Autism Spectrum Disorder (ASD; Chapter 22)

Video Link



Bringing the Early Signs of Autism Spectrum Disorders Into Focus

 http://youtu.be/YtvP5A5OHpU

DSM-5

Definition

 A neurodevelopmental disorder characterized by persistent deficits in social communications and social interactions and by repetitive or restricted behaviors, interests, and activities

Prevalence Rates of ASD in Four Countries [1] Research Study

 Western Australia, Denmark, Finland, and Sweden  Compared rates of ASD in 2000 and 2011 in children aged 10 years

Prevalence Rates of ASD in Four Countries [2]

 Found increases in ASD diagnoses  96% in Finland  121% in Western Australia  175% in Denmark  354% in Sweden 

Source

: See next slide

Prevalence Rates of ASD in Four Countries [3]

Atladottir, H. O ., Gyllenberg, D ., Langridge, A ., Sandin, S ., Hansen, S. N ., Leonard, H ., Gissler, M ., Reichenberg, A ., Schendel, D. E ., Bourke, J ., Hultman, C. M ., Grice, D. E ., Buxbaum, J. D ., & Parner, E. T . (2014). The increasing prevalence of reported diagnoses of childhood psychiatric disorders: a descriptive multinational comparison.

European Child and Adolescent Psychiatry.

Advanced online publication. doi: 10.1007/s00787-014-0553-8

Some Facts about ASD [1]

 In 2011 –2012, about 1 in 50 children in the United States had a diagnosis of ASD, with a prevalence rate of about 2% for children ages 6 –17 years  ASD occurs in all ethnic and socioeconomic groups  Parents of children ages 6 –17 years with ASD reported that 58.3% of cases were mild, 34.8% were moderate, and 6.9% were severe

Some Facts about ASD [2]

 ASD is almost five times more common among boys (3.23%) than among girls (.70%)  Approximately 40% of children with ASD do not speak  Approximately 25% to 30% of children with ASD begin speaking at 12 to 18 months of age but then stop speaking

Some Facts about ASD [3]

 Before child’s first birthday, parents may have concerns about child’s  Social, communication, and fine-motor skills  Vision and hearing

Some Facts about ASD [4]

 Children with higher IQs  Tend to show fewer symptoms  Usually are identified as having an ASD at a later age

Some Facts about ASD [5]

 Children with other developmental disorders, such as  Language disorder or  Intellectual disability may also exhibit behaviors that suggest a possible ASD (see Table 22-1 on p. 601 in main text)

Lifetime Costs of ASD in USA and UK [1] Research Study



Aim of study:

Conduct a literature review on the cost of ASD for individuals and families.



Year:

2013 

Countries:

United States and United Kingdom

Lifetime Costs of ASD in USA and UK [2] Findings

Costs associated with ASD:  Special education services  Loss of parental productivity  Residential care as adults  Supportive living services as adults  Individual productivity costs  Medical costs

Lifetime Costs of ASD in USA and UK [3] Results

 Individuals with ASD

and

with intellectual disability:  $2.4 million in United States  $2.2 million in United Kingdom  Individuals with ASD

and

without intellectual disability:  $1.4 million in United States  $1.4 million in United Kingdom

Lifetime Costs of ASD in USA and UK [4] Comment

 What are the most effective interventions that make the best use of scarce societal resources?

 How can we best coordinate services across many different service systems?

 How can we best deal with the enormous effect of ASD on children, their families, their schools, and society?

Lifetime Costs of ASD in USA and UK [5] Source

 Buescher, A. V. S., Cidav, Z., Knapp, M., & Mandell, D. S. (2014). Costs of autism spectrum disorders in the United Kingdom and the United States.

JAMA Pediatrics.

Advanced online publication. doi:10.1001/jamapediatrics.2014.210

Why Are More Children Diagnosed with ASD?

 Greater public awareness  More clearly defined public policies  Availability of more extensive social services and education  Availability of better and more sensitive diagnostic tools

Etiology of ASD [1] Genetic Causes

 Identical twins are more likely to have ASD than nonidentical twins  Increased rates of ASD among siblings and first-degree relatives  ASD tends to occur about 10% of the time in children who have genetic or chromosomal disorders

Etiology of ASD [2] Genetic Causes (Cont.)

 Genetic mechanisms may produce an excessive number of brain cells in the prefrontal cortex  Older fathers may pass on significantly more random genetic mutations to their offspring than younger fathers  Older mothers are at a 30% higher risk of having a child with ASD than younger mothers

Etiology of ASD [3] Environmental Factors

 Some children with ASD have spontaneous DNA mutations  Adverse fetal environment may place the fetus at increased risk for developing ASD  Antibodies in the mother’s blood during pregnancy may interfere with fetal brain development by attacking healthy tissue

Etiology of ASD [4] Environmental Factors (Cont.)

 Toxic chemicals in the environment  Lead and mercury can interfere with normal brain development in the fetus

Etiology of ASD [5] Environmental Factors (Cont.)

 Variations in brain structure and function are thought to play a role in ASD  Rate of growth of the amygdala (an almond-shaped mass of nuclei located deep within the temporal lobe of the brain) may be abnormal and disproportionate to total brain growth in very young children with ASD

Etiology of ASD [6] Environmental Factors (Cont.)

Research Study on ASD and Prenatal Pesticides 

Sample:

970 children (developmental delay, normal development, and ASD) studied during 1997 –2008

Etiology of ASD [7] Environmental Factors (Cont.)



Results:

Residential proximity to organophosphate pestisides at some point during gestation was found to be associated  With a 60% increased risk for ASD  Highest during the 3 rd trimester

Etiology of ASD [8] Environmental Factors (Cont.)

 Organophosate pestisides are variety of organic compounds that contain phosphorus and often have intense neurotoxic activity 

Conclusion:

Results strengthen evidence linking neurodevelopmental disorders with gestational pesticide exposure, particularly, organophosphates

Etiology of ASD [9] Environmental Factors (Cont.)



Source:

Shelton, J. F., Geraghty, E. M., Tancredi, D. J., Delwiche, L. D., Schmidt, R. J., Ritz, B., Hansen, R. L., & Hertz-Picciotto, I. (2014). Neurodevelopmental disorders and prenatal residential proximity to agricultural pesticides: The CHARGE study.

Environmental Health Perspectives.

Advanced online publication. doi:10.1289/ehp.1307044

Etiology of ASD [10] Environmental Factors (Cont.)

Research Study on ASD and Prenatal Exposure to Selective Serotonin Reuptake Inhibitors

(

SSRIs) 

Sample:

968 mother-child pairs 

Results:

Prenatal exposure to SSRIs (antidepressants like Prozac and Zoloft) in boys may increase their susceptibility to ASD (effect stronger in boys than girls)

Etiology of ASD [11] Environmental Factors (Cont.)



Conclusion:

Research findings, however, remain inconsistent about the relationship between SSRIs and ASD

Etiology of ASD [12] Environmental Factors (Cont.)



Source:

Harrington, R. A. Lee, L-C., Crum, R. M., Zimmerman, A. W., & Hertz-Picciotto, I. (2014). Prenatal SSRI use and offspring with autism spectrum disorder or developmental delay.

Pediatrics, 133

(5), e1241 –e1248. doi: 10.1542/peds.2013-3406

DSM-5

Diagnostic Criteria for ASD [1] A. Persistent deficits in social communication and social interaction across multiple contexts

1. Deficits in social-emotional reciprocity 2. Deficits in nonverbal communicative behaviors used for social interaction 3. Deficits in developing, maintaining, and understanding relationships

DSM-5

Diagnostic Criteria for ASD [2] B. Restricted, repetitive patterns of behavior, interests, or activities

 1

.

Stereotyped or repetitive motor movements, use of objects, or speech  2

.

Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior

DSM-5

Diagnostic Criteria for ASD [3] B. Restricted, repetitive patterns of behavior, interests, or activities (Cont.)

 3. Highly restricted, fixated interests that are abnormal in intensity or focus  4. Hyperreactivity or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment

Features Associated with ASD [2]

 Regression in development  Difficulties in eating or sleeping  Aggressive behavior (toward themselves like self-injurious behavior or toward other people)

Features Associated with ASD [4]

 Savant skills  Ability to calculate extremely difficult mathematical equations without a calculator but not calculate the correct change when purchasing items  Ability to draw highly accurate and detailed perspective drawings  Ability to sing with perfect pitch

Features Associated with ASD [5]

 Savant skills (

Cont.

)  Ability to state the day of the week for a date far in the past or future  Ability to play a piano concerto after hearing it once

Research on Signs of ASD Related to Age [1] Early Identification (Around ages 2

–

5 years)

Impairments in  Nonverbal communication  Pretend play  Inflexible routines  Repetitive motor behaviors

Research on Signs of ASD Related to Age [2] Later Identification (Around ages 5

–

8 years)

Impairments in  Peer relations  Conversational ability  Idiosyncratic speech

Research on Signs of ASD Related to Age [3]

 Authors concluded that the number of diagnostic behaviors are inversely associated with the age of identification of children with ASD

Research on Signs of ASD Related to Age [6]



Source:

Maenner, M. J., Schieve, L. A., Rice, C. E., Cunniff, C., Giarelli, E., Kirby, R. S., Lee, L.-C., Nicholas, J. S., Wingate, M. S., & Durkin, M. S. (2013). Frequency and pattern of documented diagnostic features and the age of autism identification.

Journal of the American Academy of Child & Adolescent Psychiatry, 52

(4), 401 –413. doi:10.1016/j.jaac.2013.01.014

Disorders Comorbid with ASD [1]

 Medical  Asthma  Skin allergies  Food allergies  Ear infections  Frequent severe headaches  Sleep disorders  Sensory processing problems  Feeding disorders

Disorders Comorbid with ASD [2]

 Psychiatric Disorder  Social anxiety disorder  ADHD  Oppositional defiant disorder  Anxiety disorder  Language disorder  Depressive disorder

Disorders Comorbid with ASD [3]

 Neurological disorders  Chromosomal  Genetic disorders

Intellectual Functioning of Children with ASD [1]

 About 50% to 62% have IQs of 70 or above  “Low functioning” used to describe those with IQs of 69 or below  “High functioning” used to describe those with IQs of 70 or above  IQs tend to be stable  No specific cognitive profile

Intellectual Functioning of Children with ASD [2]

 No cognitive profile can reliably distinguish children with ASD from children with other disorders  But children with ASD have relative strengths on some Wechsler subtests  Block Design  Matrix Reasoning  Picture Concept

Intellectual Functioning of Children with ASD [3]

 And have relative weaknesses on other Wechsler subtests   Comprehension Vocabulary   Symbol Search Coding  IQs may improve as a result of intensive early interventions

Intellectual Functioning of Children with ASD [4]

 Children with ASD have higher IQs when they have  Adequate conversational speech or  Social relationships

Intellectual Functioning of Children with ASD [5]

 Poorly developed language skills in children with ASD include  Imitation  Sequencing  Organization  Seeing relations between pieces of information

Intellectual Functioning of Children with ASD [6]

 Poorly developed language skills in children with ASD include (

Cont.

)  Identifying central patterns or themes  Distinguishing relevant from irrelevant information  Deriving meaning from the bigger picture

Intellectual Functioning of Children with ASD [7]

 Relatively well-developed skills in children with ASD include  Perceptual discrimination  Retrieval of visual knowledge  Visual reasoning  Attention to visual detail  Rote memory

Intellectual Functioning of Children with ASD [8]

 Children with ASD and savant abilities tend to have low IQs  Children with ASD usually have  Selective memory deficits rather than widespread and all-encompassing ones

Observing Children with ASD [pp. 606 – 607; 1] Areas to Observe

 Use of  Eye contact  Facial expressions  Gestures  Vocalizations  Interactions with others  Interactions with examiner

Observing Children with ASD [pp. 606 – 607; 2] Areas to Observe (Cont.)

 Transitions  Use of language  Play  Motor behavior  Attention and activity level  Awareness of social cues and expectations

Tips for Testing Children with ASD [1]

 Adapt the environment  Select a room in a quiet area  Have comfortable lighting  Wear little or no perfume or cologne  Change room if sensory stimuli are distracting (e.g., child is screaming, avoiding, or covering ears)  Use tangible rewards (e.g., food reinforcers with permission or games)

Tips for Testing Children with ASD [2]

 Use frequent breaks  Make sure you have the child’s attention when you speak  Talk slowly  Use short and simple phrases  Be concrete  Avoid complex grammatical forms  Repeat or rephrase sentences

Tips for Testing Children with ASD [3]

 Avoid reliance on purely auditory cues  Use visual cues when possible to help children understand language  Use simple written to-do lists  Use a picture schedule of activities

Learn about Child’s Communication Skills

 Ask parents and teachers for advice on how to best work with the child  Observe the child in his or her classroom  See list of questions on p. 607 in main text  Under no condition should you use facilitated communication to interview a child with ASD (see pp. 607 –608 in main text)

Assessment Measures for ASD

 See p. 608 in main text

Useful ASD Forms [1]

 Table J-1. Observation Form for Recording Behaviors That May Reflect Autism Spectrum Disorder and Positive Behaviors (p. 155 in RG)  Table J-2. Modified Checklist for Autism Disorder in Toddlers (M-CHAT) (p. 157 in RG)  Table J-3. Autism Spectrum Disorder Questionnaire for Parents (p. 158 in RG)

Useful ASD Forms [2]

 Table J-4. Checklist of Possible Signs of an Autism Spectrum Disorder (p. 160 in RG)  Table J-5.

DSM-5

Checklist for Autism Spectrum Disorder (p. 161 in RG)

Evaluating Assessment Information

 See questions in Table 22-3 for evaluating assessment information in cases of ASD (pp. 609 –610 in main text)

Interventions for Children with ASD [1]

 See pp. 609 –614 in main text for a discussion of interventions for ASD  See Handouts K-1 to K-4 (pp. 162 –217 in RG) for parents and teachers  Interventions are designed to improve  Communication skills  Executive functions skills  Problem-solving skills  Organizational skills

Interventions for Children with ASD [2]

 Interventions are designed to improve (

Cont.

)  Interpersonal and social skills  Learning readiness skills  Academic skills  Motor skills

Interventions for Children with ASD [3]

 And to reduce  Restricted behaviors  Repetitive behaviors  Intense behaviors and interests that interfere with functioning or cause harm to the individual or to others

Alternative ASD Therapies [1] The Following ASD Therapies Are Not Supported By Research

 Auditory integration training (listening through headphones to electronically modified music, voices, or sounds)  Chelation (heavy metal removal)  Gluten- and casein-free diets (gluten is a protein found in wheat and other grains, and casein is a protein found in milk and milk products)

Alternative ASD Therapies [2] The Following ASD Therapies Are Not Supported By Research (Cont.)

 Herbal remedies (e.g., St. John’s wart, ma huang, kava kava)  Hyperbaric oxygen chamber treatment (use of a pressure chamber to administer oxygen at higher pressure than in the atmosphere)

Alternative ASD Therapies [3] The Following ASD Therapies Are Not Supported By Research (Cont.)

 Intravenous immunoglobulin (injection of pooled antibodies separated from the plasma of multiple donors)  Manipulation or craniosacral massage (physical manipulation of the skull and cervical spine)

Alternative ASD Therapies [4] The Following ASD Therapies Are Not Supported By Research (Cont.)

 Melatonin treatment (a nutritional supplement used to promote sleep)  Vitamins A, B6, and C, megavitamins, and magnesium treatment (designed to address supposed metabolic abnormalities in children with ASD)

Prognosis for Children with ASD [1]

 Many behaviors associated with ASD may change, diminish, or completely fade over time  However, communication and social deficits may continue in some form throughout life

Prognosis for Children with ASD [2]

 More favorable prognosis is for children with ASD who have  Early and intensive intervention  Some communicative speech before 5 years of age  IQs above 70

Prognosis for Children with ASD [3]

 Prospect for employment is not encouraging  In 2009 about 53% worked for pay outside the home since leaving high school

Traumatic Brain Injury (TBI; Chapter 23)

TBI [1]

 Approximately 1 million children in the US each year sustain head injuries from  Falls  Physical abuse  Recreational accidents  Motor vehicle accidents  Approximately 75% of TBIs are mild  Still, TBI account for 30.5% of all injury related deaths among children

TBI [2]

 TBI in infants under the age of 1 year associated with  Physical abuse  Shaken baby syndrome  Thrown infant syndrome  TBI in toddlers and preschoolers associated with  Falls  Physical abuse

TBI [3]

 TBI in children over the age of 5 years associated with  Bicycle injuries  Motor vehicle injuries  Sports-related accidents and injuries

TBI [4]

 Children under 20 years who are treated in emergency departments for TBI sustain their injuries from  Sports and recreation activities 30%  Motor vehicle collisions 20%

Observable Effects of TBI in Children [1]

 TBI may produce physical, cognitive, and behavioral symptoms (see Table 23-2 on p. 632 in main text)  Contact health care provider if a child shows any of these symptoms after sustaining a head injury  Changes in play  Changes in school performance  Changes in sleep patterns

Observable Effects of TBI in Children [2]

 Contact health care provider if any of these symptoms show after a child sustains a head injury (

Cont.

)  Convulsions or seizures  Persistent headaches  Inability to recognize people or places  Irritability, crankiness, or crying more than usual

Observable Effects of TBI in Children [3]

 Contact health care provider if any of these symptoms show after a child sustains a head injury (

Cont.

)  Lack of interest in favorite toys or activities  Loss of balance or unsteady walking  Loss of consciousness  Loss of newly acquired skills

Observable Effects of TBI in Children [4]

 Contact health care provider if any of these symptoms show after a child sustains a head injury (

Cont.

)  Poor attention  Refusal to eat or nurse  Slurred speech  Tiredness or listlessness  Vomiting  Weakness, numbness, or decreased coordination

Effects of TBI Related to Several Factors

 Location, extent, and type of brain injury  Child’s age  Child’s preinjury  Temperament  Personality  Cognitive and psychosocial functioning  Type, promptness, and quality of treatment

Sports-Related Concussions [1]

 About 40 to 50 million children in US participate in organized sports

Sports-Related Concussions [2]

 Incidence of mild TBI in children who participate in sports is high —about 1,275,000 annually  Football (22.6%)  Bicycling (11.6%)  Basketball (9.2%)  Soccer (7.7%)  Snow skiing (6.4%)

Sports-Related Concussions [3]

 Rates of Concussion  Highest in full-contact sports (e.g., football, boy’s lacrosse, ice hockey, rugby)  Moderate in moderate-contact sports (e.g., basketball, soccer)  Lowest in minimal contact sports (e.g., volleyball, baseball, softball)

Sports-Related Concussions [4]

 Consider the cumulative effects of sports related concussions  Possibility of long-term permanent damage in the form of chronic traumatic encephalopathy  See Table 23-3 for list of symptoms of a possible concussion (p. 636 in main text)

Sports-Related Concussions [5]

 If one or more of these symptoms are present, adults on the scene should  Call 911  Contact the child’s parents immediately  This is especially critical because concussions can result in an intracranial hemorrhage, which is life-threatening

Brief Mental Status and Follow-UP Examinations

 Use SCAT3 (see p. 635 in main text)  Or ask questions on p. 636 in main text  Ask follow-up questions on p. 636 in main text  Refer child to a health-care provider if coaching staff or parents report that the child shows any of the symptoms on p. 637 in main text

Rehabilitation Programs in Schools [1]

 When child returns to school note the behaviors shown on p. 637 in main text  Consider guidelines shown on p. 638, 640 in main text and in Exhibit 23-2 on p. 639 in main text in setting up a rehabilitation program

Rehabilitation Programs in Schools [2]

Help teachers carry out appropriate strategies for  Reducing or eliminating barriers to learning  Reintegrating the child into the classroom  Establishing objectives  Using effective instructional procedures  Give teachers Handout K-3 (pp. 185 –209 in RG)

Protecting Children from TBI

 See list of suggestions on pp. 643 –644 in main text  Research should continue to focus on ways to reduce the severity and occurrence of sports-related injuries

NIH Toolbox [1]

 A set of royalty-free neurological and behavioral tests designed to assess in children and adults between the ages 3 –85 years  Cognitive functions  Sensory functions  Motor functions  Emotional functions

NIH Toolbox [2]

 See Table 24-7 on pp. 670 –671 in main text  NIH Toolbox tests are also available in Spanish  See reference —National Institutes of Health and Northwestern University (2012) — for link to tests