Child psychiatrists, alongside child neurologists and pediatricians, have typically been the medical people concerned with the detection, diagnosis, and management of autism spectrum disorders (ASD, which is soon to be elevated to official DSM 5 terminology). With a prevalence approaching 1% in most recent surveys, including in Canada,1 the impact on individuals and their families, as well as on educational and health services, is increasingly recognized in professional and public debates. Interestingly, the only epidemiologie survey of autism among adults provides supportive, albeit preliminary, evidence for a prevalence rate of 1% in young and older adults as well.2 Nevertheless, adults with autism have received little attention in the medical literature, and their specific needs have been largely neglected by health service providers. Adult subjects with ASD, and with preserved language and cognitive skills, are among those who have been consistently underserved. In March 2010, a special working group of North American experts met to identify issues related to aging in autism. The review of published data and scientific evidence pointed to a serious knowledge vacuum about the topic. Indeed, the subsequent report concluded that little is known about the phenomenology and associated features [of ASD] as individuals age; about underlying neurobiological changes over time; and about specific medical, psychiatric, and social service needs, including the need for long term care.3,p2154 Similar conclusions were reached by other panels of reviewers.4,5 Among the issues identified were the needs for psychiatric care and services. There are several challenges that adult mental health services face with adult patients with autism. The first one has to do with the diagnosis of ASD in an adult. In several countries, referrals of adults for assessment of a possible ASD diagnosis have become more common. The referral often occurs in an adult whose child has recently been diagnosed with ASD and who recognizes similar developmental and symptom patterns in his or her own trajectory. Referrals of adults with uncertain psychiatric diagnoses and with a long-standing history of problematic behaviours and social difficulties have also become more common. Nevertheless, diagnosing adults with ASD poses specific challenges, especially when developmental history and early symptom patterns cannot be accurately assessed owing to poor memory or unavailability of an informant (as when parents cannot be interviewed) and (or) to lack of corroborative medical record evidence. Second, as with other neurodevelopmental disorders, subjects with ASD are known to have an increased susceptibility to psychiatric disorders. These conditions, especially anxiety and affective disorders and also catatonic syndromes, may result in unusual clinical presentations. The assessment of psychopathology among adults with autism can prove difficult owing to either poor language and cognitive functioning or to specific reporting difficulties experienced by adults with higher-level skills. People with autism may have specific difficulties in so-called reading minds, poor insight into social situations and relationships, a literal understanding, and pragmatic conversational difficulties. As a consequence, misdiagnosis can occur and has indeed been reported.6 The corresponding requirements to modify psychiatric assessment procedures and interviews remain to be properly addressed. Third, management techniques may equally necessitate some adjustment, such as particular care in using psychotropic drugs in patients with special dietary and weight management needs or the requirement to modify psychological interventions, with emphasis added on behavioural approaches and the need to work collaboratively with caregivers, at all ages of the patient. Fourth, with findings unfolding at a high pace from ongoing molecular genetic studies,7 adults with ASD, their siblings, and at times their spouses and offspring, will approach adult psychiatrists with questions about risk of recurrence that are increasingly complex to answer, even with whole genome sequencing soon becoming the standard for DNA testing. …
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Jan 1, 2017
Su-Hyuk Chi + 4
