Autism and Autistic Spectrum Disorders

1
Autism and Autistic Spectrum Disorders

• Part II Practice
• Assessment, management and treatment

2
Assessment Detection

• With the advent of standardized diagnostic tools
  (ADI-Revised, ADOS-G) expert clinicians can
  reliably diagnose autism by age 3
• But most children are not diagnosed until age 4
  to 5 years
• Typically 2 to 3 years after parents first seek
  professional help
• Parents often sense there is something wrong
  with their childs relatedness or how
  connected their child is with others and / or
  the environment or that their language is delayed

3
Assessment Detection

• Parents often feel brushed off by physicians
• yes he quiet he will grow out of it
• she is just a girl all girls are shy
• dont worry
• Most children are seen by at least three
  professionals for assessment prior to diagnosis

4
Assessment Detection

• Can Autism be Detected at 18 Months? The needle,
  the haystack and the CHAT
• Baron-Cohen S, Allen J, Gillberg C.
• Br J Psychiatry 1992161839-943
• 41 high risk infants with a sibling with autism
• 4 children exhibited clear signs of autism at 18
  months
• Such findings, together with autisms severity,
  its staggering prevalence and relative merits of
  early intervention, all argue for the importance
  of early detection

5
Consensus Panel 2000

• American Academy of Neurology
• American Academy of Pediatrics
• American Academy of Child and Adolescent
  Psychiatry
• Population based screening in two stages
• Routine developmental surveillance (including
  measures to detect general developmental delay)
• Specifically to detect delayed speech

6
Web LinkPractice Parameters for the Assessment
and Treatment of Children, Adolescents and Adults
with Autism and Other Pervasive Developmental
Disorders

• J Am Acad Child Adolesc Psychiatry, 3812
  Supplement, December 1999
• The full text of the Practice Parameters a long
  document, however it covers all the aspects of
  diagnosis, investigation and treatment.

7
Screening Instruments

• Checklist for Autism in Toddlers (CHAT)
• The Quantitative CHAT (Q-CHAT)
• The Modified CHAT (M-CHAT)
• The Screening Test for Autism (STAT)
• The Pervasive Developmental Disorders Screening
  Test II (PDDST-II)
• The Early Screening for Autism Questionnaire
  (ESA)
• All of these sound wonderful
• BUT
• What about the toddler in the family doctors
  office?

8
Detection

• Education of family practitioners about early
  development
• Knowing what questions to ask
• Knowing how to ask questions
• Most parents (usually the mothers) present with
  questions that something is wrong but they
  cant put their finger on it

9
Screening Questions

• Pregnancy
• severe bleeding
• gestational diabetes
• infections
• fetal growth
• alcohol, drug use
• medications
• herbs and natural remedies

10
Screening Questions

• Delivery major problems
• prematurity
• did the delivery room become busy -the team
• fetal distress
• resuscitation
• Early neonatal NICU
• complications of prematurity
• severe neonatal disease / infection
• seizures

11
Screening Questions

• Developmental Milestones
• Motor crawling and walking
• Language and communication skills

12
Normal Language Development

• Birth to age one
• Babies begin to process the communication signals
  they receive.
• During the first months of life, they are usually
  able to recognize their mother's voice and
  actively listen to language rhythms.
• By 6 months of age, most babies express
  themselves through cooing with vowels and one or
  two consonants.
• This progresses to babbling and repeating sounds.
  In addition, babies learn to vary their cry to
  communicate their needs.
• By their first birthday, babies understand and
  can identify each parent, often by name ("mama,"
  "dada"). They repeat sounds they hear and may
  know a few words.

13
Normal Language Development

• Age one to three
• A toddler's speech and language foundation grows
  rapidly after the first birthday through age 2.
• 1-year-olds learn that words have meaning. They
  point to things they want and often use one or
  two-syllable sounds, such as "baba" for "bottle.
• By age 2, children usually can say between 20 and
  50 words and recognize the names of many objects.
  They also understand simple statements and
  requests, such as "all gone."

14
Normal Language Development

• Age one to three continued
• Many 2-year-olds talk a lot. They usually can
  name some body parts (such as arms and legs) and
  objects (such as a book). Not all their words are
  intelligible some are made-up and combined with
  real words.
• In addition to understanding simple requests,
  they can also follow them (such as "put the book
  on the table"). They usually can say between 150
  to 200 words, some of which are a simple two-word
  combination, such as "want cookie." Pronouns
  (like "me" or "she") are used, but often
  incorrectly.
• It is also normal for a child to be fairly quiet.
  Quiet children who communicate through gestures
  and facial expressions are likely to develop
  normal language skills.

15
Normal Language Development

• Age three to five
• More sophisticated speech and language develops
  from ages 3 through 5.
• By age 3, children learn new words quickly and
  can follow two-part directions (such as "wash
  your face and put your shoes away").
• They start to use plurals, short complete
  sentences, and most of the time can be understood
  by others outside of their family. "Why" and
  "what" become popular questions.
• 4-year-olds use longer sentences and can describe
  an event. They understand how things are
  different, such as the distinction between
  children and grown-ups.
• 5-year-olds usually can carry on a conversation
  with another person.

16
Screening Questions connectedness

• Infant temperament
• colicky, quiet, anxious, distant, happy, calm
  etc
• Eye contact gaze avoidance, looking past
• When you look back do you think your baby was
  too quiet or calm?
• When did you first think something was unusual?
• What was that?

17
Physical Examination

• Look at the face eyes, palpebral fissures
• nose (saddle)
• philtrum
• lips
• ears
• (Ask the parent if the child looks different to
  siblings, relatives)
• Muscle tone
• Does the child look awkward, uncoordinated?
• Does the child latch well to the nipple during
  feeding

18
Physical Examination

• Gaze
• Eye tracking
• Following
• Hearing responds to and localizes sounds, volume

19
Investigations

• If suspicious of a developmental problem with the
  above screening
• Audiology
• Ophthalmology
• Paediatric referral

20
What to tell the parent

• If one of the screening questions, physical
  examination findings or audiology, ophthalmology
  reveal evidence of a deviation in developmental
  trajectory
• simply till the parent that and further
  investigations are required.

21
The Hard to Reassure Parent

• An overly anxious parent?
• Family history of developmental disorders
• A missed post natal depression
• Family problems
• Very rarely symptom exaggeration for other
  reasons

22
High functioning autism and Aspergers syndrome.

• Present at an older age
• Less evidence of developmental delay but more
  evidence of developmental deviations and
  psychiatric symptoms
• Fine motor skills (buttons, cutting)
• Poor printing, copying
• Anxiety
• Obsessive rituals and routines
• Over-interest in certain topics.

23
Social relationships

• Clinical autism Aloof and distant
• High functioning autism/ Asperger
• Social oddities
• Play alongside others
• Hanging back in social situations

24
Specialist assessment level one

• Detailed history
• Detailed physical and developmental examination
  (fragile X, tuberous sclerosis, FAS etc)
• Audiology
• Visual examination
• Blood work- include TSH and possibly Pb (pica)
• Chromosomes, fragile X
• Metabolic studies (urine and plasma amino acids,
  organic acids)

25
Specialist assessment level two

• EEG if history suggestive of seizures/absences
• severe delay (motor and /or language)
• abnormal neurological examination
• CT/MRI not usually helpful
• abnormal neurological examination
• head circumference
• abnormal facies
• other abnormal morphological findings

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Specialist assessment level three

• Consultations
• Developmental pediatrics
• Occupational therapy (include sensory
  assessment)
• Speech language assessment
• Physiotherapy
• Psychology intellectual assessment
• Medical genetics
• Neurology
• Psychiatry

27
Specialist assessment level four

• Case conference
• design management plan
• Funding for services PUF
• educational coding
• FSCD
• Connecting the family with supporting agencies

28
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

29
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)
• The Denver model
• LEAP (learning experiences and alternative
  program for preschoolers and parents)

30
Local Calgary Resources

• Web Links
• The Society for the Treatment of Autism
• Autism Calgary
• Both Sites contain excellent information and
  links.
• Dont hesitate to contact them if you need any
  help!

31
Early intervention programs Lovaas

• Lovaas IO. Behavioral treatment and normal
  educational
• and intellectual functioning in young autistic
  children
• J Consult Clinics Psychol 1987 55 3-9
• Controlled study
• Intensive and comprehensive approach
• 40 hrs a week for 2 years during early preschool
  period.
• remarkable gains in language and IQ
• Claimed 50 of children no longer symptomatic
  (recovered)
• BUT
• significant methodological issues
• no one has replicated results as dramatic as
  these other researchers using the Lovaas
  approach document improvement but not recovery
• Web link
• Lovaas Institute for Early Intervention

32
Early intervention programs

• The literature supports
• delivering interventions for more than 20 hours
  weekly that are individualized, well planned and
  target language development and other areas of
  skill development significantly increase
  childrens developmental rates- especially in
  language compared to no or minimal treatment
• Bryson et al 2003

33
Early intervention programs unanswered questions

• How many hours needed to get optimum effects?
• Is one method better than another?
• If recovery is not expected what are the most
  important outcomes? (social skills, language, IQ,
  adaptive skills, decrease in autistic symptoms?)
• To what extent are these independent outcome
  variables?
• Which is the best indicator of adult outcome?

34
Education of autistic children

• Traditionally segregated classrooms
• Inclusion now recommended with
• Individual program plans IPPs
• Educational coding
• Teacher assistant / aide
• Speech language therapy
• Occupational therapy
• Funding and access to service issues

35
Sensory Integration Treatment

• Sensory integration is the neurological process
  of organizing the information we get from our
  bodies and from the world around us for use in
  daily life
• Sensory integration provides a crucial foundation
  for later more complex learning and behavior
• The organization of behavior, learning and
  performance is a natural outcome of the process,
  as is the ability to adapt to incoming sensations

36
Sensory Integration Treatment

• Sensory integration dysfunction is a complex
  neurological disorder, manifested by difficulty
  detecting, modulating, discriminating or
  integrating sensation adaptively.
• This causes children to process sensation from
  the environment or from their bodies in an
  inaccurate way, resulting in "sensory seeking" or
  "sensory avoiding" patterns or "dyspraxia", a
  motor planning problem

37
Signs of Sensory Integrative Dysfunction

• Overly sensitive to touch, movements, sights, or
  sounds.
• Behavior issues distractible, withdrawal when
  touched, avoidance of textures, certain clothes,
  and foods. Fearful reactions to ordinary movement
  activities such as playground play. Sensitive to
  loud noises. May act out aggressively with
  unexpected sensory input.
• Under reactive to sensory stimulation. Seeks out
  intense sensory experiences such as body
  whirling, falling and crashing into objects. May
  appear oblivious to pain or to body position. May
  fluctuate between under and over-responsiveness.
• Unusually high/low activity level. Constantly on
  the move or may be slow to get going, and fatigue
  easily.

38
Signs of Sensory Integrative Dysfunction

• Coordination problems. May have poor balance, may
  have great difficulty learning a new task that
  requires motor coordination, appears awkward,
  stiff, or clumsy.
• Delays in academic achievement or activities of
  daily living. May have problems in academic
  areas, despite normal or above normal
  intelligence. Problems with handwriting, scissors
  use, tying shoes, buttoning and zipping clothes.
• Poor organization of behavior. May be impulsive,
  distractible, lack of planning in approach to
  tasks, does not anticipate result of actions. May
  have difficulty adjusting to a new situation or
  following directions. May get frustrated,
  aggressive, or withdraw when they encounter
  failure.
• Poor self concept. May appear lazy, bored, or
  unmotivated. May avoid tasks and appear stubborn
  or troublesome

39
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

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Web Links Sensory Integration

• Fast Facts on Developmental Disabilities
• A good overview
• A School Psychologist Investigates Sensory
  Integration Therapies
• Promise, Possibility, and the Art of Placebo.
• Steven R. Shaw, NCSP NASP Communiqué October 2002
• Quite a good critical article

41
Alternative treatments

• No other group seems drawn to exposing their
  children to unproven and sometimes dangerous
  treatments more than the parents of autistic
  children
• 1/3 to 1/2 of all families use these
• Vitamins (high dose B6 and magnesium especially
  popular)
• Minerals
• Herbs
• Diets gluten free, sugar free, anti-yeast
  (fungal), casein free etc
• Dimenthylglycine (DMG)
• Secretin
• Cranio-sacral-therapy
• Trans cranial magnetic fields
• Chelation
• Auditory integration training
• Irlen lens system
• Homeopathy etc, etc

42
Social skills training, social scripts and social
stories

• A method for teaching verbal individuals
  (including high functioning autism and
  Asperger's) the unwritten social rules and body
  language signals that people use in social
  interaction and conversation.
• Carol Gray uses a technique called "social
  stories" to help illustrate these social rules in
  a variety of situations and appropriate
  responses. Social stories and "scripting" are
  also used with nonverbal individuals to teach
  appropriate responses and prepare the individual
  for transitions.
• In very young child, they may be in the form of
  photographs or pictures.
• For an excellent Web Site on this treatment
  intervention, go here
• The Gray Center for Social Learning and
  Understanding

43
Alternative treatments Web links

• SEPARATING FACT FROM FICTION IN THE ETIOLOGY AND
  TREATMENT OF AUTISM
• A Scientific Review of the Evidence
• J.D. Herbert, I.R. Sharp, B.A. Gaudiano
• An excellent paper
• Cure Autism Now
• The official site of the Autism Research
  Institute founded by Dr. Bernard Rimland, PhD.
  A controversial figure who has, many have said,
  given much false hope to families of autistic
  children.

44
Psychopharmacological management

• No curative treatment
• Medications usually used sparingly and mostly in
  children with troubling comorbid conditions or
  maladaptive behaviours
• Much of the information available regarding
  psychotropic use has been gathered in adults and
  transposed down
• Many single case reports and open studies
• Few double blind, placebo controlled studies
• Off label
• Interactions with natural treatments always
  ask

45
Psychopharmacological management neuroleptics

• Although there is no strong evidence of dopamine
  involvement neuroleptics have been used for many
  years to control aggression, stereotypic
  behaviours, tics and impulsivity.
• Atypical neuroleptics risperidone, olanzepine,
  quetiapine
• Before starting CBC, ALT, fasting BS, lipids,
  cholesterol, prolactin, ECG
• Side effects appetite and weight increase, type
  II diabetes, lipid changes, cardiac arrhythmias
  (QTc interval), EPS, TD
• Monitoring repeat blood work and ECG at 3 and 6
  month, then annually, 6 monthly AIMS, physical
  examination for EPS and TD. Height / weight /
  growth chart each 3 months
• Dosage start low 0.25 mg bid and adjust

46
Psychopharmacological management SSRIs

• Clear evidence of abnormal brain 5-HT
• SSRIs target anxiety, obsessions, stereotypic
  movements, mood stability
• Fluoxetine, paroxetine, fluvoxamine, sertraline,
  citalopram, venlafaxine. Also the TCA
  clomipramine
• Side effects sedation, agitation, high arousal,
  increased risk of suicidal ideation, withdrawal
  syndrome

47
Psychopharmacological management stimulants

• Mixed responses in autism
• Methylphenidate, Concerta, dexedrine (Adderal),
  atomoxifine
• Target hyperactivity, impulsivity,
  distractibility
• Side effects appetite suppression, sleep
  disturbances, worsening of tics, obsessions,
  stereotypic movements, agitation, mood lability
• Dosage always introduce at low dose and increase
  slowly
• Stimulants can dramatically successful or
  dramatically disastrous!

48
Psychopharmacological management anticonvulsants

• Used mainly as mood stabilizers and to reduce
  affective lability
• Seizures
• Carbemazepine, valproic acid, toprimate,
  gabapentin
• The relationship between seizures and behaviour
  is complex
• Usually need to monitor blood levels, WBC, LFTs
• It is uncertain whether the recommended serum
  levels used for the treatment of epilepsy apply
  when these drugs are used as mood stabilizers
• No controlled study evidence

49
Psychopharmacological management others

• Anxiolytics, benzodiazepines anxiety, mood
• Buspirone anxiety, mood
• Naltrexone hydrochloride self abuse, stereotypic
  movements
• Beta blockers anxiety, aggression
• Amantadine antiparkinsonian ?improves
  development progress

50
Summary

• Early developmental screening is critical
  population based
• Office screening is fairly straight forward
• Although a nuisance knowing the details of
  language development is critical
• Never dismiss a mothers feelings
• The mainstay of management rests on psychosocial
  interventions
• speech language and communication therapy
• occupational therapy
• behavioural therapy
• possibly sensory integration therapy
• social scripting and social stories
• Coordination of the clinical team is critical
• Advocacy
• Medical interventions, although they can be
  helpful, are at most as adjunct