ASD Flashcards
what is the DSM-V key criteria to be dx w ASD
- impaired social communication skills
- restricted, repetitive behaviors
- sx present in early childhood
- everyday functioning impaired/limited d/t sx
what is the CDC’s definition of ASD
group of developmental disabilities that can cause significant social, communication, and behavioral challenges
what dictates where on the spectrum of autism someone is (3)
- degree of support required
- under what conditions individual may have issues w social communication and other sx of ASD
- qualifiers that accompany dx (ex: ID, language deficits)
how and why do individuals w ASD benefit from motor interventions
benefit both motor and socially
motor issues related to praxis and motor planning
- progress motor skills -> social growth to play with other kids
- frank motor skills
what is the prevalence of ASD
inc and don’t know why
- most common pedi developmental disorder
- more commonly dx in males than females
what is the etiology of ASD
genetic vulnerability w environmental trigger
- ASD is heterogenous which makes research into causation difficult
what are 6 environmental factors to the etiology of ASD
- mother taking valproic acid (for epilepsy, BPD) while pregnant
- advanced age paternal > maternal
- prenatal exposures
- extreme psychosocial conditions
- air pollutants
- heavy metals
what is a debunked environmental trigger
vaccines (esp MMR)
what medications a mom might be on that can inc ASD risk of child
valproic acid - epilepsy, BPD
SSRIs - inconsistent evidence
what role does a father with an advanced age play as an environmental trigger
de novo mutations
d/t cumulated inc risk of mutations in spermatogenesis across lifespan of father
thoughts on prenatal exposures being an environmental trigger
suggested, not definitive in its effect on the fetal environment
what are 5 prenatal exposures that may be environmental triggers
maternal obesity
DM
HTN
maternal infection -> immune response
high fetal sex steroid exposure
describe how a maternal infection may be an environmental trigger as prenatal exposure
immune response to infection passing thru placenta, inflammatory response could have impact on developing neuro processes in fetus
- low grade neuro inflammation
describe extreme psychosocial conditions as an environmental factor
institutionalization w low levels of stim & care can lead to autistic-like characteristics
- initial presentation of ASD, but amenable to treatment
extreme maternal stress as well
describe air pollutants as an environmental factor and what the evidence is
neuroinflammation and oxidative stress - relative to developing fetus
modest evidence
what heavy metals are environmental factors
toxic exposure to lead
- mercury esp
what are 3 predisposing genetic factors
- inc risk w some inherited conditions
- chromosomal abnormalities
- inc risk if sibling/twin has ASD
what inherited conditions is there an inc risk of ASD in (3)
fragile X
Rett syndrome
tuberosclerosis complex
what is an example of chromosomal abnormalities that may be seen as a genetic factor to ASD
dup15q syndrome
what evidence is there of family/twins as predisposing genetic factor
if older sib w ASD, 20% will be dx w ASD also
inc risk of ASD in identical twins (greater than fraternal)
what is the incidence of genetic causation noted in ASD
majority of cases will have no identifiable genetic cause
what 3 structures were different when seen in an ASD brain when autopsied
limbic system
cerebellum
cerebral cortex (inconsistent findings)
how is a clinical dx made
thru clinical observation and behaviors
what differences are seen in the limbic system in ASD
smaller and more dense amygdala and hippocampus vs neurotypical brains
what differences are seen in cerebellum in ASD
dec size and dec # of Perkinje cells in some patients
what differences were seen in the cerebral cortex in ASD (while findings were inconsistent)
disorganized
subtle cortical dysgenesis
- inferior frontal gyrus pars opicularis (part of Broca’s area)
- prefrontal and temporal cortex
- inc microglia infiltration and activation
what did a fMRI show in an ASD brain
alternate pathways of motor cortex activation, excitatory/inhibitory neurotransmission
where are mirror neurons located and what is their role in a neurotypical brain? what role can MNs play when combined w limbic system?
located in pars opicularis
active when performing goal-directed actions and when observing others doing same action
- perhaps neural mechanism for automatically understanding others’ intentions and actions
MNs + limbic system = mediate empathy and social connection
what is the theoretical causation of autism based off the anatomical differences in the brain
in ASD level of activation of MNs is different than in TD
altered MNs + limbic system can also explain why ASD kids seem to lack empathy and social engagement
where is the pars opicularis and what is it supplied by
frontal lobe
- near broca’s area
MCA
how do social skills present in ASD (6)
- impaired social reciprocity
- poor shared attention
- avoidance of eye contact (not always)
- seem indifferent/aloof, preference to be alone
- attached to parents (not show in typical ways)
- limited empathy
how does limited empathy present in social skills (2)
- affects ability to predict/understand other’s actions
- unable to read social cues
how can poor shared attention manifest in ASD
difficulty w give and take interactions
what is a classic early sign of ASD social skills
avoidance of eye contact
why don’t ASD babies/children show attachment to parents in typical ways
lack of social reciprocity
what are 5 communication presentations of ASD
- varied deficits
- may present w unusual use of language
- impaired conversation
- missed cues, body language, tone, ability to understand idioms
- inc awareness of difficulties w age -> anxiety/depression
how does communication present in varied deficits
non verbal, non vocal, to fully verabal
may coo, babble early and then stop
delayed development
echolalia
just words, not meaning
what does it mean that ASD could present w unusual use of language
unable to combine into meaningful sentences
echolalia
how can conversation be impaired in ASD
unable to initiate or sustain
monologue on favorite topics
- fixation you can’t break
- directs conversation
- not in age appropriate way
what are 3 ways behavior can present in ASD
- odd repetitive motions (“stereotypies”)
- persistent, intense preoccupation
- desire absolute routine
how can stereotypies present
range
- from finger flapping to self injurious behaviors
ex: tapping fingers, clapping, flapping
how can persistent, intense preoccupation behavior present in ASD
line up objects but not to “play with”
- numbers, science, trains, vacuums
how can excitement play into behavior presentations
as get more excited -> pitch of vocalization goes up, inc speed of stereotypies
what is the significance of ASD desiring an absolute routine
need routine to predict
surprise = panic/anxiety
helpful to start w routine when first working w ASD, but w effective intervention, improvements are possible
what are the 3 broad areas of motor dysfunction
postural control
visual-motor
bilateral coordination
what is the relationship of motor impairment to ASD
not a co-existing separate dx
- part of ASD picture
what are postural control deficits seen in ASD
reactive
anticipatory
how is ambulation present in ASD
often delayed onset
how are gross motor and fine motor skills impact
early delays
what are gait patterns seen in ASD (4)
(varied):
toe walking
ataxic like
shuffling
normal
is toe walking addressed and how
might resolve on its own
usually needs intervention
- behavior (normalize heel touching ground)
- passive stretching
- strengthening
what are gait differences NOT caused by
anatomical changes - dec ROM or hypertonia
may develop reduced ms length and weakness secondarily
DCD and ASD in their presentation
DCD = motor issues alone
ASD = include similar impairments/limitations
what are 6 specific motor impairments present w ASD
- postural control deficits
- gross motor/fine motor coordination and development
- ambulation onset
- gait patterns varied
- imitation and praxis
- dec endurance and physical activity levels
how does impaired fine and gross motor coordination present in ASD
UE/LE
(B)
visuomotor
what is praxis
motor planning - figuring out what to do and how to do it
- including fine motor ADLs
when can imitation and praxis impairments be identified
as early as 2yo
what is the impact of motor presentations of ASD that should be considered
consider inc complexity of skills as child ages
- requires inc motor planning, motor imitation
what are clinical sensory presentation in ASD (3)
disordered sensory integration
- issues w sensory modulation
- connection w dyspraxia
describe how issues of sensory modulation can present in ASD
difficulty regulating and organizing self in response to sensory input (think ANS)
possibilities = varied (running “hot or cold”)
- hypo-responsive
- hyper-responsive
- most exhibit range from hypo to hyper
what greater impact does sensory modulation have
alertness level
- by filtering out what is important and what isn’t help to figure out what to focus on
how is disordered sensory integration seen in ASD connected to dyspraxia
using body, relating to some objects in environment, organizing own behavior
what other health conditions can present w ASD (6)
epilepsy
GI disorders
sleep disruption
feeding/eating
mental health
premature death
when is epilepsy even more commonly seen in ASD
if person has both ASD and ID
what are classic sx of epilepsy in ASD (2)
staring spells
ms stiffening/jerking of limbs
what are more subtle sx of epilepsy in ASD (3)
- sleep disturbances/sleepiness
- unexplained marked irritation/aggression
- regression in development
what is a red flag to watch for when working w someone w both ASD and epilepsy
status epilepticus
what are sx of GI disorders in ASD (4)
- freq abd pain
- painful stooling
- diarrhea
- constipation
what GI dx are associated w ASD (3)
ulcerative colitis
food allergies
- lactose
- celiac dz
GERD
what are chronic GI issues related to in ASD
inc severity of behavioral sx (esp nonverbal)
- often d/t inc discomfort
how common is sleep disorders in ASD
50% have chronic sleep issues
what sx of sleep disorders are present in aSD
difficulty falling asleep, remaining asleep
chronic issues connected w behaviors
how does sleep disorders in ASD impact their support system
affects parents/primary givers
- chronic stress associated w poor sleepers, concern ab wandering
what are 3 potential causes of sleep disorders in ASD
- genetic mutations regulating circadian rhythm
- seizures
- anxiety disorder and other behavioral issues
what can a feeding disorder be attributed to in ASD
high selectivity/restrictions (textures, brands, colors, flavor) and/or disruptive behavior
what eating disorders are seen in ASD (3)
pica
chronic overeating & obesity
anorexia, bulimia
what is seen ab the incidence of obesity in ASD
higher incidence than in general population
what are 5 mental health disorders seen in ASD
ADHD
anxiety
depression
schizophrenia
bipolar disorder
what are considerations of depression in ASD
inc rates w age and w inc intellectual capacity (more aware of differences)
can be difficult to tease out non-verbal, not able to describe
what characteristics of growing up w ASD can contribute to developing anxiety and/or depression
difficulty navigating social situations
being unreadable to others
not recognized for strengths
difficulty engaging w others
what tests/measures involved in differential dx of ASD (2)
genetic testing
neurological eval
what differential dx should be r/o to dx ASD (5)
fragile X syndrome (chromosomal)
tuberous sclerosis
CNS infection
metabolic disorder
rett syndrome
when to sx present in ASD
<30mo
what is the problem w the current dx process for ASD
dx not made early enough
- most dz >4yo vs parents noticing <12mo
need early identification for early intervention
what are 3 observations often identified by parents before dx w ASD
“Different”
unresponsive (emotionally)
atypical pattern of development
what are 4 chief early dx signs of ASD
social isolation - and content
- not engaging w same age peers
lack of eye contact
poor language capacity
absence of empathy (seemingly)
who dx ASD
ideally a mulitdisciplinary team w ASD experience and skill
how can PT contribute to the ASD dx process
contribute to early identification
- motor impairments
what is the layout of the PT exam for a child w dx or suspected ASD
adapted to child’s behavior, communication, & sensory modulation needs
- carryover of behavioral approaches
what are 3 influences on performance during your PT exam for ASD
attention
anxiety
cog & ability to follow directions
what are strategies to begin direct exam of ASD or suspected ASD (3)
- time to warm up to strangers
- communication (method?)
- behavior, interaction, play skills (what they gravitate toward)
what 4 things should be asked in parent interview in PT exam for ASD
concerns
goals**
effective/ineffective interaction strategies
prior intervention
what 4 points do you want to know from hx of someone w ASD
- age of dx
- meds, other treatments (alternative)
- diet (ie any restrictions, gluten, lactose, etc.)
- developmental milestone achievement (more important if younger)
what setting should observations be in for ASD
natural environments where they are comfortable
what are 3 things to observe in their natural environment for ASD
- age-appropriate functional skills
- socially embedded motor skills
- spontaneous play
what about age-appropriate functional skills do we want to observe in ASD (4)
stairs
uneven terrain
fundamental skills
movement speed
what about socially-embedded motor skills do we want to observe in ASD (3)
imitation
- playing catch
- hopscotch
- patty cake
what about spontaneous play do we want to observe in ASD
lay various items out
- see what they gravitate toward
- how they coordinate body in space
what about communication in ASD do we want to observe
preferred mode
what about social skills in ASD do we want to observe (2)
take turns
spontaneous in 1:1 & group
what about cognition in ASD do we want to observe (4)
attention
arousal
multi-step directions
problem solving
what about sensory skills in ASD do we want to observe (3)
sensory preferences & ANS regulation and modulation
- how aroused are they in environment
what about behavior in ASD do we want to observe (4)
repetitive behaviors
routines
aggression
self-injurious
what are 3 types of tests and measures used in ASD
- questionnaires - parent report
- norm-referenced activity development measures
- activity overall functional skills measures
what questionnaire is also appropriate to use in ASD for parent report
DCD questionnaire
- compare performance to that of DCD to determine severity of movement/coordination issues
what are 5 norm referenced activity development measures/tests in ASD
- MABC
- Test of Gross Motor Dev
- PDMS-2
- BOT-2
- AIMS
what are 2 measures to assess overall functional skills
school functional assessment (SFA)
PEDI
describe the school functional assessment (SFA) used in ASD
used to monitor non-academic skills in elementary school such as:
- moving b/w classrooms
- negotiating lunchroom
- accessing school bus
tests participation also
age range for the PEDI-CAT
0-21yo
what populations is the PEDI-CAT valid/reliable for
multiple clinical dx
international populations
what domains of ICF does the PEDI cover
activity (3 domains)
participation (via RCAT)
what does the PEDI-CAT measure
functional skills in 3 domains:
- daily activities
- mobility
- social/cognitive
how does the RCAT subset of PEDI measure participation
assesses responsibility domain
- how much responsibility does child take vs parent
describe type of scores from PEDI-CAT
normative and scaled scores
what are the goals of PT intervention in ASD (3)
- prioritize based on highest area of need of child & family
- age-appropriate skills for full participation
- improve coordination, postural control for functional movement
how is direct PT intervention implemented for ASD (4)
highly individualized
within context (home, school)
apply motor learning strategy
carryover of behavioral/social interventions
when are PT interventions most effective for ASD
when in context that they are having difficulty
what are 4 global/educational PT interventions for ASD
- ABA
- DIR (floor time)
- PECS
- TEACCH
what are 2 interventions that both PT and OT work to implement in ASD
sensory integration
motor learning
describe what the PT intervention ABA is (per utilization in ASD)
Applied Behavioral Analysis
1:1, intensive, individualized
based on operant conditions
- positive reinforcement of desired behaviors
- rewards and punishments
describe what DIR or “floor time” is as a PT intervention for ASD
Developmental, Individual differences, Relationship based
positive reinforcement thru natural context of interaction
- based on social interaction
- shape spontaneous interactions
focus: emotional and development of relationships; sensory
- integration of cognition w social, emotional, motor , communication
PECS and TEACCH as PT interventions w ASD
PECS - picture communication system
- not limited to ASD
TEACCH - capitalize on strengths and unique qualities of individuals
- structured support for social communication
- visual and/or written info to supplement verbal communication
- specific to autism
what is sensory integration therapy as utilized with ASD (3)
to address sensory needs
modulation issues
habituation, sensory uptraining to enhance adaptive responses
what is the benefit to utilizing sensory uptraining in sensory integration therapy in ASD
can help w postural control
what is a tool of sensory integration therapy depending on child’s level of arousal
sensory breaks
- either calm down
- or ramp sympathetic systme back up
what does the evidence support the application of to address primary motor impairments, activity limitations, and participation restrictions in ASD
motor learning principles
how can motor learning principles be applied to ASD
simple tasks - learn by doing
- engage in regular routine practice
complex tasks
- explicit instruction
- part-whole practice
- feedback
- visual modeling
- hand over hand
- K of R w reward
what are 2 methods that apply motor learning to PT interventions of ASD
structured movement interventions
creative movement interventions
describe what structured movement interventions for ASD are
physical fitness
- 2-3x/wk, 10-16wks
- mod to vig, 30-60min
type: aquatic, treadmill, cycling, adapted PE, therabands
what were 3 benefits to the use of structured movement interventions in ASD
improved attendence
academics
dec stereotypies
who is structured movement interventions geared more for
“average” kid w ASD
what are 6 ex of creative motor interventions
rhythm (music, dance)
yoga
horseback riding
tech based (wii)
martial arts
outdoor play
what is the purpose of creative motor interventions (3)
integrate multiple systems: social, motor, cognitive, behavioral
whole-body, multi-limb coordination
promote functional motor skills, creative exploration, free play
taking turns in a small group
what are 7 key strategies to PT management of ASD
- structure environment
- instructions for activity
- modeling/feedback
- repetition
- active engagement
- progression
- reinforcement/rewards
what ab the environment can PT structure when managing ASD
space
rules sheet/schedule
follow routine
- introduce small changes
- learn to accept small changes
- develop spontaneity
transitions
- time to phase from activity to leaving
how can PT manage instructions for activities in ASD
verbal
gestures/sign
picture schedules
what are the positives and negatives to utilizing a group approach to PT in ASD
positive:
- learn social monitoring
- may dec anxiety
negative
- too distracting
how can PT promote repetition in treating ASD and why is this important
w/i session and across sessions
use caregivers for carryover
promotes generalization
- in one or multiple environments
how can active engagement be utilized in PT for ASD
allow for spontaneous activities/movement
- encourage child to direct activities as much as possible
allow them time to problem solve
- only prompt 2nd trial (or more prn)
what is the balance to strike w progression in PT in ASD
“just right” - allows for success
don’t want to be too frustrated by failure, create safe space that allows for success
how can reinforcement and rewards be utilized in PT for ASD
verbal/gesture (high 5)
breaks from activity to do what they want
symbolic = stickers
stay consistent w overall program
outside of direct interventions, how can PT be involved in the POC for ASD (2)
consultation/education
recreation
how can PT be used to consult/educate in ASD
HEP/fitness programs
sensory-motor breaks w/i class or home (ex: bouncing)
what should PT consider of recreation in ASD POC (3)
safety
interests
environmental stim
what are ex of PT suggested recreation in ASD POC
yoga
music/dance
horseback riding
swimming
