Lecture 7: Autism Spectrum Disorder Flashcards
If we have low tone we want to facilitate movement, if we have high tone we want to inhibit it
Lots of developmental disorders / DS / Autism = low tone
Autism is a developmental disability with 3 main subgroups. What are they
Socia Challenges
Communication Challenges
Behavioral Challenges
Old school thought was that people w/ autsim need to be fixed. Stop the flapping etc… we’ve had a shift in this thinking
What causes autism
Unknown. However, suspected that its genetic and environmental risk factors
1 in 68 children will be diagnosed w/ it, however, the prevalence may be as high as 1 in 50
Who gets autism more, boys or girls
boys 4:1
Genetic potential of autism
* increased incidence of children in families being diagnosed w/ autism
Genetic disorders associated:
* TB
* Fragile X syndrome
* Chromosome 15 deletion syndromes-Prader0Willi syndrome and Angelman syndrome
* DS
* Moebius syndrome
* CHARGE syndrome
NOTE: autism has to occur as its own diagnosis. So when its tied to somethign else its not really called autism
siblings of children w/ autism = 14.7 more likely
Although environmental factors may interact with genes to contribute to the expression of autistic symptoms- little indication of what these specific environmental factors may be
Potential Neurological Abnormalities w/ Autism
Underconnectivity in the brain
* Decreased communication between brain regions and resultatnt impairments
Decreased cortical thickness
Decreased white matter connectivity
decreased neurochemical concentrations in the brain
* this is why ADHD medications help w/ autism symptoms
Inflammation in the glia of the brains
Decreased number of Purkinje cells in the vermis and hemispheres in the cerebellum
Function of mirrior neurons might be altered
Is there an objective / blood test for autism?
No
What is out criteria for diagnosing autism (name of it)
Diagnostic and Statistical Manual 5th edition (DSM-5)
Combines the criteria from:
* Autistic disorder
* Asperger disorder
* Childhood disintegrative disorder
* Pervasive developmental disorder not otherwise specified
as of now there is no longer a thing as an asperger diagnosis
* its kind of all in autism diagnosis now
Name the 5 components of the DSM-5 test for autism
A: Deficits in social communication and interaction
B: restrictive or repetitive patterns of behavior or interests
C: Present in early development
D: Clinically significant impairment in social, occupational, or other important areas of current functioning
E: Not better explaiend by intellectual impairment
A: in the DSM 5
Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (EX are illustrative, not exhaustive)
* Do they make eye contact? Ask for help? Enjoy being near others?
Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back and forth converstaion; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions
Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication’ to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication
* Don’t understand those non-verbal communications
Deficits in developing, maintaing, and udnerstanding relationsjips, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interests in peers
* don’t understand relationships
DSM 5 critera: B
* repeittive patterns
* like routine
* hypo/hyper reactive to sensory input - so they might hate bright lights but love loud sounds, its not that they’re one or the other
DSM-5 Autism Diagnostic Criteria
C: Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities or may be masked by learned strategies in later life)
* if they’re at home and their parents let them do all their habits (think lining everything up, and having order) they may not have all the symptoms. However, in an uncontrolled environment like school more of those symptoms may come on
DSM 5
D: Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning
* have to be able to prove that it effects them somehow
DSM 5
E: These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level
w/ autism
sensory processing disorder goes along w/ autism = those kids who can’t stand certain cloths because of the way they feel
Autism can be treated not cured. You can mask lots of the symptoms
When autism is first diagnosed: Autism diagnostic criteria
Specify if:
* With or w/o accompanying intellectual impairment
* With ot w/o accompany language impairment (coding note: use additional code to identify the associated medial or genetic condition)
* Associated with another neurodevelopmental, mental, or behavioral disorder (coding note: use additional codes to identify the associated neurodevelopmental, mental, or behavioral disorders)
* With catatonia (non responive)
* Associated w/ a known medical or genetic condition or environmental factor
What is catatonia?
Non responsivenes
Which level of autism requires support?
Level 1
What level of autism requires substantial support
Level 2
What level of autism requires very substantial support?
Level 3
Level 1 Autism - lots of people, with this kind of hard to see. Might not see it if you arent a clinician
Social:
* Without supports in place, deficits in social communication cause noticeable impairments
* Difficulty initating social interactions
* Clear examples of atypical or unsuccessful response to social overtures of others
* May appear to have decreased interest in social interactions - they proably have interests but don’t know how to fit in (think coming up to the wrong person and giving a hug)
Restructed, repetitive behaviors:
* Inflexibility of behavior causes significant interference with functioning in one or more contexts
* Difficulty switching between activities (but they can)
* Problems of organization and planning hamper independence - write things down for them
Should be able to be in a regular class. may or may not have learning disabilities, meaning they may be forced to get a 504 instead of an IEP
Level 2 - requiring substantial support
* You’ll def know they have it here
Social:
* Marked deficits in verbal and nonverbal social communication skills
* Social impairments apparent even with supports in place
* Limited initation of social interactions
* reduced or abnormal responses to social overtures from others
Restricted, repetittve behaviors:
* Inflexibility of behavior
* Difficulty coping with change
* Other restrcited/repetitive behaviors-Appear frequently enough to be obvious to the vasual observer and interfere with functioning in a variety of contexts
* Distress and/or difficulty changing focus or action
Level 3 Autism - requriging substantial support
- you’ll know they have this wether you’re a clinician or not
Social:
* severe deficits inv erbal and nonverbal social communication skills cause sebere impairments in functioniong
* Very limited initation of social itneractions
* Minimal responsr to social overtures from other - often nonverbal
Restricted, repeittive behaviors
* inflexibility of behavior - they will tantrum
* Extreme difficulty coping with change
* Other restricted/repetitive behaviors markedly interfere with functioning in all spheres
* Great distress/difficulty changing focus or action
hate changing what they’re doing
Diagnosis of atusim
Experienced professional can identify it by the time the child is _
* however it is not often diagnosed until they’re 4
Early ifentification and intervention - the earlier we can get them to communicate = less tantrums
Screening tolls developed using previous diagnostic criteria and may not accurately screen for ASD under current DSM-5 criteria
The American Academy of pediatrics recommends screening for autism during well child checks at 18 and 24 months for all children
Earlier screening recommended if specific concern arises from parent or pediatrician or if sibling has ASD
PT’s, OT’s, SLP’s, teachers, physicians, psychiatrists, psychologists all screen for ASD
Appropriate referral to pediatrician and interdisciplinary team fro diagnostic evaluation
remember, school does not have to accept an outside diagnosis of autism
2
Comprehensive Interdisciplinary Evaluation:
Examins all areas of development including:
* Communication - interacting (can be signing)
* Speech - use of words/articiulation
* Language
* Fine motor - OT
* Fross motor - PT
* Perceptual motor skills - this is putting the senses togethre (can you use your vision to step forward) - PT/OT
* Self-help skills - OT
* Social-emotional
* Cognitive skills
All members of the team are eligible to be trained in the use of these tools, including PT’s
great toe walking/asymmetry common
kids w/ autism are very literal - don’t understand sarcasm well
Considerations for someone w/ autism:
Might prefer an environment with low noise and minimal visual distractions
* So we would progress from a quite closed environment –> open
Age
Cognitive status
Coping style
Past Experience
Individual Motivating Factors
Removing tags from clothing
Avoiding certain materials/textures
Food/drink limitations
Parental choices/Parenting styles - think parents who never use the word no
Patient/Caregiver Instruction
* pt requires ongoing collaboration with family members and other caregivers
* Develop new skills, learn tasks, and participate effectively when intervetion is intensive and embedded into the context of daily routines and activities
* Should focus on strategies to promote a child’s participation in daily routines and activities
* Need to be salient - make the activities mean something to them
Procedural Interventions - Autism
* Team based-family is an equal, contributing member of the team
* Interests of the child
* Parents: - Ultimately choose interventions for their children. Often base decisions from nonmedical progressionals and lay publications - talk to the parents about this
* Complementary and alternative medicine-52% and 95% of families with ASD
* Nonjudgemental with families - envidence for the effects of various types of CAm - SAfe or unsafe - other options
Guiding Principles of Effective Intervention
* No single approach works for every child with ASD
* Early intervention is best
* Family involvement - need to be involved
* Individualized programming - to the pt
* Systematic intervention - think starting easy –> harder
* Structured/predictable environments - they perform the best in these, however, they are going to have to go out in the real world
* Functional approach to behavior
Motor specific interventions for ASD
* Exercise and PA
* Strength - make it a game
* Balance
* Coordination
* Motor planning
* Functional mobility
* Proprioceptive activities
* Core strength
* Deep proprioceptive input
* Desensitatizion
* Gait training
* ROM
Exercise and PA w/ autism
Tend to participate in more sedentary activites or individual PA’s (swimming), limiting the social components or group or team based activities
Research on activity focused primarily on hcanges in behavioral or socail interactions
We know that EX can reduce some of their symptoms. It does work
Decreasing sterotypic behaviors of autism w/ EX
* Aggression
* Off-task behavior
* Elopment - running away
Increase in on-task behavior and improvement in motor skills acquisition
* so the more challenging the PA is the more likely they are to pay attention (her daughter doing gymnastics)
How effective is sensory processing intervention?
Limited proven effectiveness
Sensory processing intervention:
Limited proven effectiveness - however, it’s widely used - kids love it
Weighted vests and other compression garments
* Used to provide proprioceptive input and calming to increase attention, concentration, and focus
Brushing and sensory diets
* To increase tolerance to tactile input, increase focus, and improve organization
Fidget and fiddle toys
* To help sustain attention and concentration
Auditory integration and therapeutic listening programs
Some kids love the wieghted vests and others don’t
Lifelong implications and the role of PT
Transition to adulthood
This can be difficult for people w/ ASD
Adult system often do not utilize a service coordination model
Difficult for families to become aware of available programs and to synchronize services between programs
Young adults w/ ASD were 3 to 14 times more likely to be socially isolated than young adults with an intellectual disability, emotional disturbance, or learning disability
Talk with teenager and family about plans for education or employment after HS graduation
Refer to appropriate resources to help achieve their goals
Early involvement with transition and employment programs is key to a sucessful transition
Behavior management for children w/ autism
* Applied behavior analysis
* Differential reinforcement
* Discrete trial training
* Schedules
* Self-management
Applied Behavior Analysis (ABA)
* what is this
* How intense is this intenvention?
* How old do they have to be for this to work?
Tasks are broken down into discrete trials and then coupled w/ reinforcement to build positive behaviors
* so its lots of using positive rewards
* Not always great because its hard to generalize beavhior
Shown to improve a wide variety of skills across all areas of development
Intervention is usually intense (25-40 hours a week)
Individualizing targeting of skills
Parents are trained to become active co-teacher
Strong evidence to support over age of 3
What is differential reinforcement?
* how old to children have to be
A form of applied behavior analysis
Used to increase the occurrence of desired, functional behaviors using rewards
* so basically ignoring them until they calm down, then they get a reward
Interfering behaviors decrease because they are not reinforced
Evidence to support in children over 4
Schedules for people w/ Autism:
* Assist w/ managing challenging behavior by providing a visual learning strategy
* Masks routine more predictable
* Photographs, line drawings, three-dimensional objects, or icons
* Entire day or for a specific event
* Single place or may travel with a child between palces
* Established intervention for children ages 3 to 14
the problem is they can become too dependent on these schedules where if something changes they go crazy
Self-Management
* Teach children w/ ASD to regulate their behavior by recording when the target behavior does or does not occur
* Independently seeks or delivers reinforcers
* May involve the use of checklists, visual prompts, tokens, or wrist counters
* Established intervention for children 3 to 18
What kind of communication is used to improve social and communication skills?
* Explain unaided vs aided?
Augmented and Alternative Communication (AAC)
Unaided AAC - nothing external to your body
* Gestures
* Sign language
* Facial expressions
Aided AAC - something outside your body
* Pictures
* Symbols
* Written cues
* Speech-generating devices
What is picture exchange system?
Form of AAC
Consists of using pictures as a means for individuals with autism to communicate
Considered an emerging intervention for children 0-9
Sensory Diet
* Individualized activity plan designed to provide the specific sensory input a child needs during the day - if you have a child that needs to move all the day - than maybe they sit on a bouncy ball instead of like bitting pens and stuff annoying the rest of the people around
* Goal-Help children tolerate different sensations, regulate their alertness, increase attention span, limit sensory seeking behaviors, and handle transitions with less stress by reorganizing the NS
What is the goal of sensory integration?
Goal = address overstimulation or understimulation from the environment
* So calm it down
Focuses on creating environmental that challenges children to use all of their senses effectively
Studies suggest may improve play performance, enhance social interaction, and decrease sensitivity
Considered unestablished intervention because findings have been inconsistent or do not apply to children w/ ASD
Oharmacological Interventions
* NOTE: There is no medication for autism, but there are medicaions that improve the below
Generally used to contorl or improve:
* Attention
* Obessive compulsive behaviors
* Tantrums
* Irritability
* Self-injury
* Aggression
Categories of medications:
* Anticonvulsants
* Antidepressants
* Antipsychotics
* Stimulants
Dietary interventions for autism
* Defeat Autism Now (DAN) protocol
* Gluten free
* Casein free diets
* Omega 3 fatty acids
* Little evidence that these dietary interventions are ffective in promoting skills or positively impacting behaviors or symptoms for children w/ ASD
* Open discussion about the use of these interventions, benefits
* Risks vs cost
* Families should consult their health care providers before beginning any dietary intervention
A pattern of observable behavioral and emotional responses, which are aversive, negative and out of proportion, to certain types of tactile stimuli that most people would find to be non-painful
Tactile defensiveness
Think like “my clothing is hurting me”
“The grass ins painful, or my shirt is hurting me”
Sensory Processing Disorder
* can have this w/o autism
Sensitivity to
* Light
* Sound
* Certain fabrics
* Food Textures
Oral motor difficulties which makes eating difficult
Struggles with handwriting
balance issues
Can lead to anxiety issues, challenging behavior, poor academic perforamnce and isolation from peers
It becomes a problem when it limits social play / school activities / ADLs. However, with lots of this they can work around it where its not noticiable
