Transcript Wendy Roberts. MD, FRCPC - Kennedy House Youth Services

Wend y Rob er ts.
M D, F RCP C
WHAT IS ASD?
Developmental
Paediatrician
Hospital for Sick
Children
Professor Emerita,
Department of
Paediatrics
U n i v e r s i t y o f To r o n t o
ISAND
Integrated Ser vices
for Autism and
NEURODEVELOPMENT
al DISORDERS
October 21 , 2015.
OBJECTIVES: BY THE END OF THE
SESSION, THE PARTICIPANT WILL…
 Be able to discuss what is an ASD
 Understand the dimensions of the spectrum and the “Autisms”
 Appreciate how autism looks dif ferent at dif ferent ages
 Be able to discuss how DSM 5 criteria are applied
 Be able to explain how ASD is dif ferent from, and overlaps
with, other Developmental and Neuropsychiatric Disorders
 Understand how autism can af fect behaviour at dif ferent
stages of development
WHAT IS AUTISM?
AUTISM AS A SPECTRUM DISORDER
SPECTRUM DIMENSIONS
DETERMINE ABILITY / CHALLENGE
}
Intelligence
Social reciprocity
Use of Language
Form of Language
Insistence on sameness
Stickiness/rigidity
Sensorimotor
}
Lorna Wing, 1980
Georgiadis,Szatmari et al, 2012
Social Affect
Sharing
Narrow interests
including sensory
and repetitive
motor behaviors
and mannerisms.
Developmental History
Mental Health
ASD symptoms
ASD
Individual and family
Differences/Experience
(e.g., temperament)
Behavior
Medical Issues
Cognition, Sensorimotor,
Language/communication
& Learning Style
WHAT CAUSES ASD?
 Genetics
 3-400 neurodevelopmental genes associated with synaptic
transmission.
 Lots of overlap in genes associated with neuropsychiatric
disorders: ADHD, Anxiety, ASD, LD, bipolar, schizophrenia.
 Deletions and duplications found by microarray in 7 -10% of
ASD individuals now. Whole Genome Sequencing expected to
yield a lot more findings with the goal of developing novel
therapeutics
 Environment may play a role in vulerability genes expression:
- this includes prenatal effects, exposures for mother and
baby after birth.
WHY DON’T CLINICIANS AGREE? WHY MULTIPLE
DIAGNOSES?
 Co-existence of disorders





Attention-Deficit/Hyperactivity Disorder (ADHD)
Oppositional Defiant Disorder (ODD)
Tic disorder, (Tourette Syndrome…also a spectrum!)
Developmental Coordination Disorder
Autism Spectrum Disorder
 Sharing of symptoms across disorders (sometimes referred to
as comorbidity) is the rule rather than the exception in child
psychiatry and developmental medicine
 Res Dev Disabil. 2010 Nov -Dec;31(6):1543-51. doi:
10.1016/j.ridd.2010.06.002. Epub 2010 Jul 14. C Gillberg
WHAT HAVE PARENTS EXPERIENCED IN
EARLY YEARS?
ARE THERE ASSOCIATED MEDICAL
ISSUES?
 Autism Speaks Autism Treatment Network

GastrointestinaI problems:




Diet/nutrition/restricted food intake


Should he be on a restricted diet?
Seizures, epilepsy


Ref lux,
Constipation
Irritable bowel syndrome
Up to 40% of those with cognitive delay by young adulthood
Sleep disturbances

Delayed falling asleep and night wakenings
 Toolkits on Autism Speaks website
HOW DOES AUTISM CHANGE WITH AGE?
 20% no longer full criteria (Fein)
 Anxiety and depression emerge especially in latency age and
adolescence
 Psychosis may emerge but in less than 8%. Since some
already being treated with antipsychotics, they may mask
symptoms
 15 % may develop more aggression as enter puberty.
Medication has strong ef fect on appetite and weight gain makes aggression more troublesome.
 Adaptive skills more obviously behind unless they are
focussed on in intervention from preschool to adulthood
DSM 5 CRITERIA FOR ASD.
All of the following symptoms describing persistent deficits in
social communication/interaction across contexts, not accounted
for by general developmental delays, must be met :
 Problems reciprocating social or emotional interaction ,
including difficulty establishing or maintaining back -and-forth
conversations and interactions, inability to initiate an
interaction, and problems with shared attention or sharing of
emotions and interests with others.
 Severe problems maintaining relationships — ranges from
lack of interest in other people to difficulties in pretend play
and engaging in age-appropriate social activities, and
problems adjusting to different social expectations.
 Nonverbal communication problems such as abnormal eye
contact, posture, facial expressions, tone of voice and
gestures, as well as an inability to understand these.
DSM 5 CRITERIA CONT’D
Tw o of the four
s y m p t o ms r e l a t e d t o r e s t r i c t e d a n d r e p e t i t i v e b e h a v i o r n e e d t o
be present:
 S t e r e o typ e d o r r e p e t i t i ve speech, motor m o ve m e n t s o r u s e o f o b j e c t s .
 E xc e s s i ve a d h e r e n c e t o routines, ritualized patterns o f ve r b a l o r
n o n ve r b a l b e h a vi o r, o r e xc e s s i ve r e s i s t a n c e t o c h a n g e .
 Highly restricted interests t h a t a r e a b n o r ma l i n i n t e n s i t y o r f o c u s .
 Hyper or hypo reactivity to sensory
input or unusual interest in
s e n s o r y a s p e ct s o f t h e e n vi r o n me n t .
Symptoms must be present in early childhood but may not become fully
manifest until social demands exceed capacities . Symptoms need to be
functionall y impairing and not better described by another DSM -5
diagnosis.
 Symptom severity for each of the two areas of diagnostic criteria is now
defined. It is based on the level of support required for those symptoms
and reflects the impact of co -occurri ng specifiers such as intellectual
disabilities, language impairment, medical diagnoses and other
behavioral health diagnoses
DIMENSIONAL APPROACH

Alternative approach to categorical

Defines the disorder empirically on dimensions
ranging from:
mild impairment
severe
Multidimensional model
mild impairment
Social Communication
Inflexible Language
& Behaviour
severe impairment
OTHER DIMENSIONS
Language
Motor speech
Temperament
Intelligence
Functional/ independent living skills
FOUR COMMON COMPONENTS IN
EFFICACIOUS INTERVENTION IN YOUNG
CHILDREN
 Parent involvement in intervention, including parent coaching
focused on responsivity and sensitivity to child cues and on
teaching families to provide the infant interventions
 Individualization to each infant’s developmental profile
 Focusing on a broad rather than a narrow range of learning
targets
 Temporal characteristics involving beginning as early as the
risk is detected and providing greater intensity and duration
of intervention
 (Wallace & Rogers, 2010, pg. 1300)
NDBI SHREIBMAN
 Naturalistic Developmental Behavioral
Intervention
 Starting in infancy
 Before diagnosis given or even confirmable! (bypass waitlists)!!
Naturalistic Developmental Behavioral Interventions:
Empirically Validated Treatments for Autism Spectrum
Disorder
Laura Schreibman, Geraldine Dawson, Aubyn C. Stahmer
Rebecca Landa, Sally J. Rogers, Gail G. McGee, Connie Kasari
Brooke Ingersoll, Ann P. Kaiser, Yvonne Bruinsma
Erin McNerney, Amy Wetherby, Alycia Halladay
 J Autism Dev Disorders March 2015
 DOI 10.1007/s10803 -015-2407-8
GROUPS THAT EMERGE IN ADOLESCENCE
Various combinations
of dimensions
 IQ, Autistic symptoms,
adaptive skills,
language and
communication,
difficult temperament
and behaviour
 Environment
Dimensions
Emoti Autis
on
m
Regul.
Adapti Cognit Langu
ve
ive
age
Sever Sever
e
e
difficu
lty
Sever
e
delay
Avera- Verbal
ge to fluent
above
Moder Mild
ate
Mod
delay
Borde
rline
Lang.
Delay
Calm
Moder Mild
ate
delay
Mod
delay
Verbal
Mod
Mod
Avera
ge
Non
verbal
Sever
e
CAN MY CHILD RECOVER?
HELT, KELLEY, KINSBOURNE, PANDEY, BOORSTEIN,
HERBERT, & FEIN. NEUROPSYCHOL REV (DEC
2008) 18:339-366.
ESSENTIAL DIMENSIONS IN
DEVELOPING TREATMENT PLAN
 Communication
 Social insight
 Cognitive processing
 Need for competence, building sense of independence
 Insistence on sameness. Need for order and predictable
schedule
 Sensory interests and aversions
 Emotion regulation
 Family dynamics and supports
 Medical issues
SUMMING UP
 Autism is a complex disorder
 Interplay of dimensions makes every affected
person unique
 Understanding individual reactions and needs
makes management so much more successful
 Competence at every stage of development is
critical for self esteem and minimizing
frustration and anxiety
 Integrated interdisciplinary care throughout the
lifespan maximizes potential