Diagnosis &management of Autistic Spectrum Disorders

Moderator-Dr.Mangilal sirBy-Dr.Nimisha Sharma

Prevalence

 The prevalence rate of autism in India is 1 in 250 (figure may vary as many cases are not diagnosed)

currently 10 million people are suffering in India.

The government only recognized the disorder in 2001, till 1980s, there were reports that Autism didn't exist in India. IAP-2013

Etiology of ASDThe cause of autism is unknown. brain

abnormalities  genetic(hereditary)environmental (e.g., exposure to toxins) metabolic disorders (e.g., serotonin

deficiency), viral infections (e.g., German measles

 complications during pregnancy and delivery  unstable genes immunizations like (MMR) vaccine.  fever/flu during pregnancy . 

Checklist for sign of autism

Social interactions Communication

Seen to be in their own world

Show little eye contact Not use of gestures Not share of enjoyment or

interests Show little emotion or

empathy Not respond to their

names Show not interest to other

children or peers

Have little or no babble Have little or no spoken

language Not engage in pretend play Have echolalia which

means they echo or mimic words or phrase without meaning or in an usual tone of voice

Have difficulty understanding and following simple instructions

Autistic disorders is characterized by the inability of the children to communicate and interact socially.

An autistic is a loner. He expresses lack of interest in other people.

Extreme autistic aloneness

Language abnormalities

Rather than engage in conversation, the autistic tends to repeat the words rather than reply, answer or engage in conversation

Repetitive behaviors

An autistic extends concentration or something and preserve the sameness of the environment.

Echolalia

Is a form of autism where the autistic repeats what it said by another rather than respond to a question.

Pronoun reversals

Autistics refer to themselves by “you” and to others as “I”.

Even after acquiring speech, still it is not used for effective social communication. They do not respond to verbal comments.

Changes in DSM 5 from DSM 4 TR Diagnostic and Statistical Manual of Mental Disorders

1994-DSM 4 May2013-DSM 5

DSM 5 criteriaA. PERSISTENT DEFICITS IN SOCIAL COMMUNICATION AND SOCIAL INTERACTION ACROSS CONTEXTS, NOT ACCOUNTED FOR BY GENERAL DEVELOPMENTAL DELAYS, AND MANIFEST BY 3 OF 3 SYMPTOMS:

A1 reflects problems with social initiation and response

A2 reflects problems with nonverbal communication

A3 reflects problems with social awareness and insight, as well as with the broader concept of social relationships

IAP 2013

B. RESTRICTED, REPETITIVE PATTERNS OF BEHAVIOR, INTERESTS, OR

ACTIVITIES AS MANIFESTED BY AT LEAST 2 OF 4 SYMPTOMS:

B1 includes atypical speech, movements, and play

B2 includes rituals and resistance to change

B3 includes preoccupations with objects or topics

B4 includes atypical sensory behaviors IAP 2013

C. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)

D. Symptoms together limit and impair everyday functioning

IAP 2013

Changes include:• The diagnosis will be called Autism Spectrum

Disorder (ASD)and there no longer will be subdiagnoses (Autistic Disorder,Asperger Syndrome, Pervasive Developmental Disorder Not Otherwise Specified, Disintegrative Disorder)

>Although symptoms must begin in early childhood, they may not be recognized fully until social demands exceed capacity

Rett syndrome is a discrete neurologic disorder and is not a subdiagnosis under ASD, although patients with Rett syndrome may have ASD.

Asperger syndrome also not a subdiagnosis under DSM 5. AAP 2013

In DSM-IV, symptoms were divided into three areas (social reciprocity,communicative intent, restricted and repetitive behaviors).

The new diagnostic criteria have been rearranged into two areas: 1) social communication/interaction 2) restricted repetitive behaviors. The diagnosis will be based on symptom currently or by history, in these two areas

In summary, pediatricians should counsel parents whose children had a diagnosis of an autism spectrum disorder they do not need to be reevaluated for diagnosis .

AAP2013

SCREENING &DIAGNOSISDiagnosing of ASD can be difficult, since

there is no medical test, Doctors look at the child’s behavior and development to make a diagnosis.

ASD can sometimes be detected at 18 months or younger. By age 2, a diagnosis by an experienced professional can be considered very reliable.[1] However, many children do not receive a final diagnosis until much older.

Diagnosing an ASD takes two steps:Developmental ScreeningComprehensive Diagnostic EvaluationAAP 2013

Developmental ScreeningDevelopmental screening is a short test to tell if

children are learning basic skills when they should, or if they might have delays. During developmental screening the doctor might ask the parent some questions or talk and play with the child during an exam to see how she learns, speaks, behaves, and moves. A delay in any of these areas could be a sign of a problem.

All children should be screened for developmental delays and disabilities during regular well-child doctor visits at:

9 months18 months24 or 30 monthsAdditional screening might be needed if a child is

at high risk for developmental problems due to preterm birth, low birth weight or other reasons.

Comprehensive Diagnostic EvaluationThe second step of diagnosis is a

comprehensive evaluation. This thorough review may include looking at the child’s behavior and development and interviewing the parents. It may also include a hearing and vision screening, genetic testing, neurological testing, and other medical testing.

In some cases, the primary care doctor might choose to refer the child and family to a specialist for further assessment and diagnosis. Specialists are

Developmental Pediatricians Child Neurologists Child Psychologists or Psychiatrists

The Modified – Checklist for Autism in Toddlers

age range-16-48 monthM-CHAT------------M-CHAT follow up interview 1 min (if fails ) 5 minScoring-pass/fail scores based on falling atleast

2 critical items or 3 or more non critical itemsAccuracy-sensitivity-90%Specificity-99%Cost-6.06$

Please fill out the following about how your child usually is. Please try to answer every question. If the behavior is rare (e.g., you've seen it once or twice), please answer as if the child does not do it.

1. Does your child enjoy being swung, bounced on your knee, etc.? Yes No2. Does your child take an interest in other children? Yes No3. Does your child like climbing on things, such as up stairs? Yes No4. Does your child enjoy playing peek-a-boo/hide-and-seek? Yes No5. Does your child ever pretend, for example, to talk on the phone or take care of a doll or pretend other things?6. Does your child ever use his/her index finger to point, to ask for something? Yes No7. Does your child ever use his/her index finger to point, to indicate interest in something? Yes No8. Can your child play properly with small toys (e.g. cars or blocks) without just Yes Nomouthing, fiddling, or dropping them?9. Does your child ever bring objects over to you (parent) to show you something? Yes No10. Does your child look you in the eye for more than a second or two? Yes No11. Does your child ever seem oversensitive to noise? (e.g., plugging ears) Yes N

12. Does your child smile in response to your face or your smile? Yes No13. Does your child imitate you? (e.g., you make a face-will your child imitate it?) Yes No14. Does your child respond to his/her name when you call? Yes No15. If you point at a toy across the room, does your child look at it? Yes No16. Does your child walk? Yes No17. Does your child look at things you are looking at? Yes No18. Does your child make unusual finger movements near his/her face? Yes No19. Does your child try to attract your attention to his/her own activity? Yes No20. Have you ever wondered if your child is deaf? Yes No21. Does your child understand what people say? Yes No22. Does your child sometimes stare at nothing or wander with no purpose? Yes No23. Does your child look at your face to check your reaction when faced es Nwith

Treatments for Autism Spectrum Disorders

AUTISM SPECTRUM

There is no cure for autism; however, with appropriate treatment and education, many children with autism spectrum disorders can learn and develop. Early intervention often can reduce challenges associated with autism, lessen disruptive behavior, and provide some degree of independence.

Treatment depends on the needs of the individual. In most cases, a combination of treatment methods is more effective. Autism spectrum disorders may require lifelong treatment.

According to the National Institutes of Health (NIH), treatment for autism can include

Behavioral management therapy . Speech-language therapy

Cognitive behavior therapy Social skills training Educational

and school-based Joint attention therapy Occupational

therapy Parent-mediated therapy Physical therapy Medication treatment Nutritional therapy

Pharmacological intervention

Currently, there is no medication that can cure ASD or all of its symptoms. But in many cases, medication can help treat some of the symptoms associated with ASD, especially certain behaviors.

Any medications not approved by the FDA for treating symptoms of autism or other conditions.

One person with autism might respond to medications differently than another person with autism or than people who don't have autism.

SSRI◦ SSRIs might reduce the frequency and intensity of repetitive

behaviors; decrease anxiety, irritability, tantrums, and aggressive behavior; and improve eye contact.

Tricyclics◦ These medications are another type of antidepressant used

to treat depression and obsessive-compulsive behaviors. Psychoactive or anti-psychotic medications

◦ risperidone is approved for reducing irritability in 5-to-16-year-olds with autism.

◦ These medications can decrease hyperactivity, reduce stereotyped behaviors, and minimize withdrawal and aggression among people with autism.

Stimulant help to increase focus and decrease hyperactivity in

people with autism. They are particularly helpful for those with mild ASD symptoms.

Anti-anxiety medications Anti-convulsants

◦ Almost one-third of people with autism symptoms have seizures or seizure disorders.

Behavior ModificationBehavior modification often involves highly

structured, skill-oriented activities that are based on the individual's needs and interests. It usually requires intense, one-on-one training with a therapist and extensive caregiver involvement.

Sensory integration therapy is a type of behavior modification that focuses on helping people with ASD cope with sensory stimulation. Treatment may include having the individual handle materials with different textures or listen to different sounds.

 Play therapy is a type of behavior modification that is used to improve emotional development, which in turn, improves social skills and learning. Play therapy involves adult-child interaction

Social stories can also be used to improve undeveloped social skills. Stories are designed to help people with ASD understand the feelings, ideas, and points of view of others,

Applied Behavioral AnalysisThis treatment program (ABA) is based on

the principles of positive reinforcement . There are several methods of behavior

modification that are used to treat inappropriate, repetitive, and aggressive behavior and to provide autistic people with skills necessary to function in their environment. Most types of behavior modification are based on the theory that rewarded behavior is more likely to be repeated than behavior that is ignored. This theory is called applied behavior analysis (ABA)

ABA Three Step Procedure

Antecedent: The verbal or physical stimulus such as a command or request.

Resulting Behavioral response to stimulus or a lack of response

Consequence: the positive reinforcement or no response for inappropriate behavior

 Play therapy is a type of behavior modification that is used to improve emotional development, which in turn, improves social skills and learning. Play

therapy involves adult-child interaction

Floor Time is simply the idea that a child’s communication skills can be improved by building on his/her strengths while playing together on the floor.

Integrated Play Groups

.Promotes socialization and imagination

in children with ASD or Developmental Delays through play with non-disabled peers.

Integrated Play Groups follow rules for creation of an appropriate play environment and selection of materials, preparation of peers for play, measurement of progress and guided play.

TEACCHTraining and Education of Autistic and

Related CommuniCation for Handicapped Children

This is a highly structured program based on the “Culture of Autism”

Term refers to the “relative strengths and difficulties shared by people with autism and that are relevant to how they learn”

InterventionIn this approach, children are

evaluated to determine emergent skills and intervention is designed to build on these skills.

The intervention plan is developed for each individual child to help plan activities and experiences.

The child refers to visual supports such as picture schedules to help them predict and cope with daily activities.

SCERTSSocial Communication,

Emotional Regulation, and Transactional Support

Social Communication: spontaneous functional communication, emotional expression and secure and trusting relationships with others

Emotional Regulation

The Hanen Approach

This approach is based on the belief that parents should be the child’s language teachers, because they have the strongest bond and have many opportunities to teach language in the natural contexts of daily living.

Parents are trained by Hanen certified SLPS.

In SummaryThere are many, many different

approaches to treating Autism Spectrum Disorders.

This list is by no means comprehensive.

Parents and therapists should engage in careful research before committing to any specific program.

Communication TherapyCommunication therapy is used to treat

autistic people who are unable to communicate verbally, or to initiate language development in young children with the disorder. Speech therapy may be used to help people with autism gain the ability to speak.

Picture exchange communication systems (PECS) enable autistic people to communicate using pictures that represent ideas, activities, or items. The individual is able to convey requests, needs, and desires to others by simply handing them a picture.

Dietary ModificationsAutism is not caused by diet and the use

of dietary modifications and supplements to treat the disorder is controversial.

Researchers have found elevated levels of proteins found in wheat, oats and rye (gluten) and casein,Eliminating foods that contain gluten and casein from the diet may cause side effects and should not be done without the advice of a qualified health care provider.

Studies have shown that vitamin B, magnesium,cod liver oilsupplements may improve behavior, eye contact, attention span, and learning in autistic people. Vitamin C has been shown to improve depression and lessen the severity of symptoms.

Prognosis or outcome of autism

Some children with autism may improve at 4-6 years of age especially those with mild autism who have been treated at an early age.

Current policy of inclusion within the education system helps to support the majority of ASD sufferers within mainstream schools.

49% of adults with autism still living with parents

12% have full time employment.10% had a social life and some employment

but required some support 46% needed specialist residential provision 12% needed high-level hospital care.

Poor prognostic factors

co-existing mental retardation. environmental toxins advanced parental age

diseases that co-exist with autism like Fragile X syndrome, Down’s syndrome etc. About 10–15% of autism cases have an identifiable chromosomal abnormality.

Consider the following differential diagnoses for ASD Neurodevelopmental disorders: – specific language delay or disorder – intellectual disability or global developmental delay Mental and behavioural disorders: – attention deficit hyperactivity disorder (ADHD) – mood disorder – anxiety disorder – oppositional defiant disorder (ODD) – conduct disorder – obsessive compulsive disorder (OCD) Conditions in which there is developmental regression: – Rett syndrome – epileptic encephalopathy. Other conditions: – severe hearing impairment – severe visual impairment – selective mutism

Famous personality with ASD

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