AUTISMINCHILDREN

IAP UG Teaching slides 2015-16

 AUTISM

Autism is a developmental disorder that appears inthe

first3yearsoflife,andaffectsthebrain'snormal

developmentofsocialandcommunicationskills.

By:BrittanyAllen

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 AUTISM

LeoKanner,achildpsychiatrist,in1943firstcoined
thetermautism.
11childrendescribedwhodemonstrated:aprofound
lackofsocialengagement,failedtouselanguageto
communicate,hadanobsessiveneedforsameness.
But,faultypostulationthatautismoccursdueto
difficultiesintheparentchildrelationship.

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 AUTISM:NEURODEVELOPMENTALDISORDER

Autismisnowrecognizedasaneurodevelopmental
disorder&neurobehavioraldisorder.

Autismoccursduetounderlyingdisorderofbrain
development.

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 WHATISAUTISM?

Autismisacomplexneurodevelopmentaldisorder
characterizedby:
qualitativeimpairmentsinsocialinteraction,
qualitativeimpairmentsincommunication,and
restricted,repetitive,stereotypedpatternsofbehavior,
interestsandactivities.

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 SOMEFACTSABOUTAUTISM

AutismisNOTasingledisorder.

Autisticsymptomsoccuralongawidespectrum.

Sensoryhyposensitivitiesorhypersensitivitiestothe
environmentoftennoted.

Symptomsmayvaryinthesameautisticchildandchange
overtime.

Nospecificbiologicalmarkers.

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 DIAGNOSISOFAUTISM

Diagnosisbasedentirelyonclinicalfindings.

Ascertainwhetherthechildsspecificbehaviors
meettheDiagnosticandStatisticalManualofMental
DisordersVRevised(DSMV)criteria.

Observechildinseveralsettingsassymptomsmay
unfoldovertime.

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 DSM5
DiagnosticandStatisticalManualofMentalDisorders,5th
Edition(DSM5)revisions
Autismspectrumdisorders
Includesautism,Aspergersyndrome,PDDNOS,andchild
disintegrativedisorder(CDD)
Concentratesonrequiredfeatures
Social/communicationdeficits
Restricted,repetitivepatternsofbehavior,interests,activities
o Additionofsensorycriteria
Increasesspecificitywhilemaintainingsensitivity
Importanttodistinguishspectrumfromnonspectrum
developmentaldisabilities
Improvesstabilityofdiagnosis

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 DSM5CRITERIA:
SOCIALCOMMUNICATION

Persistentdeficitsinsocialcommunicationandsocial
interactionacrosscontexts,notaccountedforbygeneral
developmentaldelays,manifestedbyallofthefollowing:

Deficitsinsocialemotionalreciprocity

Deficitsinnonverbalcommunicativebehaviors

Deficitsindevelopingandmaintainingrelationships
appropriatetothedevelopmentallevel

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 DSM5CRITERIA:
RESTRICTED/REPETITIVEBEHAVIORS

Restricted,repetitivepatternsofbehavior,interests,
oractivitiesasmanifestedbyatleast2ofthe
following:
Stereotypedorrepetitivespeech,motor
movements,oruseofobjects
Excessiveadherencetoroutines
Highlyrestricted,fixatedintereststhatare
abnormalinintensityorfocus
Hyperorhyporeactivitytosensoryinputor
unusualsensoryinterests

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 DSMVCRITERIA

Symptomsmustbepresentinearlychildhood.

Symptomstogetherlimitandimpaireveryday

functioning.

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 DSMIVRCRITERIAFORDIAGNOSINGAUTISM

A.Impairmentinsocialinteractions(4criteria)

1.Lackseyetoeyegaze,facialexpression,gestureswhile
interacting

2.Failstodeveloppeerrelationships

3.Doesnotshareinterestswithothers(e.g.,nobringing,or
pointingoutobjects)

4.Lackssocialoremotionalreciprocity

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 DSMIVRCRITERIAFORDIAGNOSINGAUTISM

B.Impairmentincommunication(4criteria)

1.Hasdelayeddevelopmentofspeech

2.Doesnotinitiateorsustainconversation

3.Hasstereotypedandrepetitivelanguageor
idiosyncraticlanguage

4.Lacksmakebelieveplayorsocialimitativeplay

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 DSMIVRCRITERIAFORDIAGNOSINGAUTISM

C.Repetitivebehaviorsandstereotypedbehaviorpatterns(4criteria)

1.Hasstereotyped,restrictedpatternsofinterest,abnormalin
intensityorfocus

2.Hasinflexibleadherencetospecific,nonfunctionalroutinesor
rituals

3.Hasstereotypedandrepetitivemotormannerisms(e.g.,handor
fingerflapping)

4.Haspersistentpreoccupationwithpartsofobjects

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 PREVALENCEOFAUTISM

7.1per10,000inindividualsunder18yearsofage
(westerncountries).

Boysareaffectedmoreoftenthangirls.

Averagemale:femaleratiois3.8:1.

Currenthigherprevalenceratesreflectimproved
identificationofautism.

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 PREVALENCEOFAUTISMININDIA

NoprevalencedataavailablefromIndia.

Diagnosisfrequentlymissed.

Lackofawarenessandknowledgeaboutthedisorder
amonghealthprofessionals.

ButrecentreportsfromNewDelhiandChandigarh
statethatautisminNOTuncommoninIndia.

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 WHATCAUSESAUTISM?

Noonesingleunifiedtheorycanexplainetiologyofautism.

StructuralMRIbrainstudieshavedetected,thoughnot
consistently,increasedvolumeofthetotalbrainand
abnormalitiesinthecerebellum,frontallobe,andlimbic
system(amygdalaandhippocampus)inyoungchildrenwith
autism.

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 HOWEARLYCANAUTISMBEDIAGNOSED?

Infirstyearoflife:nocleardiscriminatingfeatures.

However,homevideosofinfantslaterdiagnosedto
haveautismhavedetectedfourautisticbehaviorsviz.
notpointing,notshowingobjects,notlookingat
others,andfailingtoorienttonamebeingcalled.

Abnormallyacceleratedrateofgrowthinheadsize
between614monthsofage:anearlywarningsignal
ofriskforautism.

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 EARLYDIAGNOSISISIMPORTANT

Carefulattentiontoparents'concernsandspecific
inquiryintohowchildinteracts,communicates,and
playshelpsdetectautismearly.
Autismcanbereliablydiagnosedatbetween23yrs.
ofage.
Interventiontherapywheninitiatedatanearlyage
canimproveoutcome.
Needtogiveinformationregardingrecurrencerisks
toparents.

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 ALERTINGSIGNALSINCHILDREN23YRS.OFAGE
Socialimpairments
1.Doesnotimitateactions(e.g.,clapping).
2.Doesnotshowtoystootherpeople.
3.Lacksinterestinotherchildren(e.g.,doesnotsmileator
touchfaceofanotherchild).
4.Isindifferenttootherpeople'shappinessordistress(e.g.,not
distressedwhenmothercries).
5.Preferstobealone(doesnotwantcuddlingoractcuddly).
6.Haslittleornoeyecontact.
7.Preferssolitaryplayactivities.
8.Hasoddrelationshipswithadults(toofriendlyorignores).
9.Developslossofanysocialskills.

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 ALERTINGSIGNALSINCHILDREN23YRS.OFAGE
Communicationimpairments
1.Doesnotbabble,pointby12months.
2.Doesnotspeaksinglewordsby18months.
3.Doesnotspeaktwowordspontaneous(nonechoed)phrasesby24months.
4.Haspoorresponsetoname(mayseemtobedeaf).
5.Hasdelayedlanguagedevelopment,especiallycomprehension.
6.Hasunusualuseoflanguage(e.g.,repeatswordsorphrasesinplaceof
normalresponsivelanguage).
7.Hasdeficientnonverbalcommunication(e.g.,nogestureswithhandswhile
talking).
8.Doesnotparticipateinsharedimaginarygames(e.g.cannotplayringaring
rosesorothernurserygames).
9.Developslossofanylanguageskills.

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 ALERTINGSIGNALSINCHILDREN23YRS.OFAGE
Repetitiveandstereotypedbehaviorpatterns
1.Resistschangesinroutine(e.g.,rigidandlimiteddietaryhabits)
2.Inappropriateattachmenttoobjects(e.g.,carriesteddybearalldaylong)
3.Unabletocopewithchange,especiallyinunstructuredsetting(e.g.,
uncontrollablecryingwhentakenfirsttimetobeach)
4.Hasrepeatedmotormannerisms(e.g.,handflapping,rocking)
5.Playsoddlyandrepetitivelywithtoys(e.g.,linesupobjects,spinsobjects)
6.Turnslightswitchesonandoff,regardlessofscolding
7.Isoversensitivetosoundortouch(e.g.,frequentlywakesupatnight)
8.Bites,hits,aggressivetopeers
9.Laughs,criesorshowsdistressforreasonsnotapparenttoothers

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 ALERTINGSIGNALSINPRIMARYSCHOOLAGE
CHILDREN
Socialimpairments
1.Doesnotjoininwiththeplayofotherchildren(e.g.,cannotplay
football)
2.Makesinappropriatedisruptiveattemptsatjointplay(e.g.,tries
toplayfootballbutcannotunderstanditsrules)
2.Lacksclassroom"norms"(e.g.,doesnotcooperateinclassroom
activities)
3.Doesnotfollowcurrenttrends(e.g.,withregardtoother
childrensinterests)
3.Getseasilyoverwhelmedbysocialstimulation(e.g.crowd
phobia)
4.Failstorelatenormallytoadults(eithertoointenseorno
relationship)

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 ALERTINGSIGNALSINPRIMARYSCHOOLAGE
CHILDREN
Communicationimpairments
1.Speaksinamonotonoustone,orwithabnormalmodulationof
volume
2.Displayspersistentecholalia
3.Referstoselfas"you,""she,"or"he"
4.Hasunusualvocabularyforchild'sageorsocialgroup(e.g.,
knowsnamesofallworldcurrencies,capitalcitiesofall
countries)
5.Haslimiteduseoflanguageforcommunication(maybemistaken
asbeingdeafmute)
6.Hastendencytotalkfreelybutonlyaboutspecifictopics(e.g.,car
models)

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 ALERTINGSIGNALSINPRIMARYSCHOOLAGE
CHILDREN

Repetitiveandstereotypedbehaviorpatterns
1.Showsextremereactionstoinvasionofpersonalspace(e.g.
tempertantrums)
2.Showsextremeresistancetobeing"hurried"
3.Wantstowatchthesameeducationalvideorepeatedly
4.Hasintenseinterestinaparticulartopic(e.g.,traintimetables,
dinosaurs)
5.Isunabletocopewithchangeorinunstructuredsituations
(e.g.,schoolpicnic)
6.Hasunusualresponsestosensoryvisual/olfactorystimuli(e.g.
startscryinginsunlight)

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 AUTISMSCREENINGTOOLS

MCHAT(ModifiedChecklistforAutisminToddlers)

PDDBI(PervasiveDevelopmentalDisordersBehavior
Inventory)

ADIR(AutismDiagnosticInterviewRevised)

ADOS(AutismDiagnosticObservationSchedule)

CARS(ChildhoodAutismRatingScale)

TrivandrumAutismBehavioralChecklist

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 COMORBIDCONDITIONS

75%haveassociatedmentalretardation.
714%haveepilepsy.
Frequentlyhaveseriousbehavioraldisturbances,
suchasselfinjuriousbehavior,aggression,
hyperactivity,andtempertantrums.
In<10%,autismoccursinconjunctionwithknown
medicaldisorders:tuberoussclerosis,fragileX
syndrome,phenylketonuria,andcongenitalrubella
syndrome.

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 PERVASIVEDEVELOPMENTALDISORDERS

Autism Asperger Rett Childhood PDD-NOS

Syndrome Syndrome Disintegrative
Disorder

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 MANAGEMENTOFAUTISM

Amultidisciplinaryteamofprofessionalstrainedand
specializedinautismisnecessary.
Theteamshouldinclude:
Developmentalpediatrician,
Childpsychiatrist,
Occupational(behavioral)therapist,
Speechtherapist,
Psychologist,
Specialistteacherand
Socialworker.

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 INTERVENTIONSTRATEGIESFORAUTISM

Pharmacotherapy

SensoryIntegrationTherapy

AuditoryIntegrationTherapy

DietTherapy

MegaVitaminTherapy

LovaasBehavioralModification

AppliedBehaviorAnalysis

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 INITIALASSESSMENT
Thoroughmedicalexamination:detailedmedicaland
developmentalhistory,meticulousphysicalexaminationto
identifyneurocutaneousmarkersfortuberoussclerosis
(includingWood'slightexamination),anddysmorphic
featuresforfragileXsyndrome(dochromosomestudyif
indicated).
CBCandperipheralbloodsmearexaminationshouldbedone
toruleoutirondeficiencyanemiaifthechildsdietaryhabits
arelimited.
RoutineCranialCT/MRIscannotnecessary.
Audiometricandophthalmicexaminationsshouldbedoneto
ruleoutassociatedhearingandvisualdeficits,asthisis
essentialinanycommunicationdisorder.
NoneedtodoanEEGroutinelybutahighindexofclinical
suspicionshouldbemaintainedforsubtlesymptomsof
seizures.

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 EARLYINTENSIVEBEHAVIORALANDEDUCATIONAL
INTERVENTIONTHERAPY

Noknowncureforautism.
But,earlyintensivebehavioralandeducational
interventiontherapycanhelpamelioratecore
behavioraldeficits.
1525hrs/weekassoonasdiagnosisofautismis
consideredanddefinitelybeforefouryearsofage
Interventionsshouldbecontinuedfor34yrstill
theyimprovetheirabilitytolearnandgeteducated.

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 EARLYINTENSIVEBEHAVIORALANDEDUCATIONAL
INTERVENTIONTHERAPYCONT..
Aseveryautisticchildisuniquetheinterventionsarehighly
individualized.
Skillsaretaughtinsmallsteps,mastered,andthen
generalized.
Individualized1to1therapyprovidedinadistractionfree
structuredenvironmentbybehavioraltherapistsunder
supervisionofadevelopmentalpediatrician.
Onlypositivereinforcementusedtoteachchild.
Parentstrainedtogeneralizetheskillslearntbytheirchildin
thehomeenvironment.
Nonretardedautisticchildrenwhocontinuetoexperience
difficultiesinregularschoolsmayneedtoattendspecial
schoolstocontinuetheireducation.

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 JUDICIOUSUSEOFPSYCHOTROPICMEDICATIONS

Psychotropicmedicationsusedtoreduce(butnotnecessarily
eliminate)interferingbehaviorstomakethechildmore
amenabletointerventions.
Medicationsusuallyformanagementofcomorbidities
Atypicalantipsychotics(risperidone,olanzapine,clozapine)
fortempertantrums,aggression,orselfinjuriousbehavior;
Selectiveserotoninreuptakeinhibitors(sertraline,citalopram,
fluoxetine)foranxietyandrepetitivebehaviors;and
Psychostimulant(methylphenidate),opioidantagonist
(naltrexone)forhyperactivity.
Symptomaticepilepsyneedstobetreatedandappropriate
medicationprescribeddependingonseizuretype.

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IAPUGTeachingslides201516 35 35
ThankYou

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