AUTISM DISORDER -TINU TOMY-PSYCHOPATHOLOGY

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AUTISTIC DISORDER
Presented by Tinu Tomy MSc.Psychology
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PERVASIVE DEVELOPMENTAL DISORDERS

• Pervasive developmental disorders include several
  that are characterized by impaired reciprocal
  social interactions, aberrant language
  development, and restricted behavioral
  repertoire. Pervasive developmental disorders
  typically emerge in young children before the age
  of 3 years, and parents often become concerned
  about a child by 18 months as language
  development does not occur as expected.

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The DSM-IV-TR includes five pervasive
developmental disorders

1. Autistic disorder,
2. Rett's disorder,
3. Childhood disintegrative disorder,
4. Asperger's disorder,
5. Pervasive developmental disorder not otherwise
   specified

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HISTORY

• As early as 1867, Henry Maudsley, a psychiatrist,
  noted a group of very young children with severe
  mental disorders who had marked deviation, delay,
  and distortion in development. In that era, most
  serious disturbance in young children was
  believed to fall within the category of
  psychoses.

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• Leo Kanner, in his classic paper Autistic
  Disturbances of Affective Contact, coined the
  term infantile autism and provided a clear,
  comprehensive account of the early childhood
  syndrome..

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AUTISTIC DISORDER (historically called early
infantile autism, childhood autism, or Kanner's
autism)

• Autistic disorder is characterized by symptoms
  from each of the following three categories
• Qualitative impairment in social interaction,
• Impairment in communication,
• Restricted repetitive and stereotyped patterns of
  behavior or interests.

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Epidemiology

• Prevalence
• 8 cases per 10,000 children
• Sex Distribution
• more frequent in boys than in girls.
• . Socioeconomic Status
• Over the past 25 years, no epidemiological
  studies have demonstrated an association between
  autistic disorder and any socioeconomic status.

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Etiology and Pathogenesis
Genetic Factors Biological Factors Perinatal
Factors Neuroanatomical Factors Biochemical
Factors Psychosocial and Family Factors
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DSM-IV-TR Diagnostic Criteria for Autistic
Disorder

• A total of six (or more) items from (1), (2), and
  (3), with at least two from (1), and one each
  from (2) and (3)
• 1.qualitative impairment in social interaction,
  as manifested by at least two of the following
• marked impairment in the use of multiple
  nonverbal behaviors such as eye-to-eye gaze,
  facial expression, body postures, and gestures to
  regulate social interaction

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• failure to develop peer relationships appropriate
  to developmental level
• 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)
• lack of social or emotional reciprocity

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• 2.qualitative impairments in communication as
  manifested by at least one of the following
• 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 or mime)
• in individuals with adequate speech, marked
  impairment in the ability to initiate or sustain
  a conversation with others
• stereotyped and repetitive use of language or
  idiosyncratic language
• lack of varied, spontaneous make-believe play or
  social imitative play appropriate to
  developmental level

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• 3.restricted repetitive and stereotyped patterns
  of behavior, interests, and activities, as
  manifested by at least one of the following
• -encompassing preoccupation with one or
  more stereotyped and restricted patterns of
  interest that is abnormal either in intensity
  or focus
• apparently inflexible adherence to specific,
  nonfunctional routines or rituals
• stereotyped and repetitive motor mannerisms
  (e.g., hand or finger flapping or twisting, or
  complex whole-body movements)
• persistent preoccupation with parts of objects

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• Delays or abnormal functioning in at least one of
  the following areas, with onset prior to age 3
  years (1) social interaction, (2) language as
  used in social communication, or (3) symbolic or
  imaginative play.
• The disturbance is not better accounted for by
  Rett's disorder or childhood disintegrative
  disorder.

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ICD-10 Diagnostic Criteria for Pervasive
Developmental Disorders

• Childhood autism
• Abnormal or impaired development is evident
  before the age of 3 years in at least one of the
  following areas
• receptive or expressive language as used in
  social communication
• the development of selective social attachments
  or of reciprocal social interaction
• functional or symbolic play.

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• B. A total of at least six symptoms from (1),
  (2), and (3) must be present, with at least two
  from (1) and at least one from each of (2) and
  (3)
• 1.Qualitative abnormalities in reciprocal social
  interaction are manifest in at least two of the
  following areas
• failure adequately to use eye-to-eye gaze, facial
  expression, body posture, and gesture to regulate
  social interaction

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• lack of socioemotional reciprocity as shown by an
  impaired or deviant response to other people's
  emotions or lack of modulation of behavior
  according to social context or a weak
  integration of social, emotional, and
  communicative behaviors
• failure to develop (in a manner appropriate to
  mental age, and despite ample opportunities) peer
  relationships that involve a mutual sharing of
  interests, activities, and emotions
• lack of spontaneous seeking to share
  enjoyment, interests, or achievements with
  other people (e.g., a lack of showing, bringing,
  or pointing out to other people objects of
  interest to the individual)

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• 2.Qualitative abnormalities in communication are
  manifest in at least one of the following areas
• a delay in, or total lack of, development of
  spoken language that is not accompanied by an
  attempt to compensate through the use of gesture
  or mime as an alternative mode of communication
  (babbling)
• relative failure to initiate or sustain
  conversational interchange (at whatever level of
  language skills is present), in which there is
  reciprocal responsiveness to the communications
  of the other person
• stereotyped and repetitive use of language or
  idiosyncratic use of words or phrases
• lack of varied spontaneous make-believe or (when
  young) social imitative play.

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• 3.Restricted, repetitive, and stereotyped
  patterns of behavior, interests, and activities
  are manifest in at least one of the following
  areas
• an encompassing preoccupation with one or more
  stereotyped and restricted patterns of interest
  that are abnormal in content or focus or one or
  more interests that are abnormal in their
  intensity and circumscribed nature though not in
  their content or focus
• apparently compulsive adherence to specific,
  nonfunctional routines or rituals

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• stereotyped and repetitive motor mannerisms that
  involve either hand or finger flapping or
  twisting, or complex whole body movements
• preoccupations with part-objects or nonfunctional
  elements of play materials (such as their odor,
  the feel of their surface, or the noise or
  vibration that they generate).
• C.The clinical picture is not attributable to the
  other varieties of pervasive developmental
  disorder specific developmental disorder of
  receptive language with secondary socioemotional
  problems reactive attachment disorder or
  disinhibited attachment disorder, mental
  retardation with some associated emotional or
  behavioral disorder schizophrenia of unusually
  early onset and Rett's syndrome.

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Atypical autism

• Abnormal or impaired development is evident at or
  after the age of 3 years (criteria as for autism
  except for age of manifestation).
• There are qualitative abnormalities in reciprocal
  social interaction or in communication, or
  restricted, repetitive, and stereotyped patterns
  of behavior, interests, and activities. (Criteria
  as for autism except that it is unnecessary to
  meet the criteria for number of areas of
  abnormality.)
• The disorder does not meet the diagnostic
  criteria for autism. Autism may be atypical in
  either age of onset or symptomatology the two
  types are differentiated with a fifth character
  for research purposes. Syndromes that are
  atypical in both respects should be coded.
  Atypicality in both ages of onset and
  symptomatology

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Atypicality in age of onset

• The disorder does not meet Criterion A for
  autism that is, abnormal or impaired development
  is evident only at or after the age of 3 years.
• The disorder meets Criteria B and C for autism.

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Atypicality in symptomatology

• The disorder meets Criterion A for autism that
  is, abnormal or impaired development is evident
  before the age of 3 years.
• There are qualitative abnormalities in reciprocal
  social interactions or in communication, or
  restricted, repetitive, and stereotyped patterns
  of behavior, interests, and activities. (Criteria
  as for autism except that it is unnecessary to
  meet the criteria for number of areas of
  abnormality.)
• The disorder meets Criterion C for autism.
• The disorder does not fully meet Criterion B for
  autism.

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Atypicality in both age of onset and
symptomatology

• The disorder does not meet Criterion A for
  autism that is, abnormal or impaired development
  is evident only at or after the age of 3 years.
• There are qualitative abnormalities in reciprocal
  social interactions or in communication, or
  restricted, repetitive, and stereotyped patterns
  of behavior, interests, and activities. (Criteria
  as for autism except that it is unnecessary to
  meet the criteria for number of areas of
  abnormality.)
• The disorder meets Criterion C for autism.
• The disorder does not fully meet Criterion B for
  autism.

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BEHAVIORAL CHARACTERISTICS

• Qualitative impairment in social interaction
• Disturbance in language and communication
• Stereotyped behavior
• Instability of mood and affect
• Response to sensory stimuli
• Associated behavioral symptoms and physical
  symptoms
• Intellectual functioning

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High functioning autism

• About 20 of the PDD
• Above average IQ
• Superior vocabulary skills
• Learning disability
• Motor deficit
• Less impaired on TOM test
• Speech less commonly delayed

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SOME TOOLS

• CHAT(Check list for autism in toddler)
• CARS(Childhood autism rating scale)
• ADOS(Autism diagnosis observation schedule)
• TOM(Theory of mind)

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Procedure for Differential Diagnosis on a
Multiaxial System

• Determine intellectual level
• Determine level of language development
• Consider whether child's behavior is appropriate
  for
• chronological age
• mental age
• language age

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• If not appropriate, consider differential
  diagnosis of psychiatric disorder according to
• pattern of social interaction
• pattern of language
• pattern of play
• other behaviors
• Identify any relevant medical conditions
• Consider whether there are any relevant
  psychosocial factors

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Autistic Disorder versus Schizophrenia with
Childhood Onset

Criteria Autistic Disorder Schizophrenia (with Onset before Puberty)
Age of onset Before 38 months Not under 5 years of age
Incidence 2 to 5 in 10,000 Unknown, possibly same or even rarer
Sex ratio (MF) 3 to 41 1.671 (nearly equal, or slight preponderance of males)
Family history of schizophrenia Not raised or probably not raised Raised
Socioeconomic status (SES) Overrepresentation of upper SES groups (artifact) More common in lower SES groups
Prenatal and perinatal complications and cerebral dysfunction More common in autistic disorder Less common in schizophrenia
Behavioral characteristics Failure to develop relatedness absence of speech or echolalia stereotyped phrases language comprehension absent or poor insistence on sameness and stereotypies Hallucinations and delusions thought disorder
Adaptive functioning Usually always impaired Deterioration in functioning
Level of intelligence In most cases subnormal, frequently severely impaired (70) Usually within normal range, mostly dull normal (15 to 70)
Pattern of IQ Marked unevenness More even
Grand mal seizures 4 to 32 Absent or lower incidence
(Courtesy of Magda Campbell, M.D., and Wayne Green, M.D.) (Courtesy of Magda Campbell, M.D., and Wayne Green, M.D.) (Courtesy of Magda Campbell, M.D., and Wayne Green, M.D.)
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Autistic Disorder versus Mixed Receptive-Expressiv
e Language Disorder
Criteria Autistic Disorder Mixed Receptive-Expressive Language Disorder
Incidence 2 to 5 of 10,000 5 of 10,000
Sex ratio (MF) 3 to 41 Equal or almost equal sex ratio
Family history of speech delay or language problems Present in about 25 of cases Present in about 25 of cases
Associated deafness Very infrequent Not infrequent
Nonverbal communication (e.g., gestures.) Absent or rudimentary Present
Language abnormalities (e.g., echolalia, stereotyped phrases out of context) More common Less common
Articulatory problems Less frequent More frequent
Level of intelligence Often severely impaired Although may be impaired, less frequently severe
Patterns of intelligence quotient (IQ) tests Uneven, lower on verbal scores than dysphasic patients, lower on comprehension subtest than dysphasic patients More even, although verbal IQ lower than performance IQ
Autistic behaviors, impaired social life, stereotypies, and ritualistic activities More common and more severe Absent or, if present, less severe
Imaginative play Absent or rudimentary Usually present
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Prognosis

• Research shows that 50 of children diagnosed
  with autism will remain mute throughout their
  lives.
• Approximately 10 of autistic individuals have
  savant abilities

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Intervention
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INTERVENTION

• Early intervention
• combined developmental educational
  behavioral approach
• Pharmacological intervention

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• Behavioral Interventions research suggests that
  early, intensive behavioral interventions may
  improve outcomes for children with autism and
  help the children achieve their maximum
  potential.
• Sensory Integration integration and
  interpretation of sensory stimulation from the
  environment enhances cognition.

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• Diet people with autism are more susceptible to
  allergies and food sensitivities than the average
  person. The most common food sensitivity in
  children with autism is to gluten and casein.
• Vitamin Therapy parents have reported that they
  have tried B6/magnesium often with good or even
  spectacular results.

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Some factors associated with treatment

• Childs inability to seek assistance
• The need to recognize special vulnerabilities
  that children youth might experience that place
  them at great risk for developing emotional
  problems
• The need for treatment for parents as well as
  child
• The possibility of using parents as change agent
• The problem of placing the child outside the
  family
• Importance of early intervention before the
  problem becomes acute

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MOST BENEFICIAL

• Between 2-4 yrs
• Intensive 15-40 or more hours per week
• Need a schedule through out the day
• Intervention should be continued over 1-2 yrs or
  more

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WHAT TO TEACH

• Attending skills
• Communication skill
• Imitation skills
• Self help skills
• Parent as co-therapist

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Teaching Tips for Children with Autism

• Use visuals
• Avoid long strings of verbal instruction
• Encourage development of childs special talents
• Use childs fixations to motivate school work
• Use concrete, visual methods to teach number
  concepts
• Let child use a typewriter instead of writing
• Protect child from sounds that hurt his/her ears

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• Place child near a window and avoid using
  fluorescent lights
• Interact with child while he/she is swinging or
  rolled in a mat
• Dont ask child to look and listen at the same
  time
• Teach with tactile learning materials (e.g.,
  sandpaper alphabet)
• Use printed words and pictures on a flashcard
• Generalize teaching

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Parenting a Child with a Disability

• Seek the assistance of other parents
• Rely on positive resources in your life (e.g.,
  church, counselors)
• Learn the terminology
• Seek information (e.g., internet, support
  groups)
• Maintain a positive outlook

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• Find programs for your child
• Take care of yourself
• Decide how to deal with others
• Keep daily routines as normal as possible
• Know that you are not alone
• Most importantly, keep your sense of humor

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OUTCOME

• Influenced by
• Severity
• Degree of retardation
• Verbal ability
• Comorbid seizures

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PREVENTIVE INTERVENTION

• Routine developmental surveillance
• Good parenting skills
• lots of interaction
• play
• restrict TV

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Thank You