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

1. Autistic Spectrum Disorders
Prepared by: Dr. Shewikar El Bakry
Ass. Prof. of Neuropsychiatry
Banha University

2. Agenda
Introduction to Autism
Clinical Picture
Red Flags
Etiology
Diagnosis
Identifying Tools
Management

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.

5. 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.

6. 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

7. 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

8. What is Autism
• Autism is a complex neurobiological
disorder
• Inhibits a person's ability to
– Communicate
– Develop social relationships
– Often accompanied by behavioral challenges.

9. 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

10. 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

11. 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

12. 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

13. 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

14. Red Flag: Any loss of speech or
babbling or social skills
Regression at any age is cause for
immediate referral

16. Clinical Picture
No real fear
of dangers!
Inappropriate
laughing
or giggling

17. 17
Apparent insensitivity
to pain
May not want
cuddling

18. 18
Sustained unusual or
repetitive play;
Uneven physical
or verbal skills
May avoid eye contact

19. 19
May prefer
to be alone Difficulty in expressing
needs; May use gestures

20. 20
Inappropriate attachments
to objects
Insistence
on
sameness

21. 21
Echoes words
or phrases
Inappropriate response
or no response to sound

22. 22
Spins objects
or self
Difficulty in
interacting
with others
Clinical Picture

23. Clinical Picture
Does not seek opportunities
to interact with
others.
Unwillingness and/or inability
to engage in
cooperative play

24. Clinical Picture
Fails to produce appropriate facial
expressions to specific occasions.

25. Clinical Picture

26. Clinical Picture

28. 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.

29. 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.

30. 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.

31. 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

32. 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

33. 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.

34. 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.

35. Etiology
• Psychoanalytical
• Genetic
• anatomical brain areas annomelies
• Infection
• Vaccination
• Prenatal and perinatal factors
• Environmental
• Toxins

36. • 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

37. 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

38. 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

39. 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)

40. SECTION A:-

41. SECTION B:-
-
-
-
-
-

42. 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

43. Data Collection for Analysis ,
and Program Changes
• Design student progress measurement systems
• Conduct assessment and evaluation
• Use data-based decision-making

44. 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?

45. 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

46. 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

47. 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

48. 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)

49. 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

50. 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).

51. 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…

52. 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

53. Another approach to therapy
Dealing with the yeast overgrowth.
Dealing with the leaky gut.
Heavy metals and their effects.
Chelation.
Methylcobalamin.
53

54. 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

55. Content Areas
• Communication
– Teaching the child to use nonverbal
communicative gestures.
– Teaching motor imitation.
– Teaching the meaning and important of
communication.
– Teaching symbolic representation.

56. Environmental and Classroom Arrangement
• Employ visual strategies
• Use techniques of structured teaching
• Use consistency in designing the learning
environment
• Monitor and modify environmental stimuli

58. 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

59. 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.

61. 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.

62. 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”

63. Motor and Sensory
• Hippo Therapy
Dance Movement
Therapy
Chiropractic
Therapy
Coloured FiltersWeighted
Items

64. Other
• Animal Therapy
• Dolphin Therapy
• Assistance Dog

66. Psychotherapy
• Play provides a safe psychological
distance from their problems and allows
expression of thoughts and feelings
appropriate to their development

67. • Play
– social ,physical ,constructive
,symbolic, and independent.
– Age-appropriate play skills
– Individual teaching and directly guided in
inclusive preschool experiences.

68. Psychotherapy
• Holding Therapy
• CBT
• Music Therapy
• Art Therapy

69. 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.

70. Behavioural and Developmental
• Social Stories™ and Autism

73. 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

74. • Role of families :
– Families are at the helm of their child’s
treatment.
– Parents are the primary teachers
– Home visits are scheduled as needed.

75. Questions