ࡱ> sr23(  L 8http://www.autism-society.org/site/PageServer?pagename=LivingwithAutismhttp://www.autism-society.org/site/PageServer?pagename=LivingwithAutism`/ 0DArialngslr(0(z[ 0 DWingdingslr(0(z[ 0 @ .  @n?" dd@  @@`` $PUf ** HH>> 5 ()  135678:;<=?@ABCDEFGHLIJKLMNOPQRS 0AA0 f@-QoO ʚ;q*ʚ;g4<d<d@z[ 0ppp@ <4ddddl 0Dr <4!d!dl< 0<4BdBdl< 00___PPT10 ___PPT9ph( ?  %(Autism Heather Bartsch July 17-21, 2006!!  Terminology (@Pervasive developmental disorders (PDD) Autistic Disorder Asperger s Syndrome Rett Syndrome Childhood disintegrative disorder PDD- not otherwise specified (NOS).(y(y,:  O HistoryAutism means  living in self In 1911, Swiss psychiatrist Bleuler coined term for schizophrenia Kanner accredited with the first description of autism in 1943 1978 DSM III autism was classified as a pervasive developmental disorder ",: Epidemiology Increasing prevalence 1 in 166 American children born today will have autistic spectrum disorder (CDC) Males > Females (4:1) Affects any race and socioeconomic statusBQ@Q@Etiology mUnknown (80-85% of cases) Secondary (15-20%) Down syndrome, Fragile X syndrome, and Prader Willi syndrome J.=.=6$1 Theories on Etiology^Genetics Autistic siblings 3-9%;Broad autistic phenotype 12.4-20.4% Monozygotic twins > concordance than dizygotic twins 50% chance of typical autistic disorder Symptoms often differ between twins Linkage studies suggest polygenic inheritance Linkage with 7q associated with severe developmental delay and delayed expressive language Environmental  pL.[ pL.[  i Theory on Etiology IIVaccines Preservative thimerosal contained in vaccines could cause autism MMR associated with autism via enterocolitis that allowed for absorption of neurotoxins No causal relationship established.  , I O Pathology Overall larger brain volume Corpus callosum is smaller than normal Frontal lobe, amygdala, and hippocampus are enlarged Frontal lobes and cerebellum contain abundance of white matter Neurons are closely packed together ",#&Tests|Screening CHAT (Checklist for Autism in Toddlers) 18-36 months of age Intended to indicate if further evaluation is needed for autism 5 to 10 minutes to administer, 9 yes/no questions answered by parent, 5 direct observation questions to corroborate parents findings Further evaluation Autism Behavior Checklist (ABC): a behavior checklist completed by a parent. Autism Diagnostic Interview-Revised (ADI-R): a structured interview. Childhood Autism Rating Scale (CARS): a test combining parent reports and direct observation by the professional. Pre-Linguistic Autism Diagnostic Observation Schedule (PL-ADOS), a test using direct observation of the child's behavior as elicited by the examiner  P(PPPPPP (        DSM-IV CriteriaYA total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3): qualitative impairment in social interaction qualitative impairments in communication restricted repetitive and stereotyped patterns of behavior, interests, and activities Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play. The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder. xsP P PfPs:#1   Treatment Behavioral Applied Behavior Analysis (ABA) Based on psychologist Skinner s work in animals Behavior can be altered with repeated drills and rewards Developmental, Individual-Difference, Relationship based (DIR) Stanley Greenspan, child psychiatrist Exchange of emotional signals between mother and infant form the basis for learning in childhood A.K.A. floortime  Z ZiZ?ZZZ  i?  a  Treatment II Drugs Used to treat symptoms such as repetitive behavior, hyperactivity, aggression/self-injury, anxiety/affective symptoms Examples: Lithium, SSRIs, antipsychotics, stimulants, naltrexone, buspirone, clonidine, beta-blockers `b     Community ResourcesPatient Family Siblings Questions?    References Autistic Spectrum Disorders in Children edited by Vidya Bhushan Gupta, 2004. Wallis, Claudia.  Inside the Autistic Mind, Time, May 15, 2006. Agin, Marilyn.  The  Late Talker -- When Silence Isn t Golden. Contemporary Pediatrics, November 1, 2004. Glascoe FP: Communicating with parents. Young Exceptional Children 1999;2(4):16  Living with Autism , http://www.autism-society.org/site/PageServer?pagename=LivingwithAutism, July 14, 2006. Clinical Practice Guideline: Report of the recommendations. Autism/Pervasive Developmental Disorders, Assessment and Intervention for Young Children (Age 0 to 3 years), No. 4215, 1999.  Autism and Chronic Disease: Little evidence for thimerosal as contributing factor. Up to Date OnLine, July 14, 2006.  Autism and Chronic Disease: Little evidence for MMR as contributing factor. Up to Date OnLine, July 14, 2006.  Developmental and behavioral screening tests in primary care. Up to Date OnLine, July 14, 2006.l" Z'T2Pi`G 'l]U 0c/  ! 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S ! 0  ! rAutism comes from the Greek  aut which means self and  ism which refers to a state. The Swiss psychiatrist Bleuler coined the term autism in 1911 to describe a state of self absorption due to poor social relatedness in schizophrenia. Kanner later borrowed the term autism in 1943 to describe 11 children that  were oblivious to other ppl, did not talk or parroted speech, used idiosyncratic phrases, who lined up toys in long rows, and who remembered meaningless facts. And these observations would later form the basis of the definition for autism. Using the term autism to describe these individuals led to some confusion with schizophrenia, since the term originally was used to describe behavior seen in schizophrenics. It was not until 1978 that autism was given its own category in the DSM III under pervasive developmental disorder and its association with schizophrenia removed.PP{^+H  0޽h ? 3380___PPT10.5p*\ 0  l(  X  C    !  S +! 0  ! n8The originial DSM III definition was overly inclusive.  ,H  0޽h ? 3380___PPT10.9pu  0   @( (  X  C    !   S /! 0  ! * nPervasive developmental disorders is an umbrella term encompassing autistic disorder, Asperger s syndrome, rett syndrome, childhood disintegrative disorder, and PDD-NOS. Some experts prefer the term  autistic spectrum disorders instead of PDD to underscore the autistic features that are common to all of these disorders. PDD-NOS child exhibits many of the features of autism but is not severely impaired in all three areas of functioning, age of onset can be later than 3 years of age Asperger s typical communication skills development up to 3 years of age but later in life found to have autistic like behaviors in addition to significant problems with pragmatic language Rett s syndrome girls, dramatic regression in language, motor, and social skills before the age of 2 years; permanent, acquired microcephaly; hand wringing and severe gaze aversion, MECP2 mutation Childhood disintegrative disorder typical onset in children ages 5 to 10 years of age; undergo severe generalized deteoration in cognitive functioning (mild MR); questionable placement under PDD.$8MtV  | }  GH  0޽h ? 3380___PPT10.[ 0 TLP(  X  C    !L  S O! 0  ! Speech and language delays are the leading developmental concern in parents of children younger than 5 years. Glascoe reported that when a parent had a single developmental concern, 65% of the time it was about expressive language skills.2 CHAT questions ask if the child exhibits specific behaviors, including: social play, social interest in other children, pretend play, joint attention, pointing to ask for something, pointing to indicate interest in something, rough and tumble play, motor development, and functional play. The CHAT also includes observations of five brief interactions between the child and the examiner, which enable the clinician to compare the child's actual behavior with the parental reports. Autism Behavior Checklist (ABC) The Autism Behavior Checklist (ABC) is a list of questions about a child's behaviors. The ABC was published in 1980 (Krug et al., 1980) and is part of a broader tool, the Autism Screening Instrument for Educational Planning (ASIEP) (Krug et al., 1978). The ABC is designed to be completed independently by a parent or a teacher familiar with the child who then returns it to a trained professional for scoring and interpretation. Although it is primarily designed to identify children with autism within a population of school-age children with severe disabilities, the ABC has been used with children as young as 3 years of age. The ABC has 57 questions divided into five categories: (1) sensory, (2) relating, (3) body and object use, (4) language, and (5) social and self-help. Autism Diagnostic Interview - Revised (ADI-R) The Autism Diagnostic Interview-Revised (ADI-R) is a semi-structured interview for a clinician to use with the child's parent or principal caregiver. The original version of this test, the Autism Diagnostic Interview (ADI) was published in 1989 (LeCouteur et al., 1989) and was correlated to the ICD-10 definition of autism. The original ADI was intended primarily for research purposes, providing behavioral assessment for subjects with a chronological age of at least five years and a mental age of at least two years. The ADI-R (Lord et al., 1994) is a shorter version of the ADI, which has been developed for clinical use. It is intended to be briefer and more appropriate for younger children than the ADI. The ADI-R takes from 11/2 to 2 hours to administer and can be used with children as young as two years of age (with a mental age greater than 18 months). The ADI and the ADI-R focus on getting maximal information from the parent about the three key areas defining autism: (1) reciprocal social interaction; (2) communication and language; and (3) repetitive, stereotyped behaviors. The Childhood Autism Rating Scale (CARS) is the most widely used standardized instrument specifically designed to aid in the diagnosis of autism for use with children as young as 2 years of age. Published in 1980 (Schopler et al., 1980), the CARS was originally correlated to the DSM-III and then to the DSM-III-R. The CARS is intended to be a direct observational tool used by a trained clinician. It takes about 20-30 minutes to administer. The 15 items of the CARS include: Relationships with People, Imitation, Affect, Use of Body, Relation to Non-human Objects, Adaptation to Environmental Change, Visual Responsiveness, Auditory Responsiveness, Near Receptor Responsiveness, Anxiety Reaction, Verbal Communication, Nonverbal Communication, Activity Level, Intellectual Functioning, and the clinician's general impression. Pre-Linguistic Autism Diagnostic Observation Schedule (PL-ADOS) The Autism Diagnostic Observation Schedule (ADOS; Lord et al., 1989) consists of eight tasks, four focusing on social behaviors and four on communicative behaviors. The test was intended primarily for older, higher-functioning, verbal autistic children. The Pre-Linguistic Autism Diagnostic Observation Schedule (PL-ADOS; DiLavore et al., 1995) is a version of the ADOS modified to diagnose young children (under the age of 6 years) who are not yet using phrase speech. It is a semi-structured assessment of play, interaction, and social communication and takes about 30 minutes for a trained clinician to administer. In the primary care setting, time is of the essence. Most like the CHAT is the most feasible unless there is a special interest the practioner has in these disorders. Most likely the patient would be referred to a developmental specialist for further evaluation. Alternatives to a busy clinic schedule and need to administer screening tests is to use parent self report tests which can be filled out prior to the visit. Shortcomings here included failure to return forms, not comfortable with reading and writing, etc. Whereas pitfalls of direct observation can be time and also if the patient is not in a cooperative mood that day (tired, hungry, etc). XP-@  bn  H  0޽h ? 3380___PPT10.\`iP  0 ``(  X  C    !  S r! 0  ! bBehavioral modification remains the mainstay of treatment in autism. Special diets (e.g. gluten free, etc) or drugs have not proved efficacious. ABA has been around the longest. And initial studies in 1987 by Lovaas at UCLA showed promising results 9/19 autistic children taught 40 hours/week had big jumps in IQ and were able to pass the first grade. Only 1 out 40 in control groups accomplished this. Study was repeated in 2000 modest success rate at academic measures and no gains in social behavior.$%H  0޽h ? 3380___PPT10.bfJA  0 pQ(  X  C    !  S ! 0  ! S?Distribute card and talk about some of the subtitles and resources. To keep in mind that you may be treating the autistic child but to keep your radar up for trouble with the parents and other children coping. You may have a social worker hard at work for the autistic child but overlooking the other family members. H  0޽h ? 3380___PPT10.duq 0 NF$(  $X $ C    !F $ S @! 0  ! Objective of drug therapy in autistic children is to modify maladaptive behaviors including hyperactivity, agression, self abusive behavior, anxiety, and temper tantrums.k 7H $ 0޽h ? 3380___PPT10.f08 0 ,$(  ,X , C     , S d  0   &Speech and language delays are the leading developmental concern in parents of children younger than 5 years. Glascoe reported that when a parent had a single developmental concern, 65% of the time it was about expressive language skills.2 n|H , 0޽h ? 3380___PPT10.a 0 $0(  0X 0 C    ! 0 S ! 0  ! @Ethylmercury- half life of seven days, so, cleared from infant s system relatively quickly. Thimerosal has been used as a preservative in Hep B, DTaP, and Hib.Z Q $H 0 0޽h ? 3380___PPT10.4.v 0 4(  4X 4 C    ! 4 S (! 0  ! tPost mortem findings in autistic children indicate that their brains are different from human beings without autism.H 4 0޽h ? 3380___PPT10. g  0 <(  <X < C    ! < S 8[! 0  !  H < 0޽h ? 3380___PPT10.ǩ+   0 @(  @X @ C    ! @ S ! 0  !  H @ 0޽h ? 3380___PPT10.ǩv-   0 D(  DX D C    ! D S @! 0  !  H D 0޽h ? 3380___PPT10.ǩ]9    0 H(  HX H C    ! H S dA! 0  !  H H 0޽h ? 3380___PPT10.ǩB   0 0P(  PX P C    ! P S @! 0  !  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