Autism Spectrum Disorders

1. Autism Spectrum Disorders By Stephen Eddey M.H.Sc.,B.Comp.Med.,Dip.App.Sc. (Nat).,Ass.Dip.Chem.Cert.I.V.(Workplace Training and Assessment).

2. History of Autism • Term autism originally used by Bleuler (1911) • To describe withdrawal from social relations into a rich fantasy life seen in individuals with schizophrenia • Derived from the Greek autos (self) and ismos (condition) • Leo Kanner – 1943 • Observed 11 children • Inattention to outside world: “extreme autistic aloneness” • Similar patterns of behavior in 3 main areas: • Abnormal language development and use • Social skills deficits and excesses • Insistence on sameness

3. History of Autism • Psychiatrist Hans Asperger (1944) - describes “little professor” syndrome • Eisenberg and Kanner (1956) • Added autism onset prior to age 2 • Further refined definition of autism • Creak (1961) • Developed 9 main characteristics • Believed they described childhood schizophrenia • Incorporated into many descriptions of autism and commonly used autism assessment instruments today

4. History of Autism • Rutter (1968) • Said the term autism led to confusion! • Argued autism was different than schizophrenia • Higher M:F ratio • Absence of delusions & hallucinations • Stable course (not relapse/marked improvement) • Further defined characteristics (for science, research) • National Society for Autistic Children • One of the 1st & most influential parent groups for children with autism in U.S. • Wrote separate criteria (for public awareness, funding) • Added disturbances in response to sensory stimuli & atypical development • Did not include insistence on sameness

5. Diagnostic and Statistical Manual of Mental Disorders • Published by the American Psychiatric Association • Classification of mental disorders used in the US • Infantile autism included for • first time in DSM-III • Changed to autism in DSM-III-R • DSM – IV published in 1994 • Text Revision in 2000

6. WHAT IS AUTISM? • 3 categories for autism in IDEA? • Today, autism is a severe form of a broader group of disorders • These are referred to as pervasive developmental disorders(later) • Typically appears during the first 3 years of life

7. WHAT IS AUTISM? • Very likely neurological in origin – not emotional, not the refrigerator mom • Prevalence is 2-6/1000 individuals (1/2 to 1 ½ million affected) • 4 times more prevalent in boys • No known racial, ethnic, or social boundaries • No relation to family income, lifestyle

8. WHAT IS AUTISM? • Autism impacts normal development of the brain in areas of social interaction and communication skills. • Difficult to communicate with others and relate to the outside world. • Occasionally, aggressive and/or self-injurious behavior may be present.

9. WHAT IS AUTISM? • May exhibit repeated body movements (hand flapping, rocking). • Unusual responses to people • Attachment to objects • Resistance to change in routine • Sensory sensitivities

10. WHAT ARE THE TYPES? • Actually, the “umbrella” heading is Pervasive Developmental Disorder (PDD). • Autism is one of the 5 PDDs. • All have commonalities in communication and social deficits • Differ in terms of severity

11. 1. Autistic Disorder • Impairments in social interaction, communication, and imaginative play. • Apparent before age 3. • Also includes stereotyped behaviors, interests, and activities

12. 2. Asperger’s Disorder • Impairments in social interactions, and presence of restricted interests and activities • No clinically significant general delay in language • Average to above average intelligence

13. 3. Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS) • Often referred to as atypical autism • Used when a child does not meet the criteria for a specific diagnosis, but there is severe and pervasive impairment in specified behaviors

14. 4. Rett’s Disorder • Progressive disorder which, to date, has only occurred in girls. • Period of normal development and then the loss of previously acquired skills • Also loss of purposeful use of hands, which is replaced by repetitive hand movements • Beginning at age of 1-4 years

15. 5. Childhood Disintegrative Disorder • Normal development for at least the first 2 years • Then significant loss of previously acquired skills

16. Conclusions on Types • Autism is a spectrum disorder • This means that symptoms and characteristics can present themselves in wide variety of combinations, from mild to severe • Autistic individuals can be very different from each other • “Autism” is still commonly used to refer to any of the 5 PDDs

17. What causes (and doesn’t cause) autism? • Good agreement in general that autism is caused by abnormalities in brain development, neurochemistry, and genetic factors • Bettleheim’s theory of psychogenesis?

18. How is Autism Diagnosed? • No definitive medical test • Team uses interviews, observation, and specific checklists developed for this purpose. • Team might include neurologist, psychologist, developmental pediatrician, speech/language therapist, learning consultant, etc. • Must rule out MR, hearing impairment, behavior disorders, or eccentric habits

19. CHARACTERISTICS • 1. Communication/Language • 2. Social Interaction • 3. Behaviors • 4. Sensory and movement disorders • 5. Resistance to change (predictability) • 6. Intellectual functioning

20. 1. Communication/language • Broad range of abilities, from no verbal communication to quite complex skills • Two common impairments: • A. Delayed language • B. Echolalia

21. A. Delayed language • 50% of autistic individuals will eventually have useful speech (?) • Pronoun reversal: “You want white icing on chocolate cake.” • Difficulty in conversing easily with others • Difficulty in shifting topics • Look away; poor eye contact • Facilitated communication??????

22. Elements of Facilitated Communication • 1. Physical Support • 2. Initial training/introduction • 3. Maintaining focus • 4. Avoiding competence testing • 5. Generalization • 6. Fading

23. B. Echolalia • Common in very young children (Age 3) • Immediate or delayed (even years) • Is there communicative intent with echolalia?

24. 2. Social Interaction • One of hallmarks of autism is lack of social interaction • 1. Impaired use of nonverbal behavior • 2. Lack of peer relationships • 3. Failure to spontaneously share enjoyment, interests, etc. with others • 4. Lack of reciprocity • Theory of mind?

25. 3. Behaviors • Repetitive behaviors, including obsessions, tics, and perseveration • Impeding behaviors (impede their learning or the learning of others) • Will need positive behavior supports • A. Self-injurious behavior • B. Aggression

26. 4. Sensory and movement disorders • Very common • Over- or under-sensitive to sensory stimuli • Abnormal posture and movements of the face, head, trunk, and limbs • Abnormal eye movements • Repeated gestures and mannerisms • Movement disorders can be detected very early – perhaps at birth

27. 5. Predictability • Change in routine is very stressful • May insist on particular furniture arrangement, food at meals, TV shows • Symmetry is often important • Interventions need to focus on preparing students for change if possible

28. 6. Intellectual functioning • Autism occurs in children of all levels of intelligence, from those who are gifted to those who have mental retardation • In general, majority of individuals with autism are also identified as having mental retardation – 75% below 70 • Verbal and reasoning skills are difficult • Savant syndrome

29. Pervasive Developmental Disorders • Come under section in DSM-IV-TR entitled… • Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence • Includes • Mental retardation • Learning disorders • Motor skills disorders • Communication disorders • Pervasive developmental disorders • Attention-deficit and disruptive behavior disorders • Feeding and eating disorders of infancy or early childhood • Tic disorders • Elimination disorders • Others: separation anxiety disorder, selective mutism, reactive attachment disorder of infancy or early childhood, stereotypic movement disorder, disorder of infancy, childhood, or adolescence - NOS

30. DSM Category: PDDs Pervasive Developmental Disorders Childhood Disintegrative Disorder Rett’s Disorder Autistic Disorder PDD- Not Otherwise Specified Asperger’s Disorder • PDDs are characterized by severe and pervasive impairment in 3 main areas • Social interaction • Communication • Repetitive and restricted behaviors

31. Diagnostic Criteria for Autistic Disorder (299.00) • To receive a diagnosis of autism, a child must have at least 6 of the characteristics in the 3 areas (note minimums in each area) • In one of the areas, onset must be before age 3

32. DSM Criteria for an Autism Diagnosis: Social Interaction • Must meet 2 of the following: • Marked impairment in multiple nonverbal behaviors (e.g., eye contact, facial expressions) • Failure to develop peer relationships for age • Lack of spontaneous seeking to share enjoyment, interests or achievement with others • Lack of social or emotional reciprocity

33. DSM Criteria for an Autism Diagnosis: Communication • Must meet 1 of the following: • Delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication) • Marked impairment in ability to initiate or sustain conversation with others • Stereotyped and repetitive use of language • Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level

34. DSM Criteria for an Autism Diagnosis: Restricted Repetitive and Stereotyped Patterns of Behavior, Interests, and Activities • Must meet 1 of the following: • Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that’s abnormal in intensity or focus • Inflexible adherence to specific, non-functional routines or rituals • Stereotyped and repetitive motor mannerisms (e.g., hand flapping, rocking) • Persistent preoccupation with parts of objects

36. DSM Criteria for PDD-NOS • Severe and pervasive impairment in the development of reciprocal social interaction along with • Communication skills OR • Presence of stereotyped behavior, interests, and activities • But criteria are not met for any other PDD

37. Rett’s Disorder

38. Childhood Disintegrative Disorder

39. What are ASDs? • Autism Spectrum Disorders • Continuum comprised of autism, Asperger’s, and PDD-NOS (Volkmar & Klin, 2005) • “the concept of autism is evolving from the singular autistic disorder into the plural autistic spectrum disorders (ASDs)” (Filipek, 2005, p.535) • Wing (1997) said that attempts to differentiate b/w these disordes have been “arbitrary…difficult to apply and unhelpful in clinical practice” (p. 1761)

40. DSM V • Proposed Revision of Autism Diagnosis • http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=94#

41. Prevalence Terminology Incidence: the number of new cases of disease in a defined group of people over a specific time Prevalence: the number of existing disease cases in a defined group of people during a specific time period Prevalence of ASD has continued to increase since first survey in 1966 – why? Increases in requests for service Changes in diagnostic criteria Increased assessment opportunities Better awareness by pediatricians, teachers, parents An actual increase in cases?

42. CDC Statistics Occur in all racial, ethnic, and socioeconomic groups Four times more likely to occur in boys than in girls Parents who have a child with an ASD have a 2%–8% chance of having a second child who is also affected.

43. CDC Statistics - ASDs In 2003, 62% of the children who had an ASD had at least one additional disability Of those children, 68% had mental retardation/intellectual impairment 8% had epilepsy – lower than previous In 1997, 18%-42% Other associated features Hyperactivity Short attention span Impulsivity Aggressiveness Self-injury Unusual responses to touch, smell, sound, and other sensory input. Abnormal eating habits (e.g., selectivity, pica) Abnormal sleeping habits. Abnormal moods or emotional reactions. Gastrointestinal issues such as chronic constipation or diarrhea 

44. CDC Statistics - ASDs Some children with ASDs show hints of future problems within the first few months of life. In others, symptoms may not show up until 24 months or later. Studies have shown that one third to half of parents of children with ASDs noticed a problem before their child’s first birthday, and nearly 80%–90% saw problems by 24 months. Some children with ASDs seem to develop normally until 18–24 months of age and then they stop gaining new language and social skills, or they lose the skills they had. Children with ASDs develop at different rates in different areas of growth. Splinter skills Delays in one area and age-appropriate in another and in some cases even advances Inconsistent in how skills get developed Can read but can’t tell you what sound a “b” makes

45. CDC Statistics - ASDs Can often be detected as early as 18 months. But national average age of diagnosis is between 4 and 5 While all children should be watched to make sure they are reaching developmental milestones on time, children in high-risk groups—such as children who have a parent or  brother or sister with an ASD—should be watched extra closely…

46. Autism and Developmental Disabilities Monitoring (ADDM) Network The ADDM Network is a group of programs funded by the Centers for Disease Control and Prevention (CDC) to determine the prevalence of ASDs in US communities. The ADDM Network’s first two ASD prevalence reports were released in the February 9, 2007, issue of the Morbidity and Mortality Weekly Report Surveillance Summaries. 2000 6.7 per 1,000 for 8-yr olds 2002 6.6 per 1,000 8-yr olds That’s about 1 in 150 children in these commuynicites The prevalence was much lower (3.3 per 1,000) in Alabama and higher (10.6 per 1,000) in New Jersey in 2002. (About 1 in 94) Prevalence stayed the same from 2000 to 2002 in four of the six sites with data for both years. It rose slightly in Georgia and significantly in West Virginia, indicating the need for tracking prevalence over time.

47. New Prevalence Rates • http://www.nytimes.com/2009/12/19/health/19autism.html • http://www.cdc.gov/ncbddd/autism/index.html

48. Current Prevalence Rates • Nationwide • One in 110 children is estimated to have autism spectrum disorders nationwide. • In Missouri: • 934 students diagnosed in 1997 • 5,777 students in 2009 • Since 1992, autism prevalence has increased at an average of 22% each year

49. Prevalence of ASD has continued to increase since first survey in 1966 – why? • Increases in requests for service • Changes in diagnostic criteria • Increased assessment opportunities • Better awareness by pediatricians, teachers, parents • An actual increase in cases?

50. Ideally, what does the diagnostic process look like? • Assess all characteristics/abilities • 3 major areas, adaptive behavior, IQ • Assess in multiple ways with multiple sources • Interview, observation, checklist/rating scales • Parent, teacher, professional examiner • Assess over time with multiple observations in multiple settings • Home, school, daycare • Structured, unstructured