Module 13 Autism ADHD Sleeep and Behavioural Disorders Flashcards
Autism Spectrum Disorder.
What is it?
Autism spectrum disorder (ASD) is a developmental disability caused by differences in the brain. People with ASD often have problems with social communication and interaction, and restricted or repetitive behaviors or interests. People with ASD may also have different ways of learning, moving, or paying attention.
Have an understanding about the diagnostic criteria of ASD
Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history
Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history
Severity is based on social communication impairments and restricted repetitive patterns of behavior
Specify if:
With or without accompanying intellectual impairment
With or without accompanying language impairment
Associated with a known medical or genetic condition or environmental factor
The most notable symptoms of and signs of Autism are:
- Non-developed or poorly developed verbal and nonverbal communication skills
- Abnormalities in speech patterns, impaired ability to sustain a conversation
- Abnormal social play
- Lack of empathy
- Inability to make friends
- Stereotypical body movements
- Marked need for sameness
- Very narrow interests
- Preoccupation with parts of the body
10.Withdrawn and often spends hours in solitary play
11.Ritualistic behavior prevails
12.Tantrum-like rages may accompany disruptions of routine
13.Eye contact is minimal or absent.
14.Visual scanning of hand and finger movements, mouthing of objects, and rubbing of surfaces may indicate a heightened awareness and sensitivity to some stimuli
15.Diminished responses to pain and lack of startle responses to sudden loud noises reflect lowered sensitivity to other stimuli.
16.If speech is present, echolalia, nonsense rhyming, and other idiosyncratic language forms may predominate.
EARLY DETECTION OF AUTSIM
Infant Toddler Checklist 9months- 18 months of age)
What are some early detection ideas- it may affect the outcome.
Ie General retrospective parental reports
First year
Second year
* Excessive brain growth (head circumference) between months 1-2 and 6-14 should raise suspicion of autism
General retrospective parental reports:
- isolation from others
- failure to play like other children - apparent deafness
- empty gaze
- failure to attract attention
- lack of smiling
- poor imitation of movements
- concerns over delayed speech
-restlessness and hyperactivity.
First year:
1. lack of social smile
2. lack of appropriate facial expression 3. hypotonia
4. poor attention.
Second year:
1. preference for aloneness
2. lack of eye contact
3. lack of appropriate gestures
4. lack of emotional expression.
5. less likely to show an object or point to objects, 6. less likely to orient to their name
7. abnormalities in orientation to visual stimuli
8. aversion to touch
What are some early motor impairments
- By 12 months of age:
hypotonia and unusual posturing;
atypical behaviors, such as hand flapping, finger flicking, shaking head and rolling eyes
delayed onset of independent sitting and walking;
postural instability
head lag;
impairment of fine motor skills. - By 18 months of age:
lower fine motor skills, perhaps also lower gross motor skills reduced motor control
postural instability. - At 2 years:
unusual postures,
hypoactivity, and hypotonia
lower gross and/or fine motor skills increased repetitive behaviors.
What are the sensory subtypes in autism?
- Sensory Adaptive
-seeks sensations that are unlikely to be functionally limiting - Taste smell sensitive
-Characterised by extreme taste and smell sensitivity along side moderate- level concerns in auditory filtering and under responsive/ seeks sensation. - Postural inattentive
-characterised by extreme difficulties in postural processing alongside moderate level concerns in auditory filtering and under responsive/ seeks sensation. - Generalised sensory difference: experiences significant difficulties across all areas of sensory difference.
Sensory type
1. research has linked sensory hyper-reactivity with increased anxiety, GI disturbances and repetitive behaviour in children with ASD.
2. Postural inattentive and generalised sensory difference may experience difficulties in attention and motor skills.
Sensory hyperactivity display behaviours consistent with intolerance and sensitivity to specific sensory stressors.
Children were reported to exhibit heightened response to
1. Select taste and smells
2. Movement, tactile, visual, and auditory stimuli
List 14 Subtypes of Autism
- ADHD
- Allergies
- Food intolerance
- Fragile X syndrome
- Gastrointestinal symptoms
- Hyperactivity
- Methylation deficiency
- Mitochondrial dysfunction
- PANDAS*
- 1Phenol intolerance
- PTEN* mutations, macrocephaly
- Rett syndrome
- Seizures
- Tuberous sclerosis
*Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections
List 21 Risk factors for Autism
- Identical twin of sibling with autism
- Allergies
- Asthma
- Presence of brain autoantibodies
- Caesarean section with general anaesthesia
- Environmental toxin exposure
- Exposure to heavy metals
- Exposure to mould
- Haemorrhage
- High fever
- Infection
- Low birth weight
- Low APGAR score
- Obesity
- Oxytocin, prolonged use for labor induction
- Preeclampsia
- Prematurity
- Psoriasis
- Psychotropic medication use 20. Sexual abuse
- Stress
What are some Environmental insults to be aware off?
The incidence of autism has risen 10 fold since the early 1980’s
There is underlying genetic vulnerability
-Heavy metals
-Pesticides
-Chemicals
-Food sensitivities and allergies
-Infections- chronic and acute
Prenatal influences on dopamine activity are especially well documented including:
-effects of maternal psychosocial stress
-maternal fever
-use of certain medications
-fetal hypoxia
Chronically high maternal levels of dopamine caused by the pressures of increasingly urbanised societies and by changing maternal demographics such as more working, educational achievement level, age of 1st born - can all contribute to the rise.
The dopamine link to some of the major disorders like
- ADHD
- Autism
- Bipolar disorder
- Obsessive compulsive disorder
- Parkinsons disease
- Schixophrenia
- Substance abuse
- Tourettes syndrome
Autism is more affected by prenatal insults in the first and possibly second trimesters
Autism reflects a relative over activation of the left hemisphere which is relatively deficient in social and pragmatic communicative skills.
The left hemisphere is generally regarded as superior in
The right hemisphere is superior in:
The left hemisphere is generally regarded as superior in
1. Grammer
2. Mathematics
3. Reasoning
4. Other aspects of abstract intelligence
The right hemisphere is superior in:
1. Self- awareness
2. Emotional expression
3. Judgement of speaker intent
4. Proverb interpretation
5. Various other pragmatic and social behaviours
The specific roles of the two hemispheres are paralleled by the greater concentrations of
1. DA and acetylcholine in the left hemisphere
2. Norepinephrine (NE) and serotonin (also known as 5-
hydroxytryptamine, or 5-HT) in the right
Prenatal as opposed to genetic factors appear to be paramount in the establishment of functional lateralization in humans
Excessive folate and B12 during pregnancy have been linked to a dramatic increase in autism risk in offspring, new research shows.
The replacement of folic acid > 5 methyl THF in prenatal vitamins - important
Maternal prenatal vitamin intake during 1st tri may reduce ASD recurrence in families that already have an ASD kid.
Insecticide is BAD
No screen time before 18 months
Good to know
Autism is characterised by:
- Oxidative stress
- Decreased methylation capacity
- Limited transsulfration production of cysteine and GSH
- Mitochondrial dysfunction
- Intestinal dysbiosis
- Increased toxic metal burden
- Cerebral hypofusion
- Immune dysregulation
Gut-Brain-Immune Axis
* These are the fastest developing systems in the first 3 years of life
The Mercury connection.
1 in 3 newborns have a blood mercury levels above safety limit.
The aluminium connection:
Aluminium is very high in the brain tissue of ASD kids/n
Get a shit load of aluminium and mercury In Vaccinations
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Clinical and Laboratory Findings in Autism
- Complete digestive stool analysis
- Hair mineral analysis
- Heavy metal blood and urine analysis
- Essential Fatty acid profile
- Plasma amino acid profile
- Food sensitivity panel IgG and IgE
- Pesticide residues
Management of Autism
Gluten and Casein free diet
Eliminating foods containing gluten and casein - 60-80% improvement
3 months strict exclusion (more aware, less brain fog, better eye contact, increased language and receptive and expressive, decreased pain tolerance, improved bowel function and better sleep )
Treatment with AntibioticsL
1. treatment of dysbiosis (and related gut symptoms)
2. Stabilisation of mucosal barrier (dressing leaky git) by
-increasing mucin expression.
-reducing bacterial overgrowth
-stimulating mucosal immunity
-synthesizing antioxidant substances
3. Effects on the gut related immune system
4. effects on gut- neuro connections
PROTOCOL:
- Eliminate gluten and casein
-Start with organic foods, reduce toxic load
-Whole foods, decreased processed foods
-be gentle with changing diet
Avoid food additives (colouring agents, artificial sweeteners, avoid preservatives)
Eliminate IgG, IgE and IgA positive foods (blood tested)
Reducing toxic exposures:
Arsenic- chicken, wood, rice
mercury- fish, emissions, vaccinations, corn syrup
Lead- water, soil dust
Household chemicals
Nutrients?
zinc, selenium, magnesium, iron, calcium, iodine, chromium (common mineral deficiencies)
Vit C- improved symptom severity
Zinc- vital for heavy metal removal
Essential fatty acids- omega 3- often deficient
Vit D- consistently low in ASD, neuroprotective, decreased allergic sensitisation
Treatment Protocol -Nutrients
Vitamin B6 and Mg2+
Dimethylglycine (DMG)
Trimethylglycine (TMG) (60ml per day)
Speech is m.c consistent benefit and behaviour. Transient hyperactivity will benefit from folic acid and VitB12.
Folic acid- essential to numerous metabolic pathways
-several researchers report folic acid has good effects on pts with ASD or Fragil X syndrome.
Calcium:
Nutrient supplementation for heavy metal detoxification in Autistic individuals
- A hypoallergenic multiple vitamin daily, during both chelation and non-chelation phases * A hypoallergenic multiple mineral, during the chelation off days (should exclude copper) * Alpha-Lipoic acid (ALA), preferably in combination with chelator9
- Zinc – 2 mg/kg body weight/day, maximum 50 mg/day, only during chelation off days
- Selenium – 1-4 mcg/kg/day, preferably as L-selenomethionine
- Vitamin C – 4,000 mg/day up to bowel tolerance94
- Vitamin E – 6 IU/kg/day, as mixed tocopherols. Soy sensitivity is possible * Coenzyme Q10 – 100 mg/day
- Vitamin B6 – up to 500 mg/day, or P5P – up to 100 mg/day
- B complex - including generous folate and B12
- Glycine – 150-250 mg/day
- Melatonin – up to 0.1 mg/kg at bedtime, as a sleep aid when indicated
Biomedical Management of autism
- Address the gut issues
- Nutritional supplementation & Dietary modifications
- Reduction of oxidative stress
- Detoxification
- Normalisation of immune function
- Reduce brain inflammation
- Reduce environmental exposures
And adjust their subluxations!
Chiropractic: Some possible roles in management of Autism
- Improving gut function: - constipation
- Encopresis
- bowel control
- Improvement in bladder control
- Improvement of behaviour
- Improvement of sleep
- Tensegrity and mechanotransduction
- Immune function
- Pain relief
ADHD
Attention Deficit Hyperactivity Disorder
How should we focus our examination on a child with ADHD
Identify issues with hearing and/ or vision
Examine abdomen (eg liver span) -allergies
Full neuro exam
Neuro-maturation exam
Clinical attention problem scale (questionairre)
What is the dopamine link with ADHD?
What is the cerebellar link with ADHD?
hypo function of dopamine pathways is a consistent feature of the disorder.
Cerebellar link:
cerebellum is linked with the prefrontal cortex in a functional way. We often see an asymmetry in cerebellum volume in children with ADHD.
-Cerebellum also has connections to the reticular structure of the brainstem, which is important for autonomic, emotional and motivational behaviour.
What are the Environmental Influences in ADHD? Many likely contributory factors are:
-Sensitivities to food additives
-Intolerance to foods
-Nutrient deficiencies and imbalances
-heavy metal intoxication
-Toxic pollutant burden
-abnormal thyroid responsiveness
-Perinatal environmental pollutants
Heavy metal toxicity:
children exposed acutely or chronically to lead, arsenic, aluminium, mercury, or cadmium often have attentional defects, emotional lability, and behavioural reactivity.
Lead is damaging to cognition and behaviour and can cause developmental delay and mental retardation as well.
Hypothyroidism and ADHD
Causes of Hypothyroidism:
Synthetic chemicals and pesticides and herbicides- main suspects along with industrial chemicals. Use of organic foods needs to be stressed.
Vitamins and ADHD
What are common deficiencies?
Folic Acid
Thiamin
Niacin
Vit C
Were most commonly found to be low in children who responded to supplementation with measurable improvement.
Deficiencies of Vitamin A, E, B12, riboflavin, and of minerals were linked to bad behaviour
Improvements couldn’t be expected unless all deficiencies were corrected.
Iron and ADHD: most common nutrient deficiency in US school aged children.
Iron deficiency is associated with decreased attentiveness, narrower attention span, decreased persistence, and lowered activity levels, which respond positively to supplementation.
Magnesium- significantly decreased hyperactivity.
How can Chiropractic influence ADHD?
-Afferentation
sensory processing
perception
helps with sleep (affects mood/ behaviour)
helps digestion
Pain reduction
There is insufficient evidence to evaluate the efficacy of chiro care for paediatric and adolescent ADHD.
How should we as Chiropractors manage a child with ADHD
Adjustments
Instruct to avoid all food colourings, flavourings and preservatives
Reduce sugar intake
Use organic foods
reduce environmental load
Focus intensive treatment during drug free periods (school holidays)
Neurofeedback
IgG profile to assess for food allergies
CDSA Bioscreen medical
Test for lead and thyroid function
Supplements eg Neuropro (metegenics), zinc, EFA (DHA), magnesium, B vitamins,
What is the prognosis with medical management OF ADHD?
50% of children with ADHD function well in adulthood
The remaining continue to exhibit symptoms of inattention and impulsivity
Deliquent behaviour during teens and later antisocial personality disorder may be evident in as many as 50-80% of those who continue to be affected
SLEEP DISORDERS
What are examples of sleep disorders?
Eg abnormal type of sleep eg narcolepsy- regulation of sleep and wake is abnormal)
2. Abnormal behaviour during sleep (eg enuresis or sleep walking) or
3. A pathophysiologic event that occurs during sleep eg obstructive sleep apnoea
Sleep-Wake disorders afflict 1/3 of all children
What are questuibs relevant to infants and preschool -aged children include?
- Sleep environment (eg crib or parents room)
- Sleep position (eg prone or supine)
- Need for sleep aids (eg pacifier, rocking, patting)
- Time a child goes to bed
- Time of the final morning awakening
- Presence of habitual snoring, mouth breathing, sweating
- gastroesophageal reflux
- Abnormal behaviour suggestive of seizures and parasomnia
- Behaviour during the daytime (irritability, hyper-reactivity, sleepiness)
- Number of daytime naps and their duration
- medication that may affect sleep- wake function
- Interventions the parents carry out to improve sleep.
13.
Intrinsic dyssomnias
Obstructive sleep apnea
Intrinsic dyssomnias are sleep disorders that originate from internal causes and may include: Altitude insomnia. Substance use insomnia. Sleep-onset association disorder.
Often results from?
Often results from:
1. Obesity and metabolic syndrome
2. adenotonsillar hypertrophy
3. neuromuscular disease, eg, muscular and myotonic dystrophy,
4. congenital myopathies
5. spinal muscular atrophy
6. craniofacial abnormalities
- The presenting problem in children with sleep-disordered breathing depends on the age.
- In children younger than 5 years presentation includes
1. snoring is the most common complaint
2. mouth breathing
3. diaphoresis (excessive abnormal sweating)
4. paradoxic chest movement,
5. restlessness
6. frequent awakenings
7. witnessed apneic episodes - Children 5 years and older commonly present with
1. enuresis
2. behavioral problems
3. decreased attention span
4. failure to thrive
5. snoring
Intrinsic Dyssomnias:
Narcolepsy
Kleine - Levin Syndrome
Narcolepsy:
* Chronic, lifelong disorder characterized by
1. irresistible attacks of daytime sleepiness lasting
15–30 minutes
2. cataplexy (sudden loss of muscle tone in association with emotional stimuli like fright or surprise)
3. sleep paralysis (an inability to move for a few seconds at sleep onset)
Kleine-Levin syndrome
* The rare Kleine-Levin syndrome typically presents in adolescents.
* There is a predominance of males, with a mean age of onset of 15 years.
* The episodes of severe hypersomnia and mood disturbance are present in all patients, but variability was observed in the type of mood change, between aggressiveness to decreased psychomotor activity
Extrinsic dyssomnias
Extrinsic dyssomnias are sleep disorders that originate from external causes and may include: Insomnia. Sleep apnea. Narcolepsy.
Sleep onset association disorder
Limit-setting sleep disorder
Inadequate sleep hygiene
Insufficient sleep syndrome
Sleep onset association disorder
* Sleep onset association disorder mainly results from poor sleep habits.
* Children learn to expect the conditions that are present at sleep onset and become dependent on them to return to sleep after a night waking.
* Children who are used to falling asleep in their parents’ arms while being rocked or fed a bottle often need their parents to re- establish these conditions after a night waking and are unintentionally trained by their parents to expect these conditions.
* Management consists of
firmly eliminating association with external objects/actions,
placing the infant to sleep in his/her own crib
encouraging the parent to leave the room before the infant falls asleep
* Eliminating the daytime naps and postponing bedtime by an hour were also advised as they may make the child sleepier and more prone to fall asleep
Limit-setting sleep disorder
* Repeated requests for stories, water, or another television show are common, and bedtime is frequently inconsistent.
* There is delayed sleep onset due to bedtime resistance, which is defined as requiring more than 20 minutes to fall asleep after going to bed.
* The degree of sleep loss depends on the length of time the child requires to fall asleep but is often enough to result in behavior and learning problems during the day.
* Management includes appropriate bedtime routines, and a consistent bedtime.
* Parents should be encouraged to be firm in their limit setting, both day and night
Inadequate sleep hygiene
* Inadequate sleep hygiene includes those habits that enhance wakefulness and interrupt the sleep period, leading to a decrease in the quality or quantity of sleep and excessive daytime sleepiness.
* Examples of these habits include
1. engaging in stimulating activities near bedtime,
2. using the bed for activities not related to sleep (eg, playing, watching television),
3. consumption of caffeine near bedtime, s
4. leeping in uncomfortable bedroom (eg, too cold, hot,
bright, or noisy)
* Inconsistent bedtimes and inappropriate napping are also a major contributor to the problem
* Advised solution is modification of the sleeping environment to promote restful sleep, and parents may also adopt supportive bedtime routines as storytelling
Insufficient sleep syndrome
* Insufficient sleep syndrome is the most common cause of excessive daytime sleepiness in children and adolescents.
* It arises when the child fails to get an adequate amount of sleep to maintain appropriate wakefulness during the day
* Close to 45% of high school students were reported to have expressed a need for more sleep on questionnaire surveys.
* Sleep diaries extending over 1–2 weeks and actigraphy can be used to document sleep length.
* Management is reported to consist primarily of modifying the daytime schedule in order to obtain more sleep at night
Parasomnias
Parasomnias are disruptive sleep-related disorders. Abnormal movements, talk, emotions and actions happen while you’re sleeping although your bed partner might think you’re awake. Examples include sleep terrors, sleepwalking, nightmare disorder, sleep-related eating disorder and sleep paralysis.
Sleep onset association. disorder
Sleep walking
Nocturnal enuresis
Confusional arousals
* Confusional arousals occur in the first 3 hours after sleep onset when the child experiences an abrupt transition from the deepest phases of NREM sleep, ie, stages 3 and 4, to a lighter stage of sleep
* The episodes of arousal are commonly brief in duration, usually lasting 2–10 minutes
* The child often appears confused and disoriented, with incoherent speech, and will re-enter deep sleep and have no recall of the episode next day
* Predisposing factors for confusional arousals which alter stages 3 and 4 NREM sleep include obstructive sleep apnea,
fatigue,
sleep deprivation, and
irregular wake/sleep schedules
* Parents should be reassured that these episodes are harmless, will diminish as the child matures, and that they should not try to awaken their child during the episode
Somnambulism
* In somnambulism (sleep walking) the child sits up in bed with eyes open but is “unseeing.”
* Activity may range from restlessness in bed to walking through the house.
* The child does not meaningfully interact with people and is often easily agitated; speech is usually mumbled and slurred, and is rarely intelligible.
* Arousal is difficult and, if successful, the child will appear confused, and recollection of the event is rare
* Sleep walking is common, occurring in 1%–15% of children, and usually begins at the age of 4– 8 years, is more common in boys than in girls, and is often associated with enuresis.
* Because the sleepwalker may try to unlock doors or windows, safety precautions must be taken.
* Management includes informing parents that the child is truly asleep and should be gently redirected back to bed without awakening.
* This sleep behavior is usually outgrown by adolescence
* Bedrooms for sleepwalkers should be on the ground floor of the home, and windows and
doors must be secured.
* An intervention that proved effective in one study was scheduled awakenings
Waking the child 15 minutes before the sleepwalking had been occurring, making sure the child was fully awake for at least 5 minutes.
With the use of this technique, sleepwalking was quickly extinguished in more than 80% of children
- Nocturnal enuresis is one of the most prevalent sleep problems in children and widely regarded as a parasomnia by most sleep researchers because it occurs only during NREM sleep.
- The etiology of primary enuresis is likely to be multifactorial.
- Achieving continence is maturational, and children who lag developmentally at 1 and 3 years of age are more likely to be enuretic at age 6 years.
- Family history of enuresis is often present.
- Enuretic children have been reported to have a lower functional bladder capacity, although their true bladder capacity is normal
- Management options include Chiropractic adjustment
Limiting fluid intake in evening Waking the child
Medications
Bedwetting alarms
whatever finished this module
