Professional Documents
Culture Documents
DISORDERS
DR.R.G.ENOCH
MD PSYCHIATRY II YR
GMKMCH, SALEM
TOPICS
Introduction
History
Epidemiology
Etiopathogenesis
Clinical features
Neuroimaging
Differential diagnosis
Treatment
Other disorders in the spectrum
Conclusion
Autism spectrum disorder, previously known as the pervasive
developmental disorders, is a phenotypically heterogeneous group of
neurodevelopmental syndromes, with polygenic heritability,
characterized by a wide range of impairments in social
communication and restricted and repetitive behaviors.
Sex Distribution
four times more common in boys than in girls.
In clinical samples, girls with autism spectrum disorder more often exhibit intellectual
disability than boys.
Social Class
Although a few early studies supported Kanner's impression of an
association between autism and upper socio-economic status, most
epidemiological studies published in the 1990s have failed to reveal such
association.
Bias - more educated parents seek referral, families from disadvantaged
backgrounds are still underrepresented in clinical samples.
Autism clearly is seen in all social classes and in all countries.
ETIOLOGY AND
PATHOGENESIS
Genetic factors
Immunological factors
Pre and perinatal factors
Comorbid neurological disorders
GENETIC FACTORS
One study found an increased size of amygdala in the first few years of life, followed by a decrease in
size over time.
The size of the striatum has also been found in several studies to be enlarged, with a positive
correlation of striatal size with frequency of repetitive behaviors.
Immunological Factors
Prenatal factors
advanced maternal and paternal age at birth,
maternal gestational bleeding,
gestational diabetes, and
firstborn baby.
Perinatal risk factors
birth trauma,
fetal distress,
low birth weight,
low Apgar score,
congenital malformation,
ABO or Rh factor incompatibility and
hyperbilirubinemia.
Many of the obstetrical complications that are which are risk for autism spectrum
disorder are also risk factors for hypoxia, which may be an underlying risk factor
itself.
Comorbid Neurological Disorders
EEG abnormalities and seizure disorders occur with greater than expected frequency
4 to 32 % have grand mal seizures at some time, and
about 20 to 25 % show ventricular enlargement on (CT) scans.
Various EEG abnormalities are found in 10 to 83 %, and although no EEG finding is specific
to autistic disorder,
there is some indication of failed cerebral lateralization.
The current consensus is that autism spectrum disorder is a set of behavioral syndromes
caused by a multitude of factors acting on the central nervous system.
Psychosocial Theories
Studies comparing parents of children with autism spectrum disorder with parents of
normal children have shown no significant differences in child-rearing skills.
Kanner's early speculations that parental emotional factors might be implicated have been
clearly rejected.
Other Etiologies
Phenylketonuria, neurofibromatosis, and congenital rubella.
Children with congenital rubella when followed over time, their “autistic-like” features
tend to diminish; exhibit a range of sensory deficits and mental retardation, which
complicate the diagnostic process.
Postmortem and Neuroimaging Studies
The social, language, and behavioral problems suggest that the syndrome affects a functionally
diverse set of neural systems. The initial insult is localized, branching off into more pervasive
impairments.
Those who have difficulty with complex information processing have widespread cortical
abnormalities. Those with emotional deficits and social difficulties have pathology in the limbic
system.
Postmortem studies - decrease in the no. of Purkinje cells and granule cells in the cerebellum.
These abnormalities, including a lack of gliosis indicates a prenatal origin.
• A series of MRI studies
focusing on the cerebellar
vermis revealed finding of
a decrease in the
midsagittal area of vermal
lobules VI and VII.
they focus more on the mouth region rather than on the eye region and rather than scan the entire
face focus more on individual features of the face.
In response to socially relevant stimuli, they have greater amygdala hyperarousal.
Tasks involving "theory of mind," that is, the ability to attribute emotional states to others, fMRI
studies find the right temporal lobe and other areas become activated in controls. This difference has
been hypothesized as due to dysfunction of the mirror neuron system (MNS).
Atypical patterns of frontal lobe activation have been found during face processing tasks
DIAGNOSIS AND
CLINICAL FEATURES
DSM-5 Diagnostic Criteria
A. Persistent deficits in social communication and social interaction across multiple contexts,
as manifested by the following,
1 . Deficits in social-emotional reciprocity
2 . Deficits in nonverbal communicative behaviors used for social interaction
3 . Deficits in developing, maintaining, and understanding relationships
B. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least
two of the following
1 . Stereotyped or repetitive motor movements, use of objects, or speech
2 . Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or
nonverbal behavior
3 . Highly restricted, fixated interests that are abnormal in intensity or focus
4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the
environment
C. Symptoms must be present in the early developmental period
D. Symptoms cause clinically significant impairment in social, occupational,
or other important areas of current functioning.
E. These disturbances are not better explained by intellectual disability
Specify if:
With or without accompanying intellectual impairment
With or without accompanying language impairment
Associated with a known medical or genetic condition or environmental factor
Associated with another neurodevelopmental, mental, or behavioral disorder
With catatonia
1. Persistent Deficits In Social Communication and Interaction.
A variety of EEG abnormalities may be seen in autism, including diffuse and focal spikes,
paroxysmal spike-and-wave patterns, multifocal spike activity, and a mixed discharge.
abnormal EEGs is significantly higher in mentally retarded autistic individuals.
High incidence of EEG abnormalities and seizure disorders in autism was one of the first
compelling evidence of a biological basis.
Abnormalities of cognitive potentials, particularly the auditory P300 (which represents the
brain's processing of sensory stimuli), have been shown to be abnormal in autism. This
presumably reflects abnormalities in higher auditory processing and neural pathways
ASSESSMENT TOOLS
The Child Autism Rating Scale (CARS)
The Autism Diagnostic Observation Schedule (ADOS)
Autism Detection in Early Childhood (ADEC)
The Autism Diagnostic Interview – revised (ADI-R)
The Social Communication Questionnaire (SCQ).
Ages and Stages Questionnaires (ASQ)
Parent’s Evaluation of Development Status (PEDS)
Modified Checklist for Autism in Toddlers (M-CHAT)
Screening Tool for Autism in Toddlers and Young Children (STAT)
Indian Scale for Assessment of Autism
Domains
social relationship and reciprocity;
emotional responsiveness;
speech, language and communication;
behavior patterns;
sensory aspects and
cognitive component.
DIFFERENTIAL DIAGNOSIS
1. Social (Pragmatic) communication disorder
display global impairments in both verbal and nonverbal areas, whereas children with
autism spectrum disorder are relatively weak in social interactions compared to other
areas of performance.
Children with intellectual disability generally relate verbally and socially to adults and
peers in accordance with their mental age.
4. Language Disorder
infants with autism spectrum disorder may babble only infrequently, whereas deaf infants often have a
normal babbling that gradually tapers off and stop at 6 months to 1 year of age.
Deaf children generally respond only to loud sounds, whereas children with autism spectrum disorder
may ignore loud or normal sounds and respond to soft sounds.
Deaf children seek out nonverbal social communication
audiogram or auditory-evoked potentials indicate significant hearing loss in deaf children.
COURSE AND PROGNOSIS
Autism spectrum disorder is typically a lifelong disorder with a highly variable severity
and prognosis.
IQs > 70 with average adaptive skills, who develop communicative language by ages 5 to
7 years, have the best prognoses.
Early intensive behavioral interventions lead to recovery and function in the average
range.
Ritualistic and repetitive behaviors do not seem to improve substantively over time.
The prognosis improves if the home environment is supportive.
TREATMENT
PSYCHOSOCIAL INTERVENTIONS
E. Educational interventions
PSYCHOPHARMACOLOGICAL INTERVENTIONS
PSYCHOSOCIAL INTERVENTIONS
A. Early intensive behavioral and developmental interventions
1. UCLA/Lovaas-based Model.
1. Behavioral Therapy.
Applied behavioral analysis has been found to be somewhat effective
in reducing some repetitive behaviors
Early intervention is recommended for repetitive behaviors that are
self-injurious;
behavioral interventions may need to be combined with
pharmacologic treatments to adequately manage the symptoms.
2. Cognitive-Behavioral Therapy.
There is a significant evidence from RCTs for the efficacy of CBT for symptoms
of anxiety, depression, and obsessive-compulsive disorders in children.
There are fewer controlled trials of this treatment in children with autism
spectrum disorder
there are at least two published studies in which CBT was used to treat
repetitive behavior in individuals with autism spectrum disorder.
D. Interventions for comorbid symptoms
1. Neurofeedback.
This modality has been administered in an attempt to influence
symptoms of ADHD, anxiety, and increased social interaction
by providing computer games in which the desired behavior is reinforced
the child wears electrodes that monitor electrical activity in the brain.
The aim is to to prolong the electrical activity present during the desired
behaviors
2. Management of insomnia in autism spectrum disorder.
Both behavioral and pharmacologic interventions may be administered.
The most common behavioral intervention is changing the parents behavior first toward the child at
bedtime and throughout the night
reinforcement and attention for being awake should be removed, leading to a gradual extinction of
the "staying awake" behavior.
Several studies using massage therapy before bedtime provided an improvement in falling asleep and
a sense of relaxation.
E. EDUCATIONAL INTERVENTIONS
1. Treatment and Education of Autistic and
Communication related Handicapped children (TEACCH).
Originally developed at the University of North Carolina
at Chapel Hill in the 1970s
TEACCH involves structured teaching based on the
notion that children with autism spectrum disorder have
difficulty with perception
incorporates many visual supports and a
picture schedule to aid in teaching
academic subjects as well as socially
appropriate responses.
The physical environment is arranged to
support visual learning, and the day is
structured to promote autonomy and
social relatedness.
2. Computer-based approaches and virtual reality.
centered on using computer-based programs, games to teach language acquisition
and reading skills.
This provides the child with a behaviorally based instruction that is appealing for
the child.
The Let's Face It! program is a computerized game that helps to teach to recognize
faces.
It consists of seven interactive computer games that target changes in facial
expression, attention to the eye region of the face, holistic face recognition, and
identifying emotional expression.
The trained children had improvement in
their ability to focus on the eye region of
a face and improved their face-
processing skills.
Several studies using virtual reality
environments have provided evidence of
their value.
In one study, a virtual cafe for children
allowed the children to practice ordering
and paying for drinks and food by
navigation with the use of a computer
mouse.
PSYCHOPHARMACOLOGICAL
INTERVENTIONS
Methylphenidate was moderately efficacious at doses of 0.25 to 0.5 mg/kg for youth with autism spectrum
disorder and ADHD symptoms.
Efficacy of methylphenidate was less effective in children with ADHD with autism spectrum disorder, than
without autism spectrum disorder.
Children with autism spectrum disorder developed more frequent side effects, including increased
irritability, compared to ADHD children.
Side effects include increased stereotypies, gastrointestinal upset, sleep problems, and emotional lability.
Among nonstimulants, atomoxetine was found more effective than placebo. Side effects included sedation,
irritability, constipation, and nausea.
Clonidine, an a-agonist has also been studied in children with autism spectrum disorder for the treatment of
hyperactivity with mixed results.
Guanfacine was also found to be of use in some cases.
3. Repetitive and Stereotypic Behavior.
These core symptoms of autism spectrum disorder have been studied using selective
serotonin reuptake inhibitor (SSRI) antidepressants, second-generation antipsychotics
(SGAs), and mood-stabilizing agents such as valproate.
Fluoxetine was found only slightly better than the placebo.
Risperidone, was found to be effective in targeting restrictive and repetitive behaviors
along with irritability
4. Agents Administered For Behavioral Impairment Based On Open Trials.
Quetiapine is tried when risperidone and olanzapine are not efficacious or well tolerated.
50 to 200 mg/day. Adverse effects include drowsiness, tachycardia, agitation, and weight
gain.
Clozapine - aggression and self-injurious behavior when they coexist with psychotic
symptoms. The most serious adverse effect is agranulocytosis. Its use is generally limited
to treatment-resistant psychotic patients.
Ziprasidone in treatment resistant children. Adverse effects include sedation, dizziness,
and lightheadedness.
Lithium is used for aggressive or self-injurious behaviors when antipsychotic medications
are not effective.
5. Agents Used For Behavioral Impairment In Autism Spectrum Disorder Without
Evidence Of Efficacy.
Amantadine, which blocks NMDA receptors, has been studied for the treatment of
irritability, aggression, and hyperactivity with significant improvement.
Some researchers have suggested that abnormalities of the glutamatergic system
may contribute to the emergence of autism spectrum disorders.
Clomipramine has also been used in, but there are no RCTs.
Naltrexone based on the notion that blocking endogenous opioids would reduce
autistic symptoms.
Tetrahydrobiopterin, in a daily dose of 3 mg/kg significant improvement in social
interaction score after 6 months of active treatment.
low-dose venlafaxine (Effexor) was efficacious in autistic disorder with self-injurious
behavior and hyperactivity. 18 .75 mg per day
Complementary and Alternative Medicine (CAM) Approaches
Safe interventions that have been applied to target both core and associated behavioral
features include :
music therapy, to promote communication and expression; and
yoga, to promote attention and decrease activity level.
Melatonin reduces sleep-onset latency in children that is deemed safe and shown to be
efficacious
Other agents with unknown efficacy include vitamin C, multivitamins, essential fatty acids,
and the amino acids carnosine and carnitine.
RETT SYNDROME
Before the onset of childhood disintegrative disorder, language has usually progressed
to sentence formation. Whereas in autistic disorder, in whom language generally does
not exceed single words or phrases before diagnosis of the disorder. Once the disorder
occurs, however, those with childhood disintegrative disorder are more likely to have
no language abilities.
In Rett syndrome, the deterioration occurs much earlier than in childhood
disintegrative disorder, and the characteristic hand stereotypies of Rett syndrome do
not occur in childhood disintegrative disorder.
Course and Prognosis.
The course of childhood disintegrative disorder is variable, with
• a plateau reached in most cases,
• a progressive deteriorating course in rare cases, and
• some improvement in occasional cases to the point of regaining the ability to
speak in sentences.
Most patients are left with at least moderate mental retardation.
Treatment.
Treatment of childhood disintegrative disorder includes the same components
available in the treatment of autistic disorder.
ASPERGER'S DISORDER
Treatment.
The treatment approach is identical to that of other autism spectrum disorder.
Mainstreaming in school may be possible.
Compared with autistic children, have less impairment in language skills and more self-
awareness.
CONCLUSION
Our perception of autism has evolved over time. Sixty years ago autism was
considered as developmental delay or mental retardation.
Today it is recognized as an independent neurologically based disorder of
significance, a major public health problem, and a topic of much research.
Researchers have struggled to find a cause for the disorder without great success.
Despite this difficulty, research continues in ever more sophisticated directions.
Numerous treatments have been developed that help children with autism to
maximize their potential to learn and become socially fluent.
SUMMARY
Autism spectrum disorder, is a phenotypically heterogeneous group of neurodevelopmental syndromes
The etiology includes Genetic factors, Immunological factors, Pre and perinatal factors, Comorbid
neurological disorders.
Persistent deficits in social communication and social interaction and Restricted, repetitive patterns of
behaviour.
The treatment includes behavioural, social skill, educational, pharmacological approaches.
Rett syndrome - onset after 6 months of normal development with loss of purposeful hand movements,
stereotypic motions, the loss of previously acquired speech, irregular respiration, rigidity.
Childhood disintegrative disorder - marked regression in intellectual, social, and language functioning, bowel
or bladder control after 2 years of normal development.
Asperger's disorder qualitative impairment in reciprocal social interaction and behavioral oddities without
delays in language development
REFERENCES