Prevalence of Autism Spectrum
Disorders & Autistic Traits in a
Youth Mental Health Service
Dr Rick Fraser
Sussex EIP service
SPRiG June 24th 2011
Overview
Autism spectrum disorders
Autism and psychosis
ASD in Orygen data
Further research/clinical development
Autism Spectrum Disorders
Autism as a concept has developed over the past 50 years
since Kanner first described it in 1943
Developmental disorder
Classic triad of symptoms
• qualitative impairments in social interaction
• qualitative impairments in communication
• restricted/repetitive patterns of interests and
behaviours
Impairments present before age 3 years
Present model of a continuum of related disorders, referred
to as autism spectrum disorders, with classic Kannerian
autism lying at one extreme.
Epidemiology of ASD
ASD ~ 1 per 100 (Schechter , 2008)
Autism ~ 0.5 per 1000 (Fombonne, 2009)
More common in the paediatric population than are some
better known disorders such as diabetes, spina bifida, or
Down syndrome (Matson, 2007)
Male:female ratio of approx 4:1 (Fombonne, 2005)
Misdiagnosis of ASDs
•
•
•
•
•
•
•
•
Schizophrenia spectrum
Social phobia
OCD
Depression/Bipolar
GAD
Schizoid PD
Other developmental disorders & LD
Conduct disorder
Autism and Psychosis
Can co-occur (Skokauskas , 2010)
Can be difficult to distinguish some psychopathology
(Dossetor, 2007)
Some commonalities in cognitive dysfunction eg Theory of
Mind (Pilowsky, 2000)
Historically
• Autism definition = from Greek autos ‘self ’ (Oxford
Dictionary)
• 1911 - Bleuler’s 4 As of schizophrenia (ambivalence,
loosening of associations, affective incongruity &
autism)
• 1960’s – Autism as ‘Childhood schizophrenia’
Autism and Schizophrenia
Both neurodevelopmental disorders.
Symptoms of autism first appear during early life while
schizophrenic positive symptoms do not typically
appear until adolescence at the earliest (Delisi, 1992).
Distinct disorders – but are they??
May be some degree of clinical and phenomenological
overlap (Skokauskas, 2010).
Potential for misdiagnosis (Nylander & Gillberg, 2001)
Autism and Schizophrenia
Autism shares many negative features of schizophrenia,
such as social withdrawal and communication
deficiencies, but not positive symptoms such as
hallucinations and delusions (Andreasen et al, 1986).
No greater rate of schizophrenia reported in those with
ASD compared to normal population (Asperger 1:200)
- or is there? (Mouridsen, 2008)
Early onset SCZ – may show premorbid ASD (McKenna,
1994)
Possible common genes eg MECP2 (Shibayama, 2004)
Recent study – higher rate of schizophrenia in parents
of those with ASD (Daniels, 2008)
Psychotic Disorders and ASD
(Skokauskas, 2010)
Prevalence of Autism Spectrum Conditions in a
Youth Mental Health Service
Fraser R, Cotton S, Angus B, Gentle E, Allott K, Thompson A, 2011
Orygen Youth Health
•
•
•
•
•
•
First YMHS in Australia (? world)
15 – 25 year olds
>1,000,000 in catchment area
180,000 in age range
>2000 referrals per annum (screening & assessment)
Provision of services to around 600 young people at any
one time
• EPPIC, PACE, Mood, HYPE clinics
• Caseloads of 20-35 per full time case manager
Orygen ASD Prevalence Study 2008
• Cross sectional study
• Total 523 young people
• Information from treating clinicians – interview with
DSMIV PDD classification as prompt – preceded by 3 inhouse education sessions re ASD/psychiatric comorbidity
• Autism, Asperger’s Syndrome and PDD NOS (not Rett’s
or Childhood Disintegrative Disorders)
• 1) Definite diagnosis
• 2) Autistic traits (> 1 trait from 3 domains)
• 3) No traits
Sample Characteristics
Mean age – 19.7
Male – 45.5%
Female – 54.5%
Audit Results - EPPIC
• Total – 282
•
•
ASD confirmed = 3.4%
ASD traits = 9.6%
•
Potential total ASD – 13%
• Male 72%
• Female 28%
Audit Results - PACE
• Total - 89
•
ASD confirmed = 1.7%
•
ASD traits = 10.3%
•
Potential total ASD = 12%
• Male – 39%
• Female – 61%
Mood Clinic
• Total - 152
•
ASD confirmed = 5.0%
•
ASD traits = 3.57%
•
Potential ASD = 8.57%
• Note – none in HYPE
Audit Results - OYH
3.4% confirmed rate of ASD in OYH
7.8 % ASD traits in OYH
11.2% total confirmed and ASD traits in OYH
Approx 60% in EPPIC
Approx 10% in PACE
Mean ages
• ASD confirmed = 17.0
• ASD traits identified = 19.81
• No ASD = 20.02
Conclusions
Rate of ASDs in youth mental health service higher than in
community settings (3.4%)
Significant number of other young people with ASD traits
and possible undiagnosed ASD (7.8%)
ASD/psychiatric comorbidity potentially complicates
diagnosis and treatment
Younger age for those with prior diagnosis of ASD –
possibly indicating greater impairment when comorbid
conditions
Validation of an ASD screening tool for use in a
community based youth mental health service
(Fraser, Cotton, Gentle, Thompson)
Cross sectional 3 phase study
Phase 1 screening questionnaire of all OYH clients via case manager –
ASDASQ – 10 item screening questionnaire
Phase 2 further questionnaires of screen positives plus control group –
looking at comorbidity - SCID I & II
Phase 3 gold standard for ASD diagnosis – clinical interview/ADI for
screen positives and sample of controls
Aims
• Validate ASDASQ for use in youth population
• Further information regarding comorbidity and potential
misdiagnosis
ASDASQ
1. Does the patient have any problems regarding contacts with others? (e.g. cannot get or keep friends the same age, or
cannot get reciprocally satisfying contacts with sexual partners).
2. Is the patient odd, eccentric “one of a kind”?
3. Do you find the patient compulsive or rigid, occupied by rituals, routines or rules?
4. Has the patient trouble with clothing, grooming and personal care? (e.g. conspicuously old-fashioned or ill-fitting
clothing).
5.Has the patient, or has he/she earlier had special interests, i.e. an intense interest that keeps the patient from engaging
in other activities, or an interest that the patient wants to talk about all the time? (The subject of interest is not
important, but the intense engagement or repetitive talking about it)
6. Has the patient a bizarre language or a strange/unusual voice? Does he/she speak in a very grammatical or oldfashioned way, or use standard phrases or clichés, or talk in an unnecessarily loud or low voice? Does he/she talk in
a monotonous, shrill or whining voice?
7. Has the patient an unusual non-verbal communication, e.g. abnormalities in gaze, gestures or facial expression,
unusual posture, stiff gait etc?
8. Does the patient seem to have a lack of common sense, or lack the ability to understand or foresee the consequences
of his/her doings or sayings? This might cause the patient to repeatedly get into difficult or embarrassing situations,
or get others into these situations.
9. Is the patient very uneven in his/her abilities i.e. very skilful in some areas while lacking elementary knowledge or skills
in others?
10. Has the patient had any contacts with child and adolescent psychiatry?
Preliminary results from Phase 1
Total 506 registered clients
482 ASDASQ (24 missing)
• 36 scored > 7 = 7.5% (at risk of ASD)
• 7 scored 8
• 4 scored 9
• 5 scored 10
13 scoring 6
• If cut off is > 6 then = 10.2% (at risk of ASD)
1 scoring 5 with a previously diagnosed ASD
ASDASQ scores
Initial conclusions
• Similar rates of ASD & at risk of ASD to previous study
reinforcing idea that there are potential undiagnosed
ASDs within the service
• Potentially short 10 item screening tool will be valid in
youth population
• Comorbidity data not yet analysed
ASD Comorbidity Clinic in OYH
•
•
•
•
•
•
•
•
•
Diagnostic review
Reviews
Treatment
2ry consultation
Group programme
Research
Database
ASD special interest group
Links with other clinics and research centres
Psychoeducation materials
Future possibilities for Sussex
•
•
•
•
•
Increase awareness of ASDs among clinicians
Staff training
Research collaborations
Increase knowledge base through publication
Practice guidelines – esp comorbidity and working with
young people/adults
• Service development in EIS – ASD Special Interest Group
• Encourage links with existing services –
CAMHS/Neurobehavioural clinic/ADHD service etc
• Youth ASD/developmental disorders service?
Thank you