IntellectualDiability_13_10_14

Question 1

What are the different sub-types of autistic spectrum disorders?

Answer 1

Kanner’s syndrome: This subtype of ASC has learning difficulties with little or no languageAsperger’s syndrome: This subtype of ASC has average/high IQ with fairly good languagePervasive developmental disorder-NOS: This subtype of ASC has autistic traits present but not in sufficient level to warrant a diagnosis of ASC

Question 2

Why has there been an apparent increase in the prevalence of Autistic Spectrum Condition (ASC) in the last 100 years?

Answer 2

1) More inclusive criteria for diagnosis.2) Greater public awareness of the condition.3) Recognition of undiagnosed adults.

Question 3

What is the current prevalence of ASC?How about Kanner’s and Asperger’s syndromes, and what are the male:female sex ratios of these conditions?On an average GP list, how many people with ASD might there be?

Answer 3

1 in 100 people with ASD.Kanner’s = 1 in 10,000 with a ratio of 4:1 M:F.Asperger’s = 1 in 100 with a ratio of 9:1 M:F.18-24 patients with ASD on average GP list.

Question 4

Can you define ASC? When did it start?

Answer 4

The consensus is that ASC is a pervasive developmental neurological condition with multimodal causation. It is probable that ASC has been present in society for a very long time; it has only just been noticed and differentiated. The core criteria for making a diagnosis of ASC are deficits in:Social communicationSocial imaginationSocial interactionwith restricted repetitive behaviours.

Question 5

What has brain imaging shown us about ASC?

Answer 5

Functional MRI scanning has found that the autistic brain operates in a different fashion to the non-autistic brain when presented with social tasks.

Question 6

What is the test for ASC?

Answer 6

Making the diagnosis is a process of clinical evaluation. There is no specific test that can diagnose ASC.

Question 7

What is “mind blindness”?

Answer 7

Theory of Mind is the term used to describe the instinctive understanding the other people have their own thoughts and beliefs, different from one’s own. Lack of this is called “mind blindness”.Mind Blindness can result in an apparent lack of empathy; without the ability to predict what others might be thinking or feeling, how is it possible to react with appropriate emotion?

Question 8

What are the three core features of ASC - the triad of ASC?

Answer 8

1) Lack of social imagination - difficulty in understanding other people’s intentions and behaviours, with inability to predict outcome of interactions outside of routines.2) Difficulty with social communication - problems with understanding and using verbal and non-verbal forms such as tone of voice, body language, and facial expression.3) Problems with social interaction - difficulty in understanding theory of mind, also difficulty managing one’s own thoughts and feelings.

Question 9

How about repetitive behaviour in ASC?

Answer 9

Early repetitive behaviours may include flapping hands or spinning around (‘stimming’) or show as preferences for ordering objects in a particular way. Some behaviours are a response to sensory issues and will either aid increased perception of pleasurable stimuli or avoidance of unpleasant ones.In older children this may be exhibited as rigid play routines, often copied from TV, where there is little scope for variation from their script.The focus of attention may shift to the collection of information, usually of an ‘object’ nature. This can range from dinosaurs to government statistics or scientific data.

Question 10

What are the consequences of repetitive behaviour in ASC?

Answer 10

1) Environmental structuring: means ordering possessions in particular ways.2) Time structuring: means having to carry out tasks at a certain time and in a particular sequence.3) Social structuring: means restricted topics of conversation and highly focussed interests allowing prediction of social interactions.

Question 11

What if changes are imposed on repetitive behaviours in ASC?

Answer 11

Any imposed changes to the patient’s routines or environment may create anxiety and result in potentially difficult behaviours. These behaviours could be caused by problems with executive function in the autistic brain or be a way of regulating stress levels for the patient.

Question 12

What sort of social difficulties might people with ASC encounter?

Answer 12

Difficulties understanding social rules might lead to inadvertent aggression or being bullied.Failure to make or keep friends might be compensated by solitary activities, but will result in problems later in life with relationships, in the workplace, or social situations in general.”Oddness” may be tolerated, but mind blindness may make someone appear insensitive or rude, as can incorrect understanding of social rules and conventions.

Question 13

What sort of communication difficulties might be encountered by someone with ASC?

Answer 13

Someone with ASC may have difficulty recognising and using facial expressions, body language, and tone of voice.Direct eye contact may be uncomfortable. Gaze aversion may give the impression of ignoring people.Literal interpretation of words can lead to misunderstanding of idiomatic speech.Alexithymia may also present a problem.

Question 14

What lis Alexithymia? How might this present/affect someone with ASC?

Answer 14

A lack of words to describe emotion. In ASC this can lead to sudden extreme outburst of emotion; due to inability to communicate how they feel, then becoming overloaded with feelings.

Question 15

What sort of sensory issues might afflict someone with ASC?

Answer 15

Sensory distortion affects 90% of people with ASC. This is not to be confused with synaesthesia, though this may also be present. Thresholds of pain sensation may be either heightened or reduced. There is an inability to filter out unpleasant stimuli. No more than one or two senses can be processed at a time. As well as the usual ‘five’ senses, vestibular and proprioceptive stimuli need to be considered.Examples include:-Stamping gait to ensure contact with apparently shifting ground-Reaction to fluorescent lights flickering-Electronic beeping being physically painful-Certain clothing materials being extremely uncomfortable to bear

Question 16

ASC can often be made more difficult to diagnose because they are “masked” by other conditions, such as…?(name 7 - there are 11 listed!)

Answer 16

Epilepsy/seizure disordersLearning disabilities – dyslexia and dyscalculiaAnxiety disordersMood disordersAggressionPsychosisAttention deficit hyperactivity disorderMovement disordersDyspraxiaTourette’s syndromeReceptive/expressive language difficulties

Question 17

What are some red flags for diagnosis of a child with ASC?

Answer 17

-No babbling by 12 months-No gesturing (pointing, waving, etc.) by 12 months-No single words by 16 months-No two-word spontaneous phrases by 24 months-Any loss of any language or social skills at any age

Question 18

At what age is it possible to diagnose an ASC?

Answer 18

-NOT before 6 months!-Features can be present and recognised from around 18-24 months.-BUT sometimes it is not picked up until much later, sometimes even not until old age!

Question 19

Are their questionnaires for helping to screen for ASC?

Answer 19

Yes! They can help with the diagnosis, but not make it alone.NICE recommend the AQ-10 for adults, and the Q-CHAT for children.

Question 20

What are the advantages and disadvantages of the use of questionnaires in screening for ASC?

Answer 20

Advantage of questionnaires and checklists: A patient, parent or carer can use their test results as a way of introducing the subject of diagnostic assessment at consultation.Disadvantages of questionnaires and checklists: The disadvantages are that they take some time to complete and are not reliable enough to make a diagnosis but they can indicate if further assessment is indicated.

Question 21

How long will a full assessment for ASC take? Who to refer to if you think one is needed?

Answer 21

A full assessment will take several hours!Children should be referred to CAMHS or paediatric services. May also need SALT assessment.Adults should be referred to a psychologist or psychiatrist with a special interest in autism, or to an autism worker (if available).Private assessments can be carried out by clinical psychologists with a special interest in autism.

Question 22

If ASC is suspected, what other diagnoses should be excluded?

Answer 22

Hearing lossChildhood psychosisRett’s syndromeChildhood disintegrative disorderFragile X syndromeMetabolic disorders

Question 23

What tests might be carried out to exclude differentials for ASC?

Answer 23

Amino acid and lipid analysisKaryotypingComprehensive hearing testEEG (if indicated)MRI (if indicated)

Question 24

Is there any relevant legislation relating to ASC? What does it require?

Answer 24

The Autism Act 2009 required Local Authorities to appoint lead professionals to develop diagnostic and assessment services for adults with suspected autism in their areas.

Question 25

Can a child “grow out” of ASC?

Answer 25

Nope! The effects of the triad of impairments can be modified but the underlying problems remain. The level of functioning can alter over time.

Question 26

Do people with autism have no imagination?

Answer 26

No! Well, not necessarily; the point is that they often have no SOCIAL imagination; they can be very imaginative in other ways.

Question 27

Do people with autism lack empathy.

Answer 27

No! Well, not usually - not more than any other people are likely to lack empathy! But they might have difficulty expressing that empathy - this can give false impressions to other people.

Question 28

Can people with ASC speak?

Answer 28

Surprisingly, one-third will NOT speak owing to the severity of the condition! But there are plenty of people with ASC can of course speak, and some do so very well!

Question 29

Communication failure can occur in people with ASC, this might result in “meltdown” - can you elaborate on this?

Answer 29

The first sign of communication failure to those unfamiliar with the patient may be when he or she suddenly flies into a rage or totally withdraws. The patient may have been unaware of their anxiety levels increasing or have been unable to communicate this. Physical or verbal violent outbursts are common. The patient is no longer in conscious control of their actions and destruction of property or physical injuries may ensue.Usual intellectual function will re-establish once anxiety levels have reduced. However, the opportunity for further communication may have been lost if the patient, because of their impaired social imagination, believes their distress was caused by the other person.

Question 30

How can communication with someone with ASC be improved/maximised? (there are 6 things).

Answer 30

1) Explain carefully - carefully explain what you are about to do and why (especially of intervention). remember if demonstrating on model, “mind blindness” may render this ineffective.2) Allow processing time - increased processing time may be needed to answer a question - be wary of repeating a question too early as this may result in the patient having to start thinking through the question again and result in frustration.3) Be direct and clear - be wary of the use of metaphor and simile and idiom. Body language and facial expression may be ignored. Don’t be put off by an averted gaze.4) Provide a suitable environment - e.g., avoid flickering or fluorescent lights or humming computers.5) Ask questions clearly - make sure clear language is used to ensure the question is understood. If not understood, a non-sequeter answer may result. Increasing anxiety may also result, this can result in repetitive actions or vocalisations as coping strategies.6) Maintain routine - for example, try to keep the same doctor and the same room, maybe at the same time and day!

Question 31

How can healthcare be made more accessible to patients with ACS?(there are 7)

Answer 31

1) It may be helpful to arrange that the first or last appointment of the day is given so that anxiety created by delays is minimised2) By having a standard approach, increased familiarity will allow the ASC person to reduce anxiety. This could include same doctor, same nurse, same room/lighting3) By attending several times to increase familiarity with staff and rooms, anxiety about the unexpected can be reduced4) Directly enquire whether there are any problems with the room. You may be surprised at how many distractions there are5) Listen to what the patient is saying and ask for clarification where things are not clear6) Demonstration of interventions such as blood taking can be helpful. Don’t use models as it can be confusing to the patient. Remember that a mirror-image demonstration is potentially different.7) Enquiry about the patient’s emotional state may be met with incomprehension

Question 32

What are the essential points to get across to someone with a new diagnosis of ASC? (there are 5)

Answer 32

1) ASC is a lifelong condition2) It is not anyone’s fault or a result of any individual factor3) Social interactions are inherently difficult4) Interventions exist to ease problems with social interaction and reduce their impact5) Support is available through various agencies

Question 33

Being given a diagnosis of an ASC can result in typical stages of adjustment process (similar to a bereavement reaction) and it is possible to get stuck in one stage without help or prompting. What are the 6 stages?

Answer 33

1) Shock/Denial2) Pain/Guilt3) Anger/Blame4) Reflection/Loneliness5) Processing/Reconstruction6) Acceptance/Hope

Question 34

How might parents react to one of their children being diagnosed with ACS?

Answer 34

Parents’ responses to a diagnosis in one of their children is often complex. Those who feel they have been struggling to be heard by educational or health services may be angry at perceived delays in diagnosis. Only by allowing this anger to be expressed can the path be cleared to look at the next steps.Explaining the complexity of diagnosis and reassurance that no single factor is to blame for someone having an ASC is appropriate. Reassurance that planning for appropriate services is now a statutory duty can be given.

Question 35

Apart from the patient with ASC, who else has needs that need to be considered?

Answer 35

Carers often have unrecognised needs. Listening to how the impact of caring is affecting them and acknowledging their burden is crucial. Direct enquiry about the carer’s emotional well-being may reveal depression.

Question 36

How can carer’s of people with ASC be helped?

Answer 36

As a GP, it is important to listen to and explore the concerns and problems of carers. Acknowledgment of their difficulties can prevent escalating anxieties and frustrations.Enabling the carer to get a deeper understanding of how the person with ASC thinks and acts as they do can give insight into how to prevent problems. Local support groups can reduce the impact of feeling alone and provide potential solutions to the problems facing carers.Suggestions about how to access support and local services can be beneficial.

Question 37

What is the aim of support for someone with ASC

Answer 37

The aim of support is to allow affected people to rise to the challenge of dealing with the condition rather than letting it turn into a crisis.

Question 38

What domains would an ideal assessment of someone newly diagnosed with ASC include?

Answer 38

1) Health issues – access to dental and medical care, appropriate interventions to deal with mental health problems, possible alcohol and substance abuse2) Social issues – housing, work, education, support to deal with the outside world3) Financial issues – benefits (e.g. Disability Living Allowance, Employment and Support Allowance)4) Carer issues – respite, support

Question 39

What possible areas of intervention are there for someone with an ASC?(there are 8!)

Answer 39

1) Diet2) Medication3) Aids4) Communication work5) Behavioural6) Psychological7) Emotional8) Financial

Question 40

Why might the input of a dietician be useful in someone with an ASC?

Answer 40

General dietary advice is often of benefit as there can be a lack of variety in the diet of many patients with ASCs. Reasons may include a dislike of certain food textures, tastes and colours, or a lack of knowledge about food preparation.A dietician assessment may identify solutions to these problems with an opportunity for education about nutrition. Clear instructions and logical explanations can allow weight management and avoid the problems associated with obesity.

Question 41

Are there ever any medications used in the management of ASC?

Answer 41

Anxiety and sleep disturbance are common problems and affect the patient’s ability to deal with social interactions. Adjuvant use of medication can facilitate the effectiveness of behavioural and psychological interventions for anxiety and mood disorders. Atypical antipsychotics (olanzapine, risperidone) have been used with success.Adjuvant treatment with selective serotonin reuptake inhibitor (SSRI) antidepressants in low-maintenance doses can alleviate anxiety. Using higher doses tends not to work owing to side-effects.Melatonin has been used in some patients to help establish a better sleep pattern.

Question 42

What is the role of acting lessons/role play in ASC?

Answer 42

Allow the patient to try different ways of dealing with common social situations.Feedback from a mentor can teach new strategies and allow a wider range of responses.Insight can be given as to how facial expressions and body language are used in a “normal” population.

Question 43

What is the role of computer programs in ASC?

Answer 43

Can allow the practice of some aspects of communication, through studying body language and facial expression.

Question 44

What is the role of intensive interaction in ASC?

Answer 44

This is a form of sensory interaction to replace verbal conversation in those patients who lack verbal skills or who are difficult to engage with. It approaches communication from the patient’s sensory world, thus avoiding the complexities of spoken language.

Question 45

What is applied behavioural analysis in ASC patients?

Answer 45

Applied behavioural analysis (ABA) has been derived from the Lovaas approach and is based upon positively reinforcing desired responses.Reward systems tend to take advantage of the special interest of the child/adult. Completion of staged tasks will earn the opportunity to have time following the chosen interest.An example of ABA: If a person has an interest in ‘flags of the world’, these could be used as symbols of attainment and after collecting a set number, a reward is given. This takes advantage of the patient’s particular special interests and increases engagement.

Question 46

Is there a role for psychological interventions in managing patients with ASC?

Answer 46

Therapeutic counselling can only be helpful if a counsellor is aware of how to communicate with someone with an ASC and the patient has the ability to engage with the process. In the case of delayed diagnosis owing to the underlying ASC being masked by other issues, the patient may already have been seen by a counsellor with no net benefit.Cognitive behavioural therapy can successfully challenge thoughts of low self esteem, depressive thinking and anxiety. It appeals to patients with its logical approach.Relationship counselling can help patients and partners resolve issues that have arisen through inadvertent communication failures.

Question 47

Why and how are emotional interventions useful in ASC?

Answer 47

Emotions can be a mystery to someone with an ASC. Alexithymia (deficiency in being able to describe or relate to emotions) is very common. Owing to limbic processing problems, patients tend to have an ‘on−off’ emotional range, rather than a gradual continuum.Learning to recognise the sensations of emotions and taking steps to avoid high levels of anxiety that interfere with activities of living can be done in several ways. Keeping scrapbooks of pictures and objects associated with emotional states, such as ‘happy’ or ‘sad’, allows the development of insight into what is being felt. These objects associated with emotion can then be graded and ‘emotion thermometers’ developed to teach the different levels of a particular emotion.

Question 48

What about financial support for people with ACS?

Answer 48

Benefits are available to assist with the increased care needs of patients with ASC.Disability Living Allowance is appropriate even in the absence of physical problems because the condition prevents normal functions of daily life. While the patient may be able to carry out individual components of a task, such as shopping, the problems associated with the triad of impairments can prevent the task being completed without assistance. The failure to progress to complete the task is owing to the autistic process.Travel passes can facilitate the ability to get out of the house and to reduce transport stresses.

Question 49

What statutory rights to support do people with ASC have?

Answer 49

1) The local authority2) Education - provision of statementing and educational support services.3) Residential and supported living - can be contracted out to specialist agencies.4) Social services - addressing social care needs.

Question 50

What voluntary national services exist to help people with ASC?

Answer 50

-National autistic society-Carers UK

Question 51

People with ASC are especially vulnerable and in need of support both at diagnosis and at times of change. Name these 4 common times of change?

Answer 51

AdolescenceAdulthoodWorkOld age

Question 52

At a review of someone with an ASC, it is appropriate to enquire directly about?5 areas.

Answer 52

1) Physical health - health promotion cues regarding smoking, alcohol and exercise2) Mental health - consider referral for therapies or adjuvant medication, as recommended by NICE, for depression or anxiety3) Education and work issues - discuss whether there are additional resources available that have not been used4) Financial concerns - benefits received5) Health of carers - including parents, partners and siblings and whether there are any concerns from them

Question 53

When a child with an ASC moves to secondary school, what things could be done to help them cope with the transition?

Answer 53

Moving from primary to secondary school can raise issues with new roles and structures. The child will find that their accustomed level of support alters. Clear timetabling, careful wording of homework assignments and school maps will assist. A quiet area for respite from overstimulation is helpful. School libraries can be a sanctuary for the overloaded child.

Question 54

What risks to health might be encountered (to a greater extent than normal) by people with ASC?

Answer 54

Increased anxiety can result in alcohol and substance misuse. Teenagers and young adults may resort to recreational drugs to self-manage anxiety and sleep problems. Inappropriate behaviours can result in involvement with the police and criminal justice system.

Question 55

Work for someone with ASC may be difficult. What can someone with ASC offer in particular? Who can help with finding work? What is a potential pitfall? What legislation is potentially relevant?

Answer 55

Careers advice from someone familiar with ASC is essential. The ideal job will use the patient’s superlative abilities to use routines, their meticulous attention to detail, specialist interests, punctuality and their personality to the maximum benefit.Social interactions at work are potentially problematic but can increase the person’s confidence in social situations.Education of employers about the benefits of employing someone on the spectrum and how to make appropriate workplace adjustments to meet Disability Discrimination Act requirements can result in a worthwhile job being found.

Question 56

What workplace strategies can be put in place to help someone with ASC be able to have a fulfilling and productive work life?(Name 4)

Answer 56

Workplace strategies should include the following simple steps:1) Giving clear instructions about how to carry out the job required2) Education of work colleagues about avoiding misunderstandings through unclear communications3)Attention to the workplace environment4) Unexpected changes need to be kept to a minimum. This includes shift-pattern changes, alteration of work duties and changing job requirements.