This document provides an overview of the management of pervasive developmental disorder (autism). It begins with a brief history and description of autism. It then discusses clinical presentation including deficits in social behavior, communication problems, and unusual behaviors. It covers assessment, diagnosis, treatment including educational, behavioral and medical interventions, and prognosis. Treatment is multidisciplinary and individualized, aiming to minimize core deficits and maximize independence. Speech/language therapy, developmental therapies, and behaviorally-based treatments are commonly used. Medications may help target specific symptoms but do not impact core deficits. The prognosis is variable, with early diagnosis/treatment and no cognitive impairment predicting better outcomes.

2. Management of Pervasive
Developmental Disorder
Prof. Hani Hamed Dessoki,Prof. Hani Hamed Dessoki,
M.D.PsychiatryM.D.Psychiatry
Prof. PsychiatryProf. Psychiatry
Chairman of Psychiatry DepartmentChairman of Psychiatry Department
Beni Suef UniversityBeni Suef University
APA memberAPA member

3. DisclosureDisclosure
 NO relevant financial relationships with aNO relevant financial relationships with a
commercial interest.commercial interest.

4. AUTISMAUTISM
Autism is a brain disorder that impairsAutism is a brain disorder that impairs
a person’s ability to communicate, forma person’s ability to communicate, form
relationships, socially interact, andrelationships, socially interact, and
respond appropriately within a givenrespond appropriately within a given
environmentenvironment..

5. From kanner to theFrom kanner to the
MillenniumMillennium
 In 1943, Leo Kanner published his paper on autismIn 1943, Leo Kanner published his paper on autism
 He clearly described 11 childrenHe clearly described 11 children
 socially isolatedsocially isolated
 autistic disturbances of affective contactautistic disturbances of affective contact
 impaired communicationimpaired communication
 behavioral inflexibilitybehavioral inflexibility
 It is congenital disease, runs in familiesIt is congenital disease, runs in families
 It is rare diseaseIt is rare disease
 More in males, higher social classesMore in males, higher social classes

6. CHARACTERISTICSCHARACTERISTICS
 MayMay avoidavoid eye contacteye contact
 May appear or respond as ifMay appear or respond as if deafdeaf
 MayMay lack awarenesslack awareness of the existence feelings ofof the existence feelings of
othersothers
 Can be physicallyCan be physically aggressiveaggressive or have outburstsor have outbursts
when familiar environment or routine is changedwhen familiar environment or routine is changed
 Can remainCan remain fixated on single activityfixated on single activity or objector object
 May engage in strange actions such asMay engage in strange actions such as handhand
flapping, or rocking.flapping, or rocking.

7. IncidenceIncidence
 10 years ago Autism and PDD occurred in approximately 510 years ago Autism and PDD occurred in approximately 5
to 15 per 10,000 births.to 15 per 10,000 births.
 These disorders were four times more common in boysThese disorders were four times more common in boys
than girls.than girls.

8. Why rising rate of autismWhy rising rate of autism??
 Partly due to better
awareness/diagnosis.
 So, primary reason is most likely
increased exposure to
environmental factors (mercury,
antibiotics, MMR, pesticides,
iodine deficiency)

9. Autism is a spectrum disorderAutism is a spectrum disorder
 Symptoms less classicSymptoms less classic
 Range of potential manifestation : severelyRange of potential manifestation : severely
handicapped to subtle symptoms with minimalhandicapped to subtle symptoms with minimal
disabilitydisability
 High functioning & Asperger syndromeHigh functioning & Asperger syndrome
 Autistic featuresAutistic features

10. TypesTypes

11. Parental Concerns
(Wiggins, Baio, Rice, 2006(
Recent study indicated most children
with an ASD diagnosis had signs of
a developmental problem before the
age of 3, but average age of
diagnosis was 5 years.

12. Clinical pictureClinical picture
 Deficits in social behaviorDeficits in social behavior
 Problems in communicationProblems in communication
 Unusual pattern of behaviorUnusual pattern of behavior

13. Deficits in social behaviorDeficits in social behavior
 Central symptom (core symptom)Central symptom (core symptom)
 No eye contactNo eye contact
 No interest of human voiceNo interest of human voice
 No anticipatory postureNo anticipatory posture
 Decrease facial responsivenessDecrease facial responsiveness
 No bondingNo bonding
 No social reference, Showing, shared attentionNo social reference, Showing, shared attention
& affect& affect
 No separation anxietyNo separation anxiety

14. Problems in communicationProblems in communication
 Non verbal communicationNon verbal communication
 Understanding of speechUnderstanding of speech
 Speech developmentSpeech development

15. Non verbal communicationNon verbal communication
 Infant: crying & screamingInfant: crying & screaming
 Pulling adult (no appropriate facial expression)Pulling adult (no appropriate facial expression)
 No nodding & shakingNo nodding & shaking
 No imitative gamesNo imitative games
 No copy of adult behaviorNo copy of adult behavior
 Imitative play skill: stereotyped, repetitive, based onImitative play skill: stereotyped, repetitive, based on
their own experiencetheir own experience
 Extreme of emotions or expressionless most of theExtreme of emotions or expressionless most of the
timetime

16. Speech developmentSpeech development
 Babble (impaired amount )Babble (impaired amount )
 MuteMute
 EcholaliaEcholalia
 Pronouns reversalPronouns reversal
 Monotonous, robot, no change of emphasis orMonotonous, robot, no change of emphasis or
emotional expressionemotional expression
 Impaired function of speech: stereotypedImpaired function of speech: stereotyped
phrases (cartoon), lack imagination &phrases (cartoon), lack imagination &
abstractionabstraction
 Lack of to-and-froLack of to-and-fro

17. Unusual pattern of behaviorUnusual pattern of behavior
 Resistance to changeResistance to change
 Ritualistic or compulsive behaviorRitualistic or compulsive behavior
 Abnormal attachment to odd objectsAbnormal attachment to odd objects
 Unusual response to sensory experiencesUnusual response to sensory experiences
 Objects are manipulated without regard of theirObjects are manipulated without regard of their
usual functionsusual functions
 Preoccupations of certain featuresPreoccupations of certain features

18. Associated featuresAssociated features
Disturbance of motilityDisturbance of motility
 Delay motor developmental milestonesDelay motor developmental milestones
 Impaired motor coordinationImpaired motor coordination
 Stereotyped movementsStereotyped movements

19. Intelligence & cognitive deficitsIntelligence & cognitive deficits
 40-60% IQ less than 5040-60% IQ less than 50
 20-30 % IQ above 7020-30 % IQ above 70
 Areas of normal or near normal skillsAreas of normal or near normal skills
 Verbal IQ lower than performance IQVerbal IQ lower than performance IQ
 AspergerAsperger’’s disorders disorder
 Better verbal than performance IQBetter verbal than performance IQ

20. EpilepsyEpilepsy
 4-40%4-40%
 AdolescenceAdolescence
 FemaleFemale

21. Why it is difficult to diagnoseWhy it is difficult to diagnose??????
 Cognitive limitationsCognitive limitations
 Diminished ability to think abstractlyDiminished ability to think abstractly
 Lack of communication skillsLack of communication skills
 Symptoms not classicSymptoms not classic
 Unawareness & inability to describe internalUnawareness & inability to describe internal
statestate (interview & questionnaire ineffective)(interview & questionnaire ineffective)
 Lack of social relatedness & motivation toLack of social relatedness & motivation to
report symptomsreport symptoms

22. EtiologyEtiology
Autism is a neurodevelopmental disorder with a biologicalAutism is a neurodevelopmental disorder with a biological
basis , no definite causebasis , no definite cause
 Cortical dysfunctionCortical dysfunction
 Neurotransmitters dysfunctionsNeurotransmitters dysfunctions
 Vaccination factorVaccination factor
 Food allergyFood allergy
 Antibiotic overuseAntibiotic overuse
 Toxic exposure theoryToxic exposure theory
 Immune diseaseImmune disease

23. Mædica - a Journal of Clinical Medicine
ORIGINAL PAPERS
Maedica A Journal of Clinical Medicine, Volume 7 No.1 2012
Toxic Metals and Essential Elements in Hair
and Severity of Symptoms among Children
with Autism
Eleonor BLAUCOK-BUSCHa; Omnia R. AMINb; Hani H. DESSOKIc; Thanaa
RABAHd
a Lecturer, researcher and advisor, International Board of Clinical Metal
Toxicology & German Medical Association of Clinical Metal Toxicology,
Hersbruck, Germany
b Associate Prof. of Psychiatry, Cairo University, Egypt
c Associate Prof. of Psychiatry- Beni-Suef University, Egypt
d Researcher of Public Health and Biostatistics, National Research Center,
Egypt

24. Vaccines and Autism
 No reliable study has
shown a link between
the MMR vaccine and
autism
 Avoiding vaccines
can place your child
at risk for catching
serious diseases

25. Clinical course &Clinical course &
prognosisprognosis
 The diagnosis of autism is stableThe diagnosis of autism is stable
 The outcome in school, work, or socialThe outcome in school, work, or social
functioning variedfunctioning varied
 Symptoms persist but changeSymptoms persist but change
 AdolescenceAdolescence
 hyperactivity---- underactivityhyperactivity---- underactivity
 Increase anxiety & attentionIncrease anxiety & attention
 Increase sexual curiosity (masturbation in publicIncrease sexual curiosity (masturbation in public
places)places)

26.  Minority can have independent lifeMinority can have independent life
 AspergerAsperger’’s disorders disorder
 Better outcome as regard education, occupation,Better outcome as regard education, occupation,
marriage, need for institution, autonomymarriage, need for institution, autonomy
 More aggression & sexual offensesMore aggression & sexual offenses

27. Comorbid psychiatric disordersComorbid psychiatric disorders
 Other psychiatric symptoms are commonOther psychiatric symptoms are common
 Subsyndromal or comorbid diagnosisSubsyndromal or comorbid diagnosis
 Important for management planImportant for management plan

28. Common Comorbid psychiatricCommon Comorbid psychiatric
disordersdisorders
 Inattention & hyperactivityInattention & hyperactivity (difficulty shifting, lack of(difficulty shifting, lack of
arousal)arousal)
 Obsession & compulsionsObsession & compulsions
 Anxiety & fearsAnxiety & fears
 Mood disorderMood disorder (average ability, puberty)(average ability, puberty)
 Oppositional & antisocial behaviorOppositional & antisocial behavior (rigidity ,lack of(rigidity ,lack of
understanding of social norms)understanding of social norms)
 TicsTics
 PsychosisPsychosis (more deterioration & positive symptoms)(more deterioration & positive symptoms)

29. Differential diagnosisDifferential diagnosis
 General mental retardationGeneral mental retardation
 Developmental language disorderDevelopmental language disorder
 OCDOCD
 Sensory impairmentSensory impairment
 Selective mutismSelective mutism
 Psychosocial deprivationPsychosocial deprivation

30. Assessment, WhatAssessment, What??
 Autistic symptomsAutistic symptoms
 Level of intellectual abilityLevel of intellectual ability
 Language development (expressive & receptive)Language development (expressive & receptive)
 Learning styleLearning style
 Neuropsychological strength & weaknessNeuropsychological strength & weakness
 Adaptive functioningAdaptive functioning
 Family systemFamily system
 Financial resourcesFinancial resources
 Behavioral problemsBehavioral problems
 Other psychiatric symptomsOther psychiatric symptoms
 Other medical condition (epilepsy)Other medical condition (epilepsy)

31. TreatmentTreatment
 No cure for autismNo cure for autism –– no cause is knownno cause is known
 ComprehensiveComprehensive
 MultidisciplinaryMultidisciplinary
 Individualized (heterogeneous group+ differentIndividualized (heterogeneous group+ different
goals)goals)
 Updated according to needsUpdated according to needs

32. ASD Management
 Outcomes are variable
 Behavioral characteristics change over time
 Most remain on spectrum as adults
 Ongoing problems with independent living,
employment, social relationships and mental
health
 Predictors of better outcome
 Earlier age of diagnosis and treatment
 No cognitive impairment
 Early language and nonverbal skills
 Social skills
 Not – presence, degree of “autistic” symptoms

33. 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

34. Speech/Language Therapy
 Behaviorally based/ intensive structured teaching
 E.g., Verbal Behavior
 Augmentative strategies
 Sign language
 Aided augmentative/ alternative systems
 Decrease non-communicative language
 Developmental-pragmatic approaches
 appropriate use of language in social situations
 Social skills training

35. Developmental: Motor
 Fine motor coordination
 Adaptive skills
 Sensory Integration
 Addresses sensory
abnormalities
 “Systematic
desensitization”
 No evidence of
corresponding
neurological changes
 Coordination
difficulties
 Natural environment
 Adaptive physical
education or in the
community

36. Psychopharmacology
 Adjunct to educational,
developmental &
behavioral treatments
 So far no evidence of
impact on core
symptoms
 Evidence supporting is
variable
 Treat target symptoms
 Stereotypies
 Withdrawal
 Obsessions
 Irritability
 Hyperactivity
 attention span
 self-injurious behavior
 Aggression
 sleep

37. MedicationsMedications
 AntipsychoticAntipsychotic
 Antidepressants (classic/SSRI)Antidepressants (classic/SSRI)
 Psychostimulants & alpha-adrenergic agonistPsychostimulants & alpha-adrenergic agonist
 Mood stabilizers & anticonvulsantsMood stabilizers & anticonvulsants
 HormonesHormones
 SupplementsSupplements

38. Other medication & supplementsOther medication & supplements
 Vitamin B6 & magnesiumVitamin B6 & magnesium
 Diet therapyDiet therapy
 HormoneHormone
 Chelating agentChelating agent

39. Symptoms/ Disorders Freq Treatments
Attentional, impulsivity,
hyperactivity
59% Behavioral intervention
Psychopharmacotherapy – stimulants, atomoxetine,
alpha agonists, anti-anxiety
Anxiety 43-84% Behavioral treatment – relaxation, cognitive
Psychopharmacotherapy – SSRI, alpha agonist
Depression 2-30% Psychotherapy
Medication – anti-depressants
Obsessive compulsive
symptoms
37% Behavioral treatment, supportive counseling;
Medication – SSRI, others
Disruptive, irritable or
aggressive behavior
8-32% Behavioral intervention
Medication – atypical neuroleptics (risperidone,
arapiprazole, others)
Self-injurious behavior 34% Behavioral intervention
Medication (e.g., naltrexone, risperidone, others)
Tics 8-10% Medications; Alpha agonist (clonidine, guanfacine),
others
Sleep disruption 52-73% Sleep diary; sleep hygiene; behavioral supports;
investigate possible medical comorbidity/ies as
cause(s)
Psychopharmacology

40. Biologically Based ttt
 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…

41. Strategies to Improve ExecutiveStrategies to Improve Executive
FunctionFunction
 Simplify tasks into discrete, concrete steps.Simplify tasks into discrete, concrete steps.
 Usual visual aids (pictures, schedules, check-off lists.)Usual visual aids (pictures, schedules, check-off lists.)
 Use hand’s on learning (see one, do one, repeat as necessary.)Use hand’s on learning (see one, do one, repeat as necessary.)
 Prepare for transitions and new experiences.Prepare for transitions and new experiences.
 Decrease distractions.Decrease distractions.
 Decrease stressors.Decrease stressors.
 Coordinate assignments.Coordinate assignments.

Make sure challenges are a good match for abilities.Make sure challenges are a good match for abilities.

42. Non pharmacologicalNon pharmacological
 Educational interventionEducational intervention
 Language & speech therapyLanguage & speech therapy
 Behavioral therapyBehavioral therapy
 Social skills trainingSocial skills training
 Working with the parentsWorking with the parents
 Sensiomotor therapySensiomotor therapy
 Sensory integration therapySensory integration therapy
 Auditory integration therapyAuditory integration therapy
 Music therapyMusic therapy

43. Language & speech therapyLanguage & speech therapy
 Stimulate the natural ability for learning languageStimulate the natural ability for learning language
 One to oneOne to one
 2-3 hours/week every day2-3 hours/week every day
 Involvement of parents : generalizationInvolvement of parents : generalization

44. Social skills trainingSocial skills training
 Identify skill , broke it into several componentsIdentify skill , broke it into several components
 Recognize social cuesRecognize social cues
 Response to social cuesResponse to social cues
 encourage generalizationencourage generalization
 Role modelingRole modeling
 Role playRole play
 VideoVideo
 Social storiesSocial stories
 Group (well structured) or individualGroup (well structured) or individual
 Adult mediated or peer mediatedAdult mediated or peer mediated

45. Behavior therapyBehavior therapy
Change of unwanted behaviorChange of unwanted behavior
 Select the target behaviorSelect the target behavior
 Frequency, intensityFrequency, intensity
 definable, measurable, observabledefinable, measurable, observable (hit self with hand, get frustrated when asked to(hit self with hand, get frustrated when asked to
complete work)complete work)
 Antecedent event & consequenceAntecedent event & consequence (attention, self stimulation)(attention, self stimulation)
 Understand the communicative functions of difficult behaviorUnderstand the communicative functions of difficult behavior
 What to do instead?What to do instead?
 Positive reinforcementPositive reinforcement
 Prevent the behavior by changing the antecedent eventPrevent the behavior by changing the antecedent event
(scheduling activities)(scheduling activities)

46. Take Home MessageTake Home Message
 It is very important establish a set of evidence-
based standards for pharmacological,
educational and behavioral interventions for
children with autism spectrum disorders.