ASD Flashcards
Epidemiology
Epidemiology = 1.1% in the UK (3-6 per 1,000 live births in the UK)
- Presentation 2-4yo (when language and social skills normally rapidly expand)
- Most have decreased IQ (savant syndrome is very rare)
Boys (75%) > girls (25%)
RFs: sibling with ASD, parental psychotic/affective disorder, birth CNS defect, prematurity (<35w GA), sodium valproate, learning disability, chromosomal disorders (Down’s), genetic disorders (Fragile X), ADHD, HIE
Associations: Fragile X syndrome, Tuberous sclerosis, neurofibromatosis, Di-George, Rett’s syndrome, mitochondrial disorders, Down’s syndrome, Prader-Willi / Angelman’s syndrome, epilepsy
Types of ASD
Autistic Spectrum Disorders:
o Autism – 1.4 per 1,000
oAsperger syndrome (distinguished by no delay in language/cognitive development) – 0.3 per 1,000
Psychosis in adult life; marked clumsiness
o Rett syndrome (medical disorder (X-linked; MECP2 gene; affects girls > boys) – <0.2 per 1,000
S/S: develop normally to ~2yo à sudden deterioration + less social interaction + struggle to feed, etc.
Childhood disintegrative disorder (CDD) – <0.2 per 1,000
Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) – 4.5 per 1,000 (most common ASD)
Diagnostic criteria
(A) Abnormal or impaired development evident ≤3-years-old
- Receptive or expressive language
- Development of selective social attachments or of reciprocal social interaction
- Functional or symbolic play
(B) A total of ≥6 symptoms from (1), (2) and (3), with ≥2 from (1) and ≥1 from each of (2) and (3):
(1) Qualitative impairment in social interaction (≥2); e.g.
- Failure adequately to use eye-to-eye gaze
- Failure to develop peer relationships
- Lack of socio-emotional reciprocity
- Lack of spontaneous seeking to share enjoyment, interests, etc. with other people
(2) Qualitative abnormalities in communication (≥1); e.g.
- Delay in or total lack of, development of spoken language (no attempt to compensate)
- Relative failure to initiate or sustain conversation
- Stereotyped and repetitive use of language or idiosyncratic use of words or phrases;
- Lack of varied spontaneous make-believe play
(3) Restricted, repetitive, and stereotyped patterns of behaviour, interests, and activities (≥1); e.g.
- Preoccupation with stereotyped and restricted patterns of interest
- Apparently compulsive adherence to specific routines or rituals
- Repetitive motor mannerisms involving hand, finger flapping and whole-body movements
- Preoccupations with non-functional elements of play materials (such as their odour)
(C) The clinical picture is not better described by other medical disorder
Easy diagnostic trio – deficits in… (evident when <3yo):
- Verbal and non-verbal communication hallmark = immediate/delayed (>2yo) echolalia
- Reciprocal social interaction
- Restrictive or repetitive behaviours/interest
Investigations
Hearing, speech and language assessment
o Cognitive assessment (e.g. WISC, WPPSI)
o Autism diagnosis and assessment – GOLD-STANDARD
- ADI-R / Autism Diagnostic Inventory – Revised
- ADOS / Autism Diagnostic Observatory Schedule
o Childhood Autism Rating Scale (CARS)
Management
MDT / Patient-Centered care is key (this is a spectrum, so everyone is different):
MDT: paediatrician, child, adolescent psychiatrist, educational or clinical psychologist, SALT, OT, specialist health visitor / social worker, specialist nurse (SN)
1st line: psychosocial play-based intervention:
- Increase attention, engagement (play specialists) and reciprocal communication (SALT)
- Increase carers’ and teachers’ understanding of patient’s communication/interaction pattern
E.G. EarlyBird (<5yo), EarlyBird Plus (4-8yo)
- Include techniques to expand the child’s communication, interactive play and social routine
Applied Behaviour Analysis (ABA) from behavioural nurses:
- Focuses on improving specific behaviours (i.e. social skills, communication, reading) as well as adaptive learning skills (i.e. fine motor dexterity, hygiene, grooming, domestic capabilities)
o Challenging behaviour:
1st line: psychosocial assessment (anticipate and reduce factors increasing risk of behaviour):
- Reduce impairment in communication (consider visual aids)
- Co-existing physical disorders (i.e. otitis media)
- Co-existing mental health problems (i.e. GAD, ADHD)
- Physical environment (i.e. lighting, noise)
- Reduce unintentional reinforcement of behaviour that reinforces
2nd line: pharmacological – used if behaviour making psychosocial training ineffective:
- Antipsychotic medication (review at 3-4 weeks; stop at 6 weeks if no clinical indication)
- Melatonin for sleep difficulties
- Methylphenidate for attention difficulties
- SSRIs for obsessional behaviours
o Adjust the social and physical environment to suit the child (i.e. lighting, noise levels, visual support)
o Reasonable adjustment (a law to encompass helping people with disabilities in the community)
o Families and Carers à offer an assessment of the family/carer needs (i.e. personal and practical support):
- Plan for the future including health transition for the child
- Plan for extra support (i.e. educational, social, etc.) – “EHC” plan is a legal document to outline this
o Transition to adult services (≥16yo):
- “CPA” / “Care Plan Approach” system
- Involve the young person and offer a social care assessment at age 18
Complications
Complications
- Failed relationships, including marriage(s)
- Unemployment, problems at work
- Poor general health, inability to live independently
- Social isolation, reduced QoL
- Increased vulnerability to mental health problems e.g. anxiety and depression
- Premature mortality
Prognosis
- Lifelong disorder
- Improved prognosis with early diagnosis and assessment
PACES
PACES
It is a developmental disorder where the child struggles to engage and understand social interactions
It is often accompanied by problems with speech and language and it is associated with the development of ritualistic and repetitive behaviours
Autism is a spectrum, so it is difficult to predict the extent of the impact on the child’s life
Firstly, we will refer you to some specialists who will do a more thorough assessment of John
Management involves an MDT Approach (paediatrician, GP, psychologist, psychiatrist, speech and language therapist, occupational therapist, educational and social services
Psychological interventions to reduce ritualistic behaviours
Speech and language therapy (with a focus on social skills)
Educational assessment and plan
Carer’s needs will also be attended to and link them to support websites:
National Autistic Society
