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Autism CBE January 2006

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Autism CBE January 2006 Powered By Docstoc
					              Autism:
          Co-morbid Conditions

Dr. Jennifer E. Fisher M.B., B.S., MRCPsych, FRCP(C)
             Clinical Associate Professor
               Department of Psychiatry
               The University of Calgary

             Consultant Psychiatrist
               Developmental Clinic
            Alberta Children’s Hospital
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                   Definition


“The Pervasive Developmental Disorders (PDD) are a
group of neurodevelopmental / neuropsychiatric
disorders characterized by specific delays and
deviance in social, communicative and cognitive
development with an early onset, typically in the first
years of life. Although commonly associated with
mental retardation, these disorders differ from other
developmental disorders in that their developmental
and behavioural features are distinctive and do not
simply reflect developmental level”
                    (Rutter, 1978)
           The Genetics of Autism
   (PEDIATRICS Vol. 113 No. 5 May 2004, pp. 472-486)



“Autism is a complex, behaviorally defined,
static disorder of the immature brain that is
of great concern to the practicing
pediatrician because of an astonishing 556%
reported increase in pediatric prevalence
between 1991 and 1997, to a prevalence
higher than that of spina bifida, cancer, or
Down’s syndrome.”
       Concerns about the current situation

   The massive increase in reported prevalence
    over the last decade
   DSM and "cook-book" diagnosis
   Service provision and diagnostic requirements
   The pathologizing of gifted individuals
   Is “the spectrum” a valid construct?
   Unconventional ideas regarding aetiology
   Unproven and unorthodox treatments
   The clear lack of evidence based thinking
         Evidence-based medicine
               (courtesy Dr. John McLennan)




                     Definition

“The conscientious, explicit and judicious use of
current best evidence in making decisions about
the care of individual patients”
                (Sackett et al., 1996)
              Evidence-based medicine
                    (courtesy Dr. John McLennan)




            Evidence informed health care:

   Deals with groups of patients and populations, in
    addition to individual patients.

   Recognizes the factors that legitimately influence
    decision making in health care.

   Empirical evidence should play a central role.
              Evidence-based medicine
                      (courtesy Dr. John McLennan)




                            Evidence

   As developed through systematic and
    methodologically rigorous research, emphasizing
    the use of science while de-emphasizing the use of
    intuition, unsystematic clinical experience ….”
            (Evidence-Based Medicine Working Group, 1992)
             Evidence-based medicine


       Should we, who practice in the field of
          Autistic Disorders be worried?

                     A definite “yes”
                      Why is autism such a
  fertile ground for pseudoscience and unorthodox treatments?

SEPARATING FACT FROM FICTION IN THE ETIOLOGY AND TREATMENT
                              OF AUTISM
                A Scientific Review of the Evidence
              J.D. Herbert, I.R. Sharp, B.A. Gaudiano
Eugen Bleuler


                   1911
     First use of the word “autism"
      in his work on Dementia
      Praecox
      (note Kraepelin 1905)




     The three “A’s” of
      schizophrenia:
          - altered association
          - altered affectivity
          - ambivalence and autism
                       History


Kretschmer 1924: “Schizoid Character”
                 “Schizothymia in Average People”
                       “Detached Idealism”

Ssucharewa 1926: Boys with “Schizoid personality
  disorder”

Leo Kanner 1943: “Autistic disturbances of affective
  contact”

Hans Asperger 1944:     High Functioning autism
                         History

    The term “autistic psychopathy”was used by:

    Van Krevelen and Kuipes      1962
    Van Krevelen                 1971
    Wurst                        1974
    Dauner and Martin            1978




Newson            1970    “More able autistic people”
DeMeyer et al             1981 “High functioning Autism”
Wing                      1981 coined the term “Asperger’s
Syndrome” (AS)
                         History



Asperger’s Syndrome: rapidly accepted in UK, Scandinavia and
                           Canada



     PDD: used in the USA, widely accepted by the 1970s



   The term Asperger’s Syndrome was adopted by the WHO in
    1992 and by the American Psychiatric Association in 1994
                                         Autism and Schizophrenia




                                                                                  (Web Link)
                                                                      Israel “Issy” Kolvin
                                                                          (1929 – 2002)



There was long standing confusion between “infantile autism”, childhood psychosis and
schizophrenia. The seminal work of Kolvin and his group (part of the “Newcastle
Group”) in the early 1970s separated schizophrenia from autism. It was thought, prior to
Kolvin that many adult schizophrenics had childhood histories of autism and a high
proportion of childhood autists became schizophrenic.

Studies in the childhood psychoses. I. Diagnostic criteria and classification Kolvin, Br. J. Psychiatry. 1971 Apr; 118(545):381-4
Studies in the childhood psychoses. II. The phenomenology of childhood psychoses. I Kolvin, C Ounsted, M Humphrey, A
McNay. Br. J. Psychiatry. 1971 Apr, 118(545):385-95
                                            DSM III – 1980




    Autism (as we know the concept today) did not become a “diagnostic
    entity” until 1980 when “operational criteria” for “infantile autism”
    were established.

            - onset before 30 months of age
            - lack of responsiveness to other human beings
            - gross impairment in communication and language
            - bizarre responses to the environment


(American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd edition. Washington (DC):
                                       American Psychiatric Association: 1980)
                   DSM-IV (1994)




Definitional issues have been a major part of the
substantial problems in establishing accurate
epidemiology, understanding the natural history of the
condition, comparing studies, replicating research
findings and speculating on prognosis

  …….. never mind trying to understand the medical
          and psychiatric co-morbidities.
 The DSM-IV Pervasive Developmental Disorders


                Autistic Disorder

                Rett’s Disorder

    Childhood Disintegrative Disorder (CDD)

            Asperger’s Disorder (AD)

Pervasive Developmental Disorder – Not Otherwise
                    Specified
                  (PDD-NOS)
                    Autistic disorder




                Kanner’s syndrome, classical autism
(Kanner, L. Autistic disturbances of affective contact. Nervous Child
                             1943; 2:217)
 Impaired social interaction, communication, repetitive behaviours,
             restricted range of interests and activities.
                 Delays must occur before age three
                  Rett’s disorder I



Progressive developmental delay, mainly girls, 1 /
  20,000
Normal early infancy
Deceleration in head circumference between 5 and 48
  months
Loss of fine motor skills and characteristic hand
  wringing movement develops
Lower limb and trunk weakness leading to wide based
  gait
Then language loss and delay
Decreased interest in the environment and social
  interaction – appear autistic
                   Rett’s disorder II



Between age 2 and 10 years social interaction
  improves
Attempts are made at communication
Eye contact improves
But usually severe mental retardation
By adolescence: muscle wasting, scoliosis, spasticity,
  decreased mobility
Seizures in some 20%?
Sporadic gene mutation encoding X-linked methyl-CpG
  binding protein in a few cases

    (Included in DSM IV to allow clinician to make
                differential diagnosis)
              Childhood Disintegrative disorder



   Heller’s syndrome
   Extremely rare progressive disorder, prevalence 1.7 / 100,000
   Commoner in males
   Usually 2 years of normal development in all spheres
   To meet criteria the child must manifest deterioration in 2 of the
    following areas
         Language
         Social skills or adaptive behaviour
         Bowel or bladder control
         Play skills
         Motor skills
   Clinical presentation is very similar to “classical autism” but
    worse outcome

      (Included in DSM IV to allow clinician to make differential
                               diagnosis)
                Asperger’s syndrome




  Asperger, H. Die “Autistichan Psychopathen” im kindersalter
Archive fur Psychiatrie und Nervenkrankheiten 1944; 117: 76-136.
                    Asperger’s syndrome


   Impaired social interaction
   Restricted range of interests and activities
   Early language skills preserved but communication skills
    impaired (pragmatics)
   Conversational ability hampered for example by intense
    interests in certain topics
   (trains, weather, electricity, space, dinosaurs and factual lists)
   Can speak incessantly – “little professors” – using unusual
    words and phrases
   Numerous faux pas
   Motor delays are common
   Usually of normal intellect but frequently have learning
    disabilities
                             (case example)

   Closely related is Nonverbal Learning Disability (NLD, NVLD)
A short detour


   NVLD
           Characteristics of Nonverbal Learning Disorders

   Visual-Spatial: faulty spatial perception and spatial
    relations

   Motor: lack of coordination, balance problems, fine motor
    skills problems

   Academic: problems in math, reading comprehension,
    handwriting, copying and written output, organization,
    problem-solving, higher reasoning Strengths: strong
    verbal and auditory memory

   Social: poor comprehension of nonverbal
    communication, deficiencies in social judgment and
    social interaction

   Emotional: high anxiety, easily overwhelmed, fearful,
    obsessive, difficulties with transition and novel situations,
        NLD - Psychiatric impact: visual-spatial abilities



   Difficulty forming visual images

   Focusing on detail and failing to grasp the whole

   Poor visual memory (copying, reading, facial recognition,
    direction finding)

   Knowing where their bodies are in space (gym, bumping into
    people, personal space)
             NLD - Psychiatric impact: coordination


   Clumsiness / awkward

   Poor balance

   Spilling and knocking objects over, falling and bumping into
    things

   Problems with scissors, buttons, shoelaces, school crafts

   Bike riding, skating and no-one wants to play with them at the
    park
             NLD - Psychiatric impact: academic


   Significant difficulties in math and reading
    comprehension, concept formation, problem solving,
    transfer of learned material from one setting to
    another

   Telling time and handling money

   Telling a story and missing the point

   Laborious printing and copying

   Minimal written output
 NLD - Psychiatric impact: academic




   Oh …… but (s)he speaks so well

Elementary school was so good – it must
       be a behaviour problem

   Lazy, “could do better”, avoidant



“The Illusion of Competence”
              NLD - Psychiatric impact: social



   Novel situations, new games, sleep overs
   Empty talk that goes on and on and on
   Boring monologues – the dinner table – changing
    subjects
   Unusual rhythms, variations, tone and inflections to
    speech
   Rude, interrupting
   Don’t get jokes and their jokes and comments are
    inappropriate. Incongruent sense of humour. Faux
    pas
   Staring at people
   They want to play with others but others don’t want
    to play with them
      NLD - Psychiatric impact: social




If only they did have Asperger’s Syndrome!
              NLD - Psychiatric impact: emotional



   Interpreting emotional experiences of others
    and themselves
   Anxiety (generalized anxiety disorder, social anxiety disorder)
   Panic episodes (panic disorder)
   Obsessiveness (obsessive compulsive disorder)
   Poor self concept and self esteem
   Isolation
   Depression / self harm
          PDD not otherwise specified (PDD-NOS)




   This diagnosis is used for children who do not fit the
    other categories
   Often reserved for the “odd” children – sometimes
    known as “bubble children”
   DSM IV is somewhat ambiguous and does not lay
    out clear criteria
   Open to much interpretation
   Frequently used
Clarity?
                      Not in the least!

   The late 1980s and 1990s exploded with a host of
                   “new diagnoses”

High functioning autism
Sensory Integration Dysfunction
Non-verbal Learning Disability
Right Hemisphere Syndrome in Children
Hyperlexic Syndromes
Visual Spatial Motor Disorder
DAMP (deficits in attention, motor control, memory and
  perception)
Multiplex Developmental Disorder
Pragmatic Language Disorder
     “Autistic symptoms”



also associated with some cases of:

  Gilles de la Tourette’s Syndrome
  Obsessive Compulsive Disorder
  Social Anxiety Disorder
  Disorders of Written Expression
  Developmental Coordination Disorder
Not only was there an explosion in “diagnoses”
       but also in theories of causation



   Vaccination
   Diet
   Electromagnetic waves (power cables)
   Infection
   Pollutants
   Abnormal trace elements
   Allergies
                etc, etc ,etc
An occupational hazard of academics attempting to classify and
             understand the autistic spectrum




           “Ha! Webster’s blown his cerebral cortex”
          Autistic Spectrum Disorders




  “A spectrum of related diagnostic categories”


Within the “spectrum” of categories researchers
have attempted to identify stable dimensions of
symptom presentation that manifest across all of the
categories.
                           Szatmari et al (2002)

129 children with autism and other forms of PDD from two
samples with different inclusion criteria were assessed using
the Vineland Adaptive Behaviour Scales (VAB) to measure level
of functioning and the Autism Diagnostic Interview (ADI) to
measure the severity of autistic symptoms. Two relatively
robust dimensions were identified:

Dimension I:                     representing autistic symptoms
                          (ADI measures of: reciprocal social
interaction,                     repetitive movements and
communication)


Dimension II:             representing level of functioning
                          (VAB measures of: socialization,
                                 communication, motor skills, daily
living skills)


    (Szatmari et al: Quantifying Dimensions in Autism: A Factor-Analytic Study.
             J. Am. Acad. Child Adolesc. Psychiatry, 41:4, April 2002)
Why is it important to identify robust domains of symptoms?



                 Szatmari, 2002:

“If it were true that autism / PDD is composed of
more than one dimension, this would have important
implications for research into neurobiological
mechanisms. Separate dimensions may be
influenced by separate etiological mechanisms, a
model that has also been suggested for
schizophrenia (Andreason and Carpenter, 1993) and
could be equally applied to autism”
        Functional neuroimaging techniques



Positron Emission Tomography (PET)
functional Magnetic Resonance Imaging (fMRI)
Magnetic Resonance Spectroscopy (MRS)
Magnetoencephalogram (MEG)

…… are beginning to correlate and map observed symptom
complexes (as measured by standardized instruments, such as
the ADI and ADOS) {Szatmari’s dimensions and van Praag’s
“psychological dysfunctions”} with disturbances in regional brain
functioning and neurotransmitter abnormalities.
Dyslexia
Other uses of the MRI



                Match the MRI

              Stephen Harper
              Paul Martin
              George Bush
              All of the above
                            Epidemiology

        Prevalence rates have increased over the last decade
        ? a true increase
        ? related to shifting diagnostic criteria and categories
        ? due to international differences (DSM vs ICD-10)
        ? a “fashionable” diagnosis
        ? better education of teachers, psychologists and
         physicians

   Rates of “classical autism” have increased, but modestly

   Rates of Rett’s disorder and CDD have not increased

   Rates of Asperger’s syndrome and PDD-NOS have risen a great deal

   Then we have all of the other associated “diagnoses” (described
    above) that have become fashionable in the last 10 to 15 years - and
    these are often inappropriately used interchangeably with Asperger’s
    and PDD-NOS
                          Epidemiology


                          Frombonne (2003)

Autistic disorder
21 epidemiological studies from 13 countries since 1987
huge methodological problems identified (sampling , definition)
rates from 2.5 / 10,000 to 30.8 / 10,000

                     “best estimate”: 10 / 10,000

Asperger’s syndrome / PDD-NOS
reviewed 32 studies
same methodological issues

AS:    2.5 / 10,00
PDD:   15 / 10,000
         Epidemiology




 Autistic Spectrum Disorders

All diagnoses “taken together”
      57.9 to 67.5 / 10,000
                          Epidemiology



Sex ratio:      male – female: ranges from 1.33 to 16.0. Mean: 4.3

Social class:   no SES differences

Ethnicity:      likely no differences for “classical autism”

? AS and PDD more “fashionable” diagnoses in Western culture

? DSM vs ICD issues once more (North America vs Europe)
            Associations: Cognitive Function




Frombonne (2003):     40% severe retardation
                 30% mild to moderate retardation
                 30% normal intellect

Includes all “subtypes”: classical, Asperger’s syndrome and PDD-
   NOS


                   Classical autism:
       75% severe to profound mental retardation
               Associations with Medical Disorders



   In general the proportion of cases attributable to
    specific medical conditions is low and identifying
    clear causal relationships is complex

   Speculations of such associations were usually
    based on case reports

   For example: it was “established” clinical
    impression that there was a strong relationship
    between autism and congenital rubella – this “idea”
    had to be revised because it became apparent that
    cases became “less autistic” with the passage of
    time.
              Associations with Medical Disorders




   Frombonne (2003):
                  reported on 15 studies
                  rates from 0 – 16.7%
                  mean 6%

   Gillberg and Coleman (1996): about 25%

   Rutter et al (1994): I think more accurate at 10%
           Associations with Medical Disorders



Data does not suggest more than chance associations between autism
                                 and:


             Down’s syndrome
             Congenital rubella
             Cerebral palsy
             Phenylketonuria
             Neurofibromatosis
       Associations with Medical Disorders


                     However:

4% of autistic children have fragile X syndrome
(Dykens and Volkmar 1997)

Rates of autism are increased in tuberous sclerosis
(Smalley et al 1992)

Infants with sensory handicaps may present with “autistic
like” symptoms because of unusual movements and / or
language difficulties, but usually the criteria for DSM
Autistic disorder are not met.
              Associations with Medical Disorders

                                 Epilepsy

   In various studies rates from 5 – 38.3%

   Mental retardation in autism is predictive for the
    development of seizures

   Rates are highest in adolescents and adults – up to 1/3
    may have seizures

    (However in 1 study (Rutter et al 1994) 39% of children under age 3 years
    had seizures. A UK study using narrow diagnostic criteria – i.e. severe
    classical cases)
         Associations with Psychiatric Disorders


   Numerous reports of associations with “behavioural
    disorders”

   Are such associations greater than would be
    expected by chance alone?

   Are such symptoms and behavioural manifestations
    part of the primary autistic condition or the
    manifestation of other comorbid conditions? (Tsai
    1996)
              Associations with Psychiatric Disorders

                               Associations include:

          Oppositional behaviour
          Anxiety
          Depression
          Hyperactivity
          Poor attention
          Tics
          Obsessive and compulsive behaviour


    Volkmar et al: Practice Parameters for the Assessment and Treatment of Children, Adolescents and
    Adults with Autism and Other pervasive Developmental Disorders. J. AM. ACAD. CHILD ADOLESC
    PSYCHIATRY. 38:12 Supplement, December 1999
          Associations with Psychiatric Disorders


   Diagnosis of these disorders is particularly difficult in
    individuals who are largely or entirely mute or function in the
    severely or profoundly mentally retarded range

   Diagnosis of these associated problems in higher functioning
    individuals (e.g. the gifted, Asperger’s disorder, high
    functioning autism etc) may result in functional diagnoses of
         Generalized anxiety disorder
         Social anxiety disorder
         Obsessive compulsive disorder
         Schizoid, schizotypal, avoidant or other personality
    disorders

    And these may be assumed to be primary diagnoses standing
    alone and mask exploration of underlying autistic spectrum
    disorders. This can be particular problem in adult psychiatry
      Associations with Psychiatric Disorders

It is reasonable to assume that lower functioning individuals
and those closer to a diagnosis of “classical autism” have a
greater frequency of:

            behavioural difficulties
            hyperactivity
            mood lability
            self injury
            manneristic and stereotypic movements

Higher functioning individuals have more evidence of manifest
and self described:

            anxiety
            “social phobia”
            depression
     Associations with Psychiatric Disorders



Obsessive compulsive problems probably occur
with equal frequency across the spectrum but
manifest differently as a property of severity and
degree of cognitive delay, for example:

A severely autistic person with severe to profound
IQ delay may sit and arrange blocks or spin wheels
in a purposeless manner

A higher functioning person may demonstrate
sophisticated rituals or want to count in binary or
insist on relating all numbers to degrees Kelvin
    High functioning autism and Asperger’s syndrome.


   Present at an older age
   Less evidence of developmental delay but
    more evidence of developmental deviations
    and psychiatric symptoms
   Fine motor skills (buttons, cutting)
   Poor printing, copying
   Anxiety
   Obsessive rituals and routines
   Over-interest in certain topics.
               Associations



 Attachment   disorder

 “Maternal   deprivation”

 Psychosocial    dwarfism

 “Refrigerator   mothers”
                            The vaccination controversy

The issues of regression in autism came to the forefront as part of
      the measles, mumps, rubella (MMR) vaccine controversy

   Wakefield (1998) described a small group of children with
    autism who had diarrhea and who lost previously acquired
    developmental skills after receiving MMR vaccination at 15
    months.

   Taylor et al (2002) found no association

   Numerous studies since then have not confirmed an
    association


    Wakefield A. Ilial-lymphoid-nodular hyperplasia, non-specific colitis and pervasive developmental disorder in
    children. Lancet 1998; 351:637-41

    Taylor B et al. Measles, mumps and rubella vaccination and bowel problems or developmental regression in
    children with Autism: population study. BMJ 2002; 324:393-6
                        Vaccines and mercury

   There has also been controversy about the relation
    between high mercury levels in children with autism
    and the use of thimerosal in vaccines.

   The hypothesis is that vulnerable children will
    develop neurodevelopmental problems secondary to
    the neurotoxic effect of mercury.

   There is no evidence supporting this.

   Thimerosal has not been present in Canadian
    vaccines since 1992, except in one preparation of
    the hepatitis B vaccine that children receive at birth.
    This vaccine contains mercury levels well below
    safety estimates (12.5 mcgm Hg)
       Nelson K, Bauman M. Thimerosal and autism. Paediatrics 2003; 111:674-9
                   DSM, n., abbrev


Abbreviation for the "Diagnostic and Statistical Manual", a
lengthy work of comic fiction published by the American
Psychiatric Association (APA). Currently in its fourth major
edition (known as the DSM-IV), this volume hilariously attempts
to classify every aspect of human existence as a disorder,
thereby legitimating the involvement of its members in devising
expensive and intrusive methods of "treatment" for every living
person. Having already introduced several delightfully
whimsical categories, the ultimate goal of the DSM's witty and
satirical writers is to develop so many categories that every
living person will require the services of at least one
psychiatrist, eventually ensuring that there will be more
psychiatrists than people. Despite its great comic potential,
this mischievous document has been little noticed by the
general public due to its large physical size and high cover
price.
                   Management

                    Should address:

   Establishing goals for language/communication
    interventions
   Establishing goals for educational intervention
   Prioritizing target symptoms/comorbid conditions
   Monitoring multiple domains of functioning
   Behavioral adjustment
   Adaptive skills
   Academic skills
   Social/communication skills
   Social intervention with family members and peers
   Monitoring medications
                  Early intervention programs


    “psychosocial interventions can change the disorders course”

   Such programs involve highly focused and individualized
    teaching activities targeting all areas of development

   Several different programs eg:
    TEACCH (Treatment and Education of Autism and related
    communications handicapped children)

   The Denver model

   LEAP (learning experiences and alternative program for
    preschoolers and parents)
              Local Calgary Resources


                   Web Links


 The Society for the Treatment of
              Autism

             Autism Calgary

Both Sites contain excellent information and links.
            Early intervention programs: Lovaas


       Lovaas IO. Behavioral treatment and normal educational
        and intellectual functioning in young autistic children
                J Consult Clinics Psychol 1987 55 3-9

   Controlled study
   Intensive and comprehensive approach
   40 hrs a week for 2 years during early preschool period.
   “remarkable gains in language and IQ”
   Claimed 50% of children no longer symptomatic (“recovered”)

                               BUT
                significant methodological issues
     no one has replicated results as dramatic as these: other
         researchers using the Lovaas approach document
                   improvement but not recovery

                            Web link
              Lovaas Institute for Early Intervention
           Early intervention programs


             The literature supports

“delivering interventions for more than 20 hours
weekly that are individualized, well planned and
target language development and other areas of skill
development significantly increase children’s
developmental rates- especially in language
compared to no or minimal treatment”

                Bryson et al 2003
    Early intervention programs: unanswered questions


   How many hours needed to get optimum effects?

   Is one method better than another?

   If recovery is not expected: what are the most
    important outcomes? (social skills, language, IQ,
    adaptive skills, decrease in autistic symptoms?)

   To what extent are these independent outcome
    variables?

   Which is the best indicator of adult outcome?
          Education of autistic children


   Traditionally segregated classrooms
   Inclusion now recommended with
             Individual program plans IPPs
             Educational coding
             Teacher assistant / aide
             Speech language therapy
             Occupational therapy

   Funding and access to service issues
           Sensory Integration Treatment

   Sensory integration is the neurological process of
    organizing the information we get from our bodies
    and from the world around us for use in daily life

   Sensory integration provides a crucial foundation for
    later more complex learning and behavior

   The organization of behavior, learning and
    performance is a natural outcome of the process, as
    is the ability to adapt to incoming sensations
           Sensory Integration Treatment



   Sensory integration dysfunction is a complex
    neurological disorder, manifested by difficulty
    detecting, modulating, discriminating or integrating
    sensation adaptively.

   This causes children to process sensation from the
    environment or from their bodies in an inaccurate
    way, resulting in "sensory seeking" or "sensory
    avoiding" patterns or "dyspraxia", a motor planning
    problem
         Signs of Sensory Integrative Dysfunction


   Overly sensitive to touch, movements, sights, or sounds.

   Behavior issues: distractible, withdrawal when touched,
    avoidance of textures, certain clothes, and foods. Fearful
    reactions to ordinary movement activities such as playground
    play. Sensitive to loud noises. May act out aggressively with
    unexpected sensory input.

   Under reactive to sensory stimulation. Seeks out intense
    sensory experiences such as body whirling, falling and
    crashing into objects. May appear oblivious to pain or to body
    position. May fluctuate between under and over-
    responsiveness.

   Unusually high/low activity level. Constantly on the move or
    may be slow to get going, and fatigue easily.
         Signs of Sensory Integrative Dysfunction

   Coordination problems. May have poor balance, may have
    great difficulty learning a new task that requires motor
    coordination, appears awkward, stiff, or clumsy.

   Delays in academic achievement or activities of daily living.
    May have problems in academic areas, despite normal or above
    normal intelligence. Problems with handwriting, scissors use,
    tying shoes, buttoning and zipping clothes.

   Poor organization of behavior. May be impulsive, distractible,
    lack of planning in approach to tasks, does not anticipate result
    of actions. May have difficulty adjusting to a new situation or
    following directions. May get frustrated, aggressive, or
    withdraw when they encounter failure.

   Poor self concept. May appear lazy, bored, or unmotivated. May
    avoid tasks and appear stubborn or troublesome
                Sensory Integration Strategies


             Some examples of treatment approaches:

   Oral sensory motor development can be aided by: whistles,
    blowers and bubble blowing kits.

   Fine motor: A number of toys like cone and ball catch, puppets
    etc

   For kids with fidgety fingers many blocks, fixes etc that help
    them focus.

   Gross motor: Bean bags, Therabands

   Vestibular and Proprioception: Swings, trampoline.

   Tactile: Fabrics, brushes

   High arousal / anxiety: weighted jackets, “squishes”
                   Alternative treatments

     No other group seems drawn to exposing their children to
     unproven and sometimes dangerous “treatments’ more than
                    the parents of autistic children
                 1/3 to 1/2 of all families use these

        Vitamins (high dose B6 and magnesium especially
    popular)
        Minerals
        Herbs
        Diets: gluten free, sugar free, anti-yeast (fungal), casein
    free etc
        Dimenthylglycine        (DMG)
        Secretin
        Cranio-sacral-therapy
        Trans cranial magnetic fields
        Chelation
        Auditory integration training
        Irlen lens system
        Homeopathy             etc, etc
Social skills training, social scripts and social stories

    A method for teaching verbal individuals (including high
     functioning autism and Asperger's) the unwritten social rules
     and body language signals that people use in social interaction
     and conversation.

    Carol Gray uses a technique called "social stories" to help
     illustrate these social rules in a variety of situations and
     appropriate responses. Social stories and "scripting" are also
     used with nonverbal individuals to teach appropriate responses
     and prepare the individual for transitions.

    In very young child, they may be in the form of photographs or
     pictures.


    For an excellent Web Site on this treatment intervention, go here
        The Gray Center for Social Learning and Understanding
     Alternative “treatments”: Web links




           Cure Autism Now
 The official site of the “Autism Research
 Institute” founded by Dr. Bernard Rimland,
PhD. A controversial figure who has, many
have said, given much false hope to families
              of autistic children.
            Psychopharmacological management

   No curative treatment

   Medications usually used sparingly and mostly in children with
    troubling comorbid conditions or maladaptive behaviours

   Much of the information available regarding psychotropic use
    has been gathered in adults and “transposed down”

   Many single case reports and open studies

   Few double blind, placebo controlled studies

   “Off label”

   Interactions with “natural treatments” – always ask
         Psychopharmacological management: neuroleptics


   Although there is no strong evidence of dopamine involvement
    neuroleptics have been used for many years to control: aggression,
    stereotypic behaviours, tics and impulsivity.

   Atypical neuroleptics: risperidone, olanzepine, quetiapine

   Before starting: CBC, ALT, fasting BS, lipids, cholesterol, prolactin,
    ECG

   Side effects: appetite and weight increase, type II diabetes, lipid
    changes, cardiac arrhythmias (QTc interval), EPS, TD

   Monitoring: repeat blood work and ECG at 3 and 6 month, then
    annually, 6 monthly AIMS, physical examination for EPS and TD.
    Height / weight / growth chart each 3 months

   Dosage: start low; 0.25 mg bid and adjust
            Psychopharmacological management: SSRIs


           Clear evidence of abnormal brain 5-HT

   SSRIs target: anxiety, obsessions, stereotypic movements,
    mood stability

   Fluoxetine, paroxetine, fluvoxamine, sertraline, citalopram,
    venlafaxine. Also the TCA clomipramine

   Side effects: sedation, agitation, high arousal, increased risk of
    suicidal ideation, withdrawal syndrome

				
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