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AutismClinicalPresentation

AutismClinicalPresentation
Author:JamesRobertBrasic,MD,MPHChiefEditor:CarolyPataki,MDmore...
Updated:Dec15,2014

History
Behavioralanddevelopmentalfeaturesthatsuggestautismincludethefollowing:
Developmentalregression
Absenceofprotodeclarativepointing
Abnormalreactionstoenvironmentalstimuli
Abnormalsocialinteractions
Absenceofsymbolicplay
Repetitiveandstereotypedbehavior

Developmentalregression
Between13%and48%ofpeoplewithautismhaveapparentlynormaldevelopmentuntilage1530months,when
theyloseverbalandnonverbalcommunicationskills.Theseindividualsmayhaveaninnatevulnerabilitytodevelop
autism.Althoughregressionmaybeprecipitatedbyanenvironmentalevent(eg,immuneortoxicexposures),more
likelyitiscoincidentalwithotherenvironmentalevents.

Protodeclarativepointing
Protodeclarativepointingistheuseoftheindexfingertoindicateanitemofinteresttoanotherperson.Toddlers
typicallylearntouseprotodeclarativepointingtocommunicatetheirconcernforanobjecttoothers.Theabsenceof
thisbehaviorispredictiveofalaterdiagnosisofautism. [89,90]
Thepresenceofprotodeclarativepointingcanbeassessedbyinterviewoftheparentorcaregiver.Screening
questionsinclude"Doesyourchildeverusehisorherindexfingertopoint,toindicateinterestinsomething?"A
negativeresponsetothisquestionsuggeststheneedforaspecializedassessmentforpossiblepervasive
developmentaldisorder.

Environmentalstimuli
Incontrasttotoddlerswithdelayedornormaldevelopment,toddlerswithautismspectrumdisorderaremuchmore
interestedingeometricpatterns.Toddlerswhopreferdynamicgeometricpatternstoparticipatinginphysical
activitiessuchasdancemeritreferralforevaluationforpossibleautismspectrumdisorder. [91]
Parentsofchildrenwithautismreportunusualresponsestoenvironmentalstimuli,includingexcessivereactionoran
unexpectedlackofreactiontosensoryinput.Certainsounds(eg,vacuumcleanersormotorcycles)mayelicit
incessantscreaming.Playingaradio,stereo,ortelevisionataloudlevelmayappeartoproducehyperacusis,a
conditioninwhichordinarysoundsproduceexcessiveauditorystimulationofapainfulmagnitude.Sometimes
parentsmustrearrangethefamilyroutinesothatthechildisabsentduringnoisyhousekeepingactivities.
Childrenwithautisticdisordermayalsodisplayexaggeratedresponsesorragetoeverydaysensorystimuli,suchas
brightlightsortouching.

Socialinteractions
Individualswithautismmaydisplayalackofappropriateinteractionwithfamilymembers. [92]Moreover,difficulties
insocialinteractionsarecommon.Childrenmayhaveproblemsmakingfriendsandunderstandingthesocial
intentionsofotherchildrenandmayinsteadshowattachmentstoobjectsnotnormallyconsideredchildoriented.
Althoughchildrenwithautisticdisordermaywanttohavefriendshipswithotherchildren,theiractionsmayactually
driveawaythesepotentialcompanions.Theymayalsoexhibitinappropriatefriendlinessandlackofawarenessof
personalspace.
Isolationlikelyincreasesinadolescenceandyoungadulthood.Interviewswitharepresentativesampleof725
youthswithautism(meanage19.2y)determinedthatthemajorityhadnotintheprecedingyeargottentogether
withfriendsorevenspokenwithafriendonthetelephone. [93]

Highpainthreshold
Anabsenceoftypicalresponsestopainandphysicalinjurymayalsobenoted.Ratherthancryingandrunningtoa
parentwhencutorbruised,thechildmaydisplaynochangeinbehavior.Sometimes,parentsdonotrealizethata
childwithautisticdisorderishurtuntiltheyobservethelesion.Parentsoftenreportthattheyneedtoaskthechildif
somethingiswrongwhenthechild'smoodchanges,andmayneedtoexaminethechild'sbodytodetectinjury.

Language
Speechabnormalitiesarecommon.Theytaketheformoflanguagedelaysanddeviations.Pronominalreversalsare
common,includingsaying"you"insteadof"I."Somespeechhabits,suchasrepeatingwordsandsentencesafter
someoneelsesaysthem,usinglanguageonlythechildunderstands,orsayingthingswhosemeaningisnotclear,
mayoccurnotonlyinautismbutinotherdisordersaswell.

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BaronCohenandcolleaguesdemonstratedthattheabsenceofsymbolicplayininfantsandtoddlersishighly
predictiveofalaterdiagnosisofautism. [89,90]Therefore,screeningforthepresenceofsymbolicplayisakey
componentoftheroutineassessmentofwellbabies.Theabsenceofnormalpretendplayindicatestheneedfor
referralforspecializeddevelopmentalassessmentforautismandotherdevelopmentaldisabilities.
Oddplaymaytaketheformofinterestinpartsofobjectsinsteadoffunctionalusesofthewholeobject.For
example,achildwithautisticdisordermayenjoyrepeatedlyspinningawheelofacarinsteadofmovingtheentire
caronthegroundinafunctionalmanner.Thenonfunctionalplayofaboywithautismisillustratedinthevideofiles
below.Pleasenotethatvideosrepresentadiagnosticassessmentofachild.Thechildisallowedtoexhibitthe
abnormalbehaviorstodemonstratethoseitemsonavideoforconfirmationbyblindraters.Ifthechildexhibited
behaviorsdangertohimself,suchasselfinjuriousbehaviors,ordangeroustoother,suchasattackingothers,then
theexaminerwouldintervenetopreventinjurytothechildandothers.Thevideosdonotinanywayrepresent
treatmentforthedisorder.(Thesecondandthirdvideosalsodemonstrateanaforementionedtrait,thelackof
appropriateinteractionwithfamilymembers.)[92]
A7yearoldboywithautisticdisordertookdailyvitaminsandnoothermedicationsatthetimeofassessment.Theexaminer
repeatedmovementsofthetelephonereceiverandtappingonthetelephonereceiverinitiallyexhibitedbythesubject.Theexaminer
repeatedthesubject'sactionsseveraltimesinanattempttoelicitrepetitionofthemovementbythesubject.Instead,thesubjectdoes
notacknowledgethepresenceoftheexaminer.Helooksawayfromtheexaminer.Heturnshisbacktotheexaminer.Thesubject
spinsbyrotatingonacentralverticalaxisinhisbody.Heexhibitsnonfunctionalplaywiththetelephone.Hedisplaysfrequentfinger
wigglingandtheotherhandstereotypies.Hefrequentlyvocalizesindecipherablesoundsandbrieflyrocks.Hetiltshisheadandlooks
outofthecornerofhiseyeforafewseconds.Pleasenotethatmediafilerepresentsadiagnosticassessmentofachild.Thechildis
allowedtoexhibittheabnormalbehaviorstodemonstratethoseitemsonavideoforconfirmationbyblindraters.Ifthechildexhibited
behaviorsdangertohimself,suchasselfinjuriousbehaviors,ordangeroustoother,suchasattackingothers,thentheexaminer
wouldintervenetopreventinjurytothechildandothers.Themediafilesdoesnotinanywayrepresenttreatmentforthedisorder.
Theexaminermayattempttoestablishasequenceoftakingturnshittingaplatewithablock.Theexaminersays,"Myturn,"andthen
tapstheplate.Theexaminergivestheblocktothesubjectandsays,"Yourturn."Thesubjectmaybephysicallyassistedinthe
activityifthedesiredresponsedoesnotoccur.Thefollowingisaclinicalexample:A7yearoldboywithautisticdisordertookdaily
vitaminsandnoothermedicationsatthetimeofassessment.Theexaminerattemptedtoelicitturntakingbyhittingtheplatewitha
block.Thechildrepeatedlyjumpsandrotates.Heexhibitsnonfunctionalplaywiththetelephone.Hetiltshisheadandpeersoutofthe
cornerofhiseye.Heisinterestedinthefeelofthestick.Heexhibitsquickhandmovementswithsmalltoys.Whenhisfatherandhis
brotherleavetheroom,thechilddoesnotacknowledgetheirdeparture.Whenhisfatherreturnstotheroom,hedoesnotruntogreet
him.Heappearsindifferenttothedepartureandthereturnofhisfather.Herepeatedlytouchesthesurfaceofthewoodenblock.He
touchesthesurfaceofafurlikecloth.Healsoplacesthisclothtohismouthtofeelthetextureonhislips.Heisalsofascinatedwitha
stringofyarn.Hemovesthestringofyarnupanddownandbackandforth.Thisisnonfunctionalplaywithordinaryitems.Please
notethatmediafilerepresentsadiagnosticassessmentofachild.Thechildisallowedtoexhibittheabnormalbehaviorsto
demonstratethoseitemsonavideoforconfirmationbyblindraters.Ifthechildexhibitedbehaviorsdangertohimself,suchasself
injuriousbehaviors,ordangeroustoother,suchasattackingothers,thentheexaminerwouldintervenetopreventinjurytothechild
andothers.Themediafilesdoesnotinanywayrepresenttreatmentforthedisorder.
Thefollowingisaclinicalexamplethatcontinuesthesegmentofpriorvideo:A7yearoldboywithautisticdisordertookdaily
vitaminsandnoothermedicationsatthetimeofassessment.Heappearsindifferenttothedepartureofhisbrotherfromtheroom.He
alsodoesnotrespondwithagreetingwhenhisbrotherreturns.Heappearsinterestedinhisnonfunctionalplay.Hedisplaysminimal
acknowledgmentofthedepartureandreturnofhisbrother.Inparticular,hedoesnotrespondtohisbrother'stouchinghimonthe
shouldertogreethim.Instead,hedemonstratesinappropriatefriendlinesswiththepsychologistwhoisevaluatingtheprocedures.
Althoughheneversawherbeforethisassessment,hesuddenlygoestohertokissher.Pleasenotethatmediafilerepresentsa
diagnosticassessmentofachild.Thechildisallowedtoexhibittheabnormalbehaviorstodemonstratethoseitemsonavideofor
confirmationbyblindraters.Ifthechildexhibitedbehaviorsdangertohimself,suchasselfinjuriousbehaviors,ordangerousto
other,suchasattackingothers,thentheexaminerwouldintervenetopreventinjurytothechildandothers.Themediafilesdoesnot
inanywayrepresenttreatmentforthedisorder.

Childrenwithautisticdisordermayenjoyrepeatedlyliningupobjectsordroppingobjectsfromaparticularheight.
Theymayalsobefascinatedwithitemsthatarenottypicaltoys,suchaspiecesofstring,andmayenjoyhoarding
rubberbands,paperclips,andpiecesofpaper.Inaddition,childrenwithautisticdisordermayspendhourswatching
trafficlights,fans,andrunningwater.Someparentsreportthattheymustlockthebathroomdoortopreventthe
childfromflushingthetoiletalldaylong.

Responsetofebrileillnesses
Childrenwithautismmaybeparticularlyvulnerabletodevelopinfectionsandfebrileillnessesduetoimmunologic
problems.Byseekingpediatricinterventionpromptlyattheonsetofinfectionsandfebrileillnesses,parentsmaybe
abletoabortsequelaeofchronicinfections.
Duringafebrileillness,childrenwithautisticdisordermayshowadecreaseinbehavioralabnormalitiesthatplague
theparentswhenthechildiswell(eg,selfinjuriousbehaviors,aggressiontowardothers,propertydestruction,
tempertantrums,hyperactivity).
Thisinhibitionofnegativebehaviorsmayoccurwithvariousfebrileillnesses,includingearinfections,upper
respiratorytractinfections,andchildhoodillnesses.(Aparentmaysay,"Whenheissuddenlyanangel,Iknowthat
hehasanearinfection.")Therecoveryofthechildfromthefebrileillnessmaybeaccompaniedbyanabruptreturn
ofthechild'susualproblematicbehaviors.

AutismScreeningChecklist
HavingparentsfillouttheAutismScreeningChecklistcanidentifychildrenwhomeritfurtherassessmentfor
possibleautism.Seetheimagebelowforaprintableversionofthechecklist.

ThesignificanceofanswerstoindividualAutismScreeningChecklistitemsisasfollows:Item1A"yes"occursinhealthychildren
andchildrenwithsomepervasivedevelopmentaldisordersa"no"occursinchildrenwithautism,Rettsyndrome,andother
developmentaldisorders.Item2A"yes"occursinhealthychildren,notchildrenwithautism.Item3A"yes"occursinhealthy
childrenandchildrenwithAspergersyndrome(ie,highfunctioningautism)a"no"occursinchildrenwithRettsyndromechildren

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withautismmayelicita"yes"ora"no"somechildrenwithautismneverspeaksomechildrenwithautismmaydevelopspeech
normallyandthenexperiencearegressionwiththelossofspeech.Item4A"yes"occursinhealthychildrenandchildrenwith
Aspergersyndromeandsomeotherpervasivedevelopmentaldisordersa"no"occursinchildrenwithdevelopmentaldisorders
childrenwithautismmayelicita"yes"ora"no."Items510Scoresof"yes"occurinsomechildrenwithautismandinchildrenwith
otherdisorders.Item11A"yes"occursinhealthychildrena"no"occursinsomechildrenwithautismandinchildrenwithother
disorders.Items12,13Scoresof"yes"occurinsomechildrenwithautismandinchildrenwithotherdisorders.Items1419
Scoresof"yes"occurinchildrenwithschizophreniaandotherdisorders,notinchildrenwithautism,Aspergersyndrome,orother
autismspectrumdisorders.Thehigherthetotalscoreforitems510,12,and13ontheAutismScreeningChecklist,themorelikely
thepresenceofanautismspectrumdisorder.

ThesignificanceofanswerstoindividualAutismScreeningChecklistitemsisasfollows:
Item1A"yes"occursinhealthychildrenandchildrenwithsomepervasivedevelopmentaldisordersa"no"
occursinchildrenwithautism,Rettsyndrome,andotherdevelopmentaldisorders
Item2A"yes"occursinhealthychildren,notchildrenwithautism
Item3A"yes"occursinhealthychildrenandchildrenwithAspergersyndrome(ie,highfunctioningautism)
a"no"occursinchildrenwithRettsyndromechildrenwithautismmayelicitayesora"no"somechildren
withautismneverspeaksomechildrenwithautismmaydevelopspeechnormallyandthenexperiencea
regressionwiththelossofspeech
Item4A"yes"occursinhealthychildrenandchildrenwithAspergersyndromeorsomeotherpervasive
developmentaldisordersa"no"occursinchildrenwithdevelopmentaldisorderschildrenwithautismmay
elicita"yes"ora"no"
Items510Scoresof"yes"occurinsomechildrenwithautismandinchildrenwithotherpervasive
developmentaldisorders
Item11A"yes"occursinhealthychildrena"no"occursinsomechildrenwithautismandinchildrenwith
otherpervasivedevelopmentaldisorders
Items12,13Scoresof"yes"occurinsomechildrenwithautismandinchildrenwithotherpervasive
developmentaldisorders
Items1419Scoresof"yes"occurinchildrenwithschizophreniaandotherdisorders,notinchildrenwith
autism,Aspergersyndrome,orotherautismspectrumdisorders
Thehigherthetotalscoreforitems510,12,and13ontheAutismscreeningchecklist,themorelikelythatan
autismspectrumdisorderispresent.

PhysicalExamination
Screening
Screeningwellbabiesforsignspredictiveofautisticdisorderisimportant.BaronCohenandcolleaguesobserved
thatabnormalitiesinpretendplay,gazemonitoring,andprotodeclarativepointingnotedintoddlersduringwellchild
visitsintheUnitedKingdomwereusefulinpredictingthelaterdiagnosisofautisticdisorder. [89,90]
BaronCohenandcolleaguesdevelopedasetofvalidandreliabletoolstoscreenforautismspectrumdisordersover
thelifespan, [94]includingtheChecklistforAutisminToddlers(CHAT)anditsrevisions,theModifiedCHAT
(MCHAT)andtheQuantitativeCHAT(QCHAT),fornewbornsandtoddlers, [89,90,95]aswellastheAutism
SpectrumQuotient(AQ),forchildren, [96]adolescents, [97]andadults. [98]Thepossibleculturallimitationsofthese
toolsindifferentethnicgroupsinvariousgeographicregionsremaintobedemonstrated.
Pretendplay
Inscreeningforthepresenceofsymbolicplay,othermakebelieveplaymaybesubstitutedbasedoncultural
relevance.Thechildshouldrespondappropriatelytoapretendactivitycomparedwithmostotherchildrenofthe
sameculture.
Gazemonitoring
Theassessmentofnormalgazemonitoring,suggestedbyBaronCohenandcolleagues,consistsofthefollowing
steps:(1)thecliniciancallsthechild'sname,pointstoatoyontheothersideoftheroom,andsays,"Ohlook!
There'sa[nameatoy]!" [89,90](2)ifthechildlooksacrosstheroomtoseetheitemindicatedbytheclinician,then
ajointattentionisestablished,indicatingnormalgazemonitoring.
Protodeclarativepointing
BaronCohenandcolleaguesestablishedthefollowingprotocoltoassessforthepresenceofprotodeclarative
pointing:
Saytothechild,Where'sthelight?orShowmethelight
Anormalresponseisforthechildtopointwithhisorherindexfingeratthelightwhilelookingupatthe
clinician'sface [89,90]
Ifthechilddoesnotrespondappropriately,theproceduremayberepeatedwithateddybearoranyother
unreachableobject

Bodymovement
Clumsiness,awkwardwalk,andabnormalmotormovementsarecharacteristicfeaturesofautisticdisorder.
Manifestationsofattentiondeficithyperactivitydisorderthatareveryoftenassociatedwithautisticdisorderinclude
hyperkinesisandstereotypies.
Commonabnormalmotormovementsinchildrenwithautismincludehandflapping,inwhichtheupperextremityis
rapidlyraisedandloweredwithaflaccidwristsothatthehandflapslikeaflaginthewind.Handflappingtypically
occurswhenthechildishappyorexcited.Itmayoccurincombinationwithmovementoftheentirebody,suchas
bouncing(ie,jumpingupanddown)androtating(ie,constantlyspinningaroundaverticalaxisinthemidlineofthe
body).
Childrenwithautisticdisorderalsooftendisplaymotorticsandareunabletoremainstill.Becausechildrenwith
autisticdisorderareoftenmentallyretardedandnonverbal,expressingsubjectiveexperiencesassociatedwiththe
movementisoftenimpossibleforthem.Thus,thediagnosisofakathisiacannotbeappliedinthesecases,because
thisdiagnosisrequirestheverbalizationofasensationofinnerrestlessnessandanurgetomove.

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Headandhandfeatures
Aberrantpalmarcreasesandotherdermatoglyphicanomaliesaremorecommoninchildrenwithautisticdisorder.
Althoughtheheadcircumferenceofchildrenwithautismmaybesmallatbirth,manychildrenwithautism
experiencearapidincreaseintherateofgrowthfromage6monthsto2years. [4]Theheadcircumferenceis
increasedinasubgroupofapproximatelyonefifthofthepopulationofchildrenwithautisticdisorderwithoutknown
comorbidconditions. [99]Increasedheadcircumferenceismorecommoninboysandisassociatedwithpoor
adaptivebehavior.Theheadcircumferencemayreturntonormalinadolescence. [5]

Ratingprocedures
Patientswithautisticdisordermeritacarefulassessmentofmovements.Thecaregiverandcliniciansmaybeasked
whetherthepatientshowsanyunusualmotionsinthemouth,face,hands,orfeetand,ifso,maybeaskedto
describethemandhowtheybotherthepatient.
Thepatientmaybeaskedtositonthechairwithlegsslightlyapart,feetflatonthefloor,andhandshanging
supportedbetweenthelegsorhangingovertheknees.Thepatientmaybeaskedtoopenhisorhermouthand
thentwicetostickoutthetongue.
Ifthesubjectdoesnotperformtherequestedaction,theexaminerthenrepeatedlyperformstheactionsinthedirect
viewofthesubjecttodemonstratethedesiredactions.
Thepatientmaybeaskedtosit,stand,andlieonasheetonthefloorfor2minutesineachpositionandtoremain
motionlesswhileineachposture.Ineachposition,thepatientisasked,"Doyouhaveasensationofinner
restlessness?"and"Doyouhavetheurgetomove?"Thesequestionsrequireanappropriatedevelopmentallevel
forausefulresponse.Therefore,mostchildrenwithautismcannotrespondappropriately.
Intheabsenceofaclearverbalresponse,thesubjectiveitemsarenotrated.Nevertheless,theobjectivebehaviorof
thechildcanbeobservedandrated.

Assessingstereotypies
Movementsobservedinindividualswithautisticdisorderarefrequentlyclassifiedasstereotypies(eg,purposeless,
repetitive,patternedmotions,postures,andsounds).Stereotypiesaredividedintothefollowing3topologicclasses:
OrofacialEg,tongue,mouth,andfacialmovementssmellingandsniffingandothersounds
ExtremityEg,hand,finger,toe,andleg
HeadandtrunkEg,rolling,tilting,orbangingofthehead,androckingofthebody
Stereotypiesoccurininfantswhoarenotautisticandinchildrenwithmentalretardation.Regularassessmentof
stereotypiesisavaluablepracticebecausestereotypiesmaybotherotherpeopleandinterferewithperformanceat
school,work,andhome.Routineassessmentofstereotypiesbefore,during,andaftertreatmentisvaluablein
determiningtheeffectsofinterventions.
StereotypiesareassessedforclinicalpurposesthroughregularuseoftheTimedStereotypiesRatingScale.Forthis
procedure,theoccurrenceofstereotypiesisnotedduring30secondintervalsovera10minuteperiod.Foradditional
informationabouttheratingofstereotypies,pleaseseeTardiveDyskinesia.

Selfinjuriousbehaviors
Aparticularlyseriousformofstereotypyisselfinjuriousbehavior.Selfinjurymaytakeanyofthefollowingforms:
Pickingattheskin
Selfbiting
Headpunchingandslapping
Headtoobjectandbodytoobjectbanging
Bodypunchingandslapping
Pokingtheeye,theanus,andotherbodyparts
Lipchewing
Removalofhairandnails
Teethbanging
Selfinjurycanresultinmorbidityandmortality.Forexample,eyepokingandheadbangingmaycauseretinal
detachmentsresultinginblindness.Althoughonlyaminorityofthepopulationofchildrenwithautismmanifestself
injury,theyconstitutesomeofthemostchallengingpatientsindevelopmentalpediatrics.

Physicalabuse
Childrenwithautismandrelatedconditionsmaypersistincessantlywithrepetitivebehaviorsthatannoyothers,
despiteinstructionstocease.Childrenwithautismspectrumdisordertypicallydonotrespondtospankingandother
formsoftraditionaldiscipline.Parents,teachers,andothersmayeventuallylosecontrolandinflictphysicalinjuryon
thechild.
Forthisreason,childrenwithautismspectrumdisorderareathighriskforphysicalabuseinaddition,whenphysical
abuseoccurs,thesechildrenmaynotreportit.Therefore,pediatriciansandotherhealthcareprovidersmust
maintainahighlevelofsuspicionforthepossibilityofphysicalabusewhenassessingchildrenwithautismspectrum
disordersandmustconductregular,carefulphysicalexaminations.

Sexualabuse
Unlikemanyotherchildrenwithmentalretardation,childrenwithautisticdisorderaretypicallyphysicallynormalin
appearance,withoutdysmorphicfeatures.Theymaybebeautifulchildrenand,thus,mayattracttheinterestof
thosewhoaresexuallyarousedbychildren.Childrenwithautismspectrumdisordermaylackabilitytocommunicate
inappropriatesexualcontacttoresponsibleauthorities.
Thus,parents,teachers,healthcareproviders,andothersmustmaintainahighlevelofsuspicionforthepossibility

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ofsexualabusewhenassessingchildrenwithautismspectrumdisorder.Onphysicalexamination,external
examinationofgenitaliaisappropriate.Ifbruisesandotherevidenceoftraumaarepresent,thenpelvicandrectal
examinationsmaybeindicated.

Examinationofsiblings
Siblingsofchildrenwithautismareatriskfordevelopingtraitsofautismandevenafullblowndiagnosisofautism.
Atenthofthesiblingsofchildrenwithautismmeetthediagnosticcriteriaforanautismspectrumdisorder.An
additionalfifthofsiblingsofchildrenwithautismhavedelayeddevelopmentoflanguage. [39]Screeningshouldbe
performednotonlyforautismrelatedsymptomsbutalsoforlanguagedelays,learningdifficulties,socialproblems,
andanxietyordepressivesymptoms. [3]

ContributorInformationandDisclosures
Author
JamesRobertBrasic,MD,MPHAssistantProfessor,RussellHMorganDepartmentofRadiologyand
RadiologicalScience,DivisionofNuclearMedicine,JohnsHopkinsUniversitySchoolofMedicineActiveStaff,
DepartmentofRadiologyandRadiologicalScience,DivisionofNuclearMedicine,JohnsHopkinsHospital
CourtesyStaff,DepartmentofRadiology,JohnsHopkinsBayviewMedicalCenter
JamesRobertBrasic,MD,MPHisamemberofthefollowingmedicalsocieties:AmericanAcademyofChildand
AdolescentPsychiatry,AmericanAcademyofNeurology,andMovementDisordersSociety
Disclosure:MedscapeRoyaltyOtherNeuroscienceNet,LLCRoyaltyOtherNationalInstitutesofHealth
Grant/researchfundsOther
ChiefEditor
CarolyPataki,MDHealthSciencesClinicalProfessorofPsychiatryandBiobehavioralSciences,Universityof
California,LosAngeles,DavidGeffenSchoolofMedicine
CarolyPataki,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofChildandAdolescent
Psychiatry,NewYorkAcademyofSciences,andPhysiciansforSocialResponsibility
Disclosure:OtsukaPharmaceuticalConsultingfeeBoardmembership
AdditionalContributors
MaryLWindle,PharmDAdjunctAssociateProfessor,UniversityofNebraskaMedicalCenterCollegeof
PharmacyEditorinChief,MedscapeDrugReference
Disclosure:Nothingtodisclose.
Acknowledgments
ThisresearchissupportedbytheEsselFoundation,theBrainandBehaviorResearchFoundation(NARSAD),
theTouretteSyndromeAssociationInc,theNationalInstitutesofHealth,theDepartmentofPsychiatryof
BellevueHospitalCenter,andtheNewYorkUniversitySchoolofMedicine.ThecooperationoftheHealthand
HospitalsCorporationoftheCityofNewYorkisgratefullyacknowledged.
Theauthoralsogratefullyacknowledgesthetechnicalassistanceinthepreparationofthevideoportionsofthis
articleoftheDigitalMediaCenterattheSkirballInstituteofBiomolecularMedicineattheNewYorkUniversity
MedicalCenter.

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