Intellectual Disability and autism spectrum disorder Flashcards
ID (intellectual disorder) and ASD (autism spectrum disorder)
Disorders identified early in development- some identifiable at birth or soon after, some identified when demands exceed ability
Affect the individual throughout the lifespan, idividual will always have this issue, in some cases intervention can improve outcome of core issue, but largely core issues remain throughout life
Screening for ID and ASD
All kids should be screened for intellectual abilities and cognitive functioning
AAP recommends standardized screening at 9,12,18, 24, 30 months (bright futures)
Further developmental evaluation is required whenever a child fails to meet any of the following milestones: babbling by 12 mo, gesturing (pointing waving bye bye) by 12 months, single words by 16 months, 2 word spontaneous phrases by 24 months, loss of any language or social skills at any age
All children who screen positive should be referred to testing of cognitive and adaptive functioning
Children may come to attention late as demand exceed abilities
Genetic work up
Standard of care for any new diagnosis of ASD/IDD that is idiopathic
Chromosomal microarray- in all cases of idopathic ASD/IDD regardless of gender
Fragile X- in all males, in females with low IQ/family history of low IQ
PTEN testing- if head circumference is >2 SDs aboce the mean and other body measurements not similarly elevated
MECP2 testing- in females with microcephaly, regression, seizures
Physical work up
Physical exam- hearing screening, vision screening, woods lamps (ro Tuberous sclerosis)
Other medical issues- seizures (staring or regression, with marked development of aphasia and EEG= Landaue-kleffner syndrome)
Infections- encephalitis or meningitis, endocrine- hypothyroidism, metabolic- homocystinuria, toxic- FAS
Intellectual disability, intellectual developmental disorder
Etiology of ID/IDD
Prenatal- Genetic and chromosomal, malformations or growth errors (down syndrome, fragile X, etc), Maternal illness and infections, teratogens and toxins, substance abuse
Perinatal- delivery complications, infections
Post natal- trauma, infections, toxins, environmental, medical conditions
Unknown
Why diagnose an ID/IDD
ID/IDD describes symptoms and functioning but does not indicate cause
Helps to communicate with schools, agencies, and other health care providers
provides a foundation for interactions with individual and collaborators
Conveys needs to schools, agencies, and other health care providers
Provides wording to obtain services, assistance
Who can diagnose and ID IDD
Child psychiatrists, testing psychologist, neuropsychologist, school psychologists, psychology or neuropsychological clinic
Mental health clinic with testing psychologist or neuropsychologist
State clinic or center
special needs clinic
What it takes to diagnose a ID/idd
- Deficits in intellectual functions: such as reasoning, problem solving, planning, abstract thinking, judgement, and academic learning and learning from experience, confirmed by both clinical assessment and individualized, standardized intelligence testing (book smarts)
- Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility in the three domains (street smarts)
- Onset of intellectual and adaptive deficits during the developmental period
Diagnosis- the three domains of Adaptive functioning
Conceptual or academic- competency in memory, language, reading, writing, math, acquisition of practical knowledge, problems solving, and judgment in novel situation
Social- awareness of others thoughts, feelings, and experiences including empathy, interpersonal communication skills, friendship abilities, and social judgment
Practical- Self management skills across settings including ADLs, money management, recreation, self management of behavior, job responsibilities, No longer any IQ criteria for these domains
Mild severity level
Conceptual domain- difficulties in learning academic skills involving reading, writing, arithmetic, time, or money. Impaired abstract thinking, executive function, short-term memory, functional use of academic skills
Social domain- Immature in social interactions, concrete or immature language, difficulties regulating emotion and behavior, limited understanding of risk in social situations, at risk of being manipulated (gullibility)
Practical domain (may function at age-appropriate level, need support with complex tasks, jobs that do not emphasize conceptual skills, support required for abstract concepts
Moderate severity level
conceptual domain- language and pre-academic skills develop slowly, Slow progress in reading, writing, math, time and money understanding, markedly limited compared with that of peers, remain at a very concrete level
Social domain- Marked differences in social and communicative behavior, social judgement and decision making abilities are limited, need social support for work success
Practical domain- Extended teaching and time needed to become independent, can achieve participation in all household tasks by adulthood, need extended teaching and ongoing supports, independent jobs that require limited conceptual and communication skills, need considerable support to manage social expectations, maladaptive behavior in a significang minority and causes social problems
Severe severity levels
Conceptual domain- limited attainment of conceptual skills, little understanding of written language or of concepts involving numbers, quantity, time, and money, caretakers provide extensive supports for problem solving
Social domain- limited vocabulary and grammar, family members and familial others are a source of pleasure and help
Practical domain- Require support including meals, dressing, bathing, and elimination, require supervision at all times, cannot make responsible decisions regarding well being of self or others, long term teaching and ongoing support in skill acquisition in all domains, maladaptive behavior, including self injury in a significant minority
Autism (spectrum disorder) epidemiology
about 1/59 kids, 5x more common among boys (1 in 42 vs 1 in 89 in girls), about 1/2 of individuals with Autism have average intellectual abilities compared to 1/3rd of individuals a decade ago (more people are smart)
Emerging risk factors for ASD (correlations and not causations)
Advanced paternal/maternal age
Family members with autistic features, sibling with ASD, infections during pregnancy and lengthy fevers, short birth spacing, folate prenatal and early pregnancy
SSRIs and valproate, pesticides, air pollution, diabetes, obesity, AI disease,
DSM 5 ASD diagnosis
A. persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history
Deficits in social-emotional reciprocity, deficits in nonverbal communicative behaviors used for social interaction, deficits in developing, maintaining, and understanding relationships
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least 2 of the following, currently or by history-
Stereotyped or reptitive motor movements, use of objects or speech, insistence on sameness, inflexible adherance to routines, or ritualized patterns of verbal or non verbal behavior, highly restricted, fixated interests that are abnormal in intensity or focus hyper or hypo reactivity to sensory input or unusal interest in sensory aspects of environment
C. symptoms must be present in the early developmental period
D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning
E. These disturbances are not better explained by intellectual disability (IDD) or global developmental delay (deficits in social communication cant be better explainted by cognitive level of functioning)
ASD specifiers and levels
many specifiets Level 1 (requiring some support)--> Level 3 (requiring very substantial support)
Trajectory of IDD and ASD
Lifelong, dynamic and variable in its course, dependent on etiology, dependent on its interventions, dependent on its individual characteristics
ASD vs ID
about 45% of individuals with ASD have a co-occuring diagnosis of ID
In individuals with ASD: ID must be identified above and beyond the criteria for ASD
In individuals with ID: Criteria for ASD be met above and beyond the criterua for ID (Poor social skills or social skills not at the chronologic age norms is not enough)
ID is not tied to ability to talk or communicate person with ASD can be non verbal, affected by their ASD severely, and have a normal intelligence
Support planning for ASD and ID
ASD and ID are life long diagnosis- using strength based learning and intervention can maximize gains in life, individual educational plans, social interventions to maximize functioning, make the most of what they can do
Multimodal approach to supporting individual- Case management, education, medical if needed, behavioral if needed, psychiatric if needed
Cooccurring medical issues
look to etiology, if known for medical screening or needs
22q11.2 deletion- (velocardiofacial syndrome, or DiGeorge syndrome)- look for midline abnormalities in cardiac, thymus, etc
Down syndrome- psoriasis, early dementia
Seizures are more common in idividuals with ASD and ID
GI issies- constipation
Psychiatric illness- much higher rates than the general population
People with ASD and ID need a different approach to patient Care
Talk to patient at their level of functioning
could be younger or just different
Find out if there is a legal guardian or if there should be, court process at which another is granted decision making for the person
Psychiatric Co occurring disorders
2.5-4 times more frequently in children with ID/IDD than children without
All psychiatric diagnosis can be found in kids with ID/IDD
Can be related to etiolgy of ID IDD
Psychosocial treatments of CO-occurring, disorders and behavioral symptoms
Behavioral therapy- positive reinforcement, applied behavior analysis
Individual therapy- use cognitive strengths
Family therapy- training in behavioral techniques and working around living with a person with IDIDD
Pharmacotherapy for Co-occurring disorders and behavioral symptoms
THERE ARE NO EVIDENCE BASED BIOLOGICAL TREATMENTS FOR THE CORE FEATURES OF AUTISM SPECTRUM DISORDER
-Pharmacotherapy should only be considered as part of a comprehensive treatment plan to address co-occurring psychiatric disorders and behavioral symptoms
- Little research on meds in pop with ID/IDD
- Consider all med co-occurring factors
- Treat psych comorbidities according to the guidelines for that diagnosis, regardless of the diagnosis for ID/IDD
- Meds to treat behavior problems should com secondary and with plan to address the problem in a multimodal approach
- more sensitive to effects of meds -positive an dnegative, start low and go slow
Non pharm treatment for ASD
Behavioral intervention are the ONLY treatment for the core symptoms of autism
Evidence based
Best to : Start early, start hard, in all settings the child is in, involve parent training
Applied behavioral analyisis
it is a theory of intervention that analysis why a targeted behavior happens, the antecedents and consequences of that behavior, and attempts to change that behavior through behavioral techniques
There are many methods with various levels of research
It can be used in any child not just ASD, intellectual development disorders too
Each method has data, WORKs GREAT but veery expensive, lots of time energy and efforts
Why meds
Treatment of Co occurring mental health issues- ADHD, anxiety, depression, tics
To help individual take full advantage of resources, (be able to learn as much as possible in school and therapy, participate as fully as possible in social situations
To prevent change in level of care- removal to a different classroom or school, removal from community setting like placement out of home
FDA approved therapy for irritability in ASD
Second gen antipsychotics
Risperidone, Aripiprazole
Positive effects- decrease in improved aggression, irritability, self injurious behavior, temper tantrums, mood liability
Negative effects- weight gain, hyperlipidemia, hyperglycemia, abnormal movements- every 6 month check on lipids, glucose, waist, and annual eval of movememnts
