ADHD autism

2. SUBMITTED TO
PRESENTED BY
Mrs.Premavathy Miss.S.Manju
Lecturer in nursing M.Sc (N) II yr
RMCON, AU RMCON, AU

3. Introduction
Although often called autism because it is through to
be present from birth, autism usually is not conclusively
diagnosed until after 12 months of age. The word
autism comes from the Greek word auto meaning “self”
and was first used by Dr.Leo Kanner in 1943 to describe
a group of behavioral symptoms in children. The term
pervasive developmental disorder was introduced in
1980 when the American psychiatric association revised
the terminology. Disorders in this category are
characterized by severe behavioral disturbance that
affects the practical use of language as a means of
communication, interpersonal interaction, attention,
perception, and motor activity.

4. Definition
Infantile autism is a pervasive developmental
disorder characterized by (1) a total lack of
responsiveness to people, (2) gross language
developmental deficits or distortions such as
echolalia ( a meaningless echoing of words),
pronominal reversal and metaphoric language , and
(3) bizarre responses to various aspects of the
environment such as resistance to change or peculiar
interest in an animate or inanimate object.
American Psychiatric Association (1980)

5. Incidence
Autism occurs in about 2- 5 of 10,000 births in 1980.
1 to 2 in 500 children in 2008.
Four times as often in males as in females and it has
higher incidence in first born males from well educated.
Etiology
Genetic Factors
Twins is consistent with an autosomal recessive pattern
of inheritance.
Very high concordance (60% - 90%) for monozygotic
(identical).
Less than 5% concordance for dizygotic (nonidentical)
twins.

6. Etiology contd…
Deletion and duplication in chromosome 15
Thimerosal – containing neither vaccines nor the measles
– mumps rubella (MMR) vaccine.
Maternal vaginal infection during pregnancy
Anorexia during pregnancy and delivery
Bio chemical problem involving neurotransmitters or
abnormalities in the central nervous system with
dopamine, catecholamine, and serotonin levels or
pathways implicated.
Language and cognitive abnormalities are common in
relatives of autistic children.
Pre or post natal brain injury

7. Associated conditions
 Fragile X syndrome
 Tuberous sclerosis(autosomal dominant)
 Metabolic disorders( PKU – autosomal recessive)
 Fetal rubella syndrome
 Haemophilus influenza meningitis
 Structural brain abnormalities
 Encephalitis
 Neonatal hyperbilirubinemia

8. Pathophysiology
Due to disturbance in the cerebral cortex
The occurrence of seizures more frequently in autistic children
than in normal population
Initial NMR (Nuclear Magnetic Resonance) spectroscopic studies,
PET and neurological studies have shown abnormalities in partial
and frontal association cortex
 Cerebellar hypoplasia
 Purkinje neuronal loss
 Loss of Cerebellar granule cells
 Loss of cells in Cerebellar nuclei
These finding should be considered preliminary of autism

9. Clinical Manifestations
Speech and language delay
Impairment of comprehension of language
Obviously limited activities and interest
Fluent but unintelligible jargon
Impairment of social interaction
Poor eye contact
Gaze avoidance
Lack of reciprocal social smile
Lack of imaginative play
Hyperactivity
Unusual interest in TV commercials
Repetitive compulsive play activities such
as spinning an object, flipping electrical switch on and off
Rocking

10. Clinical
Manifestations
contd…
Flapping of hands
Twirling
Toe walking
Violent tempertandrum
Irritable
Chronically unhappy
Making the parents life
absolutely miserable and
unbearable
Seizures
Totally lack of response to
other people

12. Differential Diagnosis
 Mental retardations
 Developmental language disorders high
functioning in autistic childrens
 Schizophrenia
 Asperger’s syndrome
 Rett’s syndrome

13. Diagnostic Evaluation
History collection
Collect natal and post natal history, including
developmental, nutrition and family dynamics.
Physical examination and neurological examination
needed. Including vision and hearing test, speech, and
language, psychological, educational, and psychiatric
evaluations important.
Electroencephalography when the seizure is present.
Neuroimaging – CT scans
MRI, PET
Radiographic studies of the skull.
Laboratory studies.
Urine screening

14. Diagnostic Criteria For Autistic
Spectrum Disorder
Total six (or more) items from (1), (2), and (3), with at least
two from (1), and one each from (2) and (3).
Quantitative impairment in social interaction, as
manifested by at least two of the following.
(a). Marked impairment in the use of multiple non verbal
behaviors such as eye to eye gaze, facial expression, body
postures, and gestures, to regulate social interactions.
(b). Failure to develop peer relationship appropriate to
developmental level.
(c).A lack of spontaneous seeking to share enjoyment,
interests, or achievements with other people (e.g. by a lack
of showing, bringing, or pointing out objects of interest)
(d).Lack of social or emotional reciprocity.

15. Diagnostic Criteria For Autistic
Spectrum Disorder
(2).Qualitative impairments in communication as manifested
by at least one of the following:
(a). delay in , or total lack of, the development of spoken
language( not accompanied by an attempt to compensate
through alternative modes of communication such as
gesture mime).
 (b). in individual with adequate speech, marked
impairment in the ability to initiate or sustain a conversation
with others.
 (c). stereotyped and respective use of language or
idiosyncratic language.
 (d).lack of varied, spontaneous make – believe play or
social imitative play appropriate to developmental level

16. (3).Restricted repetitive and stereotyped patterns of
the behavior, interests, and activities, as manifested
at least one of the following
(a). Encompassing preoccupation with one or
more stereotyped and restricted pattern of interest
that is abnormal either in intensity or focus
(b).Apparently inflexible adherence to specific,
non functional routines or rituals
(c). stereotyped and repetitive motor
mannerisms (e.g, hand or finger flapping or twisting,
or twisting, or complex whole – body movements)
(d). persistent preoccupation with parts of
objects.

17. B. Delay or abnormal functioning in at least one
of the following areas, with onset before age
3 years; (1) social interaction, (2) language as
used in social communication, or (3) symbolic
or imaginative play
C. The disturbance is not better accounted for
by rett disorder or child hood disintegrative
disorder.

18. Team Members Involved In
Autistic Child Treatment
 Audiologist
 Psychiatrist
 Psychologist
 Special education teachers
 Speech and language therapist
 Social workers

19. Drug Management
Neuroleptics – Risperidone, Olanzapine.
Clomipramine - a tricycle
antidepressant with serotonin reuptake
inhibitor action.
Serotonin reuptake inhibitor and
clonidine
Drugs are used for control of seizure and
hyperactivity.
Promotion of normal
development
Specific language
Social interaction
Learning
Individual
psychotherapy

20. NURSING MANAGEMENT
GOALS;
(1). To meet the basic human needs:
To meet hydration, nutrition, elimination, and rest.
These children cannot verbally communicate these needs.
The nurse needs to be aware of them and to set up a routine
for the basic care.
(2). To help them from a relationship with another person.
They should assigned a primary nurse with a regular schedule
The primary nurse can use behavior modification to begin to
reward the children for eye contact or other signs of
relatedness.
The nurse should plan deliberate intrusions into their solitude
to force beginning of social interaction.

21. (3). To help them establish a means of communication.
 To begin by using sign language.
 These children do not use words to communicate
 These children to establish a means of communication
without the extreme frustration of trying to use the
words.
(4). To prevent them from harming themselves or others.
 The nurse may have prescribed medication such as
chlorpromazine or thioridine
 Physical restraint to prevent such behavior.

22. FAMILY SUPPORT
Nurse can alleviate the guilt and shame often associate
with this disorder by stressing what is known by a biological
standpoint, as well as how little is known about the causes
of Autism.
Parent need to counseling early
Society provides information on education, treatment
programs and techniques,
There is also a sibling group called SHARE(sibling helping
persons with autism through resources and energy).
Family support programme
Families are often able to provide home care and assist with
the educational services the child needs.
The family may require assisting in locating a long – term
placement facility.

23. HOME CARE STUTTERING IN YOUNG
CHILDREN
Giving the child plenty of time and the impression that you
are not rushed or in a hurry.
Looking directly at the child while he or she is talking,
being patient and never ridiculing.
Setting a good example by speaking clearly and
articulating well.
Identifying situation when sturrering increases and
avoiding them or ignoring the hesitancy.
Minimizing stress, such as talking at the child’s eye level.
Avoiding frequent questions to prevent interruption while
child speaking.
Provide positive reinforcement

24. COURSE AND PROGNOSIS
 Prognosis of infantile autism is very poor.
 Factors favorable to a good prognosis are
normal intelligence, good communicative
skills (speech and language) at onset, and
absence of seizure.
 One in six of these children makes a adequate
social adjustment and is able to do some kind
of work by adulthood.

26. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
CONTD. . .Introduction
 This disorder is characterized by poor ability to attend
to a task, motoric overactivity, and impulsivity. These
children are fidgety, have a difficult time remaining in
their seats in school, are easily distracted, have
difficulty awaiting their turn(impulsive blurt out
answers to questions), have difficulty following
instructions and sustaining attention, shift rapidly from
one uncompleted activity to another, talk excessively,
intrude on others, often seem not to listen to what is
being said, lose item regularly, and often engage in
physical dangerous activities without considering
possible consequences.

27. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
CONTD. . .Definition
ADHD is defined as a
“persistent pattern of
inattention, hyperactivity
and impulsivity, that is
more frequent and severe
than is typically observed
at a comparable level of
development”.

28. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
CONTD. . .Incidence
 ADHD affect 3- 4% of children in the USA.
 Boys are more affected than girls in a 6:1 ratio. ADHD
persists into adolescence and adult life.
 Age of onset is usually before 4 years but diagnosis is
made around 3- 4 years of age.
 Statistical data is not available for the Indian children,
experts agree that is roughly the same percentage as in
the western population.
Prevalence
 American academy of child and adolescent psychiatry
estimates10% in boys and 5% in girls of elementary
school age.

29. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
CONTD. . .Etiology
 Genetic component
 Psychological issues and
neurodevelopmental insult
 Minimal brain damage
 Excess sugar or food additives (5%)
Predisposing factors
 Developmental disorders
 Alcohol abuse
 Conduct disorder
 Antisocial personality disorders have
been shown to be more common in 1st
degree relatives of children with ADHD
than in the general population.

30. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
CONTD. . .Pathophysiology
Scientist have used PET( position emission
tomography) scanner to observe the brain at
work and have concluded that brain areas which
control attention use less glucose intake in
these parts of the brain which control attention
is proved to beneficial in some children.
Therefore, this is probably an acceptable theory
of the cause of ADHD.

31. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
CONTD. . .Clinical manifestations
 Aggression and fears
 Poor relationship with peers
 Academic difficulty
 Anxiety disorder
 Academic difficulty
 Behavioral problems at school
Infancy
 “colicky,” temperamental difficulty
 Overactive from a very earlier age
 Sleep and feeding abnormalities

32. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
CONTD. . .Clinical manifestations contd…
Toddler
 Tempertandrum
 oppositionalism
School children
 Uncontrollable
 Refusing to sit still
 Being boisterous and inattentive
 Refusing following instruction
 They often provoke others to anger and rarely learn
from their mistakes
 “Soft sign” (mixed hand preference, impaired balance,
astereognosis,dysdiadochokinesia )

33. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
CONTD. . .The diagnosis of ADHD is based on the modified criteria of DSM- IV
on hyperactivity, impulsivity and attention deficit , Either (1) or (2)
Inattentions: At least six of the following symptoms to Inattention
leave persisted for at least six months to a degree that is
maladaptative and inconsistent with developmental level.
 Clearless errors, inattentive to details
 Sustains attention poorly
 Appears to be not listening
 Follows through poorly on obligations
 Disorganized
 Avoids or dislikes sustained mental effort
 Losses needed objects
 Forgetful

34. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
CONTD. . .Hyperactivity/Impulsivity
 Fidgets or squirms
 Cannot stay seated
 Restlessness
 Loud, noisy
 Always “on the go”
 Talks excessively
 Blurts out
 Impatient
 intrusive

35. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
CONTD. . . Some studies suggested that
hyperactivity children have higher
verbal score than performance
scores on the weschsler intelligence
scale and lower scores on the
attention concentration subtest.
 Psychometric test should cover four
essential areas language skills,
visuospatial skills, sequential analytic
skills, and motor planning and
execution skills.

36. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
CONTD. . .
Differential Diagnoses
Medical conditions
 Hearing loss
 Thyroid dysfunction
 Visual disturbances
 Seizures disorders
 Allergic conditions
Mental disorders
 Oppositional defiant disorder
 Conduct disorder
 Anxiety and depressive disorder
 Pervasive developmental disorder
 Obsessive compulsive disorder
 Schizophrenia

37. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
CONTD. . .
Management (Medical treatment)
 Methylphenidate is commonly used stimulant 0.3 – 1.0
mg/kg. It generally has an effect for 2 - 4 hr. Studies of
plasma levels suggest that a dose of 0.3 mg/kg helps to
improve attention. Whereas amelioration of behavior
problems requires 0.7 mg/kg. it should be given at least 2- 3
weeks.
 Dextroamphetamine 0.2 – 0.5 mg/kg .both drug should be
given about 20 – 30 min before meals to avoid deactivation.
They should not be given after 4.00 pm to avoid insomnia.
 Magnesium pemoline initial dose 18.75 mg later half tablet
per week.

38. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
CONTD. . .
Other Treatment
 Cognitive - behavioral therapy
 Individual psychotherapy
 Parent training or education
 Social skills training
 Biofeedback
 Relaxation treatment

39. ATTENTION DEFICIT HYPERACTIVITY
DISORDER CONTD. . .
Home Management
 These children need to be provide with outdoor activities
 Play with minimal instruction would be beneficial.
 These children need to organize to get adequate sleep and
rest.
 A structured home schedule for daily activities like wakeup
time, meal time, bed time etc.
 These children need a carefully planned discipline to be
followed. Aggressive behavior should not be tolerated all risk
must be enforced with non – physical punishment.
 Overwhelming situation such as big gatherings should be
avoided till child learn to control himself.
 Structured behavioral modification program for increasing
attention span, proper discipline should be adopted.
 Child on special program in school would be beneficial.

40. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
CONTD. . .Dietary Management
 The idea that behavior disorder may be caused by
food is largely suggested by Dr. Femigoid. He saw
30 – 50% of hyperactivity children show a significant
improvement when placed on a special elimination
program of avoiding naturally occurring salicylates
and artificial food additives particularly
predetermine predisposition.
 Although this has not been conclusively proved, it is
worthwhile trying a diet based on wholesome food
and avoiding foods with artificial color or flavor.

41. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
CONTD. . .Nursing Management
 Impaired social interaction related to aggressive
behavior
 Anxiety related to confusion about one’s own
behavior
 Hyperactivity related to increase intake of glucose
rich diet
 Ineffective coping mechanism related to behavior
problem
 Bodily injury related to violence behavior due to
aggressive behavior
 Sleep pattern disturbance related to hyperactivity
 Knowledge deficit regarding treatment regiment

42. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
CONTD. . .Impaired social interaction related to
aggressive behavior
Interventions
 Assess the level of condition of the child aggressive behavior.
 Enhance the child to engage in normal daily activities to
reduced hyperactivity and attentenion deficits.
 Involve the child in play activity as like as normal child to
reduce the fear.
 Allows the child to interact the peer groups.
 Provide lovable care to the child and maintain good
conversation to the child.
 Provide behavior therapy to the child.

43. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
CONTD. . .Hyperactivity related to increase
intake of glucose rich diet
Interventions
 Reduced the child diet pattern of high rich glucose diet.
 A structured home schedule for daily activities like
wakeup time, meal time, bed time etc.
 Provide calm environment to the child
 These children need a carefully planned discipline to be
followed. Aggressive behavior should not be tolerated all
risk must be enforced with non – physical punishment
 Provide Parent training or education
 Psychological therapy should provide the child

44. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
CONTD. . .Sleep pattern disturbance related to
hyperactivity
Interventions
 Provide the child to get adequate sleep and rest.
 Provide calm and quite environment to the child
 Before bed provide cup of milk to promote sleep
pattern.
 Nutritional need should fulfill the child before bed
time
 Parents should follow the regular time for food and
sleep.

45. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
CONTD. . .Knowledge deficit regarding
treatment regiment
Interventions
 Educate parents about the disease condition of the
ADHD, and current treatment facilities of ADHD.
 Allow them to ask the doubts in the disease
condition
 Provide psychological support to the child.
 Provide Parent training or education.
 Educate about low rich glucose diet benefits to the
parents.

46. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
CONTD. . .complications
criminal
behavior
school
exclusion
challenging oppositional substance
behavior deficient misuse
ADHD teenage
Only poor social skills low self esteem pregnancy
Learning difficulties conduct
disorder
lack of
motivation

47. ATTENTION DEFICIT
HYPERACTIVITY DISORDER
CONTD. . .prognosis
 Some anecdotal studies propose that
hyperactivity continues into adolescence and
adulthood and is associated with adult
alcoholism, sociopathy, and hysteria.
 Other studies strongly suggested that
hyperactivity children do well in adulthood if
they are successfully employed