Autism and Autism Spectrum Disorders

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Autism andAutism Spectrum Disorders

• Professor Graham Martin OAM
• Director Child and Adolescent Psychiatry
• The University of Queensland

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Autism

• A severely disabling condition that develops in
  first 3 years of life
• Occurs approx 1 in every 5-600 births
• More common in boys (41)
• Features vary from child to child, and differ in
  severity from child to child
• No influence from ethnic, racial, social factors,
  income, lifestyle or parental educational levels

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Common Features

• Communication problems
• Both verbal and non-verbal, with relative lack of
  speech, repeated words, phrases or patterns
• Limited Social Interactions
• Poor eye contact and difficulty interacting
• Difficulties expressing emotions
• Poor perception of how others think and feel
• Repetitive Behaviours
• repeating words or actions
• obsessively following routines

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Causes of Autism

• Genetic
• 12 or more genes on different chromosomes may be
  involved
• Genes may
• make a person more susceptible to impact of (say)
  infection
• directly cause specific symptoms
• determine severity of symptoms

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Likely Chromosomes and Genes

• Chromosome 2
• Chromosome 7
• Chromosome 13
• Chromosome 15
• Chromosome 16
• Chromosome 17
• The X Chromosome
• HOXA1
• HOXD1
• Gamma-amino-butyric acid (GABA) pathway genes
• consensus that it is Polygenetic (gt10)

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Other Causes

• 24 of cases overlap other genetic medical
  disorders
• Fragile X Syndrome
• Tuberous Sclerosis, Phenylketonuria (PKU)
• Rett Syndrome
• Other possible causes
• in utero rubella
• encephalopathy
• cytomegalovirus

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Diagnostic Criteria

• 6 items at least 2 from (1), 1 each from (2)
  (3)
• (1) Qualitative impairment in social
  interaction, as manifested by at least two of the
  following
• 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 interaction.
• 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 lack of showing, bringing, or
  pointing out objects of interest)
• Lack of social or emotional reciprocity

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Diagnostic Criteria (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, or copying of language
  (Echolalia)
• Lack of varied, spontaneous make- believe play or
  social imitative play appropriate to
  developmental level.

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Diagnostic Criteria (3)

• Restricted repetitive and stereotyped patterns of
  behavior, interests and activities, as manifested
  by at least two 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 or copying of movements
  (Echopraxia)
• Persistent preoccupation with parts of objects.

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Diagnostic Criteria

• B. Delays or abnormal functioning in at least one
  of the following areas, with onset prior to age
  three years
• Social interaction
• Language as used in social communication or
• Symbolic or imaginative play
• C. Not better accounted for by Rett disorder or
  childhood disintegrative disorder.

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Sensory Changes

• Overly sensitive to touch (may have a tactile
  defensiveness)
• Under-responsive to pain
• Senses may be affected to a lesser or greater
  degree
• No real fear of dangers

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Play

• Lack of social interaction in play - which is
  more solitary
• Lack of spontaneous or imaginative play
• Does not imitate others actions
• Does not initiate pretend games
• Sustained odd play

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Behaviours

• Overactive or Passive
• Temper tantrums for no apparent reason
• May perseverate on a single item, idea, person
• Apparent lack of common sense
• May show aggression or violent behaviours
• May injure themselves deliberately for no
  apparent reason
• May spin objects, line things up, organize
• Inappropriate attachment to objects
• Unresponsive to normal teaching methods
• Insistence on sameness resists change in routine
• Uneven gross/fine motor skills (may not can kick
  ball but can stack chairs)

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Absolute Indications For ASD Assessment

• No babbling, or pointing, or other gestures by 12
  months
• No single words by 16months
• No 2-word spontaneous phrases by 24 months
• any loss of any language
• any loss of social skills at any age

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Specific Screen for Autism

• Full audiological assessment, lead screen if pica
  present
• CHAT, MCHAT
• Autism Screening Q
• Australian Scale for Aspergers Syndrome
• then refer for intervention and autism specific
  assessment

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Specific Autism evaluationDiagnostic Parental
Interviews

• Gilliam Autism Rating Scale (GARS)
• Parent Interview for Autism
• The Pervasive Developmental Disorders Screening
  Test ( PDDST)
• Autism Diagnostic Interview- Revised (ADI-R)

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Diagnostic Observation Instruments

• The Childhood Autism Rating Scale (CARS)
• The Autism Diagnostic Observation Schedule (ADOS)

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Intervention

• There is no cure for autism.
• Treatment and education approaches may reduce
  some challenges associated with the disability.
• Intervention may lessen disruptive behaviours.
• Education can teach self-help skills for greater
  independence.
• Intervention needs to be tailored to the
  individual, and their family

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Behaviour Therapy

• Most widely used and successful method is
  intensive behavioural intervention (IBI)
• We believe that behavior modification carried
  out in systematic, highly individualized, daily
  programming is the best overall approach now
  available to persons with autism (Graziano, )

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Team Approach

• Speech therapy
• Helps in developing communication skills which
  may include alternative forms of communication
  (sign language and the use of keyboards)
• Occupational Therapy
• Addresses specific needs for daily living

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Team Approach

• Art and music therapy can be used to increase
  communication skills, social interaction, and a
  sense of accomplishment.
• Medication may be necessary to control behaviour
  or sleep
• Dietary assessment is important - a balanced
  diet as far as possible but with extra vitamins
  and/or minerals. 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.

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Autism Spectrum Disorder

• May have to consider
• Autism
• Aspergers Syndrome (AS)
• Tourettes Syndrome (TS)
• Landau Kleffners Syndrome (LKS)
• Rett Syndrome
• Attention Deficit/Hyperactivity Disorder (AD/HD)
• Specific Learning Disabilities (SLD)
• Childhood Disintegrative Disorder (CDD)
• Prader Willi Syndrome
• Fragile-X Syndrome
• PKU
• Hurlers Syndrome
• Cornelia de Lange Syndrome
• Williams Syndrome

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Aspergers Syndrome

• Original report
• Autistic Psychopathies in Childhood (1944)
• translated into English in 1980

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Aspergers Observations

• Children
• Find it difficult to fit in socially
• Have poor social use of language
• Have limited ability to use and understand
  gestures and facial expressions
• Use repetitive, stereotypical behaviors
• Have abnormal fixations on certain objects/ areas
  of interest
• Are vulnerable to teasing and bullying

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Aspergers Syndrome

• A pervasive developmental disorder characterized
  by
• Impairment of two-way social interaction and
  general social ineptitude
• Speech which is odd/pendantic, stereotyped in
  content, but which is not delayed
• Adherence to rules, routines, rituals
• Lack of social reciprocity
• Limited non-verbal communication skills little
  face expression or gestures
• Generally equated with high functioning autism.

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Distinctions between Aspergers Syndrome and
Autism

• Children with autism exhibit a significant delay
  in language skills
• Children with Aspergers have only mild
  impairments or peculiar ways of using language

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Diagnostic Features of Aspergers

• Social Interactions
• Socially aloof, unconcerned
• Inappropriate eye contact (but usually present)
• Peer friendships occur, but may lack strategies
  to develop or maintain
• Difficulty taking the perspective of another
  person
• May often lack empathy
• Blatantly honest or straight-forward even when
  not in their best interest
• Tense and distressed when trying to cope

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Social Communication

• Superficially perfect spoken language
• May lack voice expression, difficulty
  interpreting different tones of voice
• Difficulty interpreting and using non-verbal
  communication, body language, gestures, facial
  expressions
• May take things in a very literal way
• May fail to grasp implied meanings of language
• May not easily grasp social rules or subtleties
• May talk at length about topics that are of
  interest to only him/herself
• Uses objects in an atypical fashion
• Insists that others do things according to their
  own prescribed order and rules

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Poor Problem Solving and Organizational Skills

• Difficulties in
• Situations requiring common sense
• organizing thoughts and abstract reasoning
• Transitioning from one situation to another
• Deficits in
• mental planning
• Impulse control
• Self monitoring
• Strong desire for orderliness may delay achieving
  goals

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Limited Interests and Preoccupations

• May talk at length about topics that are of
  interest to only him/herself
• Redirects conversations back to topics of
  interest even at risk of being ridiculed or
  shunned
• Friends interested in similar things
• Jobs in areas of interests

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Pragmatic Disorder

• Lack of understanding about the reciprocity of
  verbal and nonverbal communication
• Decreased understanding and use of gestures
• Decreased use of questions
• Difficulty maintaining a conversation

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Tests

• Test of Pragmatic Language
• Test of Problem Solving

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Effective Strategies to Teach Pragmatic Language

• Social Language Groups
• Social Language Stories
• Reciprocal Conversation with Therapist
• Role Playing
• Videotaping
• Coaching During Social Times

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Language Disorder

• Sometimes language learning is precocious
• There must be words by 2 years and phrases by 3
  years
• Style of learning language may be like an
  autistic child echolalia, difficulty learning
  pronouns, difficulty understanding verbal
  explanations

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Tests

• Preschool Language Scale-4
• Clinical Evaluation of Language
• The Test of Language Development
• Expressive One Word Vocabulary Test
• Peabody Picture Vocabulary Test

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Language Test Scores Show an Unusual Profile

• Highest scores are in expressive vocabulary,
• Next highest are in receptive vocabulary,
• Next are in grammatical structures,
• Often below average are tests of problem solving,
• Lowest area is in pragmatic language skills.

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Teach Flexibility

• COMPROMISING
• If you compromise, you are doing the right thing.
• Compromise means letting the other person have
  his way.
• If you do this, you get a bonus point.

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Teach Flexibility

• BEING BOSSY
• Often turn other children off by being bossy,
  controlling and judgmental.
• So, they lose a point (or a turn) for teasing
  criticizing another child.
• Alternately, they get extra points for saying
  something nice.
• If the child starts out saying several nice
  things, he is not teased as much.

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Resources

• www.ocali.org
• www.autism-society.org