Peds - 18 - Autism

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autism spectrum disorder

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DSM IV Diagnostic Criteria for Pervasive Developmental Disorder (PDD) aka Autism Spectrum Disorder
The Triad

Based on a Combination of Features:
-Impairment in Social Interaction
-Impairment in Communication
-Repetitive Behaviors and Fixated Interest

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Symptoms unfold between 18-24 months

Head circumference larger:
-Brain over growth
-Group average by 24 months is off the chart with increased circumference

Diagnosis usually made between 18-24 months

Motor control issues

Overly focused, poor gaze (not good at looking at you when communicating), not imitating, not sharing (but will do parallel play, but not interact with person next to them)

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brain is overgrown
inappropriate manipulation of objects - perseveration

dyspraxia - may or may not know what u want them to do, and can't pull it off (sounds like apraxia)

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The Brain!

Cerebellum is one of the most consistent sites of neuroanatomic abnormality in autism

Cerebellum plays a role in multiple
functional domains: cognitive, affective,
sensory, and motor

Increased activation of cerebellum is seen in autistic persons

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cerebellum - coordination, balance, vision, motor learning, motor control, scaling/timing of movements

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Lack of typical behaviors

Social Interaction
-Gaze for social referencing - acknowledge, glance at person
-Joint attention - attend and respond to what someone is saying

Language
-Expressive language - also a problem
-Receptive language

Communication
-Conventional gestures - don't have this either
-Pretend play - also can't do this, can't play make believe (play cooking, going to store, etc)

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DSM-V Draft Diagnostic Criteria
Autism Spectrum Disorder (ASD) 2012 (is all of those things - Dr. Senesac listed them)
(___ syndrome, disintegrative something, autism, assburger,PDD nos? - hard to differentiate between last 3)

Impairments in Social Communication:
-Impairment in the integration of nonverbal behavior (gestures, facial expression, gaze) - flat, distance kind of look
-Impairment in social reciprocity
-Difficulty developing peer relationships (or even bonding with family/parents - often don't like to be touched - sensory)

Repetitive Behaviors and Restricted Interests:
-Preoccupation with restricted interests - wheels on cars example, perseverate on one thing, inappropriate behavior, fixated on one thing
-Inflexible adherence to routines - love structure/routine
-Repetitive movements (flapping of hands, strange arm movements)

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Diagnostic Tools

Interview with family:
◦Autism Diagnostic Interview (AID)

Assessment of child: *most popular (look at behaviors)
◦Autism Diagnostic Observation Schedule (ADOS)

Observation of child:
◦Childhood Autism Rating Scales (CARS)

Clinical diagnosis based on the DSM IV

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could be speech therapist, MD, psychologist diagnose.
misdiagnosed as CP, or mental retardation(and vise versa)

OT and PT, no

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Severity and Heredity of ASD

Varies-heterogeneous group

Severity does not run in families (if have one child w/ autism severe, next child might be mild)

Identical twins=60-90%

Fraternal twins and siblings=10-20% will also have it

Older parents=increased risk

Multi-risk disorder –Genes, environment (have not identified gene, its a combination of factors that produce this combination of behaviors)

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American Academy of Pediatrics

Developmental surveillance at every well child check up from 9-30 months

Recommend: Screen all children for ASD at 18 AND 24 months

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Co-morbid conditions - things to look for, does not necessarily mean they will have all of this

Cognitive delays
Speech and Language delays
ADHD
OCD
Emotional , temper tantrums, aggression - b/c frustration w/ poor communication
Eating disorders
depression
Anxiety disorders
Intellectual disorders
Sleeping disorders
Sensory disorders
Motor Delays
idiopathic toe walking (with no neurological reason - could be bouncy gait, or up on toes all the time)

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Prevalence:

1970: 1 in 2,500
1995: 1 in 500 (better assessments)
2000: 1 in 150 (better training)
2009: 1 in 110 (1 in 70 boys)

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shots (MMR), video games, vitamin d deficiency, engineers, mercury mom eat too much fish, use cell phones, being close to power stations?- is there evidence that this causes autism? no solid evidence

mental retardation - term we don't use much anymore

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Active Ingredients for Intervention

Early is better (by 3.5y/o, less effective if >5 y/o)

Goals individualized and monitored regularly

Intensity matters

Family participation is essential - especially social, nonverbal, sharing, turn taking, interactive w/ people

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if by 3.5 - regular classroom
after 5 - need their own classroom - disruptive

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Intervention
Six kinds of instruction should have priority

1. Functional, spontaneous communication (walking in a room and say hi)

2. Social instruction in various settings (what is your reason for walking in a grocery store - this is what you do in this environment. here is the routine for this environment - classroom)

3. Teaching of play skills focusing on appropriate use of toys and play with peers (play next to them, not with. they like to spine and flip stuff. don't know how to play w/ toys appropriately)

4. Instruction leading to generalization and maintenance of cognitive goals in natural contexts

5. Positive approaches to address problem behaviors (do not respond well to time outs - b/c they like to be alone, or being spanked)

6. Functional academic skills when appropriate

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Physical Therapy Interventions

Motor coordination disorder:
-Clumsiness
-Balance problems
-Low muscle tone
-Dyspraxia –motor planning problems (preparation to execute a motor task)

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Physical Therapy Interventions

Coordination skills –large muscles:
-Trunk strengthening –extension/flexion against gravity
-Combining more than one task
-Turn taking - game of catch with a ball (won't throw it back, perseverate on ball)
-Treadmill with eventual arm swing (work on reciprocal motion - b/c they walk funny)
-Foot placement skills (scaling difficulty - short step on one side, long on other)

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Exercise in General

YES, YES, YES!!!
Research has found positive effects:
-Decreased self-stimulation
-Increased academic attention
-Increased play response
-Decreased behavior problems

These activities included:
Vigorous jogging, exercise coordination, biking

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autism is treatable when caught early

the early you intervene, the better

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