Transcript Jerome Sattler, PhD Presentation

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 3rd 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 injuryrelated 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 sportsrelated 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