Download - Autism autism spectrum disorder (ASD)
Autismautism spectrum disorder (ASD)Dr. Anne ZbarackiParental presentationApril 9,2014
Autism Definition Epidemiology Diagnosis Screening Spectrum Treatment Local help Potential causes (or not)
http://www.youtube.com/watch?v=YtvP5A5OHpU
Definition From DSM V- biologically based neurodevelopment
disorder characterized by impairments in two major domains 1 deficits in social communication and social interaction 2 restrictive repetitive patterns of behavior, interests,
activities Must be present in early development Cause clinically significant impairment in social,
occupational, or other important areas of current functioning
Severity 3 levels- requiring support, substantial support , very substantial support
Definition ASD covers
Classic autism Childhood disintegrative disorder Pervasive developmental disorder–nos Asperger
Epidemiology Prevalence
4 times more in males than females Increased since 70’s, up to 1:50 Sibling of ASD child, 7% if affected is
female, 4% if male, >30% if 2 or more affected
Epidemiology Associated conditions
Intellectual disability Seizures Genetic disorders
Tuberous sclerosis Fragile X Smith-Lemli-Opitz
Diagnosis Like anything else need
Complete history PE Neurological examThen, direct assessment of social, language, and cognitive developmentParent interviews for concerns and behavior hxStructured observation of social and communicative behavior and play
Diagnosis Hx-
Family hx, 3 generation since can be genetic milestones, play skills, behavior, regression Parental concerns, hearing, vision, speech/language Communication behaviors, pointing, eye contact ,
response to name Hx of repetitive, ritualized behaviors- hand flapping Not tolerating change or transition Self injury Seizures Eating (pica), sleep
Diagnosis Language delay, mental retardation,
fragile x, Rett, Angelman, Prader-Willi, Smith-Lemli-Opitz, Tuberous sclerosis, anxiety, OCD, extreme shyness, social phobia, mutism, mood disorders, schizophrenia, seizures, tic disorders
Diagnosis Exam- will need extra time
Growth patterns, esp head circumference, early acceleration then stabilization
Ht/wt- low, high Skin with Wood’s lamp- hypopigmented,
tuberous sclerosis Dysmorphic as in Fragile X, long face, large
ears & testes or Angelman, ataxic gait, broad mouth
Muscle tone and reflexes
Diagnosis PCP responsibility: listen to parents
concerns and take them seriously Refer for comprehensive specialty eval
Early intervention Dept. of education
But don’t wait for the formal dx before doing something
Early diagnosis Things the PCP can do while waiting for a
formal dx Temperaments, discuss what that is, how it’s
a scale and determine where the child is. Resources at The Center for Parenting Education, Carey Temperament Scales
Socialization, supervised community play groups, development services
Language, picture books, ongoing description
Screening CDC and AAP ALARM
Autism is prevalent 1:50
Listen to parents Early as 18mo, parents are concerned
Act early Concerns, screen at 18 and 24 mo
Refer Don’t delay
Monitor Ongoing support and medical management
Screening Early indicators
Reduced response to name Reduced frequency looking at faces
Red flags No babbling by 9 months No pointing or gestures or lack of orientation to name by
12 months No single words by 16 months Lack of pretend or symbolic play by 18 months No spontaneous or meaningful 2 word phrases by 24
months Any loss of language or social skills
Screening Indications
Delayed language/ communication, regression of social or language skills, parental concern
1st stage screening Id ASD from general population
Ex: CHAT, M-CHAT, social communication questionnaire
2nd stage screening ASD from other development disorders
Ex: PDD screening test II , screening tools for autism in 2yr olds
Differential Diagnosis Global development delay/intellectual disability Social communication disorder
no restrictive repetitive behaviors Developmental language disorder
Normal socialization Language-based learning disability
Normal socialization, intent to communicate Hearing impairment
Normal reciprocal social interactions Landau-Kleffner syndrome
Normal until 3-6 Rett
Females, >18months Severe early deprivation/ reactive attachment
Caregiver neglect, improve with appropriate care Anxiety
Symptoms distressing OCD
Symptoms distressing
spectrum Classic autism Childhood disintegrative disorder Pervasive developmental disorder Asperger
Spectrum Impaired social communication and interaction
Social reciprocity Unaware of other children, lack empathy, lack
imitation Joint attention
Seeking to share enjoyment, undemanding of attention
Nonverbal Baby resists cuddling, avoid eye contact
Social relationships Lack of friendships
Spectrum Restricted and repetitive behaviors,
interests , and activities Stereotyped
Hand flapping, swaying, toe walking, self injurious
Sameness Daily routines, routes
Restricted interests Preoccupations, sensory
Treatment Management Behavioral and education interventions Medications Complementary and alternative
therapies
Treatment Management
Chronic condition, no cure, need to be individualized
Goals Improve social functioning and play skills Improve communication, functional and
spontaneous Improve adaptive skills Decrease negative, nonfunctional behaviors Promote academic function and cognition
Treatment Treatment team
You Developmental pediatrician, child neurologist,
child psychiatrist neuropsychologist Geneticist, genetic counselor Speech language pathologist Occupational therapist Audiologist Social worker
Treatment Proven aspects of education programs
High staff to student ration 1:1 or 1:2 Individualized Special expertise teachers 25 hours a week of services Fluid treatment Curriculum based on attention, imitation,
communication, play, social interaction Predictable, structured Transition planning Family involvement
Treatment Early intervention program School based special education
IDEA, individuals w/ disabilities education act, guarantees free and appropriate public education
Private Practice therapists
Treatment Your job
Longer time for appointments Routine care, preventative and screening Assess nutrition, physical activity, screen time,
alternative therapies Safety Surveillance for comorbidities
Seizures, lead poisoning, anxiety, depression, hyperactivity, sleep problems, GI
Support the family, educate on proven treatments
Treatment Prognosis
Factors that have better outcomes Presence of joint attention, functional play
skills, cognitive, decreased severity, early ID, involvement, move to inclusion
Factors with worse outcomes Lack of joint attention by 4, lack of functional
speech by 5, IQ<70, seizures and other comorbid medical and neurodevelopment conditions, severe symptoms
Treatment Behavioral and educational interventions
Maximize functioning, move child toward independence, improve quality of life for child and family
Questions to assess How many days a week, how much time Number of students and providers Therapy, time, individual or group Home therapy Providers, oversight of program, qualifications
Treatment Intervention models
Behavioral Structured teaching Development/relationship Integrative
Treatment Behavioral interventions
Applied Behavior Analysis Reinforce good behavior, decrease
undesirable thru repeated reward Teach new skills, break learned skills into
basic elements
Treatment Structured teaching, TEACCH, University of North Carolina
TEACHING. We share our knowledge of Autism Spectrum Disorder and increase the skill level of others through innovative education, teaching, and demonstration models.
EXPANDING. We are committed to expanding our own knowledge and that of others to ensure that we offer the highest quality, evidence-based services for individuals with Autism Spectrum Disorder and for their families across the lifespan.
APPRECIATING. We understand and appreciate the unique strengths of people with Autism Spectrum Disorder and their families.
COLLABORATING AND COOPERATING. We embody a spirit of collaboration and cooperation in our interactions with colleagues, individuals with Autism Spectrum Disorder and their families, and members of the larger community.
HOLISTIC. We stress the importance of looking at the whole person, their families and their communities throughout the lifespan.
Treatment Development and relationship
Teaching essential skills that were not adequately learned at the expected age Several types of models
Denver, Early start Denver, Floortime, Milieu, More than Words, Relationship development intervention, Responsive teaching
Treatment Integrative
Combining models
Specific behaviors
OT
Treatment Pharmacotherapy for medical and psychiatric
comorbidities Should be prescribed by a specialist Does not treat autism, started after interventions Only FDA approved drugs are rispridone and
ariprazole, all others are off label Used for clearly defined symptoms and tracked Benefits outweigh risks Can be difficult to assess side effects, poor
communication, more sensitive
Treatment Pharmacotherapy
Symptoms Hyperactivity, impulsivity, inattention Aggression, self injury Repetitive behaviors, rigidity Anxiety, depression, labile mood
Treatment Hyperactivity, impulsivity, inattention
Can be comorbid ADHD• Stimulants- methyphenidate, dextroamphetamine• Alpha 2 agonists- guanfacine, atomoxetine,
clonidine• Atypical antipsychotics- risperidone• Anticonvulsant- valproic acid
Treatment Aggression
Atypical antipsychotic- risperidone, aripiprazole, olanzapine, clozapine, quetiapine, ziprasidone, haloperidol Wt,ht, EKG, CBC, THS, prolactin, LFT, lipids,
glucose Lithium SSRI Beta blockers
Treatment Repetitive behaviors
SSRI-fluoxetine clomipramine Atypical antipsychotics valproate
Treatment CAM- complementary and alternative medicine
Biologic based Melatonin- sleep Secretin- GI abnormalities Omega 3- CV health Gluten free casein free- leaky gut, no hard evidence B6-Mg- inconclusive Dimethyl glycine- no harm, no benefit Probiotics Antifungal agents- yeast overgrowth IvIG Chelation- heavy metals Hyperbaric O2- enhance o2 delivery
Treatments Nonbiologic based
Music therapy Horseback riding- improved attention, distractibility, social
motivation Transcranial magnetic stimulation- decreased repetitive
ritualistic behavior Facilitative communication Auditory integration Yoga Massage, touch Acupuncture Chiropractic reiki
Local resources EDI Champions of Autism and ADHD at 3025 Kimball Ave,
319-233-0380 Cedar Valley Community Support Services 3121 Brockway
Rd, (319) 233-1288 AEA 267 Autism Resource Team http://
www.aea267.k12.ia.us/sped/resource-teams/autism/about-us/www.earlyaccessiowa.org/IowaPrograms.pdf
Black Hawk County Department of Human Services1st Five,
http://www.idph.state.ia.us/1stfive/
Local Resources The Arc of Cedar Valley
PO Box 4090Waterloo, IA 50704-4090 [email protected](319) 232-0437
Potential causes Not causes
Vaccines- MMR Thimerosal- stopped in 1992 , still
increased Might be causes
Parental age- mom and dad Environment, perinatal- teratogens, low
birth wt Genetic
Take away Id Refer Treat, reassess
Online resources American Academy of Pediatrics National Center
for Medical Home Implementation www.medicalhomeinfo.org/health/autism.html
Autism Society of America www.autism-society.org Autism Speaks Family Services Tool Kits
www.autismspeaks.org/docs/family services docs/100 day kit.pdf
The CDC www.cdc.gov/ncbddd/autism/treatment.html
First Signs www.firstsigns.org The UK National Autistic Society www.nas.org.uk
Resources Up-to-date Dsm v YouTube Primary Care for Children with Autism,
PAUL S. CARBONE, MD, and MEGAN FARLEY, PhD, University of Utah, Salt Lake City, Utah, TOBY DAVIS, DO, St. Luke's Family Medicine, Meridian, Idaho, Am Fam Physician. 2010 Feb 15;81(4):453-460.