the complete practitioner

Vol. 13 No. 9 Mental health applications

www.completepractitioner.com

September 2010

TREATMENT HIGHLIGHTS
COGNITIVE ACTIVITY AND ALZHEIMERS DISEASE Frequent cognitive activity among older individuals may compress the period of cognitive impairment associated with Alzheimers disease by first delaying and then accelerating the decline in cognitive functioning. This study tested the hypothesis that engaging in frequent cognitive activity predicts (a) a delay in cognitive decline before dementia onset in Alzheimers disease (AD), and (b) a more rapid cognitive decline after dementia onset. In 1993, all individuals 65 years of age or older from 4 neighborhoods in Chicago were invited to participate in a study on risk factors in Alzheimers disease. At the start of the study, and then at 3-year intervals, all participants underwent a set of brief cognitive performance tests to determine global cognitive functioning. Also, they were asked (as part of a cognitive activity scale) how frequently they participated in the following common cognitively stimulating activities: (1) television viewing, (2) radio listening, (3) newspaper reading, (4) magazine reading, (5) book reading, (6) game playing (eg, cards, checkers, crosswords or other puzzles), and (7) going to a museum. At each assessment (at 3-year intervals), a subset of participants underwent an extensive clinical evaluation. The clinical evaluation included a medical history, a neurological exam, cognitive tests, and lab tests. The findings of this study were based on data from 1157 participants1 who, at the start of the study, were determined by clinical evaluation to not have dementia. Overall, through up to 3 subsequent clinical evaluations, there was no cognitive impairment in 614 participants, mild cognitive impairment in 395 participants, and Alzheimers disease in 148 participants. Among the 614 participants with no cognitive impairment, engaging in frequent cognitive activity appeared to have a protective effect, as suggested by the finding that, during the followup period, there was a 52% reduction in the annual rate of global cognitive decline for each additional point on the cognitive activity scale. Among the 395 participants who developed mild cognitive impairment, frequency of cognitive activity was unrelated to the annual rate of cognitive decline. Among the 148 participants who developed Alzheimers disease, there was a 42% increase in
(continued on page 2)

OF NOTE
MEDICARE COVERAGE FOR SMOKING CESSATION COUNSELING Medicare has added coverage for smoking (or other tobacco use) cessation counseling for individuals meeting certain requirements. These requirements and other aspects of the coverage are outlined below [excerpted and adapted from Your Guide to Medicares Preventive Services, page 14].1 Who is covered? People with Medicare who are diagnosed with a smoking-related illness or who are taking medicine that may be affected by tobacco are covered for smoking and tobacco use cessation counseling. Smoking-related illnesses include heart disease, cerebrovascular disease (stroke), multiple cancers, lung disease, weak bones, blood clots, and cataracts. These diseases account for the bulk of Medicare spending today. People with Medicare who take any of the many medications whose effectiveness is complicated by tobacco use, including insulin and some medicines for high blood pressure, blood clots, and depression are also eligible for the counseling. How often is it covered? Medicare will cover up to 8 face-to-face visits during a 12-month period. Visits must be ordered by the patients doctor and provided by a qualified doctor or other Medicare-recognized practitioner. Patients costs. Patients with Original Medicare pay 20% of the Medicareapproved amount after meeting the yearly Part B deductible.
1

IN THIS ISSUE
TREATMENT HIGHLIGHTS pages 1-3 Cognitive Activity and Alzheimers Disease Alcohol Use and Mortality OF NOTE QUICKSTATS page 1 page 2 Medicare Coverage for Smoking Cessation Counseling Mental Health and Substance Abuse-Related Emergency Department Visits FDA NEWS AND REVIEW Approvals: Suboxone (new formulation) Product Safety Information: Lamictal PSYCHOPHARMACOLOGY NOTE page 5 Dopamine-Replacement Medication and the Risk for Impulsive Control Disorders ASSESSMENT Autism Spectrum Disorder RESOURCES page 8 pages 6,7 page 4

The publication is available at http://www.medicare.gov/publications/pubs/pdf/10110.pdf.

TREATMENT HIGHLIGHTS
COGNITIVE ACTIVITY AND ALZHEIMERS DISEASE
(continued from page 1)

the rate of cognitive decline for each additional point on the cognitive activity scale. That is, a high level of cognitive activity was associated with reduced cognitive decline in asymptomatic individuals, unrelated to cognitive decline in mildly symptomatic persons, and associated with accelerated decline after dementia onset in AD. The authors conclude that mentally stimulating activity in old age appears to compress the cognitive morbidity associated with AD by slowing cognitive decline before dementia onset and hastening it thereafter. The authors suggest that cognitive enrichment interventions may need to be initiated before the development of cognitive impairment, possibly because many persons with MCI [mild cognitive impairment] already have substantial levels of AD pathology.
1

Initially, 1508 dementia-free participants were included. However, insufficient data were obtained on 351 of the participants (253 died and 98 were otherwise unavailable).

Wilson RS [Rush Alzheimers Disease Center, Rush University Medical Center, 600 S Paulina Ave, Suite 1038, Chicago, IL 60612; email: rwilson@rush.edu], Barnes, LL, Aggarwal NT, Boyle PA, Hebert LE, Mendes de Leon CF, & Evans DA. Cognitive activity and the cognitive morbidity of Alzheimer disease. Neurology, 75:990-996, 2010. Support: National Institute on Aging; National Institute of Environmental Health Sciences. Note: Inconsistencies in the spelling of Alzheimer or Alzheimers reflect differences in how the disorder is referred to in the scientific literature.

How Cognitive Activity Prior to Dementia May Impact Subsequent Cognitive Functioning
The authors state that these results suggest that the benefit of delaying the initial appearance of cognitive impairment comes at the cost of more rapid dementia progression. They speculate that in some undetermined way cognitive activity enables the brain to tolerate pathologic changes that take place at the onset of dementia. Thus, the findings suggest that the cognitive activities in which the individual has engaged have enabled the brain to maintain relatively normal functioning even while the pathology accumulates to a mild or even moderate extent perhaps due to activity-dependent changes in the function and structure of neural systems underlying cognitive functioning. . . . If cognitive activity does somehow allow the brain to tolerate more pathologic changes, those with high premorbid cognitive activity are likely to have a higher pathologic burden than those with low premorbid activity at the time of dementia onset and therefore to experience a more rapidly progressive dementia course.

QUICKSTATS
Mental Health and Substance Abuse-Related Emergency Department Visits The following estimates pertain to hospital emergency department (ED) visits by adults in 2007, based on data from the Healthcare Cost and Utilization Project (HCUP). Sponsored by the Agency for Healthcare Research and Quality (AHRQ), HCUP provides estimates based on federal, state, and nongovernmental data. It is estimated that of the 95 million ED visits by adults in 2007, 1 in 8 (12 million) involved mental health and/or substance abuse (MHSA) problems. The estimates listed below pertain to the 12 million MHSA-related ED visits.
The most common MHSA reasons for ED visits were mood disorders (42.7%), followed by anxiety disorders (26.1%), alcohol-related conditions (22.9%), drug-related conditions (17.6%), schizophrenia or other psychoses (9.9%), and intentional self-harm (6.6%). MHSA-related ED visits resulted in hospital admission 40.8% of the time, a rate that was 2 times higher than that for non-MHSA conditions. [Uninsured patients were only to as likely as insured patients to be admitted for hospitalization, depending on the type of MHSA condition.] The most frequently billed party was Medicare (30.1%), followed by private insurance (25.7%), uninsured (20.6%), and Medicaid (19.8%).
SOURCE: Owens PL, Mutter R, & Stocks C. Mental Health and Substance Abuse-Related Emergency Department Visits Among Adults, 2007 (HCUP Statistical Brief #92), 2010. Agency for Healthcare Research and Quality; http://www.hcup-us.ahrq.gov/reports/statbriefs/sb92.pdf.

The Complete Practitioner (ISSN 1097-4989) is published monthly by MWK Publishing LLC, PO Box 546, Unionville, CT 06085-0546. Annual subscription rates: $109 (individual); $149 (institutions; multiple-subscription reduced rates available). Back issues are available for $9 each. Binders are available for $10 each. To order, visit our Web site at www.completepractitioner.com, or write to The Complete Practitioner, Subscriptions Department, PO Box 546, Unionville, CT 06085-0546. Editor: Murray Kuperminc PhD, Associate Editor: Anne R Vickery PhD. Editorial Advisory Board: Chairperson: Samuel M Silverman MD (Psychiatry, Addictions), Members: Susan Dickstein PhD (Psychology, Child Psychology), Paul R Dobner PhD (Molecular Biology), Michael I Lah PhD (Psychology, Psychological Assessment), Hank S Lerner MEd NCC (Health and Rehabilitation Counseling), Anthony J Saccone PhD (Psychology, Consulting Psychology), Larry Sheehan CADC/ICADC (Addictions). This newsletter is intended to provide current and relevant information for healthcare professionals. Inclusion of material in this newsletter does not indicate endorsement of any claims or recommendations made therein. Material may be reproduced for personal use only. To request permission to reproduce material for any other use, write to Reprint Requests, MWK Publishing LLC, PO Box 546, Unionville, CT 06085-0546. 2010, MWK Publishing LLC. Printed in the USA on recycled paper.

The Complete Practitioner

September 2010

TREATMENT HIGHLIGHTS
ALCOHOL USE AND MORTALITY Among older individuals, moderate drinkers are found have a lower likelihood of death (compared with former drinkers who are abstainers and with heavy drinkers) during a 20-year period. This prospective longitudinal study examined the relationship between alcohol consumption and all-cause mortality during a 20-year followup period. The participants were 1824 individuals who were between the ages of 55 and 65 at the start of the study. They had at least 1 outpatient contact with a health care facility during the past 3 years. Approximately half (937 of 1824) of the participants died during the followup. Included among the types of data collected at the start of the study were the following: daily alcohol consumption, sociodemographics, problem drinking history, current health problems, and social-behavioral factors. Data were obtained primarily by self-report. In most cases, death was confirmed by death certificate. Abstainers were defined as those who, at the start of the study, reported having abstained from alcohol throughout the past month. Since the current study stemmed from a larger project that was focused on alcohol users, lifetime abstainers were excluded. The authors note that the study sample was similar to community samples with respect to health characteristics such as prevalence of chronic illness and hospitalization. Daily alcohol consumption categories1 were defined as follows: (1) abstainer (no alcohol consumption); (2) light drinker (less than 1 drink per day); (3) moderate drinker (1 to fewer than 3 drinks per day); and (4) heavy drinker (3 or more drinks per day). These criteria were applied at the start of the study, resulting in the following distribution: 345 (19%) abstainers, 595 (32%) light drinkers, 560 (31%) moderate drinkers, and 324 (18%) heavy drinkers. Controlling for all the potential confounding factors measured in this study (eg, prior problem drinking, current health problems, and sociodemographic and social-behavioral factors such as age, gender, gender-marital status, and gender-avoidance coping interactions), heavy drinkers had a 42% increased risk of mortality, and abstainers had a 49% increased risk, compared to the risk among moderate drinkers.2 The risk of mortality among light drinkers was similar to that of moderate drinkers. (Light drinkers had a 12% greater risk than moderate drinkers, but the difference was not statistically significant.) While citing the need for further research [see box, below], the authors conclude that even after taking account of traditional and nontraditional covariates, moderate alcohol consumption continued to show a beneficial effect in predicting mortality risk.
1

Number of drinks was assessed in terms of standard drink amounts: 5 ounces of wine, 12 ounces of beer, and 1 ounces of hard liquor. Per day alcohol consumption totals were based on a composite quantity-frequency calculation that computed an average daily consumption amount. When the analyses controlled only for age and gender, abstainers had more than twice (2.22 times) the increased mortality risk than did moderate drinkers. Heavy drinkers had a 70% (1.70 times) increased risk, and light drinkers had 23% (1.23 times) increased risk.

Holahan CJ [Dept of Psychology (A8000), University of Texas at Austin, Austin, TX 78712; email: holahan@psy.utexas.edu], Schutte KK, Brennan PL, Holahan CK, Moos BS, & Moos RH. Late-life alcohol consumption and 20-year mortality. Alcoholism: Clinical and Experimental Research, 34:1-11, 2010. Support: National Institute on Alcohol Abuse and Alcoholism; Dept of Veterans Affairs.

Strengths and Limitations of This Study

The authors note the studys strengths included a large sample, a prospective design with a long followup period, and the use of analyses that controlled for a wide range of factors. However, the authors comment that the findings should be interpreted cautiously for several reasons, including the following: First, although the analyses controlled for many potential confounding factors associated with abstaining, the authors note that there may be unknown confounding factors that, if included, might have affected the results. Second, the study did not include lifetime abstainers. Third, since the study included only older participants, it is possible that the individuals who were most vulnerable may have died prior to the start of the study. Fourth, the design did not enable examination of the impact of heavy episodic drinking, number of years of abstaining, or reasons for abstaining. Fifth, the assessment of alcohol consumption was made only at the start of the study. The authors comment that it is likely that alcohol consumption declined over time, particularly among individuals who were close to the upper limit of moderate drinking. In addition, the authors examined only mortality, not quality of life. They cite research indicating that consuming more than 2 drinks per day has been associated with increased falls, a higher risk of alcohol use problems, and potential adverse interactions with medications in older adults. Further, heavy episodic drinking is associated with increased cardiovascular risk even when overall consumption is moderate. Thus, although this study has important strengths, the authors state that future research is needed to address the studys limitations.

September 2010

The Complete Practitioner

FDA NEWS AND REVIEW

APPROVALS A new formulation of Suboxone (buprenorphine and naloxone) receives FDA approval. Suboxone sublingual film was approved on August 30, 2010, for use in the maintenance treatment of opioid dependence when used as part of a complete treatment plan to include counseling and psychosocial support. As stated in the manufacturers (Reckitt Benckiser Pharmaceuticals) press release, Suboxone sublingual film has been developed through an exclusive agreement with MonoSol Rx, utilizing its proprietary PharmFilm technology, to deliver the opioid dependence treatment Suboxone in a fast-dissolving sublingual film. . . . During clinical studies, Suboxone sublingual film was shown to be faster dissolving than Suboxone sublingual tablets. Because of the faster dissolution and the taste profile, patients preferred the film. As is the case with any buprenorphine product, it may be prescribed only by physicians certified to treat opioid addiction with Schedule III, IV, and V narcotic medications under the Drug Addiction Treatment Act, 2000. Suboxone has a Schedule III classification. This new Suboxone formulation (sublingual film) is expected to be available in early October 2010 in the same doses as the currently available sublingual tablet formulation. Both formulations of Suboxone (sublingual tablet and sublingual film) contain naloxone (an opioid antagonist) in addition to buprenorphine (an opioid partial agonist). Both the sublingual tablets and the sublingual film each are supplied in two dosage strengths: (a) 2 mg buprenorphine with 0.5 mg naloxone and (b) 8 mg buprenorphine with 2 mg naloxone. The addition of naloxone in Suboxone is designed to deter intravenous use of buprenorphine. Clinical data indicate that when administered intravenously (but not when administered sublingually), the Suboxone was perceived as unpleasant and dysphoric.
Additional information is available from Reckitt Benckiser Pharmaceuticals by telephone (877-782-6966) or online (http://www.suboxone.com).

PRODUCT SAFETY INFORMATION The labeling (prescribing information) for Lamictal (lamotrigine) has been changed to warn that it can cause aseptic meningitis. The FDA states the following:
ISSUE: FDA notified healthcare professionals and patients that Lamictal (lamotrigine),[1] a medication commonly used for seizures in children two years and older, and bipolar disorder in adults, can cause aseptic meningitis. Symptoms of meningitis may include headache, fever, stiff neck, nausea, vomiting, rash, and sensitivity to light. In cases of meningitis, it is important to rapidly diagnose the underlying cause so that treatment can be promptly initiated. BACKGROUND: The decision to revise the Lamictal label is based on FDAs identification of 40 cases of aseptic meningitis in patients taking Lamictal (from December 1994 to November 2009). During this same time period, it is estimated that over 46 million prescriptions for Lamictal were dispensed. In most cases, the patients symptoms were reported to have resolved after Lamictal was discontinued. In 15 cases, symptoms returned when patients restarted Lamictal. RECOMMENDATION: Patients should be advised to contact their healthcare professional immediately if they experience signs and symptoms of meningitis while taking Lamictal. If meningitis is suspected, patients should be evaluated for other causes of meningitis and treated as indicated. Discontinuation of Lamictal should be considered if no other clear cause of meningitis is identified.
1

Lamictal is also sold as an orally disintegrating tablet (Lamictal ODT), a chewable, dispersible tablet (Lamictal CD), and as an extended release product (Lamictal XR).

Note: The above text contains excepted material from the FDA Label Change Announcement and the FDA Safety Announcement. These statements and other information (eg, Additional Information for Patients, Additional Information for Healthcare Professionals, and the Data Summary) can be accessed at http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ ucm221847.htm.

Note: All health professionals are encouraged by the Food and Drug Administration to report serious adverse events related to any medication, medical device, or special nutritional product (eg, dietary supplement). To file a report, contact MedWatch by telephone (800-332-1088), by fax (800-332-0178), or via the MedWatch Web site (http://www.fda.gov/medwatch).

The Complete Practitioner

September 2010

PSYCHOPHARMACOLOGY NOTE
DOPAMINE-REPLACEMENT MEDICATION AND THE rISK FOR IMPULSE CONTROL DISORDERS In the treatment of Parkinsons disease, the use of dopamine agonists (and, to a lesser extent, levodopa), is found to be associated with impulse control disorders. The authors of this study cite research showing preliminary evidence linking dopamine-replacement medication treatment with impulse control disorders in patients with Parkinsons disease. This study examined (a) the prevalence (at any time within the past 6 months) of 4 impulse control disorders, and (b) the associations of the impulse control disorders with dopamine-replacement medication treatment and other clinical measures. The impulse control disorders examined in the study were problem/pathological gambling, compulsive sexual behavior, compulsive buying, and binge-eating disorder. The medications examined in the study were pramipexole and ropinirole (dopamine agonists) and levodopa (a prodrug that is converted to dopamine).1 The study, conducted at 46 movement disorder centers in the US and Canada, included 3090 patients (30- to 75-years of age) being treated for Parkinsons disease. 98% of the patients were taking either a dopamine agonist or levodopa, or both, and had at least some response to treatment. 66% were taking at least 1 dopamine agonist and 87% were taking levodopa. Prevalence of impulse control disorders was determined through a semistructured interview using the following measures: (a) Massachusetts Gambling Screen; (b) Minnesota Impulsive Disorders Interview for Compulsive Buying and Sexual Behavior; and (c) DSM-IV-TR2 research criteria for binge-eating disorder. Overall, 13.6% of the patients had at least 1 impulse control disorder, with 3.9% having at least 2 impulse control disorders. The frequency of different types of impulse control disorders was as follows: problem/pathological gambling (5.0%), compulsive sexual behavior (3.5%) [higher in men; lower in women], compulsive buying (5.7%) [higher in women; lower in men], and binge-eating disorder (4.3%) [higher in women; lower in men]. Patients treated with a dopamine agonist (compared with those not receiving a dopamine agonist) were more than twice as likely to have an impulse control disorder (17.1% vs 6.9%). Each of the 4 impulse control disorders was associated with dopamine agonist use. The likelihood of having an impulse control disorder was 17.7% in patients treated with a dopamine agonist plus levodopa, 14.0% in those treated with a dopamine agonist without adding levodopa, and 7.2% in those treated with levodopa without adding a dopamine agonist. The frequency of impulse control disorders was similar between the 2 dopamine agonists (pramipexole=17.7%; ropinirole=15.5%). In addition to dopamine agonist treatment, several other factors were independently associated with impulse control disorders (eg, levodopa treatment, living in the United States [vs Canada], younger age, unmarried, current cigarette smoking, and family history of problem gambling). The authors conclude that dopamine agonist treatment in PD [Parkinsons disease] is associated with 2- to 3.5-fold increased odds of having an ICD [impulse control disorder]. This association represents a drug class relationship across ICDs. The association of other demographic and clinical variables with ICDs suggests a complex relationship that requires additional investigation to optimize prevention and treatment strategies.
1

Generic name (Trade name): pramipexole (Mirapex); ropinirole (Requip). [Levodopa is available in the US as part of a carbidopa/levodopa combination drug (Sinemet) and a carbidopa/entacapone/levodopa combination drug (Stalevo). Availability of levodopa as a solo product was discontinued in 2001. In determining dosage equivalences in relation to the dopamine agonists used in this study, the analyses accounted for the impact on levodopa by the agents used in combination with levodopa.] Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, Washington DC: American Psychiatric Association, 2000.

Weintraub D [Univ of Pennsylvania, 3615 Chestnut St, Rm 330, Philadelphia, PA 19104; email: daniel.weintraub@uphs.upenn.edu], Koester J, Potenza MN, et al. Impulse control disorders in Parkinson disease: A cross-sectional study of 3090 patients. Archives of Neurology, 67:589-595, 2010. Support: Boehringer Ingelheim. Note: Inconsistencies in the spelling of Parkinson or Parkinsons reflect differences in how the disorder is referred to in the scientific literature.

Possible Neurobiological Explanation of the Studys Findings

The authors state that this study indicates that in patients with Parkinsons disease, there are clinically significant impulse control disorders that are associated with dopamine agonists and levodopa, both of which are dopamine replacement-therapies. The explanation pertaining to how treatment of Parkinsons disease with dopamine agonists could result in the development of impulse control disorders centers around dopamine-receptor binding profiles. Dopamine2 (D2) and [dopamine1] D1 receptors, abundant in the dorsal striatum, may mediate the motor effects of dopamine-replacement therapies, whereas [dopamine3] D3 receptors are abundant in the ventral striatum, a brain region associated with both behavioral addictions and substance use disorders. Second-generation non-ergot dopamine agonists (eg, pramipexole and ropinirole) demonstrate relative selectivity for D3 receptors compared with D2 and D1 receptors. Compared to the dopamine agonists, dopamine (converted from levodopa) has greater selectivity for D1 and D2 receptors and less selectivity for the D3 receptor. The relative differences in their selectivity for the D1, D2, and D3, receptors are consistent with the more robust association between the use of dopamine agonists (in contrast to levodopa) and impulse control disorders.
September 2010

The Complete Practitioner

ASSESSMENT

AUTISM SPECTRUM DISORDER

The lists of signs of autism spectrum disorder [see below and page 7] are from the New Zealand Autism Spectrum Disorder Guideline. The 305 page guideline represents an opportunity to better understand people with autism spectrum disorder (ASD) and their families, to improve services to people with ASD and their families, and to help people better understand the information and theories around ASD and its management. . . . This guideline is the first in the world to cover the complete person over their lifetime. . . . The guideline has had input from individuals with ASD, parents of children with ASD, medical, educational and community providers, government agencies, and New Zealand and overseas researchers. 1 [Note: The Guidelines use of ASD in the singular (ie, disorder vs disorders) is explained in the text on the next page, below the box.]
Key Signs for Identification of Children 13 Years with ASD [Evidence=C]2
All children with ANY of the following findings MUST be referred for a general developmental assessment: No babble, pointing to or showing of objects or other gesture by 12 months No meaningful single words by 18 months No two-word spontaneous (non-echoed or imitated) phrases by 24 months ANY loss of any language or social skills at ANY age

Key signs which should prompt referral for a developmental assessment [modified from the United Kingdom National Autism Plan for Children (NAPC) Guideline]3: Social impairments: Lack of social smile and lack of eye contact Lack of imitation of actions (eg, clapping) Deficits in joint attention, such as lack of showing to share interest or involving others in joint play with toys or other objects Lack of interest in other children or odd approaches to other children Minimal recognition or responsiveness to anothers happiness or distress Not wanting to be picked up and cuddled Odd relationships with adults (either too friendly or distant) Limited variety of imaginative play Lack of pretend play, especially involving social imagination (ie, not joining with others in shared imaginary games) Appearing to be in his/her own world Failure to initiate simple play with others or participate in early social games Preference for solitary play activities Impairment in language development, especially comprehension Unusual use of language Poor response to name Deficient non-verbal communication (eg, lack of pointing and difficulty following the pointing of others) Failure to smile socially to share enjoyment and respond to the smiling of others Abnormalities in language development, including muteness, odd or inappropriate intonation patterns, persistent echolalia, reference to self as you or she/he beyond three years, unusual vocabulary for childs age/social group Limited use of language for communication and/or tendency to talk freely only about specific topics Over-liking for sameness and/or inability to cope with changes especially in unstructured setting Repetitive play with toys (eg, lining up objects or turning light switches on and off, regardless of scolding) Over-attentiveness to small visual details (eg, fascination with spinning wheels) Repetitive motor mannerisms Lack of flexible, cooperative imaginative play or creativity (although certain imaginary scenarios, such as those copied from videos or cartoons may be frequently re-enacted alone) Difficulty in organizing self in relation to unstructured space (eg, hugging the perimeter of playgrounds, halls)

Communication impairments:

Impairment of interests, activities and other behaviors:

Other factors which may support a diagnosis of ASD: Over- or under-sensitivity to: Sound (eg, has trouble keeping on task with background noise, responds negatively to unexpected/loud noises) Touch (eg, discomfort during grooming, avoids getting messy, picky eater, especially regarding certain textures) Movement (eg, becomes anxious or distressed when feet leave the ground, or twirls/spins/rocks self frequently during the day) Visual stimuli (eg, prefers to be in the dark, feels discomfort or avoids bright lights) Smells (eg, seeks out certain smells)

Note: These factors in isolation are not indicative of ASD. They are intended to alert professionals to think about the possibility of ASDwhether and when they make a referral will depend on the overall situation. (continued on page 7)

The Complete Practitioner

September 2010

ASSESSMENT
(continued from page 6)

AUTISM SPECTRUM DISORDER

Key Signs in Children Aged 48 Years with ASD (modified from the NAPC Guideline) [Evidence=C]
Professional concerns about more able children with ASD may not develop until children are exposed to the greater social demands of the early childhood education service or primary school environment. Indeed, prior to school entry, some may have been thought to be well advanced in their development, because of their special interests and precocious vocabulary. The following features should alert teachers and others to the possibility of ASD. The features described for younger children are also applicable to this age group. Presence of these features should trigger discussion with parents and the possible implementation of the local referral pathway.
Social impairments: Inability to join in with the play of other children, or inappropriate attempts at joint play (may manifest as aggressive or disruptive behavior) Lack of awareness of classroom norms (criticizing teachers overt unwillingness to cooperate in classroom activities inability to appreciate/follow current trends, eg, with regard to other childrens dress, style of speech, interests, etc) Easily overwhelmed by social and other stimulation Failure to relate normally to adults (too intense/no relationship) Showing extreme reactions to invasion of personal space and extreme resistance to being hurried Abnormalities in language development, including muteness, odd or inappropriate intonation patterns, persistent echolalia, reference to self as you or she/he beyond 3 years, unusual vocabulary for childs age/social group Limited use of language for communication and/or tendency to talk freely only about specific topics Lack of flexible, cooperative imaginative play/creativity (although certain imaginary scenarios, eg, copied from videos or cartoons, may be frequently re-enacted alone) Difficulty in organizing self in relation to unstructured space (eg, hugging the perimeter of playgrounds, halls) Inability to cope with change or unstructured situations, even ones that other children enjoy (such as school trips, teachers being away, etc) Preoccupation with restricted patterns of interest that are abnormal either in intensity or focus over-attention to parts of objects Unusual profile of skills/deficits (eg, social and motor skills very poorly developed, whilst general knowledge, reading or vocabulary skills are well above chronological/mental age) Any other evidence of odd behaviors, including over- or under-sensitivity to sound (eg, has trouble functioning when there is noise around), touch (eg, difficulties standing in line or close to others, avoids getting messy, or excessively touches people and objects), movement (eg, avoids playground equipment or moving toys, or seeks all kind of movement, and this interferes with daily routines), visual stimuli (eg, prefers to be in the dark, discomfort or avoids bright lights) or smells (eg, deliberately smells objects) Unusual responses to movement (eg, toe walking and hand flapping) Unusual responses to pain Any significant history of loss of skills

Communication impairments:

Impairment of interests, activities and other behaviors:

Other factors which may support a diagnosis of ASD:

Note: These factors in isolation are not indicative of ASD. They are intended to alert professionals to think about the possibility of ASDwhether and when they make a referral will depend on the overall situation.

The following description of ASD appears in the Guideline: Autism spectrum disorder is a relatively new term that recognizes there are overlaps between the currently defined subgroups within the spectrum of autism. It includes the subgroups in the category of pervasive developmental disorders (PDD), as defined in the tenth edition of the International Classification of Diseases (ICD-10 research criteria) and in the fourth edition of the American [Psychiatric Associations] Diagnostic and Statistical Manual [of Mental Disorders] (DSM-IV). It includes classical autism, Asperger[s] syndrome, and children with similar features who are categorized as PDD-NOS (Pervasive Developmental DisorderNot Otherwise Specified) in the DSM-IV. All people who are diagnosed with ASD share three sets of characteristics: (1) impairment in the ability to understand and use verbal and non-verbal communication; (2) impairment in the ability to understand social behavior, which affects their ability to interact with other people; (3) impairment in the ability to think and behave flexibly which may be shown in restricted, obsessional or repetitive activities. Although these features are characteristic of all people with ASD, there is a range of severity and intellectual function, from the severely impaired person with classical autism to a high functioning individual with Asperger[s] syndrome. The term high functioning may be misleading, however, in that levels of functioning (such as daily living skills or behavior) may not be determined by intellectual functioning. For many high functioning individuals, clinical diagnosis may only be made at a much later age. Thus, ASD is a very heterogeneous condition affecting a very diverse group of individuals with a wide range of impairment and disability. This requires an equally wide range of support and intervention.
1

Diagnosis and Initial Assessment of ASD. In: New Zealand Autism Spectrum Disorder Guideline (Ministries of Health and Education). Wellington (New Zealand): Ministry of Health, pp 33-60, 2008; http://www.moh.govt.nz/moh.nsf/indexmh/nz-asd-guideline-apr08. Evidence=C refers to recommendations that are supported by EXPERT OPINION only (eg, from external opinion and published or unpublished consensus guidelines), rather than by evidence from several studies identified as valid, applicable, and clinically relevant (Evidence=A), or by evidence that is weaker than is the case with Evidence=A, but unlikely to be overturned by new findings (Evidence=B). The National Autism Plan for Children 2003 (NAPC), . . . was developed by the United Kingdom National Autistic Society for the National Initiative for Autism: Screening and Assessment in conjunction with the Royal College of Psychiatrists, the Royal College of Paediatrics and Child Health and the All Party Parliamentary Group on Autism. The document can be purchased online at http://www.autism.org.uk.

September 2010

The Complete Practitioner

RESOURCES
CLINICAL PRACTICE GUIDELINES
PROFESSIONAL AND PATIENT RESOURCES

DrUG ABUSE
PROFESSIONAL AND PATIENT RESOURCES

Guideline Syntheses: Management of Overweight and Obesity in Children and Adolescents http://www.guideline.gov/syntheses/synthesis. aspx?id=16402 Guideline Syntheses: Management of Alzheimers Disease and Related Dementias http://guideline.gov/syntheses/synthesis. aspx?id=16414 Care of the Movement Disorder Patient With Deep Brain Stimulation http://guideline.gov/content.aspx?id=15087 Best Evidence Statement (BESt): Outcomes Assessment Tool for Children With Autism Spectrum Disorder (ASD) http://guideline.gov/content.aspx?id=15245 Best Evidence Statement (BESt): Use of Sensory Assessment Tools With Children Diagnosed With Autism Spectrum Disorder (ASD) http://guideline.gov/content.aspx?id=15246 Practice Parameters for the Psychological and Behavioral Treatment of Insomnia: An Update http://www.guideline.gov/content.aspx?id=15296 Practice Parameters for Behavioral Treatment of Bedtime Problems and Night Wakings in Infants and Young Children http://www.guideline.gov/content.aspx?id=15297 Clinical Guideline for the Evaluation, Management and Long-Term Care of Obstructive Sleep Apnea in Adults http://www.guideline.gov/content.aspx?id=15298

NIDA InfoFacts are science-based fact sheets on drug abuse and addiction. Published by the National Institute on Drug Abuse (NIDA), InfoFacts are updated regularly. Among the new or recently updated InfoFacts titles are the following:
Cigarettes and Other Tobacco Products Club Drugs (GHB, Ketamine, and Rohypnol) Cocaine MDMA (Ecstasy) Hallucinogens: LSD, Peyote, Psilocybin, and PCP Heroin Inhalants Khat Marijuana Methamphetamine Prescription and Over-the-Counter Medications Stimulant ADHD Medications: Methylphenidate and Amphetamines Salvia Steroids (Anabolic-Androgenic) Understanding Drug Abuse and Addiction Drug Abuse and the Link to HIV/AIDS Drugged Driving Comorbidity: Addiction and Other Mental Disorders Treatment Approaches for Drug Addiction

InfoFacts fact sheets can be accessed online. http://www.drugabuse.gov/infofacts/Infofaxindex.html

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In the Subscribers Area, click on Search to access articles from all previous issues of The Complete Practitioner. Resource listings are hyperlinked to their Internet sites. The Subscribers Area also includes most of our previously featured assessment articles (many containing full-text instruments). Accessing the Subscribers Area : Your subscriber number (5 or 6 digits) appears in the upper left portion of your address label. It serves as your user name, enabling you to access an area of the Web site that includes features for subscribers only. Note: If you do not have your subscriber number, you may email a request to receive your number.

Continuing Education (CE)

Three ways to earn CE credits! A 1-credit CE quiz accompanies each issue. 1-credit online CE quizzes accompanied by online versions of articles from The Complete Practitioner can be accessed at http://www.athealthce.com. A 4-credit online course is available at our Web site: http://www.completepractitioner.com. Course available: Treatment of Substance Abuse and Dependence NOTE: Quizzes/exams are cosponsored by PsychoEducational Resources, Inc (PER) or At Health, Inc (http://www.athealth.com) or by other sponsors. Information about approvals, eligibility, and price can be found on the quiz that accompanies this issue and at the online CE Web sites noted above.

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The Complete Practitioner

September 2010