like, not much insight into the symptoms so they might not be able to convey the information appropriately now with our reducing times appointment times we are only seeing like a snapshot of the system or like of the individual so that we don't know what are some

of the struggles they're experiencing in school or in like other areas unless it's like severe.

Presence of like other neurodevelopmental disorders like adhd language delays speech delays or idd they can kind of impact our ability to diagnose accurately and sometimes during the short visits that they are brought in the individuals can like mask the symptoms for a while some of the differential diagnosis again idd it can exist it can be diagnosed along with autism spectrum disorder speech delays language disorders that's another area social pragmatic communication disorder or spcd

this is something that has been introduced in the dsm-5 in a minute we'll look at how to differentiate between ASD and social pragmatic communication disorder, social anxiety, and ADHD. Now, ADHD is highly comorbid with autism spectrum disorder, almost like one in two kids. So one in two or three kids. So it's about like 30 to 50% overlap in the symptoms. There's a lot of overlap of the symptoms between ADHD and autism spectrum.

Let's say there is a kid who has short attention span or they have impulsive behaviors or because of their hyperactivity, they are not able to sustain a conversation with an individual. This can be perceived as poor social communication. Also, because of their impulsivity, they might not be disliked and might have problems with making relationships or friendships with other individuals. And so this can be mistaken for autism spectrum. And there is a high overlap between the two, in any ways.

So one of the things that can be done is probably treat the ADHD first and then evaluate if there is a suspicion for both of them.

What is social pragmatic communication disorder and how is it different from autism spectrum. Superficially social pragmatic communication disorder is asd minus the restricted and derivative behavior so if they meet the criteria remember the criteria a part a criteria for making asd diagnosis if they only have that not the criteria b then it's basically social pragmatic communication disorder, they would benefit from social skills training.

Now, autism and social anxiety disorder, sometimes social anxiety disorder can be perceived as autism. In autism, there is a difficulty in understanding the social norms regardless of the judgment, whereas in social anxiety, there is a fear of social judgment.

Now, individuals with autism can still develop social anxiety when social anxiety when it's social anxiety just by itself there is preserved social skills like in asd autism ocd they also have an overlap of symptoms so it's important to differentiate when it is ocd and when it is the serial stereotypical behaviors from, autism in ocd there is like intrusive thoughts and the rituals are like driven by anxiety there is a lot of anxiety.

Whereas in ASD, the stereotypical behaviors or repetitive behaviors are just comfort seeking. They're not driven by anxiety. Again, this is a picture or table depicting the common comorbidities in ASD. As we can see, this is only from one study, so I would take it with a grain of salt. If you look at it, there is a very high comorbidity with ADHD, almost like 50% plus. Then there is like anxiety spectrum disorders, whether it's generalized anxiety.

I'm surprised that's only 2.4%, but there's like very high specific phobia and social phobia. Then there's mood disorders. I hear only MDD is shown in the picture, which is about 20%. And then there is OCD, which is about like 40%, if you consider the subsyndromal symptoms. They did not show like, again, schizophrenia. I highly doubt it. Still seen in kids or individuals with autism spectrum still have schizophrenia.

Now, as we discussed earlier, you know, because of the sensory and the texture issues, individuals who have autism spectrum are at a very high risk for feeding disorders. One in three, or I'm sorry, one in three out of four kids who have autism spectrum disorder have problems related to eating, and they can manifest as either pica or rumination disorder, ARFID, which is the avoidant and restrictive food intake disorder. PICA and ARFID are the ones that are most commonly seen.

And then rumination disorder and then anorexia, bulimia, they're seen less frequently. Another picture basically showing the high comorbidity with intellectual disability, ADHD, and some of the associated features. Anxiety, problems with mood, sleep issues, that's a big thing. Again, GI issues because of sensory issues, that is another big thing. Seizures is also very highly, about one-third of the individuals with autism spectrum can have seizure disorders.

Now how do we manage autism so this is a very important part again it needs a team effort pediatricians behavioral therapists speech-language pathologists occupational therapists psychiatrists child psychiatrists psychologists school counselors all everybody plays an important part along with parents of course during management of autisms oftentimes you need to make several referrals including for like if for its diagnostic purposes neuropsychology or autism diagnostic evaluations for speech

delays they need speech therapy for sensory issues occupational therapy or feeding therapy behavioral therapy for like aba dir or teach again they need They probably need like several accommodations in school and support and advocacy is a very important part. I know there were some questions about support and advocacy and I'll answer when we get to the end.

The different types of behavioral therapy available for autism aba that's kind of like the most known and the gold standard it's most approved by insurance companies also, it's basically breaking down the skills into manageable parts and it uses positive reinforcement to get the desired behaviors it is you need a trained bcba for investing aba, or like at least a registered behavioral technician and it's delivered for about

20 to 40 hours for it to be most of per week for it to be most effective the dir or floor time as it's known, this basically involves one to get on the floor with the child to play and do the activities they like it's meant to support emotional and intellectual growth by helping them learn skills around communication and emotions another therapy is teach which is treatment and education of autistic and related communication

handicapped children this was developed at unc this treatment uses visual cues just picture cards to help your help one's child to learn everyday skills like getting dressed information is broken down into small steps so they can learn it more easily, then there's another one called the pecs the picture exchange communication system this is another visual based one it uses symbols and stop picture cards and the child learns to ask questions and communicate through special symbols

again of all the behavioral therapies aba seems to be the most evidence-based and goal standard. Occupational therapy can be helpful for sensory integration, improving fine motor skills and daily living skills. Social skills training is more useful for older children and adolescents. In this, there's role-playing, peer interaction, and it can be both individual as well as group.

Pharmacotherapy, this is basically where we as child psychiatrists come. Of course, we also play a role in care coordination, but most of the times the kids are referred to us for medications. Now, there is only two FDA-approved medications for management of symptoms in ASD. One's risperidone from the ages of 5 plus is for irritability and aggression, and eryproprazole Abilify, age 6 plus, again approved for irritability.

Now because these medications are approved for FDA, these are not the only medications. We use several other second generation antipsychotics off-label. Most important thing when using these medications is to monitor for the metabolic side effects and extrapyramidal side effects. Especially with Iroproposol Abilify, you can see like a paradoxical reaction like increased aggression and irritability.

That's probably especially in the individuals who are non-verbal they can experience akathisia but they do not know how to express and then that comes out as irritability and aggression. So monitoring for like EPS is very important now there are like several medications we use off-label if there is autism with like comorbid ADHD we use stimulants as still as the first line medication we just need to monitor for like any increased aggression alpha-agnes like guanfacine and clonidine are used.

Whenever we're using medications, we need to make sure that we start at low doses and titrate them very gradually. And for managing autism and anxiety, we still use SSRIs like fluoxetines or loft. Just we need to make sure we're monitoring. We need to monitor for activation side effects.

Autism and OCD, again, SSRIs. higher doses are not often required but still behavioral therapy which is exposure and response prevention adapted for asd it's it is the main state of treatment, Again, for sleep, melatonin, clonidine, we have several other medications that we use, but the most commonly used ones are melatonin, clonidine, and hydroxine. Again, each individual is very different, and so we have to adjust the medications accordingly.

I think we have time to go over a case. Okay, yeah, I think we can go over a case. This is a case example. This is a 12-year-old boy who presented with temper tantrums. He was brought in by his mother for psychiatric evaluation of temper tantrums after being referred by the school. There was also some declining school performance. Shortly after starting middle school, Brandon started complaining of stomachaches on a school day morning and was often reluctant to go to school.

After reading till here, my first thought would be social anxiety, which is still the case. I would suspect school refusal with social anxiety or some possible bullying. Those would be my different shoots. Brandon's sixth grade teachers reported that he was academically capable. So it's not in learning disability mostly, but he had a hard time making, he had little ability to make friends.

Okay, so there are some social concerns here. He seemed to mistrust the intentions of classmates who tried to be nice to him, but attempted to befriend others who laughingly feigned interest in toy cars and trucks that he brought to school. So the statement indicates two features, which is basically, you know, he has a hard time reading others, misinterpreting others' intentions. So there is some problems with social communication, and he also seemed an interest in toy cars and trucks.

If it was an elementary school kid, that's a little different for someone to be excessively interested in cars and toys in a middle school. It's slightly typical. When interviewed alone, Brandon responded with non-spontaneous mumbles. When asked questions about school, classmates and his family, when the examiner asked if he was interested in toy cars, Brandon lit up. He pulled several cars, trucks and airplanes from his backpack and while not making good eye contact.

They've talked at length about vehicles using their apparently accurate names, front-head loader, V-52, Jaguar, etc. And then asked again about school, Brandon pulled out his cell phone and showed a string of text messages like, Dumbo, Mr. Stutter, Loser, Freak, Everybody Hates You. So now this raises the suspicion of problems with social communication and again, the increased interest or fixation on cars and trucks.

Brandon added that other boys would whisper bad words to him in class and then scream in his ears in the hallway. And I hate loud noises. So some hypersensitivity to sounds. He also told the examiner that he sometimes wished that he had never been born. Now, that is a little concerning. We always have to pay attention to those. and evaluate further. Developmentally, Brandon spoke his first words at the age of 11 months and began to use short sentences by age three.

So his speech language skills seemed to be appropriate at that age, at least. He had always been very focused on trucks, cars, and trains. According to his mother, he has always been very shy and never had a best friend. So somewhat thriving in isolation as he has gotten older it has become more apparent that he struggles with jokes and typical adolescent banter because he takes things so literally. He has issues with, this would be the part where they not only misinterpret.

Brandon's mother had also seen this behavior as a little odd, but added that it was not much different from that of Brandon's father, a successful attorney who had similarly focused interests. Both of them were sticklers of routine, who lacked a sense of humor, because they probably don't understand humor, then the high rigidity.

Brandon's mother noted that he had made efforts to conceal his interest in trucks, cars, and trains outside of the home But would eagerly speak about them when encouraged So there seems to be, he has learned masking behaviors and develops some coping skills, Brandon had shared with his mother that he tries to appear normal So he has some awareness that he is probably not typical when interacting with peers at school, which is exhausting,

He often feels nervous around peers and generally tries to avoid socializing. On examination, Brandon was shy and generally not spontaneous. He made below-average eye contact. His speech was coherent and goal-directed. At times, Brandon stumbled over his words, paused excessively, and sometimes rapidly repeated words or parts of the words. So, probably some stuttering. Brandon said he felt okay but added that he was scared of school, particularly when around other children.

He appeared sad, brightening only when discussing his toy cars. He denied current suicidal ideations or plans, as well as hovicidality. He denied psychotic symptoms. He was cognitively intact. Any thoughts? Okay, so basically, he would meet all the three criteria for social communication, deficits in social communication.

He at least has two of the criteria for like the repetitive restricted interests and patterns of behavior so i think he would meet a diagnosis of autism spectrum disorder and in addition possibly no intellectual disability at least based on the information that we have here i would say he would probably be level two and would need some at least some accommodations in school at social skills training he i would say in addition to autism he probably also has stuttering disorder all

right okay that's that's my case again, thank you everyone for all that you do i know you play a very important role in coordinating care for some individuals who have Autism Spectrum Disorder.

I can take questions now, Dr. Badapati for that excellent talk. Looks like we do have a few questions in the chat. I can go ahead and read those off to you. Looks like we had one say, sometimes as patients grow up, the parents request retesting to see if autism label can be removed. Can the label be removed if patient is doing better with time? So again, if it is true, if they were rightly diagnosed as autism spectrum disorder, then it probably is not going away.

It is possible that when they were diagnosed earlier, it could be a misdiagnosis. That can be a time when it can be helpful. And again, I understand the parent's concern that they don't want to label the child as autism spectrum. Again, if they are not needing any supports or services, then it probably need not be included in the chart. But at some point or the other, it might probably again come up.

Thank you. And then another question read, can a patient with autism diagnosis also be diagnosed with mental retardation or diagnosis? Yes, definitely. So we don't use mental retardation anymore, but the intellectual developmental disability in the DSM-5, they can both coexist. However, if one has a diagnosis of intellectual disability disorder, as we discussed earlier, the social functioning should be lower. So, for example, let's say because of IDD, the kid's developmental level is at five.

They could be 10, but the development level is at a five-year-old. The social communication issue should be below that of a five-year-old. And that's when we can co-diagnose autism spectrum along with IDD. So yes, they can both be diagnosed together, IDD and ASD. Another question reads, when a diagnosis is made, does it specifically state in the diagnosis which level the patient is experiencing? It's a specifier. So the diagnosis of autism can be made and then the level of support that can be.

Does it specifically state in the diagnosis which level the patient is experiencing? So that is something that can probably change over time, you know, depending on the support level that they need.

Okay but just because there is a diagnosis we don't they again if it's done by a psychologist then they will probably put like the level of support it's a space fire and i think someone said why is the case level two and not one i think i'm guessing it's about the case that we discussed, So I would say two, because the kid is, the symptoms are pretty overt. He's the high fixation of interest. And I think he would need more than just individual therapy or like some life skills coaching.

I think he would benefit from like social skills training. So that's probably why. And he probably needs some accommodations in school. So unbehavioral therapy, which is why I would probably put it at level two. I see another one does ABA include OT or do we have to make a separate referral to OT I think that would be a different the occupational therapy referral would be different than that of ABA.

Any autism support groups in san antonio for parents yes there are definitely autism speaks is a good one and then if you are already not familiar with the morgan's mac they have the multi-access center where they have a it's like a one-stop shop it's not only exclusive it's not exclusive for kids who are on the autism spectrum any with any developmental disabilities or even other disabilities they can actually access the mac and they can they're

assigned a care navigator who can coordinate the care for like they can support the family they can support the patient or individual so that can be a good resource as well patient appears would benefit with. Noise canceling headphones i'm guessing it's about the care case yes i think yeah some individuals we actually recommend like noise-canceling headphones. And in the case, yes, it can be one of the accommodations that the person, that the kid could get.

Any autism support in San Antonio for older kids, teens, who may be never, who have never completed ABA a form that most ABA centers are for young kids?

It is true, yeah, I know a lot of the autisms, the ABA providers are kind of have like an age restriction or cutoff but it can be even for like older teens and adolescents it's just that there is like limited support again one of the best resources I would recommend is trying the Morgan's multi-assistance center and I can probably also email I have a list of some places that I can probably share Mr. Silva if I share with you you can probably send it to the group yeah okay can

school-age patients with autism who have aggressive and self-injurious behaviors benefit from a behavior modification plan. Yes the behavioral plans can i mean the aggressive behaviors and self-injurious behaviors they have like different behavioral modification plans oftentimes they kind of identify what could be the triggers to modify the setting sometimes even when there's like no apparent triggers they I also give them like helmets or like long sleeves and other issues.

Do you see patients, young patients? Yes, I see ages four plus. I've actually seen kids as young as three in the dual diagnosis. Music. We hope you've enjoyed this episode of Pediatrics Now. Click on the link for free credit if you're a practitioner. You can also email us with questions or episode ideas. That address is pediatricsnow at uthscsa.edu. We release a new episode every Friday. I'm Holly Wehman. I hope you can join us for our next episode.