ATN Annual Fall Meeting
Reviewing Progress and
Looking Toward the Future
The second annual clinical meeting of the Autism Treatment Network (ATN) took place on November 21-22, 2009 in Washington, D.C. These annual meetings provide ATN clinicians, who confer regularly by phone, an opportunity to meet face-to-face to review the year's progress in guideline development and research, make decisions in key specialty areas, and plan their activities for the ensuing year.
While the previous ATN clinical conference focused on sleep and GI issues, this year the emphasis was on Neurology, Behavioral Sciences and Psychopharmacology in the treatment of ASD and associated conditions.
The Neurology Group reviewed and fine-tuned the clinical algorithms they have been developing to help pediatricians determine when they should refer their patients with ASD for EEGs or MRI scans. They will be finalizing and piloting these algorithms in the coming months and have outlined some key research priorities for the future. Some of the issues they explored were predictors and biomarkers
related to regression, prevalence of seizures in autism, the association of inflammatory markers with certain behaviors and the design of effective clinical trials.
The Behavioral Sciences Committee has begun to develop a set of toolkits to assist parents and physicians in five key areas: 1) Transition to Adulthood; 2) Treatment for behavioral issues for children and adolescents with ASD; 3) an ABA-specific toolkit; 4) Feeding and Diet (selectivity); and 5) Toileting. Clinicians from each of the participating ATN sites volunteered to work on one or more of these by selecting a leader and developing a plan for their respective toolkits.
The Psychopharm Committee further refined their working algorithm for the medical management of antipsychotics, a class of drugs that includes commonly used medicines such as risperidone. The group is working towards piloting the guidelines early in 2010.
The second day of the meeting was focused on developing research priorities that will help clinicians address gaps in knowledge that could lead to better treatments. Guest speakers with expertise relevant to the issues in each of these areas were featured. These presentations were followed by a panel discussion that included ATN clinicians and parents of children on the autism spectrum. Neurology panelists included Patty Manning, M.D. of Cincinnati Children's Hospital and Erin Lopes, M.P.H., a parent representative to the conference. The Psychopharm panel included Ricki Robinson, M.D., of Descanso Medical Center and Doug Compton, a parent representative.
Lin Sikich, M.D., of University of North Carolina, outlined key areas of psychopharmacological research that might be fruitful for exploration by the ATN Psychopharmacology group. She recommended that researchers consider not limiting themselves to drug trials comparing a drug against a placebo (an inert pill containing no drug), but rather design comparative effectiveness trials that would compare a drug against the trial drug used in combination with another well-characterized, approved medication. This allows all trial participants a chance to benefit from any positive effects the previously approved drug may have, even if the concurrently administered trial drug is eventually found to be ineffective. She also suggested that genetics is going to be important in the development of new treatments. She pointed out that while we cannot change genetic mutations, we may be able to target the underlying biological pathways implicated in areas of known genetic susceptibility.
Michael Aman, Ph.D, of Ohio State University addressed the complexities in measuring outcomes in ASD clinical trials research. He pointed out that many of the tests commonly used may have drawbacks in the context of ASD research, citing the characteristic insensitivity of IQ tests to the effect of drugs as one example. He cautioned that in characterizing changes and outcomes in autism we should not be looking for "reversals" but instead should be tracking developmental "stepping stones." He suggested that anxiety and phobias should be explored as co-morbid disorders with ASD, but that in addition to existing psychological and behavioral measures, we should seek to incorporate physiological measures into the study design of clinical trials.
Shlomo Shinnar, M.D., Ph.D. discussed the prevalence of epilepsy in children with autism and identified risk factors. He noted that epilepsy is generally more common among people with serious neurological insults such as head trauma, cerebral palsy (CP) and autism, than in the broader population, and that the risk increases with multiple disabilities, for example having CP and mental retardation. He emphasized that while language regression associated with epileptic syndromes may sometimes be associated with autism, not every case of language regression is an indicator of autism. Generally, language regression before the age of 24 months is likely to be associated with autism, with the proviso that the child must have had a vocabulary of at least five words to qualify as "having language." Some key areas of future work identified by Dr. Shinnar include:
- Regression needs to be rigorously defined using criteria that can be reproduced among different investigators.
- The use of language in sub-typing children with autism needs to be standardized and combined with neurophysiological assessment.
- Randomized clinical trials should be conducted to determine the efficacy of antiepileptic drugs and steroids in the treatment of language regression and the core symptoms of ASD.
Joseph Piven, M.D., of the University of North Carolina described the most recent key findings from MRI structural imaging studies of patients with autism and provided advice for researchers carrying out imaging studies. He presented data from head circumference studies which suggest that some form of brain enlargement is evident during the first year of life. Among patients with autism there is evidence of other structural differences that may be linked to certain behaviors including decreased social cognition. He concluded by noting that while MRI research has been beneficial to clinical care from the standpoint of providing good evidence of structural and functional abnormalities, more evidence is needed to determine the indications for MRI in clinical care for autism.
Daniel Coury, M.D., the ATN's Medical Director, was pleased to note, "This meeting maximized the clinical expertise of our network as well as that of experts in related fields of psychopharmacology and neuroimaging. The invited speakers prompted significant discussion of potential research activities for the ATN to undertake in the near future. A formal research agenda will be generated and plans for implementing that agenda will be discussed over the coming months. The enthusiasm on the part of all present was palpable."
For updates on the status of the on-going guideline and research work of the ATN, visit www.autismspeaks.org/airp.
For more information about the Autism Treatment Network, visit the ATN webpage at www.autismspeaks.org/atn.