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 infant...
Facts on Autism – What We
Know So Far
Autism:
􀁼 occurs in approximately 1 out of 250
births,
and has a 10-17% annual growt...
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
...
Palestine statistics
• The Prevalence
• Ghaza strip 2649
from a population of
1324991
• West bank 4622 from
2311204
• The ...
What is Autism
• Autism is a complex neurobiological
disorder
• Inhibits a person's ability to
– Communicate
– Develop soc...
Facts about Autism
• One of the most
severe mental
disabilities that has
impact on the
individual's
behavior.
• Putting ou...
By the end of 7 months
• Smile back at another person
• Respond to sound with sounds
• Enjoy social play
Red Flags
•No big...
By the end of 12 months
• Use simple gestures
• Imitate actions in their play
• Respond when told “no”
Red Flags
•No back-...
By the end of 18 months
• Do simple pretend play
• Point to interesting objects
• Use several single words unprompted
Red ...
By the end of 2 years
(24 months)
• Use 2- to 4-word phrases
• Follow simple instructions
• Become more interested in othe...
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
cooperat...
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 th...
Clinical Picture (Social Skills)
Fails to produce appropriate facial
expressions to specific occasions.
􀁼 Avoids eye conta...
Clinical Picture
(Communication Skills)
• Deficits or differences in communication skills
are common with individuals with...
Clinical Picture
(Communication Skills)
• Poor receptive and expressive skills.
• 􀁼 May echo words (echolalic speech).
• 􀁼...
Clinical Picture
• Unusual and repetitive movements of the body that
interfere with the ability to attend to tasks or
acti...
Clinical Picture
• Unresponsive to normal teaching methods.
• 􀁼 Acts as deaf.
• 􀁼 Apparent over- or under-sensitivity to p...
Clinical Picture
• May use an adult’s hand like a tool for
accomplishing tasks.
• 􀁼 Does not spontaneously imitate the pla...
Etiology
• Psychoanalytical
• Genetic
• anatomical brain areas annomelies
• Infection
• Vaccination
• Prenatal and perinat...
• Common physical findings in ASD
• (all consistent with expected and reported findings of severe mercury toxicity)
• – Bl...
F84 Pervasive developmental disorder
F84.0 Childhood autism
F84.1 Atypical autism
F84.2 Rett's syndrome
F84.3 Other childh...
Changes in 2013…
 Diagnostic and Statistical Manual of Mental Disorders, 5th
Edition (DSM-5) revisions
− Autism spectrum ...
Assessment
The Autism Diagnostic Observation Schedule-
Generic (ADOS-G)
Autistic Diagnosis Interview. (ADI-R)
Vineland Ada...
SECTION A:-
SECTION B:-
-
-
-
-
-
Training of Early Head Start
Staff
Early Screening and Diagnosis of ASDs
– What are the early signs of ASD
– Why is early ...
Data Collection for Analysis ,
and Program Changes
• Design student progress measurement systems
• Conduct assessment and ...
The emergence of a
new autism model
• Older model
• • Genetically
determined
• • Brain based
• • Treatable but not
curable...
Management Plan
Should address:
• Establishing goals for language/communication
interventions
• Establishing goals for edu...
Treatment
• Goals
– Minimize core features and associated deficits
– Maximize functional independence and QOL
– Alleviate ...
Treatments and Educational
Strategies
• Autism is not a disease. There is not a single treatment
such as a drug or therapy...
Early intervention programs
“psychosocial interventions can change the disorders
course”
• Such programs involve highly fo...
Psychopharmacology
Adjunct to
educational, developmental
& behavioral treatments
So far no evidence of
impact on core symp...
Treatment
Atypical antipsychotic, Abilify
(Aripiprazole) oral formulation
was approved November
24, 2009 by the FDA for t...
Biologically Based
Supplements
B6/Magnesium, B12
DMG/ TMG
Vitamin A, Vitamin C
Folate
Omega 3 Fatty Acids
Elimination Diet...
GUT Issues must be dealt
with before dealing with
the heavy metal issue
There are 3 main issues common to all autistic
Chi...
Another approach to therapy
Dealing with the yeast overgrowth.
Dealing with the leaky gut.
Heavy metals and their effec...
Speech/Language Therapy
• Behaviorally based/ intensive structured teaching
– E.g., Verbal Behavior
• Augmentative strateg...
Content Areas
• Communication
– Teaching the child to use nonverbal
communicative gestures.
– Teaching motor imitation.
– ...
Environmental and Classroom Arrangement
• Employ visual strategies
• Use techniques of structured teaching
• Use consisten...
Behavioral Intervention
ABA (Applied Behavioral Analysis)
General behavioral teaching approach involves
reinforcement and ...
Motor and Sensory
Occupational therapy is
the assessment and
treatment of physical and
psychiatric conditions
using specif...
Motor and Sensory
• Sensory Integrative Therapy and Autism
is based on the idea that some
people struggle to
receive, proc...
Sensory Integration Strategies
Some examples of treatment approaches:
• Oral sensory motor development can be aided by:
wh...
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 feel...
• Play
– social ,physical ,constructive
,symbolic, and independent.
– Age-appropriate play skills
– Individual teaching an...
Psychotherapy
• Holding Therapy
• CBT
• Music Therapy
• Art Therapy
Behavioural and Developmental
• Relationship Development
Intervention focuses on a child’s
difficulties with flexibility o...
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 int...
• Role of families :
– Families are at the helm of their child’s
treatment.
– Parents are the primary teachers
– Home visi...
Questions
Autism spectrum disorders
Autism spectrum disorders
Autism spectrum disorders
Autism spectrum disorders
Autism spectrum disorders
Autism spectrum disorders
Autism spectrum disorders
Autism spectrum disorders
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Autism spectrum disorders

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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

    1. 1. Autistic Spectrum Disorders Prepared by: Dr. Shewikar El Bakry Ass. Prof. of Neuropsychiatry Banha University
    2. 2. Agenda Introduction to Autism Clinical Picture Red Flags Etiology Diagnosis Identifying Tools Management
    3. 3. 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.
    4. 4. 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.
    5. 5. 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
    6. 6. 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
    7. 7. What is Autism • Autism is a complex neurobiological disorder • Inhibits a person's ability to – Communicate – Develop social relationships – Often accompanied by behavioral challenges.
    8. 8. 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
    9. 9. 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
    10. 10. 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
    11. 11. 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
    12. 12. 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
    13. 13. Red Flag: Any loss of speech or babbling or social skills Regression at any age is cause for immediate referral
    14. 14. Clinical Picture No real fear of dangers! Inappropriate laughing or giggling
    15. 15. 17 Apparent insensitivity to pain May not want cuddling
    16. 16. 18 Sustained unusual or repetitive play; Uneven physical or verbal skills May avoid eye contact
    17. 17. 19 May prefer to be alone Difficulty in expressing needs; May use gestures
    18. 18. 20 Inappropriate attachments to objects Insistence on sameness
    19. 19. 21 Echoes words or phrases Inappropriate response or no response to sound
    20. 20. 22 Spins objects or self Difficulty in interacting with others Clinical Picture
    21. 21. Clinical Picture Does not seek opportunities to interact with others. Unwillingness and/or inability to engage in cooperative play
    22. 22. Clinical Picture Fails to produce appropriate facial expressions to specific occasions.
    23. 23. Clinical Picture
    24. 24. Clinical Picture
    25. 25. 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.
    26. 26. 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.
    27. 27. 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.
    28. 28. 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
    29. 29. 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
    30. 30. 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.
    31. 31. 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.
    32. 32. Etiology • Psychoanalytical • Genetic • anatomical brain areas annomelies • Infection • Vaccination • Prenatal and perinatal factors • Environmental • Toxins
    33. 33. • 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
    34. 34. 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
    35. 35. 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
    36. 36. 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)
    37. 37. SECTION A:-
    38. 38. SECTION B:- - - - - -
    39. 39. 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
    40. 40. Data Collection for Analysis , and Program Changes • Design student progress measurement systems • Conduct assessment and evaluation • Use data-based decision-making
    41. 41. 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?
    42. 42. 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
    43. 43. 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
    44. 44. 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
    45. 45. 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)
    46. 46. 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
    47. 47. 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).
    48. 48. 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…
    49. 49. 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
    50. 50. Another approach to therapy Dealing with the yeast overgrowth. Dealing with the leaky gut. Heavy metals and their effects. Chelation. Methylcobalamin. 53
    51. 51. 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
    52. 52. Content Areas • Communication – Teaching the child to use nonverbal communicative gestures. – Teaching motor imitation. – Teaching the meaning and important of communication. – Teaching symbolic representation.
    53. 53. Environmental and Classroom Arrangement • Employ visual strategies • Use techniques of structured teaching • Use consistency in designing the learning environment • Monitor and modify environmental stimuli
    54. 54. 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
    55. 55. 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.
    56. 56. 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.
    57. 57. 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”
    58. 58. Motor and Sensory • Hippo Therapy Dance Movement Therapy Chiropractic Therapy Coloured FiltersWeighted Items
    59. 59. Other • Animal Therapy • Dolphin Therapy • Assistance Dog
    60. 60. Psychotherapy • Play provides a safe psychological distance from their problems and allows expression of thoughts and feelings appropriate to their development
    61. 61. • Play – social ,physical ,constructive ,symbolic, and independent. – Age-appropriate play skills – Individual teaching and directly guided in inclusive preschool experiences.
    62. 62. Psychotherapy • Holding Therapy • CBT • Music Therapy • Art Therapy
    63. 63. 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.
    64. 64. Behavioural and Developmental • Social Stories™ and Autism
    65. 65. 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
    66. 66. • Role of families : – Families are at the helm of their child’s treatment. – Parents are the primary teachers – Home visits are scheduled as needed.
    67. 67. Questions

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