Autism Spectrum Disorders

August 2019

BOOK REVIEWS: Autism Spectrum Disorders

Aug
2019
Vol. 31. No. 3
Richard Balon, MD

Departments of Psychiatry and Behavioral Neurosciences and Anesthesiology
Wayne State University School of Medicine
Detroit, Michigan, USA

First described by Kanner and Asperger in the 1940s, autism spectrum disorders (ASDs) is a group of neurodevelopmental disorders characterized by persistent deficits in social interaction and communication, and restricted, repetitive patterns of behavior, interests, or activities. This group of disorders has received more attention lately, and it almost looks like the prevalence of ASDs has been increasing. However, “the recent upward trend in rates of prevalence cannot be attributed directly to an increase in the incidence of the disorder or to an epidemic of autism…. good evidence indicates that changes in diagnostic criteria and practices, policies for special education, service availability, and awareness of ASDs in both the lay and the professional public may be responsible for increasing prevalence over time. It is also noteworthy that the rise in number of children diagnosed occurred concurrently in many countries in the 1990s, when services for children with ASDs also expanded significantly” (p 27).

With the estimated prevalence of 0.7% (representing well over 2 million individuals in the United States) and increased demands for costly services for individuals with ASDs, there is an increased need for a better understanding of ASDs and the development of effective treatments and management strategies.

The Autism Spectrum Disorders volume edited by Drs. Eric Hollander, Randi Hagerman, and Deborah Fein presents the current state-of-the-art summary of available information about ASDs. The book consists of 12 chapters addressing epidemiology; genomics and epigenomics; environmental toxicity and immune dysregulation; psychiatric assessment and pharmacologic treatment; pediatric and neurologic assessment and targeted treatments; cognitive assessment; behavioral treatments; the DIR (Developmental, Individual Difference, Relationship- Based) model—a parent-mediated approach to interdisciplinary assessment and comprehensive intervention; autism interventions in schools; language, communications, and occupational therapy interventions; complementary and integrative approaches; and transcranial magnetic stimulation (TMS) and noninvasive brain stimulation.

The first 3 chapters addressing epidemiology, genetics, and environmental toxicity and immune dysregulation are fairly complex, dense, and not really clinically useful. I mentioned the main conclusion of the epidemiology of ASDs. The main message regarding genetics is that ASD is categorized by highly heterogenous clinical phenotypes and genotypes and that “hundreds of genes are estimated to contribute to ASD, resulting in a unifying spectrum of phenotypes, including language and social deficits with varying subphenotypes” (p 49). The third chapter notes that numerous studies reported various immune dysregulations in individuals with ASDs, and that this dysregulation may be the result of an exposure to organic pollutants (eg, polychlorinated biphenyls [PCB]), which could interfere with normal immune and neural development.

The chapter on psychiatric assessment and pharmacologic treatment emphasizes the American Academy of Pediatrics’ recommendations that all children should be screened for ASD at age 18 and 24 months in addition to regular developmental surveillance. The elements of such evaluation are similar to regular psychiatric evaluation, with an emphasis on social communication, social interaction, and restrictive and repetitive behavioral patterns. The part on pharmacologic treatment discusses the use of selective serotonin reuptake inhibitors (mostly fluoxetine), atypical antipsychotics (risperidone, aripiprazole), mood stabilizers, stimulants, and various experimental approaches (eg, oxytocin and vasopressin, memantine, amantadine).

According to the chapter on cognitive assessment, “Understanding the cognitive level and profile of the individual being assessed, no matter what the age, is crucial for providing the therapy and support that will help the individual to fulfill his or her potential and enjoy meaningful vocational and social activities. The huge range of cognitive ability in the autism spectrum, from severe intellectual impairment to very superior intelligence, and the changes that can be seen over time in cognitive and adaptive skills make characterization of each individual imperative” (p 191).

Several chapters focus on specific aspects of management. The behavioral treatments chapter discusses applied behavioral analysis, early intensive behavioral intervention, pivotal response treatment, the Early Start Denver Model, and treatment outcomes and their prediction. As noted in the chapter on school-based intervention, we know that this type of intervention is important for individuals with ASDs; however, we lack research data on it, and do not provide good training for intervening school staff and peers. The chapter on complementary and integrative approaches reflects the frustration or desperation that families have with the lack of effective treatments for ASDs, as “Families commonly use complementary and integrative medicine (CIM) in an effort to improve outcomes for their children with autism spectrum disorder” (p 307). Actually, according to some surveys, up to 95% of families use CIM for their child, and the main reasons cited for CIM use have been concerns about medication safety and adverse effects. The table in this chapter lists >50 potential biomedical CIM treatments. The chapter reviews some of these, including melatonin, omega-3 fatty acids, methyl B12, sulforaphane, pancreatic digestive enzymes and probiotics, micronutrients, vitamins, diet, immune therapies, hyperbaric oxygen treatment, massage, meditation, exercise, environmental/ sensorimotor enrichment, music therapy, animal-assisted/equine therapy, and neurofeedback. A few of them have “significant promise for treating ASD or ASD-associated symptoms.”

The last chapter deals with the use of TMS. Again, it is difficult to imagine an immediate clinical application of TMS for ASD, as “There is no single brain target for [repetitive] TMS in ASD; indeed, it is somewhat difficult to find a brain region that neuroimaging research has not implicated in the pathophysiology of ASD” (p 333). One may ask why then is an entire chapter devoted to TMS for ASD?

Autism Spectrum Disorders is an interesting book in search of an audience. It is basically a series of scholarly, detailed review articles that may be appreciated by some. However, its clinical utility is a bit questionable. Nevertheless, people running ASD treatment programs will appreciate it as a resource book.

DISCLOSURE: Dr. Balon is a member of the American Psychiatric Association Publishing editorial board.

CORRESPONDENCE

Richard Balon, MD
Wayne State University
Detroit, Michigan, USA

REFERENCES

Edited by Eric Hollander, Randi Hagerman, and Deborah Fein; Washington, DC; American Psychiatric Association Publishing; 2019; ISBN 978-1-61537-052-8; pp 360; $61 (paperback).