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  • Autism – Kanner – 1943 – initially called ‘infantile autism’ – some thought it was a form of childhood schizophrenia
    Asperger’s – Hans Asperger
    Same time as Kanner’s work on autism
    Original description was in regards to young boys with social interaction difficulties and behavior problems - 1944
  • Specific delays or abnormal functioning must be noted prior to age 3
  • Know familiar people
    One little boy I work with – references to his father….
    Myth that child with autism don’t like to be hugged
  • <number>
  • Meds aren’t the answer for these children either…
  • Example of higher functioning individual
    Very skilled at puzzles
    Some kids do have these exceptionally high areas of skill – ‘savant’ – not as common as people might think/portrayed in the media
  • Diagnosis of AS usually involves a relatively intact intellectual and language functioning
    Accompanied by the impairments in reciprocal social interaction that are associated with autism
    Have idiosyncratic interests that are often appropriate in content but always unusual in their intensity
    Qualitative impairment in social interaction (as manifested by at least two of the following):
    Marked impairment in the use of multiple non-verbal behavior such as eye-to-eye gaze, facial expression, body postures and gesture to regulate social interaction
    Failure to develop peer relationships appropriate to developmental level
    A lack of spontaneous seeking to share enjoyment, interests or achievement with other people (e.g. by a lack of showing, bringing or pointing out objects of interest to other people)
    Lack of social or emotional reciprocity
  • Most children with AS will exhibit a)
    Special interest in usually isolated – in the sense that it does not inspire interest in other neighboring interests
    The interests may come and go although some children will stick to their first and “only” interest throughout life
    Despite the interest itself changing – the pattern of interest never changes
    The individual engrosses themselves in it to the point where there is little time for anything else
    Restricted or repetitive and stereotyped patterns of behavior, interests and activities (as manifested by at least one of the following):
    Encompassing preoccupations with one or more stereotyped and restricted pattern of interest that is abnormal either in intensity or focus
    Apparently inflexible adherence to specific, non-functional routines or rituals
    Stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting or complex whole body movements
    Persistent preoccupations with parts of objects
  • The disturbance causes clinically significant impairments in social, occupational or other important areas of functioning
    There is no clinically significant general delay in language (e.g. single words used by age 2 years, communicative phrases by age 3)
    There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other then in social interaction) and curiosity about the environment in early childhood
    Criteria are not met for another specific DD or schizophrenia
    Individual may not display clinically significant delays in language (e.g. single words must be used by age 2 years and communicative phrases must be used by age 3 years)
    Individual may not display clinically significant delays in cognitive functioning or adaptive behavior
    A diagnosis of AS can not currently be made with confidence before the child’s 5th birthday and it is usually not made into well into school age
    If current or past behaviors are consistent with a DSM-IV diagnosis of autistic disorder – a diagnosis of AS can not be made
  • Difficulty with determining prevalence as there is no consistent diagnostic criteria for AS
    Child psychiatric clinic workers have reported AS in 5% of all cases
    Male to Female ratio
    Girls with AS sometimes show a slightly different constellation of symptoms then the one regarded as typical of males with this disorder
    Particularly the stereotyped patterns of interests:
    Boys with AS often amass facts about certain aspects of the environment and learn them by heart
    Girls interests may sometimes – at least superficially – appear to more social (fixated on certain people or idols or social toys)
    However on further analysis – one also finds these interests to be dependent on rote meaning
    Some girls also appear to have no interests – generally characterized by negativism and a tendency to say “no” to everything
    Girls are less aggressive
    Less prone to hyperactivity
    Conceivable that such cases are missed in epidemiological studies
    Females tend to get a diagnosis of: OCD, personality disorder, eating disorders or atypical depression
    Current prevalence figures may be an underestimating the proportion of females with AS
  • IQ profile
    Very similar to the pattern shown in children with NLD – split between their verbal and perceptual abilities  verbal abilities much higher
    This can be quite marked with a 25 point difference or more
    Communication problems affecting speech and language
    This is not part of the diagnosis but research has shown some oddities in how children with As use and understand language
    Hyperlexia is common
    Being to literal in their use and understanding of language
    i.e.. in you ask “can you open the door” the child may respond yes without opening the door
    Pragmatic difficulties – respond better to concrete questions and statements rather then open-ended ones
    Have difficultly understanding and using language in a social context
    Speech may have a flat prosody or they may mumble
    Specific adherence to certain language and speech characteristics
    Perceptual problems
    Unusual reaction to sounds
    Fussiness, may stand to close to you when they talk
    Motor control problems
    Gait may be hypotonic, ungainly or stiff, often without accompanying arm swing
    Fine motor movement may be clumsy and ill-coordinated
    Gross motor performance is problematic – difficulty riding a bike, playing sports, etc.
    May have stereotypes – such as overstretched fingers, holding their fingers close to their mouth, tightly held and shivering fists or minimal hand-flapping
    School age children with AS have often learned that these behaviors are unacceptable – actively try and hide them
  • Individuals with AS have higher than expected rates of comorbid psychiatric disorders
    Increased rate of affective disorders in families of those with AS
    Tourette Syndrome
    Limited information about the specific overlap between AS and Tourettes
    Research has shown that 1 in 10 children with AS also have Tourette Syndrome
    The rate of AS in those having Tourette Syndrome is also much higher than in the general population – 1 in 20 have AS
    Have to distinguish between stereotypies and tics
    Tics appear during the school-aged years vs. stereotypies which present at a younger age
    Tics can remit for months at a time vs. stereotypies which tend to be more persistent
    Tics can change in presentation over time vs. stereotypies which are less variable but may become miniaturized with age
    Tics tend to be brief, sudden, non-rhythmic movement that are not necessarily symmetrical vs. stereotypies may be present for longer durations and often appear to be both rhythmic and symmetrical
    Tics can occur during sleep – it is uncommon for stereotypies to occur during sleep
    Stereotypies are more based on environmental events than are tics
    Anxiety – particularly social phobia
    Children with AS report high rates of social anxiety and social stress and less satisfaction and competence in interpersonal relationships
    Have a greater perception of social difficulties
    Children with AS are aware of their social difficulties, sensitive to teasing and peer rejection (to which they are very susceptible) and prone to negative self-evaluations and loneliness
    This perception coupled with repeated experiances of negative unsuccessful social interactions may contribute to the development of comorbid aspects of psychopathology that further undermine the quality of life for these individuals
    Some of these children show negative attribution bias in response to ambiguous social situations
    Tendency to make inferences about the actions of others as reflecting negative or hostile intention may be present among some children with AS
    Paranoia of unusual quality – stemmed from confusion or perplexity about social situations and involved heightened social anxiety and self-consciousness
    It is important to distinguish between behavior that is related to OCD and those to AS by looking at the types of thoughts and behaviors
    AS – may think obsessively about a special interest
    Behavior of child with AS may be related to the child’s special interest of to sensitivities
    OCD – thoughts revolve around a certain fear
    Behavior is usually directed towards preventing an act or is a routing or ritual that is non-functional
    Conduct disorder
    Eating Disorders
    Diagnosis is more likely to go to girls rather then boys
    This may be their primary diagnoses and it is only later that AS symptoms recognized
    Abnormal eating behaviors are almost the rule in AS
    AS is more associated with anorexia nervosa rather then bulimia
    May be related to issues around food textures, lack of food variety, etc.
    Depression is the most common erroneous diagnosis in AS
    Symptoms like: reduced facial expressions, clumsy and sluggish motor movements and seemingly disinterested way of “conversing” about everyday matters – may be mistaken
    However, many people with AS also have depression
    This is most pronounced in later pre-adolescence, middle teenage and early adult life
    Clinical experience
    Milder episodes of hypomania appear to be common in AS and may show as increased activity or restlessness, increased talkativeness, more pronounced difficulty concentrating, decreased need for sleep, over-familiarity or unexpected sociability
    Suicidal ideation
    Suicidal thoughts common in AS
    Appear to be particularly frequent in adolescence and early adult life but can occur already at the age of 7
    Alcohol and drug abuse
    Especially towards the end of adolescence – sometimes in response to peer pressure
  • Only when people know the fundamentals of AS and have in-depth knowledge about the individual with the diagnosis that they can provide a good environment that does not cause concern, anxiety or stress
    School interventions
    High degree of structure
    Clear communication of expectations of the child and the rules of the school and classroom
    Clearly explaining to students and teachers AS
    Helpful treatments for the severe and common problems associated with AS – depression, obsessive-compulsive phenomena, social phobia, attention deficits and mood swings
    Have to watch for atypical reactions to drugs
    Target behavior: aggression, anxiety, stereotypes and preoccupations
    Most specific SSRI
    Associated with the lowest incidence of side-effects
    Improvement in communication and attention skills and a decrease in rituals and stereotypical behavior
    Side effects include: impulsiveness, restlessness, sleep disturbance and loss of appetite, off chance of developing bipolar disorder
    Reduce OC behavior
    Side effects: increased irritability, agitation and aggression
    Treat severe behavior problems
    Reduces stereotypies, withdrawal, hyperactivity, fidgeting and tantrums
    Side effects: parkinsonian side-effects
    Treat tantrums, aggressions or self-injurious behaviors, stereotypic and hyperactive behaviors
    Side effects: weight gains, liver dysfunction, withdrawal
  • Autism.ppt

    1. 1. Autism & Asperger’s Abbie Solish PhD Candidate Clinical-Developmental Area York University
    2. 2. Pervasive Developmental Disorders (PDD) Autistic Disorder Childhood Disintegrative Disorder PDD-NOS Asperger’s Disorder Rett’s Disorder
    3. 3. Autistic Disorder (DSM-IV) (1) Qualitative Impairment in Reciprocal Social Interaction: a) impaired nonverbals b) poor peer relationships c) lack of spontaneous social sharing d) lack of social/emotional reciprocity (must have 2 or more of 4)
    4. 4. (2) Qualitative Impairment in Communication: a) delayed/absent speech b) impaired conversational skills c) stereotyped, repetitive language d) lack of pretend and social play (must have 1 or more of 4) Autistic Disorder (DSM-IV)
    5. 5. (3) Restricted, Repetitive, & Stereotyped Patterns of Behaviour, Interests, & Activities: a) preoccupations, narrow interests b) adherence to routine, ritual c) stereotyped behaviour d) preoccupation with parts of objects (must have 1 or more of 4) Autistic Disorder (DSM-IV)
    6. 6. Ben Loves Trains Ben is 2.5 and he loves trains. He is content to play with them alone for hours. Yet he doesn’t seem to really understand that they are trains. He doesn’t pretend to make them go on the track or have crashes or imagine what the cars are carrying or talk, as he plays alone. He just lines them up in the same way every time. He gets very upset if anyone rearranges his trains. Sometimes he carries a train around with him and rubs it against his chin or waves it in front of his eyes. He never brings a train to show his father, never points to the trains to show his sister. In fact, he completely ignores his sister. Ben doesn’t talk at all, rarely looks at other people and rarely smiles…
    7. 7. Early Behaviours in Autism: What these children often do  Avoid eye contact  Avoid others, appear aloof  Use toys in repetitive, non-functional ways  Focus on parts of objects  Tantrums/problem behaviours  Odd speech (if any)  Instrumental communication  Autistic leading  Stereotypies (e.g., flapping hands)  Know familiar people
    8. 8. Early Behaviours in Autism: What these children often don’t do  Make eye contact  Imitate  Pretend play  Joint attention gestures (e.g., eye gaze, pointing)  Social interest and social play  Use language to comment  Use language for social purposes  Theory of mind
    9. 9. Early ‘Red Flags’  no babbling 12 months  no pointing, other gestures 12 months  no single words 16 months  no spontaneous 2-word phrases 24 months  any loss of language or other skills at any age  With younger children the absence of typical behaviour is more diagnostic than presence of atypical behaviour
    10. 10. Early Diagnosis  If ‘red flags’ are present, specific autism diagnostic tools are used  A diagnosis should incorporate information from various sources  A reliable & valid diagnosis can be made by age 2 by an expert clinician  Likely trend towards overdiagnosis in young delayed children and trend towards underdiagnosis in high-functioning children
    11. 11. Prevalence (best estimates)  Autistic Disorder  10 per 10,000  PDD-NOS  15 per 10,000  Asperger’s  2.5 per 10,000    Total  27.5 per 10,000 (1 per ~350)   Ratio  4:1 Males:Females 
    12. 12. Is Autism Increasing?  It depends…  Prevalence vs. Incidence  Prevalence = % of people in the population who have the disorder • Definitely increasing  Incidence = # of new cases per unit of time • Debatable, no good evidence of increase
    13. 13. Why does is seem like autism is “increasing”?  The diagnostic criteria have broadened and changed  Much better now at early diagnosis  Low functioning children can now get a diagnosis of autism rather than just MR  At the high end of the spectrum there is more recognition of the broader phenotype
    14. 14. Who has autism?  No relationship to SES  No relationship to immigrant status  No relationship to race or ethnicity  No environmental causes/clusters  Some evidence of genetic concordance
    15. 15. What “causes” autism?  A specific cause has not been yet been identified  Current investigations specific to autism include: – birth and pregnancy problems – problems in specific areas of brain – brain chemicals (neurotransmitters) – brain infections – genetics  One single cause cannot account for everything/all subtypes of PDD  We do know that it is NOT parents
    16. 16. Is there a “cure”?... New & Alternative Treatments  Auditory Training  Sensory Integration  Vitamins/Food Supplements  Special Diets/Food Allergies, Sensitivities  Physical Exercise  Holding Therapy  Deep Pressure  Facilitated Communication  Miller Method  Irlen Lenses  Patterning  Gentle Teaching  Swimming with Dolphins  Secretin  Centrifugal Therapy  …
    17. 17. New & Alternative Treatments  The problem is that most of these treatments are not supported by any research  Many parents believe in “miracle” or “breakthrough” “cures” – Gives them hope – Feel less helpless – Danger in not accepting the child as he/she is – Expensive
    18. 18. Intensive Behavioural Intervention (IBI)  “Intensive” (often 20-40 hrs/wk for 1-2 yrs.)  Begin early (usually before 4)  Schedule is highly structured and predictable  Program is individualized  Specific teaching methods vary  Include complex variety of techniques to promote independence and generalization
    19. 19. 2 Dimensions of Severity Autistic Disorder PDD-NOS Asperger’s Disorder Autistic Symptom Severity Profound Severe Moderate SuperiorAverage Severity of Intellectual Disability Mild Borderline
    20. 20. Carolyn Just Wants to Be Friends Carolyn is 12 and is great at puzzles. She can do them just as fast whether they are picture side up or upside down! She struggles with her school work, especially language arts and social studies, but is pretty good at spelling and math and has an excellent memory. She was in special education classes when she was younger, but is now in a regular class. She seems very friendly and talkative, though a bit immature. She goes up and asks questions of anyone she comes in contact with, even if they’re not interested in talking to her. She doesn’t know how to relate to other kids very well but really wants to be friends. She is enrolled in a social skills group at a local treatment agency. Her mother worries about what is in store for Carolyn as a teenager and adult…
    21. 21. Asperger’s Disorder (DSM-IV) A. Qualitative Impairment in Reciprocal Social Interaction: a) impaired nonverbals b) poor peer relationships c) lack of spontaneous social sharing d) lack of social/emotional reciprocity (must have 2 or more of 4)
    22. 22. Asperger’s Disorder (DSM-IV) B. Restricted, Repetitive, and Stereotyped Patterns of Behaviour, Interests, and Activities: a) preoccupations, narrow interests b) adherence to routine, ritual c) stereotyped behaviour d) preoccupation with parts of objects (must have 1 or more of 4 criteria)
    23. 23. Asperger’s Disorder (DSM-IV) C. Clinically significant impairment in social, occupational functioning D. No clinically significant language delay E. No clinically significant cognitive delay, adaptive behaviour
    24. 24. Prevalence  Prevalence ranges: – 3-4 in every 1000 children develop the full clinical picture of AS – 2.5 per 10,000  Why is there such a range? – No consistent diagnostic criteria for AS  6:1 Male to Female ratio – Actual ratio is believed to be closer to 4:1
    25. 25. Other difficulties associated with Asperger’s  IQ profile  Communication problems affecting speech and language – Language “oddities”: • Hyperlexia • Literal use and understanding of language • Pragmatic difficulties • Flat prosody  Perceptual problems  Motor control problems
    26. 26. Comorbidity  ADHD  Tics and Tourette Syndrome  Anxiety – Social anxiety – OCD  Conduct disorder  Eating disorders  Mood Disorders – Depression (most common secondary diagnosis) – Bipolar – Suicidal ideation  Alcohol and Drug abuse  Schizophrenia & isolated psychotic episodes
    27. 27. Interventions for Asperger’s  Not one specific empirically validated treatment (like IBI for Autism)  Social skill groups  School interventions  Medications – often used to treat comorbid conditions – have to watch for atypical reactions to the drugs • e.g., SSRIs, Neuroleptic, Stimulants, Anti-epileptic drugs, Lithium
    28. 28. Summary  Autism and Asperger’s are two of the Pervasive Developmental Disorders  Children with Autism must show impairments in social and communication abilities as well as have behavioural concerns to receive a diagnosis  Children with Asperger’s must show impairments in their social abilities and specific behavioural concerns, but do not show language impairments like children with Autism  The prevalence of Autism/Asperger’s is increasing, although perhaps not the incidence  The “cause” of Autism/Asperger’s is still unknown  There is currently no “cure” for Autism or for Asperger’s  IBI is the current intervention of choice for children with Autism