Presentation on theme: "What is Autism? ….and What in the World are We Going to do About It?"— Presentation transcript:
1What is Autism? ….and What in the World are We Going to do About It? David E. Berry, D.O., Ph.D.LewisGale PhysiciansBlacksburg PediatricsAssociate Adjunct Clinical ProfessorEdward Via Virginia College of Osteopathic Medicine
2DisclosuresThe following speaker reported no relevant financial relationships to disclose.David E. Berry, D.O., Ph.D.The following speaker(s) reported financial relationships:NoneThe planning committee members reported no relevant financial relationships to disclose
4What is the best label?Christopher, aged 4 years, has been referred to a multidisciplinary child development centre because of concern about his failure to develop normal language and social behaviour. He is seen by a paediatric neurologist, a child psychiatrist, a speech therapist and a psychologist.
5What is the best label?At the case conference, the paediatric neurologist proposes that the child has developmental dysphasia, on the grounds that his comprehension is poor and his expressive language abnormal, but hearing is adequate, ability to do non- verbal tasks such as copying or jigsaw puzzles is good, and there are no neurological signs.
6What is the best label?The psychologist, however, thinks that the child is autistic because, as well as having a language problem, his social behaviour is poorly developed: he does not play well with other children and lacks warmth in his relationships with his parents.
7What is the best label?The child psychiatrist argues that the child's social and language abnormalities are not severe enough to warrant a diagnosis of infantile autism: he does initiate communication with others, makes eye contact and enjoys rough and tumble play, but he tends to get rejected by other children because he wants them to participate in his repetitive activities and is insensitive to their needs. Christopher can produce long and complicated sentences, but his responses to questions are often inappropriate, and he often asks questions of others while disregarding the answers he receives. The psychiatrist suggests a diagnosis of Asperger's syndrome.
8What is the best label?The speech therapist states that an analysis of Christopher's language shows that it is phonologically and grammatically normal, but there are many abnormalities in the way in which language is used, and comprehension in conversational contexts is poor. She suggests that this is a case of semantic-pragmatic disorder. The psychologist responds that semantic-pragmatic disorder is just another name for autism.
9What is the best label?A visiting American paediatrician is asked to comment on the case. She examines Christopher carefully and proposes that this is a case of PDD NOS (pervasive developmental disorder not otherwise specified).
12What is autism?The word "autism," which has been in use for about 100 years, comes from the Greek word "autos," meaning "self." The term describes conditions in which a person is removed from social interaction -- hence, an isolated self.Eugen Bleuler, a Swiss psychiatrist, was the first person to use the term. He started using it around 1911 to refer to one group of symptoms of schizophrenia.In the 1940s, researchers in the United States began to use the term "autism" to describe children with emotional or social problems. Leo Kanner, a doctor from Johns Hopkins University, used it to describe the withdrawn behavior of several children he studied. At about the same time, Hans Asperger, a scientist in Germany, identified a similar condition that’s now called Asperger’s syndrome
13What do you see?One symptom common to all types of autism is an inability to easily communicate and interact with others. In fact, some people with autism are unable to communicate at all. Others may have difficulty interpreting body language or holding a conversation.
14What do you look for?Other symptoms linked to autism may include unusual behaviors in any of these areas:interest in objects or specialized informationreactions to sensationsways of learning
15Furthermore...These symptoms are usually seen early in development. Most children with severe autism are diagnosed by age 3. Some children with milder forms of autism, such as Asperger's syndrome, may not be diagnosed until later when their problems with social interaction cause difficulties at school.
16The Autism Group Pervasive development disorders (PDD) Autism Asperger's disorderPervasive developmental disorder NOSRett syndromeChildhood integrative disorder
17Autistic Disorder Children with autistic disorder cannot use verbal or non-verbal communication to interact effectively with othershave severe delays in learning language.have obsessive interest in certain objects or information.perform certain behaviors repeatedly.symptoms must have been noted before age 3.
18“Autism” is not...Pervasive development disorder -- not otherwise specified (PDD-NOS):Children diagnosed with "atypical autism"Children with PDD-NOS have symptoms that do not exactly fit those of autistic disorder or any other ASD.symptoms may have developed after age 3.symptoms may not be severe enough
19Asperger's Syndrome Many of the same symptoms Average or above average intelligence.Want to be social with others but don’t know how to go about it.Not be able to understand others' emotions.May not read facial expressions or body language well.Symptoms may not become apparent until school when behavior and communication with peers become more important.
21Rett Syndrome Children with this severe, rare condition normal development from birth through about 5 months of age.from about 5 to 48 months of age, head circumference development slows. Children lose motor skillssocial interaction and language development become impaired.
22Childhood Integrative Disorder Children begin developing normally.From about age 2 to age 10, children are increasingly less able to interact and communicate with others.They develop repetitive movements and obsessive behaviors and interests.Lose motor skills, too.Become disabled.Rarest and most severe autism spectrum disorder.
23Diagnostic and Statistical Manual of Mental Disorders DSMDiagnostic and Statistical Manual of Mental Disorders
24Autism DSM I 1952 Schizophrenic reaction occurring before puberty May differ from schizophrenic reactions occurring in other periods because of the immaturity and plasticity of the patient at the time of onsetPrimarily includes autism
25Autism DSM II 1968 Schizophrenia, childhood type Symptoms appear before pubertyMay be manifested byAutistic, atypical and withdrawn behaviorFailure to develop an identity separate from mother’sGeneral unevennessGross immaturity and inadequacy of developmentMay result in mental retardation
26Infantile Autism DSM III 1980 Onset before 30 mo of agePervasive lack of responsiveness to other people’sGross deficits in language developmentPeculiar speech patternsEcholaliaMetaphorical languagePronominal reversalBizarre response to environmentResistant to changePeculiar interests or attachmentsAbsence of delusions, hallucinations, loosening of associations, and incoherence
27Autism DSM III-R 1987A. Qualitative impairment in reciprocal social interactionLack of awareness of feelings of othersNo or abnormal seeking of comfort at times of distressNo or impaired imitationNo or abnormal social playGross impairment in ability to make peer friendships
28Autism DSM III-R 1987B. Qualitative impairment in verbal and nonverbal communicationNo mode of communicationBabbling, facial expression, gesture, mime, spoken languageAbnormal nonverbal communicationEye-to-eye, facial expression, body posture, gestures to initiate or modulate social interactionAbsence of imaginative activityAbnormal speechVolume, pitch, stress, rate, rhythm, intonation
29Autism DSM III-R 1987 Abnormal form or content of speech B. Qualitative impairment in verbal and nonverbal communicationAbnormal form or content of speechStereotyped and repetitiveEcholalia“you” for “I”Idiosyncratic use of words or phrasesIrrelevantImpairment in ability to initiate and sustain a conversation
30Autism DSM III-R 1987C. Restricted repertoire of activities and interestsStereotyped body movementsPersistent preoccupation with parts of objectsDistress of changes in trivial aspects of environmentUnreasonable insistence on routines in precise detailMarkedly restricted range of interests; preoccupation with one narrow interest
31Autism DSM IV 1994, DSM IV-R 20001. Qualitative impairment in social interactionMultiple nonverbal behaviorsEye-to-eye gazeFacial expressionBody posturesGestures to regulate social interactionFailure to develop peer relationshipsLack of spontaneous seeking to share enjoyment, interests, or achievementsLack of social reciprocity
32Autism DSM IV 1994, DSM IV-R 20002. Qualitative impairment in communicationDelay/lack of spoken languageImpaired ability to initiate or sustain conversationalStereotyped and repetitive use of languageLack of varied response to make-believe or imitative play
33Autism DSM IV 1994, DSM IV-R 20003. Restricted, repetitive, and stereotyped pattens of behavior, interests, and activitiesAbnormal in intensity or focusInflexible adherence to specific nonfunctional routines or ritualsStereotyped and repetitive motor mannerismsHand flappingComplex whole body movementsPersistent preoccupation with parts of objects
34Autism DSM IV 1994, DSM IV-R 2000Delays or abnormal function before age 3 yr in at least one ofSocial interactionLanguage in social communicationSymbolic or imaginative playThe disturbance is not better accounted for by Rett's disorder or childhood integrative disorder
35Autism DSM IV 1994, DSM IV-R 2000 Criteria for diagnosis Six or more items from 1, 2, and 3Social – at least 2 criteria metCommunication – at least 1 criterion metStereotyped behavior – at least 1 criterion metDelays or abnormal function before age 3 yr in at least one ofSocial interactionLanguage in social communicationSymbolic or imaginative play
36Autism DSM IV 1994, DSM IV-R 2000 Criteria for diagnosis The disturbance is not better accounted for by Rett's disorder or childhood integrative disorder
37Asperger's Disorder DSM IV-R 1. Qualitative impairment in social interactionMultiple nonverbal behaviorsEye-to-eye gazeFacial expressionBody posturesGestures to regulate social interactionFailure to develop peer relationshipsLack of spontaneous seeking to share enjoyment, interests, or achievementsLack of social reciprocity
38Asperger's Disorder DSM IV-R 2. Restricted, repetitive, and stereotyped pattens of behavior, interests, and activitiesAbnormal in intensity or focusInflexible adherence to specific nonfunctional routines or ritualsStereotyped and repetitive motor mannerismsHand flappingComplex whole body movementsPersistent preoccupation with parts of objects
41Prevalence1 in 80 and 1 in 240 with an average of 1 in 110 children in the United States have an ASD.Occur in all racial, ethnic, and socioeconomic groups, yet are on average4 to 5 times more likely to occur in boys than in girls.If 4 million children are born in the United States every year, approximately 36,500 children will eventually be diagnosed with an ASD.
42PrevalenceAbout 730,000 individuals between the ages of 0 to 21 have an ASD.Studies in Asia, Europe, and North America have identified individuals with an ASD with an approximate prevalence of 0.6% to over 1%.A recent study in South Korea reported a prevalence of 2.6%.Approximately 13% of children have a developmental disability, ranging from mild disabilities such as speech and language impairments to serious developmental disabilities, such as intellectual disabilities, cerebral palsy, and autism.
43Asperger's SyndromePersons with the syndrome are often workaholics, highly persistent, content with their own company and solitary artistic occupations; they focus on detail with massive curiosity and total immersion; they are novelty-seekers in terms of their art, with massive imagination in their specialised spheres. They are also far less influenced by previous or contemporary artists in their work than are ‘neurotypicals’. It appears that the autistic artist, because of his or her rather diffuse identity and diffuse psychological boundaries, has the capacity to do what the artist George Bruce described as being necessary for art: ‘One must not just depict the objects, one must penetrate them, and one must oneself become the object’.”Michael Fitzgerald, Henry Marsh Professor of Child and Adolescent Psychiatry, Trinity College Dublin in “The Genesis of Artistic Creativity: Asperger’s Syndrome and the Arts”
44Risk Factors and Characteristics Among identical twins, if one child has an ASD, then the other will be affected about 60-96% of the time.In non-identical twins, if one child has an ASD, then the other is affected about 0-24% of the time.Parents who have a child with an ASD have a 2%–8% chance of having a second child who is also affected.
45Risk Factors and Characteristics About 10% of children with an ASD have an identifiable genetic, neurologic or metabolic disorder, such as fragile X or Down syndrome.30-51% (41% on average) of the children who had an ASD also had an Intellectual Disability (intelligence quotient <=70).
46GeneticsStudies show that 5% of people with an ASD are affected by fragile X and 10% to 15% of those with fragile X show autistic traits.One to four percent of people with ASD also have tuberous sclerosis.About 40% of children with an ASD do not talk at all. Another 25%–30% of children with autism have some words at 12 to 18 months of age and then lose them. Others may speak, but not until later in childhood
47EpidemiologyThe ADDM Network is a group of programs funded by CDC to determine the number of people with ASDs in the United States.ADDM sites all collect data using the same surveillance methods, which are modeled after CDC’s Metropolitan Atlanta Developmental Disabilities Surveillance Program (MADDSP).The average ASD prevalence was 8 per 1,000 8-year-olds in and 9 per 1,000 8-year-olds in 2006 in several areas of the United States1 in 110 children.
48EpidemiologyMetropolitan Atlanta Developmental Disabilities Surveillance Program (MADDSP)MADDSP was established to determine all children who have one or more of four developmental disabilities -- mental retardation, cerebral palsy, hearing loss, and vision impairment - - in the metropolitan Atlanta area.Autism spectrum disorder was added as a fifth disability beginning in the 1996 study year.The ASD prevalence was 10.2 per 1,000 8-year-olds in the surveillance year.
49EpidemiologyCDC conducts two nationally representative surveys that provide data on health conditions in U.S. children: the National Survey of Children’s Health (NSCH) and the National Health Interview Survey (NHIS).Estimates of diagnosed autism in were 5.7 per 1,000 school-age children from the National Health Interview Survey and 5.5 per 1,000 school-age children from the National Survey of Children's Health.Both surveys showed that boys were nearly four times more likely than girls to have been diagnosed with autism.National Survey of Children’s Health, 2009: approximately 1% of children are affected with an ASD.
50Epidemiology Early ASD Surveillance Development Project CDC is funding two sites—the California Department of Health Services and Florida State University—to develop and test projects to identify the number of children under 4 years of age with ASDs.
51EpidemiologyIn late 1997, a citizen’s group in Brick Township, New Jersey, told the state Department of Health and Senior Services (DHSS) about what seemed to be a larger- than-expected number of children with autism in Brick Township.The prevalence of ASDs was 6.7 per 1000 children. The prevalence of ASDs in Brick Township seems to be higher than that in other studies, particularly studies conducted in the United States, but within the range of a few recent studies in smaller populations that used more thorough case-finding methods.
52Nobody knows What Cause Autism? Hypotheses include obstetric complications, infection, genetics, and toxic exposures
53MMR Vaccine and Autism“The evidence favors a rejection of a causal relationship at the population level between MMR vaccine and autism spectrum disorders (ASD).”- Institute of Medicine, April 2001
54Diagnosis A comprehensive evaluation Psychologist, neurologist, psychiatrist, speech therapist, and other professionals who diagnose children with ASDs.Thorough neurological assessment and in-depth cognitive and language testing.Children with delayed speech development should also have their hearing tested.Screening tools: MCHAT
55Treatment Behavior therapy Communication therapy Medical therapy Dietary therapyComplementary therapyEducational support
56Getting better all the time.... From the 1960s through the 1970s, research into treatments for autism focused on medications such as LSD, electric shock, and behavior change techniques. The latter relied on pain and punishment.During the 1980s and 1990s, the role of behavior therapy and the use of highly controlled learning environments emerged as the primary treatments for many forms of autism and related conditions.
57Behavior and Communication Therapy The primary treatment for autism addresses several key areas.Behavior, communication, sensory integration, and social skill development.Requires close coordination between parents, teachers, special education professionals, and mental health professionals.Therapists use highly structured and intensive skill- oriented training sessions to help children develop social and language skills, such as Applied Behavioral Analysis (ABA)
58Medical and Dietary Therapies Goal of medication is to make it easier for the person with autism to participate in activities such as learning and behavior therapy.Anxiety, depressionAttention problems, hyperactivity, and impulsivitySome evidence that people with autism may have certain deficiencies in vitamins and minerals.Vitamin B and magnesiumFood allergies may make behavior problems worse
59Complementary Therapies Help increase learning and communications skills in some people with autism.Music, art, or animal therapy, such as horseback riding or swimming with dolphins.
60Prognosis Highly correlated with IQ. Low-functioning patients may never live independentlyHigh-functioning individuals with autistic disorder are similar to people with Asperger syndrome.Remission is reported in anecdotal case reports.
61PrognosisBecause deficits in language and communication are often major impediments to progress in educational, work, and personal settings, specialized communication therapies and devices and training are often helpful.People with developmental disabilities are vulnerable to sexual abuse. The most severely disabled are at highest risk for sexual abuse.Children with Asperger syndrome must be trained to recognize impending sexual abuse and to develop plans of action to abort possible sexual abuse.
62OutcomeFor many children, symptoms improve with treatment and with ageChildren whose language skills regress early in life— before the age of 3—appear to have a higher than normal risk of developing epilepsy or seizure-like brain activity.During adolescence, some may become depressed or experience behavioral problemsPeople with an ASD usually continue to need services and supports as they get older, but many are able to work successfully and live independently or within a supportive environment.