Autism spectrum disorders
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Autism spectrum disorders



Autism is becoming more frequent. Diagnosis and disturbing early signs are discussed.Management is also addressed

Autism is becoming more frequent. Diagnosis and disturbing early signs are discussed.Management is also addressed



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  • Autism is considered to be one of the most severe and difficult mental disabilities that has its impact on the individual's behavior. It also affects his learning capability, social up bringing, occupation, rehabilitation and his ability for work proficiency. We were treating symptoms rather than the disease
  • Session agenda

Autism spectrum disorders Autism spectrum disorders Presentation Transcript

  • Autistic Spectrum Disorders Prepared by: Dr. Shewikar El Bakry Ass. Prof. of Neuropsychiatry Banha University
  • Agenda Introduction to Autism Clinical Picture Red Flags Etiology Diagnosis Identifying Tools Management
  • History of Autism 􀁼 Autism was first described in literature by Leo Kanner in 1943. 􀁼 He called the syndrome “early infantile autism.” 􀁼 Autism was also often misdiagnosed as childhood schizophrenia. 􀁼 Early psychologists hypothesized that children became autistic due to “cold and unnurturing” mothers. This theory was proven false in 1979.
  • Facts on Autism – What We Know So Far Autism: 􀁼 occurs in approximately 1 out of 250 births, and has a 10-17% annual growth rate. 􀁼 typically manifests around the ages of 18 months to 3 years. 􀁼 is found throughout the world in families of all racial, ethnic and social backgrounds. occurs mostly in males. The ratio is about 4:1.
  • Why study autism The rate of AUTISM was One in 10,000 Births Just 10 years ago NOW AUTISM occurs in 1 of every 150 births AUTISM AWARENESS RIBBON
  • Palestine statistics • The Prevalence • Ghaza strip 2649 from a population of 1324991 • West bank 4622 from 2311204 • The Incidence • Ghaza strip 14 from a population of 1324991 • West bank 25 from 2311204
  • What is Autism • Autism is a complex neurobiological disorder • Inhibits a person's ability to – Communicate – Develop social relationships – Often accompanied by behavioral challenges.
  • Facts about Autism • One of the most severe mental disabilities that has impact on the individual's behavior. • Putting out flames without finding the cause
  • By the end of 7 months • Smile back at another person • Respond to sound with sounds • Enjoy social play Red Flags •No big smiles or other warm, joyful expressions by six months or thereafter •No back-and-forth sharing of sounds, smiles, or other facial expressions by nine months or thereafter
  • By the end of 12 months • Use simple gestures • Imitate actions in their play • Respond when told “no” Red Flags •No back-and-forth gestures, such as pointing, showing, reaching, or waving bye •Not answering to one’s name when called •No babbling – mama, dada, baba
  • By the end of 18 months • Do simple pretend play • Point to interesting objects • Use several single words unprompted Red Flags •No single words by 18 months •No simple pretend play
  • By the end of 2 years (24 months) • Use 2- to 4-word phrases • Follow simple instructions • Become more interested in other children • Point to object or picture when named Red Flags •No two-word meaningful phrases (without imitating or repeating) •Lack of interest in other children
  • Red Flag: Any loss of speech or babbling or social skills Regression at any age is cause for immediate referral
  • Clinical Picture No real fear of dangers! Inappropriate laughing or giggling
  • 17 Apparent insensitivity to pain May not want cuddling
  • 18 Sustained unusual or repetitive play; Uneven physical or verbal skills May avoid eye contact
  • 19 May prefer to be alone Difficulty in expressing needs; May use gestures
  • 20 Inappropriate attachments to objects Insistence on sameness
  • 21 Echoes words or phrases Inappropriate response or no response to sound
  • 22 Spins objects or self Difficulty in interacting with others Clinical Picture
  • Clinical Picture Does not seek opportunities to interact with others. Unwillingness and/or inability to engage in cooperative play
  • Clinical Picture Fails to produce appropriate facial expressions to specific occasions.
  • Clinical Picture
  • Clinical Picture
  • Clinical Picture (Social Skills) • • Lack of awareness of the existence or feelings of others. • 􀁼 Severe impairment in the ability to relate to others. • 􀁼 Aloof and distant from others. • 􀁼 Appears not to listen when spoken to.
  • Clinical Picture (Social Skills) Fails to produce appropriate facial expressions to specific occasions. 􀁼 Avoids eye contact. 􀁼 Difficulty with changes in environment and routine. 􀁼 Does not seek opportunities to interact with others. 􀁼 Unwillingness and/or inability to engage in cooperative play.
  • Clinical Picture (Communication Skills) • Deficits or differences in communication skills are common with individuals with autism. • 􀁼 Difficulties in using and understanding both verbal and non-verbal language. • 􀁼 Failure to initiate or sustain conversational interchange. • 􀁼 Abnormalities in the pitch, stress, rate, rhythm, and intonation of speech.
  • Clinical Picture (Communication Skills) • Poor receptive and expressive skills. • 􀁼 May echo words (echolalic speech). • 􀁼 May use screaming, crying, tantrums, • aggression, or self-abuse as ways to • communicate. • 􀁼 Repeating words or phrases in place of normal, responsive language. • Does not refer to self correctly
  • Clinical Picture • Unusual and repetitive movements of the body that interfere with the ability to attend to tasks or activities, such as hand flapping, finger flicking, rocking, hand clapping, grimacing or eye gazing. • Marked distress over changes in seemingly trivial aspects of the environment. • 􀁼 Laughing, crying, or showing distress for reasons not apparent to others. • 􀁼 Unreasonable insistence on following routines in
  • Clinical Picture • Unresponsive to normal teaching methods. • 􀁼 Acts as deaf. • 􀁼 Apparent over- or under-sensitivity to pain. • 􀁼 No fear of real danger. • 􀁼 Uneven gross and fine motor skills. • 􀁼 May not want to cuddle or be cuddled. • 􀁼 Inappropriate attachment to objects. • 􀁼 Noticeable physical over-activity or extreme under-activity.
  • Clinical Picture • May use an adult’s hand like a tool for accomplishing tasks. • 􀁼 Does not spontaneously imitate the play of other children. • 􀁼 Tendency to spend inordinate amounts of time doing nothing or pursuing ritualistic behaviors.
  • Etiology • Psychoanalytical • Genetic • anatomical brain areas annomelies • Infection • Vaccination • Prenatal and perinatal factors • Environmental • Toxins
  • • Common physical findings in ASD • (all consistent with expected and reported findings of severe mercury toxicity) • – Blocked “mirror-neurons” in frontal cortex (inability to respond to • mom’s feelings, love, gaze, smile) • – Inflammatory Bowel Disease • – Increased size of frontal lobe and white matter • – Cerebellar atrophy (reduced number of Purkinje cells) • – Increased “neuronal packing” in cortex • – Cytoarchitectural changes in subcortical structures • – Micro-and astroglia activation with leaky blood brain barrier • – Altered glutamate receptors • – Hippocampal damage • – Elevation of inflammatory cytokines in brain and CSF: MCP-1, • IFNgamma • – IgA deficiency and increased IgE • – Lymphopenia • – T-cell abnormalities • – Abnormal NK cell function
  • F84 Pervasive developmental disorder F84.0 Childhood autism F84.1 Atypical autism F84.2 Rett's syndrome F84.3 Other childhood disintegrative disorder F84.4 Overactive disorder associated with mental retardation and stereotyped movements F84.5 Asperger's syndrome F84.8 Other pervasive developmental disorders F84.9 Pervasive developmental disorder, unspecified International Classification of Diseases 10
  • Changes in 2013…  Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) revisions − Autism spectrum disorders • Includes autism, Asperger syndrome, PDD-NOS, and child disintegrative disorder (CDD) − Concentrates on required features • Social/communication deficits • Restricted, repetitive patterns of behavior, interests, activities o Addition of sensory criteria − Increases specificity while maintaining sensitivity • Important to distinguish spectrum from non-spectrum developmental disabilities • Improves stability of diagnosis
  • Assessment The Autism Diagnostic Observation Schedule- Generic (ADOS-G) Autistic Diagnosis Interview. (ADI-R) Vineland Adaptive Behavior Scales Mullen’s communication Scales . M-CHAT, CHAT . Pervasive Developmental Disorder Screening Test .CSBS Caregiver Questionnaire .Screening Tool for Autism in Two- Year-Olds (STAT) . Childhood Autism Rating Scale .Autism Behavior Checklist (ABC)
  • SECTION B:- - - - - -
  • Training of Early Head Start Staff Early Screening and Diagnosis of ASDs – What are the early signs of ASD – Why is early diagnosis important – How to screen for autism at an early age: appropriate screeners (MCHAT) – Effective ways to collaborate and share information with families about the screening, possible need for referral, and benefits of beginning intervention early – How to make an appropriate referral for a child who fails a screening
  • Data Collection for Analysis , and Program Changes • Design student progress measurement systems • Conduct assessment and evaluation • Use data-based decision-making
  • The emergence of a new autism model • Older model • • Genetically determined • • Brain based • • Treatable but not curable Is autism a BRAIN • DISORDER? • Newer model • • Environmentally triggered • • Genetically influenced • • Both brain and body • • Metabolic abnormalities play big role • • Treatable and recovery possible • OR is it • A DISORDER THAT • AFFECTS THE BRAIN?
  • Management Plan Should address: • Establishing goals for language/communication interventions • Establishing goals for educational intervention • Prioritizing target symptoms/comorbid conditions • Monitoring multiple domains of functioning • Behavioral adjustment • Adaptive skills • Academic skills • Social/communication skills • Social intervention with family members and peers • Monitoring medications
  • Treatment • Goals – Minimize core features and associated deficits – Maximize functional independence and QOL – Alleviate family stress • Educational intervention • Developmental Therapies – Communication – Sensory, fine motor, gross motor • Behaviorally Based treatments – Core and associated symptoms – Social skills • Medical or biologic treatments • Support family in home and community
  • Treatments and Educational Strategies • Autism is not a disease. There is not a single treatment such as a drug or therapy program that will work for all individuals with autism. • 􀁼 Treatment often comes in the form of • individualized plans designed to meet all areas of need. • 􀁼 Meeting the challenges of autism is better described as educational rather than treatment. • 􀁼 No single program or service will fill the needs of everyone with autism. Strategies to help a person with autism should be part of a comprehensive plan
  • Early intervention programs “psychosocial interventions can change the disorders course” • Such programs involve highly focused and individualized teaching activities targeting all areas of development • Several different programs eg: TEACCH (Treatment and Education of Autism and related communications handicapped children) • LOOVAS method • The Denver model • LEAP (learning experiences and alternative program for preschoolers and parents)
  • Psychopharmacology Adjunct to educational, developmental & behavioral treatments So far no evidence of impact on core symptoms Evidence supporting is variable Toolkit – handouts for MD & families • Treat target symptoms – Stereotypies – Withdrawal – Obsessions – Irritability – Hyperactivity – attention span – self-injurious behavior – Aggression – sleep
  • Treatment Atypical antipsychotic, Abilify (Aripiprazole) oral formulation was approved November 24, 2009 by the FDA for the treatment of irritability associated with ASD in children aged 6-17 years. Data based on two 8 week, randomized, placebo- controlled multicenter studies evaluating its efficacy for improving mean scores on the Caregiver-rated Irritability subscale of the Aberrant Behavior Checklist (ABC-I).
  • Biologically Based Supplements B6/Magnesium, B12 DMG/ TMG Vitamin A, Vitamin C Folate Omega 3 Fatty Acids Elimination Diets Casein/ gluten free Off-label medications Secretin • Immune – Antifungal therapy – Immunotherapy, steroids – Antibiotics/Antivirals – Stem cell transplantation • Immunization- related – With-hold immunization – Chelation • Hyperbaric oxygen therapy (HBOT) Always others coming along…
  • GUT Issues must be dealt with before dealing with the heavy metal issue There are 3 main issues common to all autistic Children 1. Yeast Overgrowth 2. Leaky gut 3. Heavy Metal Accumulation 52
  • Another approach to therapy Dealing with the yeast overgrowth. Dealing with the leaky gut. Heavy metals and their effects. Chelation. Methylcobalamin. 53
  • Speech/Language Therapy • Behaviorally based/ intensive structured teaching – E.g., Verbal Behavior • Augmentative strategies – Sign language – PECS – Aided augmentative/ alternative system(s) • Decrease non-communicative language • Developmental-pragmatic approaches – appropriate use of language in social situations – e.g., SCERTS – Social skills training
  • Content Areas • Communication – Teaching the child to use nonverbal communicative gestures. – Teaching motor imitation. – Teaching the meaning and important of communication. – Teaching symbolic representation.
  • Environmental and Classroom Arrangement • Employ visual strategies • Use techniques of structured teaching • Use consistency in designing the learning environment • Monitor and modify environmental stimuli
  • Behavioral Intervention ABA (Applied Behavioral Analysis) General behavioral teaching approach involves reinforcement and consequences to shape behavior All of our parents used it! Involves the A, B, C’s Not airway, breathing circulation Antecedent Behavior Consequence
  • Motor and Sensory Occupational therapy is the assessment and treatment of physical and psychiatric conditions using specific, purposeful activity to prevent disability and promote independent function in all aspects of daily life.
  • Motor and Sensory • Sensory Integrative Therapy and Autism is based on the idea that some people struggle to receive, process, and make sense of information provided by the senses. For example, some people with autism are hyper-sensitive (over- sensitive) to some things such as loud noises but hypo-sensitive (under-sensitive) to other things such as pain.
  • Sensory Integration Strategies Some examples of treatment approaches: • Oral sensory motor development can be aided by: whistles, blowers and bubble blowing kits. • Fine motor: A number of toys like cone and ball catch, puppets etc • For kids with fidgety fingers many blocks, fixes etc that help them focus. • Gross motor: Bean bags, Therabands • Vestibular and Proprioception: Swings, trampoline. • Tactile: Fabrics, brushes • High arousal / anxiety: weighted jackets, “squishes”
  • Motor and Sensory • Hippo Therapy Dance Movement Therapy Chiropractic Therapy Coloured FiltersWeighted Items
  • Other • Animal Therapy • Dolphin Therapy • Assistance Dog
  • Psychotherapy • Play provides a safe psychological distance from their problems and allows expression of thoughts and feelings appropriate to their development
  • • Play – social ,physical ,constructive ,symbolic, and independent. – Age-appropriate play skills – Individual teaching and directly guided in inclusive preschool experiences.
  • Psychotherapy • Holding Therapy • CBT • Music Therapy • Art Therapy
  • Behavioural and Developmental • Relationship Development Intervention focuses on a child’s difficulties with flexibility of thought, emotional regulation and perspective-taking. • RDI is based on the idea that children with autism have missed key developmental milestones – such as social referencing, joint attention – that enable them to think flexibly, regulate their emotions, and understand social situations.
  • Behavioural and Developmental • Social Stories™ and Autism
  • Typical Daily Schedules of Intervention 7:30-8:30amHome dressing and mealtime programs. 9:00-12:00 Inclusive preschool intervention. 12:00-1:30 Mealtime programs ,hygiene programs. 1:30-4:30 1:1 structured teaching programs. 4:30-5:30 Play indoors and outdoors. 5:30-7:00 Chores ,mealtime program ,communication programs. 8:00-Bedtime Book routines
  • • Role of families : – Families are at the helm of their child’s treatment. – Parents are the primary teachers – Home visits are scheduled as needed.
  • Questions