AUTISM SPECTRUM DISORDER and

ATTENTION DEFICIT HYPERACTIVE DISORDER

.
• Autism spectrum disorder encompasses
Autism, Asperger’s disorder, childhood
disintegrative disorder, Rett’s disorder and
pervasive developmental disorder NOS
 AUTISM SPECTRUM DISORDERS

• not point at objects to show interest (for example, not point at an airplane flying over)
• not look at objects when another person points at them
• have trouble relating to others or not have an interest in other people at all
• avoid eye contact and want to be alone
• have trouble understanding other people’s feelings or talking about their own feelings
• prefer not to be held or cuddled, or might cuddle only when they want to
• appear to be unaware when people talk to them, but respond to other sounds
• be very interested in people, but not know how to talk, play, or relate to them
• repeat or echo words or phrases said to them, or repeat words or phrases in place of normal
language
• have trouble expressing their needs using typical words or motions
• not play “pretend” games (for example, not pretend to “feed” a doll)
• repeat actions over and over again
• have trouble adapting when a routine changes
• have unusual reactions to the way things smell, taste, look, feel, or sound
• lose skills they once had (for example, stop saying words they were using)
 ASD CAUSES AND RISK FACTORS

• Most scientists agree that genes are one of the risk factors that can
make a person more likely to develop ASD.
• Children who have a sibling with ASD are at a higher risk of also having
ASD.
• Individuals with certain genetic or chromosomal conditions, such as
fragile X syndrome or tuberous sclerosis, can have a greater chance of
having ASD.
• When taken during pregnancy, the prescription drugs valproic acid and
thalidomide have been linked with a higher risk of ASD.
• There is some evidence that the critical period for developing ASD
occurs before, during, and immediately after birth.
• Children born to older parents are at greater risk for having ASD.

https://www.cdc.gov/ncbddd/autis
m/facts.html
 ASD SCREENING AND DIAGNOSIS

• Early signs of ASD

• Avoiding eye contact,
• Having little interest in other children or caretakers,
• Limited display of language (for example, having fewer words
than peers or difficulty with use of words for communication),
or
• Getting upset by minor changes in routine.
 ASD SCREENING AND DIAGNOSIS

• The American Academy of Pediatrics (AAP) recommends developmental

and behavioral screening for all children during regular well-child visits
at these ages:
• 9 months
• 18 months
• 30 months
• In addition, AAP recommends that all children be screened specifically for ASD
during regular well-child doctor visits at:
• 18 months
• 24 months
• Additional screening might be needed if a child is at high risk for ASD (e.g., having
a sister, brother or other family member with an ASD) or if behaviors sometimes
associated with ASD are present.
 ASD TREATMENT
• Behavior and Communication Approaches
• Applied behavior analysis
• Assistive technology
• Communication boards, electronic tablets
• Speech therapy
• Occupational therapy
• Social skills training
• Dietary Approaches
• Medication
• Complementary and Alternative Medicine
AUTISTIC
DISORDER
• Also known as early infantile autism,
childhood autism or Kanner’s autism

• Characterized by:
– Qualitative impairment in social
interaction
– Impairment in communication
– Restricted repetitive &
stereotyped patterns of behavior
or interests
Leo Kanner • 1943, “Autistic
Disturbances of
Affective Contact”
• Coined the term
infantile autism
• Provided clear,
comprehensive
account of early
childhood syndrome
Epidemiology
• 8 cases per 10,000 children (0.08%)
• Onset before the age of 3
• 4 to 5 times more frequent in boys than
girls
• Girls with autistic disorder are more likely
to have more severe mental retardation
Etiology
• Supports a genetic basis
– 50 to 200 times increase in rate of autism in
siblings of an index child
– Siblings at increased risk for developmental
disorders related to communication & social
skills
• Multiple genes are involved
• Perinatal insult along with genetic
vulnerability may lead to autism
Etiology
• Disorders associated with autism
– Fragile X syndrome – 1%
• (+) gross motor & fine motor difficulties & poorer
expressive language
– Tuberous sclerosis – 2%
– Mental retardation – 70%
• 1/3 mild to moderate
• ½ severe or profound
– Grand mal seizures – 4 to 32%
Etiology
• Other implicated disorders include
– Congenital rubella
– Phenylketonuria
• Chromosomes 2, 7, 16 & 17 are implicated
• Enlargement of gray & white matter cerebral
volumes
– Greater increase in size of occipital, parietal
& temporal lobes
Diagnosis & clinical features
• Do not show any physical signs
indicating the disorder
– High rates of minor physical anomalies
– Do not show lateralization at an age when
cerebral dominance is established
• Overrespond to stimuli & underresponse
to others
• Hyperkinesis is common
Course & prognosis
• A lifelong disorder with guarded prognosis
• Those with IQs > 70 & those who use
communicative languages by ages 5 to 7
tend to have the best prognoses
• Ritualistic & repetitive behaviors did not
seem to improve over time
• 2/3 remain severely handicapped & live in
complete dependence
• 1 to 2% acquires a normal, independent
status with gainful employment
Treatment
• Goals of treatment
– Target behaviors that will improve
abilities to integrate into schools
– Develop meaningful peer relationships
– Increase likelihood of maintaining
independent living as adults
Treatment
• Interventions aim to
– Increase socially acceptable behaviors
– Decrease odd behavioral symptoms
– Improve nonverbal & verbal
communication
Treatment
• Support & counseling for parents
• Educational & behavioral interventions are
the treatments of choice
• Structured classroom training with
behavioral methods as most effective
• Antipsychotic may help reduce aggressive
& self injurious behavior
• Physical Therapy – Movement,
Coordination, and Endurance
ASPERGER’S
DISORDER
• Impairment & oddity of social interaction &
restricted interest & behavior reminiscent
of those seen in autistic disorder

• No significant delays in language,

cognitive development, or age
appropriate self help skills
Hans Asperger

• 1944
• “autistic
psychopathy”
Etiology
• Cause is unknown

• Supports presence of genetic, metabolic,

infectious & perinatal contributing factors
Course & prognosis
• Factors associated with good prognosis
– Normal IQ
– High level social skills
• Verbal & intelligent adults but relate in
awkward way to other adults, appear
socially uncomfortable & shy
Treatment
• Supportive
• Goals are to promote social behaviors &
peer relationships
• Self sufficiency & problem solving
techniques are helpful
• Physical Therapy – Movement,
Coordination, and Endurance
 CHILDHOOD
DISINTEGRATIVE
DISORDER
• Marked regression in several areas of functioning after at least 2
years of normal development
– Expressive Language skills
– Receptive language skills
– Control over bowel and bladder
– Play skills
– Motor skills

– Lack of normal function or impairment also occurs in at least two of the following
three areas:
• Social interaction
• Communication
• Repetitive behavior and interest patterns

• Also known as Heller’s syndrome & disintegrative psychosis

• After the deterioration, children resembled autistic disorder
• occurs in 1 in 100,000 boys
• Ratio of 4-8 boys to 1 girl
Etiology
• Cause is unknown
• Associated with other neurological
disorders
– Seizure
– Metabolic disorders
Course & prognosis

• Plateau reached in most cases

• Most are left with at least moderate

mental retardation
Treatment
• Same as that of autistic disorder
 RETT’S
DISORDER
Andreas Rett • 1965, Australian
physician
• Identified a syndrome
in 22 girls
• Developed normally
for at least 6
months, followed by
devastating
developmental
deterioration
• 6 to 7 cases per
100,000 girls
Etiology
• Cause is unknown
• Likely to have genetic basis
• Seen primarily in girls
• Complete concordance in monozygotic
twins
 SYMPTOMS
• Loss of speech
• Loss of purposeful use of hands
• Involuntary hand movements such as handwashing
• Loss of mobility or gait disturbances
• Loss of muscle tone
• Seizures or Rett “episodes”
• Scoliosis
• Breathing issues
• Sleep disturbances
• Slowed rate of growth for head, feet and hands
Course & prognosis
• Progressive
• Prognosis not fully known
• Patients who live into adulthood remain at
a cognitive & social level equivalent to
that in the first year of life
Treatment
• Symptomatic
• Physiotherapy for muscular dysfunction
• Anticonvulsant if necessary
• Behavior therapy
 Attention Deficit/Hyperactivity Disorder

• Excessive levels of activity

– Fidgeting, squirming, running around when inappropriate,
incessant talking

• Distractibility and difficulty concentrating

– Makes careless mistakes, cannot follow instructions, forgetful

• Congress created National ADHD

Awareness Day
– First observed September 7, 2004
 ADHD
• INATTENTIVENESS
– Not being able to focus
• HYPERACTIVITY
– Being extremely active
• IMPULSIVITY
– Not being able to control behavior
 Attention Deficit/Hyperactivity Disorder

• Three subcategories in DSM-IV-TR

1. Predominantly inattentive/distractible type
2. Predominantly hyperactive-impulsive type
3. Combined type
• Differential diagnosis
– ADHD or Conduct Disorder?
– ADHD
• More off-task behavior, cognitive and achievement deficits
– Conduct Disorder
• More aggressive, act out in most settings,
• antisocial parents, family hostility
 INATTENTIVE TYPE
• Short attention span for age (difficulty sustaining attention)
• Difficulty listening to others
• Difficulty attending to details
• Easily distracted
• Forgetfulness / weak working memory
• Make careless mistakes
• Poor organizational skills for age
• Poor study skills for age
• Difficulty following detailed instructions
• More commonly diagnosed in adults and girls
 IMPULSIVE
• Often interrupts others
• Has difficulty waiting for his or her turn in school and/or social
games
• Tends to blurt out answers instead of waiting to be called upon
• Takes frequent risks, and often without thinking before acting
• more often diagnosed in children and men.
 HYPERACTIVE
• Seems to be in constant motion; runs or climbs, at times with no apparent
goal except motion
• Has difficulty remaining in his/her seat even when it is expected
• Fidgets with hands or squirms when in his or her seat; fidgeting
excessively
• Talks excessively
• Has difficulty engaging in quiet activities
• Loses or forgets things repeatedly and often
• Inability to stay on task; shifts from one task to another without bringing
any to completion
 COMBINED TYPE
• demonstrate six or more symptoms of
inattention, and six or more symptoms of
hyperactivity and impulsivity
 DSM-5 Criteria for ADHD

• Inattention:
– Six or more symptoms of inattention for children up to age
16 years
– five or more for adolescents age 17 years and older and
adults
– symptoms of inattention have been present for at least 6
months
– are inappropriate for developmental level:

https://www.cdc.gov/ncbddd/adhd/
diagnosis.html
 DSM-5 Criteria for ADHD
INATTENTION

• Often fails to give close attention to details or makes careless mistakes

in schoolwork, at work, or with other activities.
• Often has trouble holding attention on tasks or play activities.
• Often does not seem to listen when spoken to directly.
• Often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (e.g., loses focus, side-
tracked).
• Often has trouble organizing tasks and activities.
• Often avoids, dislikes, or is reluctant to do tasks that require mental
effort over a long period of time (such as schoolwork or homework).
• Often loses things necessary for tasks and activities (e.g. school
materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses,
mobile telephones).
• Is often easily distracted
• Is often forgetful in daily activities.
https://www.cdc.gov/ncbddd/adhd/
diagnosis.html
 DSM-5 Criteria for ADHD
HYPERACTIVITY AND IMPULSIVITY

• Six or more symptoms of hyperactivity-impulsivity for children

up to age 16 years
• five or more for adolescents age 17 years and older and adults;
• symptoms of hyperactivity-impulsivity have been present for at
least 6 months to an extent that is disruptive and inappropriate
for the person’s developmental level

https://www.cdc.gov/ncbddd/adhd/
diagnosis.html
 DSM-5 Criteria for ADHD
HYPERACTIVITY AND IMPULSIVITY

• Often fidgets with or taps hands or feet, or squirms in seat.

• Often leaves seat in situations when remaining seated is expected.
• Often runs about or climbs in situations where it is not appropriate
(adolescents or adults may be limited to feeling restless).
• Often unable to play or take part in leisure activities quietly.
• Is often “on the go” acting as if “driven by a motor”.
• Often talks excessively.
• Often blurts out an answer before a question has been completed.
• Often has trouble waiting their turn.
• Often interrupts or intrudes on others (e.g., butts into conversations or
games)

https://www.cdc.gov/ncbddd/adhd/
diagnosis.html
 In addition, the following conditions must be met:

• Several inattentive or hyperactive-impulsive symptoms were present

before age 12 years.
• Several symptoms are present in two or more settings, (such as at
home, school or work; with friends or relatives; in other activities).
• There is clear evidence that the symptoms interfere with, or reduce the
quality of, social, school, or work functioning.
• The symptoms are not better explained by another mental disorder
(such as a mood disorder, anxiety disorder, dissociative disorder, or a
personality disorder).
• The symptoms do not happen only during the course of schizophrenia
or another psychotic disorder.

https://www.cdc.gov/ncbddd/adhd/
diagnosis.html
 Based on the types of symptoms, three kinds
(presentations) of ADHD can occur:

• Combined Presentation:
• if enough symptoms of both criteria inattention and hyperactivity-impulsivity
were present for the past 6 months

• Predominantly Inattentive Presentation:

• if enough symptoms of inattention, but not hyperactivity-impulsivity, were
present for the past six months

• Predominantly Hyperactive-Impulsive Presentation:

• if enough symptoms of hyperactivity-impulsivity, but not inattention, were
present for the past six months.

https://www.cdc.gov/ncbddd/adhd/
diagnosis.html
 Attention Deficit/Hyperactivity Disorder

• ADHD often comorbid with

anxiety and depression
• Prevalence estimates 3 to
7% worldwide
• More common in boys than
girls
– May be because boys’
behavior more likely to be
aggressive
• Symptoms persist beyond
childhood
– Numerous longitudinal studies
show 65 to 80% still exhibit
symptoms
– 60% of adults continue to meet
criteria for ADHD in remission

© 2012 John Wiley & Sons, Inc.

All rights reserved.
 Girls with Attention Deficit/Hyperactivity
Disorder
• Hinshaw et al. (2006) large, ethnically diverse study of girls
– Combined type had:
• More disruptive behaviors than inattentive type
• More comorbid diagnoses of conduct disorder or oppositional defiant
disorder than girls without ADHD
• Viewed more negatively by peers than inattentive type or girls without
ADHD
– Inattentive type
• Viewed more negatively by peers than girls without ADHD
– Girls with ADHD more likely to:
• Be anxious and depressed
• Exhibit neurological deficits (e.g., poor planning, problem-solving)
• Have symptoms of eating disorder and
substance abuse by adolescence

© 2012 John Wiley & Sons, Inc.

All rights reserved.
 Etiology of ADHD

• Genetic factors
– Adoption and twin studies
• Heritability estimates as high as 70 to 80%
– Two dopamine genes implicated
• DRD4
– Dopamine receptor gene
• DAT1
– Dopamine transporter gene
» Mixed support for this gene
– Either gene associated with increased risk only when prenatal
maternal nicotine or alcohol use is present
• Neurobiological factors
– Dopaminergic areas smaller in children with ADHD
• Frontal lobes, caudate nucleus, globus pallidus
– Poor performance on tests of frontal lobe function

© 2012 John Wiley & Sons, Inc.

All rights reserved.
 Etiology of ADHD

• Perinatal and prenatal factors

– Low birth weight
• Can be mitigated by later maternal warmth
– Maternal tobacco and alcohol use
• Environmental toxins
– Limited evidence that food additives or food coloring
can have a small impact on hyperactive behavior
– No evidence that refined sugar causes ADHD
– Nicotine from maternal smoking
• Exposure to tobacco in utero associated with ADHD
symptoms
• May damage dopaminergic system resulting in behavioral
disinhibition

© 2012 John Wiley & Sons, Inc.

All rights reserved.
 Etiology of ADHD

• Parent-child relationship
– Parents give more commands and have more
negative interactions
– Family factors
• Interact with genetic and neurobiological factors
• Contribute to or maintain ADHD behaviors but do
not cause them

© 2012 John Wiley & Sons, Inc.

All rights reserved.
 Treatment of ADHD

• Stimulant medications (Ritalin, Adderall, Concerta, Strattera)

– Reduce disruptive behavior
– Improve interactions with parents, teachers, peers
– Improve goal-directed behavior and concentration
– Reduce aggression
– Side effects
• Loss of appetite, weight, sleep problems
• Medication plus behavioral treatment
– Slightly better than meds alone
– Improved social skills whereas meds alone did not
– Three-year follow-up found superior benefits of meds did not
persist

© 2012 John Wiley & Sons, Inc.

All rights reserved.
 Treatment of ADHD

• Psychological treatment
– Parental training
– Change in classroom management
– Behavior monitoring and reinforcement of
appropriate behavior
• Supportive classroom structure
– Brief assignments
– Immediate feedback
– Task-focused style
– Breaks for exercise
© 2012 John Wiley & Sons, Inc.
All rights reserved.