1. Autism and Epilepsy: A Comprehensive Medical Approach
Eric BJ Segal, M.D.

2. Overview Definition of Autism (DSM-4 VS. DSM-5)
Subtypes of Autism (DSM-4 VS. DSM-5)
Epidemiology of Autism
Definition of Epilepsy
Defining Seizures
The Co-existence of these 2 Disorders
Children with Autism who Develop Epilepsy
Children with Epilepsy who Develop Autism

3. Impairments in 3 Domains: Reciprocal social interaction
What is Autism (DSM-4)?
Impairments in 3 Domains:
Reciprocal social interaction
Verbal and nonverbal communication
Restricted and repetitive interests

4. What is Autism (DSM-5)? 2 domains: Why?
Social communication impairment.
Restricted interests/repetitive behaviors.
Why?
Verbal/non-verbal communication is encompassed by social interaction.
Verbal communication and social communication deficits were being counted twice.

5. The 5 Subtypes of Autism (DSM-4)
Childhood Autism
Asperger Syndrome
PDD-NOS
Rett Disorder
Childhood Disintegrative Disorder

6. The Subtypes: Childhood Autism
Deficits involving:
Social skills
Communicative language and imagination
Narrowness of focus
Rigidity
Preoccupations
Repetitive Movements
Speech

7. The Subtypes: Asperger Syndrome
IQ >70
Language developments is NOT delayed
Social impairments are less severe

8. Not otherwise specified (NOS) or atypical autism
The Subtypes: PDD-NOS
Not otherwise specified (NOS) or atypical autism
Lacks of an operational definition makes it problematic to classify and study

9. The Subtypes: ?Childhood Disintegrative Disorder
Symptomatic after age 3 years old
Cognitive regression
Language regression
Motor regression
Loss of bowel and bladder use

10. The Subtypes: ?Rett Disorder
Normal development for the first months.
Girls
Partial/complete loss of acquired purposeful hand skills
Partial/complete loss of spoken language
Gait abnormalities
Stereotypic hand movements
Head growth deceleration

11. Handwringing in Rett Syndrome

12. New Classification. Autism Spectrum Disorder Asperger syndrome
No research evidence demonstrating difference between Asperger Syndrome.
PDD-NOS (not really pervasive)
Childhood Disintegrative disorder (rare, other neurological disorder?)
Autistic disorder

13. What’s not part of ASD? Childhood Disintegrative Disorder
Rett Syndrome
Different symptoms
Known genetic cause

14. What else is new?
Social Communication Disorder – disability in social communication without presence of repetitive behavior.
This is separate from Autism Spectrum Disorders.

15. This type of regression is called “Autistic regression.”
Regression in Autism
30% of children with Autism have a language regression (few words to loss of non- verbal skills) before reaching 2 years old.
This type of regression is called “Autistic regression.”

16. Other Disorders Also have a High Association with Autistic behaviors…
Fragile X
Angelman
Tuberous Sclerosis

17. How Common is Autism in America?
Surveillance Year
Birth Year
# of Reporting Sites
Prevalence per 1000 Children
This is about 1 in X Children…
2000
1992 6
6.7
1 in 150
2002
1994 14
6.6
2004
1996 8
8.0
1 in 125
2006
1998 11 9
1 in 110
2008
11.3
1 in 88
2010
14.7
1 in 68
*CDC Statistics
1 in 68 children.
1 in 42 boys.
1 in 189 girls.

19. Must have more than one unprovoked seizure.
What is epilepsy?
Neurological condition that produces seizures affecting a variety of mental and physical functions.
Must have more than one unprovoked seizure.

20. What is a Seizure?
“A sudden surge of electrical activity in the brain that usually affects how a person feels or acts for a short time.” – Epilepsy Foundation
Seizure Types:
Generalized
Focal
Focal with secondary generalization

21. Generalized Seizures
Generalized tonic-clonic (grand mal) - Unconscious, whole body shaking Absence (petit mal) – Staring, unawareness, brief (seconds) Myoclonic – Lightening-fast jerk of arm or leg Drop Seizures (atonic) – Loss of tone or excessive tone causing a person to fall

22. Focal (Partial) Seizures
Simple (partial) – consciousness is retained, motor, sensory, or visual system is affected.
Complex (partial) – impairment of consciousness, could present as staring or with motor symptoms.

23. How common is epilepsy in patients with autism?
30% of patients with Autism have epilepsy.
30% of patients with epilepsy have Autism.
Highest risk for Autism is seen in those whose seizures that start in the 1st year of life.
Risk for epilepsy in children with Autism is higher in those with greater intellectual disability, symptomatic vs. unknown cause, and history of regression
35-65% of patients with Autism have EEG abnormalities
Epilepsy in autism confers increased mortality

24. Difficulty in Diagnosing Epilepsy in Children with Autism
Difficulty in distinguishing a behavioral episodes (staring, repetitive movement) from an epileptic seizure.
EEG may be abnormal in patients who do not have epileptic seizures.

25. Treatment Goal for Epilepsy in Children with Autism
Eliminate seizures without negatively impacting behavior or cognition.

26. Children with Autism Who Develop Epilepsy:
For the core deficits in Autism: psychosocial therapy is highly engaged, intensive, individualized treatment is most commonly prescribed.

27. Non-pharmacological treatments are mainstay of therapy in ASD
Daily living skills, handwriting, play skills
Sensory Integration Therapy
Group based therapies to teach individuals how to respond to and initiate social interactions
Classical articulation therapy
Visual communication (PECS)
Voice simulators (Dynavox)
Keyboarding (actual typing)
Applied Behavior Analysis
More naturalistic developmental therapies
Hybrids
Behavioral therapy
Speech and Language Therapy
Occupational Therapy
Social skills training

28. Children with Autism Who Develop Epilepsy
Multiple philosophies...
Relationship-based approach: underlying developmental process.
Applied Behavior Analysis (ABA) approach: teaching behavior and skills through environmental manipulations.

29. Children with Autism who Develop Epilepsy
What’s the right drug?
No randomized controlled trials to test the effects of anticonvulsants in well-defined populations of children with Autism and epilepsy.

30. Children with Autism who Develop Epilepsy
Small open label trials: Depakote, Lamictal, Keppra, Ketogenic Diet, Vagal Nerve Stimulator.
Anticonvulsants psychotropic effects in Autistic patients have so far been equivocal.

31. Children with epilepsy who develop Autism.
Epileptic encephalopathy – a condition in which EEG abnormalities themselves are believed to contribute to the progressive disturbances in cerebral function.
Regression/slowing of cognitive, language, or behavioral development due to interictal activity.
West Syndrome, Dravet Syndrome, Lennox-Gastaut, Landau-Kleffner Syndrome.

32. West Syndrome AKA Infantile Spasms
Spasm: Sudden bending forward of head with extension of arms/legs.
Onset: between 4-8 months of life.
EEG: Hypsarrhythmia
Symptomatic vs. Unknown (Idiopathic)

33. West Syndrome AKA Infantile Spasms
Prevalence of Autism as high as 35% (depends on IQ, symptomatic vs. unknown cause, if the EEG does NOT normalize after treatment).
Does early treatment improve developmental outcomes?
The cause of the spasms is the MOST important

34. Laundau-Kleffner Syndrome
Onset: 3-6 years of age
Sudden or gradual development of aphasia (inability to understand or express language).
Starts with a child who loses language skills (does not recognize words that are familiar – verbal auditory agnosia).
EEG: near continuous epileptiform abnormalities – Electrographic Status Epilepticus of Sleep (ESES)

35. Landau-Kleffner Syndrome
Steroids, high dose benzodiazepines, immunoglobulins, Onfi, Keppra, and ketogenic diet have been associated with improvements in behavior and language function.
Surgery – Multiple subpial transection may improve language function.

36. Degree and type of regression Frequency of EEG abnormalities
So How Do We Differentiate Between Childhood Autism and Landau Kleffner?
Age of regression
Degree and type of regression
Frequency of EEG abnormalities
Autism is NOT an epileptic encephalopathy.

37. Abnormal EEG does not give the diagnosis of Epilepsy.
Should Any Autistic Child With An Abnormal EEG Receive Seizure Medicine?
Abnormal EEG does not give the diagnosis of Epilepsy.
Treat the patient….
Treating EEG abnormalities does not improve social communication.

38. Summary Definition of Autism Subtypes of Autism Epidemiology of Autism
Definition of Epilepsy
Defining Seizures
The Co-existence of these Two Disorders
Children with Autism who Develop Epilepsy
Children with Epilepsy who Develop Autism

39. Final Thoughts….
Autism and epilepsy can co-exist with other medical problems.
Your neurologist needs to play as part of the child’s TEAM…
No two patients are the same…

40. Questions?