Assessment for Autistic spectrum disorder by yaoyufang


									Assessment for Autistic
  spectrum disorder
         Dr Salma
  Consultant paediatrician
      Objectives of presentation
•   What is autism
•   Signs and Symptoms of Autism
•   Assessing for ASD
•   Aspergers
•   Management of Autism
• 116.1per 10,000 in Thames region of
  London in 2006
• 500,000 people in UK have autism
• No association with social class or
• M:F 4:1
• Autism affects the
  way in which people
  understand and react
  to the world around


     Repetitive                     n
            Autism History

• Eugene Bleuler in 1912 coined the word
• Greek word meaning “ self”
• Leo Kanner published first paper on autism
  in 1943
• Kanner syndrome “early infantile autism”
• Freud theory of autism (1950s-1960s)
• Dr Hans Asperger Austrian scientist
  described symptom of Aspeger in 1940
        Theories about autism
•   Pruning theory
•   Opioid excess theory
•   Environment
•   Genetic
•   Hypersystemisizing theory and
    empathising theory
        Opioid excess theory
• Incomplete absorption
  of casein and wheat
  produces exorphins
 Co morbidities associated with
• Learning difficulties
• Epilepsy
• Psychiatric disorders (depression,mental
  health, anxiety)
• Coordination problems
• Sleep problems
• Tics
                      Screening for ASD
      (Journal of Autism and Developmental disorders)
                   Pauline A Fillipek 1999
                     Age at Presentation

• Symptoms present before the age of 3
• Symptoms can be picked in first year of
• The average age of dx in UK not till 6
• The average age of dx in USA 3-4 years
                         Screening for ASD
         (Journal of Autism and Developmental disorders)
                      Pauline A Fillipek 1999

• Most of parents felt by 18 months something wrong with
  their child and sought medical advise by 2 years of age
• Fewer than 10% given dx at initial presentation
• 90% referred to another professional (mean age of 40
• 25% reassured not to worry
• 40% given a formal dx
• 25% referred to a third or 4th profession
    Methods used to assess autistic
          spectrum disorder
• CHAT (autism checklist for toddlers)
• ADI ( autism diagnoses Interview)
• ADOS ( autism diagnoses and observation
• 3DI (developmental, dimensional and diagnostic
  interview for autism)
• School Report
• Detailed history
• Speech and language assessment
• Psychological assessment
 Semantic Pragmatic language
• delayed language development
• learning to talk by memorising phrases, instead
  of putting words together freely
• repeating phrases out of context, especially
  snippets remembered from television
• muddling up 'I' and 'you'
• problems with understanding questions,
  particularly questions involving 'how' and 'why'
• difficulty following conversations
          DSM criteria for diagnoses of
•   I) A total of six (or more) items from (A), (B), and (C), with at least two from (A), and one each
    from (B) and (C)

•   (A) qualitative impairment in social interaction, as manifested by at least two of the
•   1. marked impairments in the use of multiple nonverbal behaviours such as eye-to-eye gaze, facial expression,
    body posture, and gestures to regulate social interaction
    2. failure to develop peer relationships appropriate to developmental level
    3. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people, (e.g., by a lack
    of showing, bringing, or pointing out objects of interest to other people)
    4. lack of social or emotional reciprocity ( note: in the description, it gives the following as examples: not actively
    participating in simple social play or games, preferring solitary activities, or involving others in activities only as
    tools or "mechanical" aids )

•   (B) qualitative impairments in communication as manifested by at least one of the following:
•   1. delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate
    through alternative modes of communication such as gesture or mime)
    2. in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with
    3. stereotyped and repetitive use of language or idiosyncratic language
    4. lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level

•   (C) restricted repetitive and stereotyped patterns of behaviour, interests and activities, as
    manifested by at least two of the following:
•   1. encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal
    either in intensity or focus
    2. apparently inflexible adherence to specific, non-functional routines or rituals
    3. stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex whole-body
    4. persistent preoccupation with parts of objects
           DSM criteria contd
• (II) Delays or abnormal functioning in at least
  one of the following areas, with onset prior to
  age 3 years:
• (A) social interaction
  (B) language as used in social communication
  (C) symbolic or imaginative play

• (III) The disturbance is not better accounted for
  by Rett's Disorder or Childhood Disintegrative
        New DSM 5 criteria
• Elimination of term pervasive
  developmental disorder
• Elimination of term Aspergers
• No language delay
• Normal intellect
       Early signs of autism
• not smiling by six months of age
• not babbling, pointing or using other
  gestures by 12 months
• not using single words by age 16 months
• not using two word phrases by 24 months
• having a regression in development, with
  any loss of language or social skills
     Autism symptoms checklist
•   Lack of eye contact
•   Failure to respond
•   Scripting
•   Strange behaviour
•   Resistance to change
•   Inexplicable actions
•   Poor motor skills
•   Perfect symmetry
     CHAT (checklist for autism in
• can be done by GP
  or health visitor
• done at 18 months
• not a diagnostic tool
• If a child fails first test
  needs to be repeated
  after one month
      CHAT questions for parents
•   A1 Does your child enjoy being swung, bounced on your knee, etc. ?
•   A2 Does your child take an interest in other children ?
•   A3 Does your child like climbing on things, such as stairs ?
•   A4 Does your child enjoy playing peek-a-boo / hide and seek ?
•   A5 Does your child ever PRETEND , for example to make a cup of tea using a toy
    cup and teapot, or pretend other things ?
•   A6 Does your child ever use his/her index finger to point, to ASK for something.?
•   A7 Does your child ever use his/her index finger to point, to indicate INTEREST in
    something ?
•   A8 Can your child play properly with small toys (e.g. cars or bricks) without just
    mouthing, fiddling or dropping them ?
•   A9 Does your child ever bring things to you (parent) to SHOW you something. ?
    CHAT section B to be observed by
               GP or HV
    Bi During the appointment has the child made eye contact with you
•   Bii Get the childs attention, then point across the room at an interesting
    object and say " Oh look! There`s a (name of toy) " Watch the childs face.
    Does the child look across at what you are pointing at ?
•   Biii Get the childs attention, then give the child a miniature tea pot and tea
    cup and say "Can you make a cup of tea?"
    Does the child pretend to pour out tea, drink it, etc. ?
•   Biv Say to the child "Where`s the light?", or "Show me the light".
    Does the child POINT with his/her index finger at the light ?
•   Bv Can the child build a tower of bricks ? If so how many. (No of
   Autism Diagnostic Observation
• Module1: pre
  verbal/single words
• Module 2: phrase
• Module 3: fluent
• Module 4: fluent
•   Scoring on communication
•   Scoring on Reciprocal social interaction
•   Observation on play
•   Observation on stereotyped behaviours
    and restricted interests
       ADOS Four Modules
• Modules based on speech rather than
• Selected module administered for 30-60
• ADOS (G) by Lord & Rutter 1995
• ADOS 1989 by Lord et al
          Marking for ADOS
              Module 1
• Communication: autism cut off=4 ASD
  cut off=2
• Reciprocal social interaction: autism cut
  off=7 ASD cut off =4
• Communication + social interaction:
  Autism cut off=12, ASD cut off=7
• Computer based programme. Full
  administration takes 3-4 hours.
• PDD screen involves 53 questions related
  to 3 main areas (a) reciprocal social
  interaction (b) social communication (c)
  stereotyped behaviour

• Detailed interview about development and
  history of the child. General 2-3 hours
         Strengths of ADOS:
• Direct observation of child to have a clear
• Standardized procedure currently
       Weakness of ADOS
• Adult led activity some children may do
  quite well
• Can miss diagnoses in younger age group
• Language based
• Does not take account of stereotyped
• Does not differentiate Aspergers
• Subjective marking
• Computer based programme
• Reporting by parents
              Interventions in Autism

• PECS (picture exchange communications system)
• TEACHH (                  treatment and education of autistic and communication related
    handicapped children)

•   TOPS (Thomas outreach project)
•   Early Bird
•   Auditory integration training
•   Music
•   OT
    Pharmacological interventions
•   Risperidone
•   Methylphenidate
•   Melatonin
•   Fluoxetine
    Multidisciplinary involvement
•   Parents
•   Paediatrician
•   Pschycologist
•   Speech and language therapist
•   School
•   Occupational therapist
               Case study
•   Name: SSC
•   DOB: 14/01/04
•   Seen for developmental delay by Com
•   Referred to CAMHS for ADHD
•   Referred to Clinical Psychologist
•   Referred to Clinical Psychiatrist
•   Referred to specialist in SCD
•   Final dx Jan 2011 by joint SALT and SCD
                  Case study
•   LC
•   DOB: 21/11/2001
•   Concerns before 2 years
•   Seen at 3 years by paediatrician, autistic
    tendencies d/c
•   9 years concerns about behaviour
•   Seen in past by OT for coordination problems
•   Academically good only problems with writing
•   ADOS, 3 DI suggest ASD
                   Case study
•   FB
•   DOB: 18/04/2005
•   Presented in Dec 2009
•   Hx: on the go, sensitivity issues, like to play on
    his own, interact with other children on his terms,
    fleeting eye contact
•   Started on treatment with ADHD
•   ADOS, 3 DI done in June
•   Final dx: ADHD + ASD
•   School: course in TEACHH
• Awareness about autism is increasing
• Age of dx is decreasing
• Autism is a neurodisability with increased
• Early diagnoses is important
• None of the method is diagnostic of autism
• School report is an integral part of assessment
• Dx is multidisciplinary
Thanks for listening

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