Autism Flashcards
Who is recognized as the first to identify autism?
Kanner in 1943
By what characteristics did Kanner describe autism?
–Lack of social engagement even as infant
–Lack of communicative language
–Obsessive need for sameness
–Difficulties with transitions
–Recognized spectrum
When was Asperger recognized?
in 1944, by Asperger
noticed have good verbal skills, strong interest in isolated areas, lack social skills
History of autism: 1940s to 2000s
- 1944- Asperger- similar conditions but different language issues
- 1950-60s- “Refrigerator mothers”
- 1960s- biological disorder
- 1970s- genetic link
- 1980s- diagnostic criteria
- 1990s- IDEA legislation
- 2000s-increase in prevalence figures
Why is autism described as an epidemic in the U.S.?
- **CDC – 289% increase since 2002!
- 1/68 in US, some say higher
- Spectrum of behavioral disorders
- *** Decrease using DSM-5 ?
Autism: boys vs girls, demographic distribution?
- Boys>girls
- No difference
–SES
–Racial
–Ethnic groups
Why have we seen an increase in autism in recent years?
- More awareness
- Better screening tools
- Better evaluation tools
- Educational options
- Other…???
DSM IV vs V Criteria, generally
Terminology used for autism in DSM IV vs V?
What is social communication disorder?
–Difficulties with verbal and non-verbal communication
–Functional limitations
•Communication, social participation and relationships, academic achievement or occupational performance
–Onset early in development, deficits not obvious until later when social demands greater
related diagnosis to autism
How does social communication DO differ from autism?
only affects communication
Characteristics of Asperger
- Same criteria for social deficits and restricted behavior
- Normal speech development
–Abnormal pronoun use, language content, social use
- Late walking, clumsy
- Rote memory
- Intense interest in selected topics
- Eccentric behavior
No longer a DSM diagnosis (now autism spectrum) but individuals may retain the label
What is the etiology of autism?
- Unclear !!
- Heterogeneous disorder
- Multifactorial
–Infectious
–Parental age
–Environmental
• Insult early in embryogenesis –> neurobiological differences
Is autism a single gene disorder?
No! “Autisms” - there are many gene variants associated w/ASD and multiple phenotypes
–Core genetic components
•Fragile X, Rett, tuberous sclerosis –single gene effects
Recurrence rate for autism?
•4-8% recurrence rate; may be 10-20%
very common question for parents to have!
Neurobiological differences associated w/autism
–Macrocephaly: 16%; microcephaly: 15%
–some have macrocephaly early, then small heads for age later
–Abnormalities of limbic and cerebellum systems
•Emotion, motivation, memory and learning
–Differences in brain chemicals/function
What are the core deficits associated with autism?
–Impairment
- social interaction
- communication
–Restricted repetitive stereotyped behaviors
When does autism typically present?
Before 36 months
How does autism typically present?
first year, second year, later onset…
•Relationship issues
– first year of life
•Language issues
–second year
•Restricted behavior
–later onset
•Loss of milestones******
What is the CDC/AAP ALARM campaign?
to increase awareness and promote early screening / identification
CDC: “Learn the Signs - Act Early campaign”
–Autism is prevalent
–Listen to parents
–Act early
–Refer
–Monitor
Rationale for early identification
–Genetic counseling
–Benefits of early intervention services
What does the pcp need to consider in early identification of autism?
–Listen to parents
–Consider atypical behaviors not just physical findings
–Surveillance
–Screening
–History
–Physical: not typically dysmorphic
–Additional medical evaluation
Red flags for autism: language
- No babbling by 12 mos
- No pointing or other gestures by 12 mo.
- No single words by 16 mos
- No spontaneous two word utterances by 24 mos
- Loss of any language skills at any age
red flags for any neuro issue
What are some common myths about people with autism?
- Never affectionate
- Never communicative
- Never make attachments
- Never make eye contact
- Always engage in self-stimulatory, repetitive behaviors
- All children with these behaviors have autism
What are some early social signs of autism?
- Limited or no smiling (normal smiling 6-8 weeks)
- Not cuddly
- Limited eye contact
- No response to name by 12 mos
- Tuning out of people but very aware of environmental noise
- **Lack of joint attention found in most ASD children
Early communication signs associated with autism
- Limited language
- Language not used to engage others
- Pop-up words: appear advanced for child’s typical skills, out of context maybe never heard again
- Echolalia
- Uneven pattern of speech development
–Colors, etc. but not used to meet basic needs.
Behavioral signs associated with autism
- Fewer gestures
- Attached to hard objects
- Repetitive actions
- Lack of pretend or imaginative play
- Blunt affect
- Sensitivity to sound - hyperacousis
difficulty transitioning
What should be looked for on PE for autism?
- Growth parameters
- Macrocephaly for tuberous sclerosis, Fragile X
- Microcephaly for metabolic disorder
- Facial features: eyes, ears, mouth, philtrum
- Skin: hypo/hyperpigmented lesions- tuberous sclerosis/neurofibromatosis
- Neuro: mental status, gait, cranial nerves, tone. reflexes
What is the M-CHAT / when is it used?
•16-30 mos
–Replaced CHAT
–99% (38) sensitivity
–87% (98) specificity
–No observation component
–Parents complete before visit
–Critical items
–Follow up interview
What is the MCHAT-R/F?
Revised!
–Uses 3 risk level algorithm
•≥ 3 on initial screening and ≥ 2 on follow up screening had 47.5% chance of diagnosis
–Higher diagnosis rate than M-CHAT without needing follow up
–Diagnosed 2 yrs earlier than national mean for diagnosis
–Earlier intervention possible
What is the Infant/Toddler checklist / when is it used?
another screening tool available
–Useful for 6-24 month olds – at risk
–Focuses on social and communication skills
What additional types of screenings should be done, in addition to MCHAT-R/F?
•Developmental assessment of all domains
–45-70% intellectual disability in ASD
•Specific language assessment
–Expressive, receptive, pragmatic, articulation
- Audiological
- Lead (if indicated)
When to refer for autism?
if you are suspicious! Know your sources, act early.
- ADOS
- Psychologist , speech & language pathologist
- Trained developmental specialist
- Neurologist, Geneticist
- For E I services – do NOT wait for confirmation of diagnosis
What other diagnoses should be considered when suspecting autism?
- Fragile X
- Tuberous sclerosis
- Angelman syndrome
- PKU
- Congenital rubella
- Inborn errors of metabolism
- Fetal alcohol syndrome
Who makes the diagnosis of autism?
a specialist
What is the role of the pcp in autism care?
specialist makes diagnosis. We:
–Time
–Empathy, encouragement
–Thoughts and questions
–Resources
- Intervention services
- Educational –written, web-based
- Support groups
–Genetic counseling
–Prognosis
–Treatment options
–Follow-up
Principles of education in autism
- Immediate referral to 0-3 program or school system IDEA- FAPE
- Early, intense
- One-to-one, small group
- Families involved, trained
- Trained staff
- Periodic student and program evaluation
Pay attention to teachers and materials. Teachers respond immediately to inappropriate behaviors. Positive reinforcement for successful progress. Some free play with structured teacher directed activities
How should education plans be made for autism?
•Based on neuropsych deficits
–Intersubjectivity (including face processing)
–Imitation
–Emotional functioning
–Sensory information processing
•Intervention behaviorally focused
What are the components of early intervention/PS programs for autism?
•Aimed at specific symptoms and behaviors
–Play skills
–Peer interaction
–Appropriate behaviors
•Use behavioral approaches
–Reduce symptom frequency/severity
–Increase adaptive skills
•Not comprehensive approach to child/family
What is involved in a developmental orientation to comprehensive tx program for autism?
–Progress thru levels of cognitive & social function
–Address key deficits –> broad changes not discreet
–Teachers and caregivers follow child’s lead
What is the gold standard for autism care?
Applied behavioral analysis: well researched!
–Systematic, measurable behavior change
–Operant learning principles
–Increase desirable behaviors
–Decrease maladaptive behaviors
–Generalize behaviors
–Functional communication and applied verbal behavior
used very often w/young children
What is TEACCH?
Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH)
- Cognitive learning theory AND behavioral techniques
- Takes advantage of good visual processing
- Highly structured learning environment
- Parental input important
- Preschool through adulthood
- Better than public school program
What is floortime?
developmental, individual differences, relationship-based DIR model
- Child-led therapeutic play
- Builds emotional reciprocity
- Builds social engagement
- Develops intellectual skills
Principles of communication interventions for autism
- Increase communication thru any means
- Signs
- Natural gestures
- Picture exchange
- Ultimate goal: develop verbal communication
- Needs high intensity program > PS
Goals of communication interventions in those w/fluent language (asperger’s)
–Goal : improve social language
- Back and forth conversation
- Social aspects of language
- Relationships
Focus of Social Skills Interventions in autism
Joint attention
•Problem: Joint attention
–Ability to engage with others
–Building block for social communication
Focus of social skills interventions in autism
•Family and educators + age
–Join in with child
–Following a point (10 months)
–Pointing to request (12 months)
–Pointing to show or comment (14-16 months)
Focus of social skills interventions w/autism
mind reading
–Understand feelings /intentions of others
–Occurs after joint attention achieved
–Requires specific curriculum (DA of 5 yrs)
not well researched
Focus of social skills interventions w/autism
Social stories
–Pictures and text about situations encountered
–Supplemented with role-play/modeling
–Useful through adulthood
not well researched
Sensory motor interventions for autism
•Integration of info from environment with info from own muscles and body movements
–Aversions to touch, texture, sounds, movement
–Engagement in self-stimulating behaviors
•Sensory overload leads to tantrums/ other behaviors
What is Sensory Integration Therapy?
- Deep pressure, brushing, weighted vest, swinging, jumping, bouncing
- Benefits not proven
- Auditory integration training and behavioral optometry
–Not proven; not endorsed by AAP
Goals / options for older children with autism
- Similar goals
- Self-contained class
- Mainstreamed
- Individual Education Plan
- 504 Plan
- Special schools
Goals / options for adolescents with autism
•Transitions
–child to adult
–school to work
–home to community
- Individual Transition Plan
- Same goals
–Communication
–Emotional and behavioral regulation
Goals for autism when going through puberty
- Higher functioning – more details about “why” of changes
- More cognitive limitations- appropriate responses and hygiene ( menstruation, masturbation)
- Self care- deodorant, shaving, menses
When are seizures most commonly seen in autism, and what type?
- Peaks in early childhood and adolescence
- Partial complex- most common
- Neurology collaboration
–Same meds used
–No need to screen EEG unless indications
GI conditions associated w/autism
•Abnormal stool patterns
–Constipation/ diarrhea
- Frequent vomiting
- Food aversions
- Food allergies
- Workup if symptoms or change of behavior
keep in mind - esp if nonverbal!
Sleep issues associated with autism and how to approach
- Very common
- Very disruptive
- GERD, OSA
- Sleep hygiene
–Restrict daytime sleep
–Routine
–Behavior plan
Maladaptive behaviors associated with autism
- Aggressive, self-injurious behaviors
- Physical cause
–Pain (numerous possibilities)
–Menses
•Environmental possibilities
–Parental expectations
–School-child mismatch
•Functional behavioral analysis by expert
How often are meds used in autism and which ones?
- 45-75% treated at some point
- SSRIs (fluoxetine)
–Repetitive, maladaptive behaviors, irritability
–Depression, anxiety
•Stimulants (methylphenidate)
–Less helpful than if pure ADHD
•Alpha2-adrenergics {clonidine, (Kapvay)}
–Hyperarousal symptoms (irritability, impulsivity, repetitive behaviors)
Risperidone
What is the first med approved for autism?
Risperidone
Indications and SEs for Risperidone
•First medication FDA approved for ASD
–Aggression,
–Self-injury
–Temper tantrums
•Side effects
–Increased appetite- weight gain
–Insulin resistance, dyslipidemia, hyperprolactinemia,
–Tardive dyskinesia, prolonged QT, seizures
CAM and autism
mind-body interventions
–Yoga
–Music therapy
CAM and autism
•Biologically-based interventions
–Vitamins
–Probiotics
–Antibiotics
–Gluten/casein free diet
CAM and autism
toxin removal
–Chelation
–Detoxification
CAM and autism
•Manipulative and body-based interventions
–Cranial sacral therapy
–Acupuncture
Why is it important to know about CAM and autism
So you know how to counself parents on what is safe and effective
What is defeatautismnow.net?
Example of a group / conference that promotes non-EBP perspectives and treatments for autism. Need to know this stuff as kids may be on very intense regimens that parents won’t bring up
DAN!
Role of APRN in autism care
- Surveillance
- Screening
- Referral
- Support
- Case coordinator
- Advocate
- Educator
- Problem solver
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