Transcript Autism Spectrum Disorders

Autism Spectrum Disorders:
Asperger Syndrome/PDD-NOS/
High Functioning Autism
Susan Ridenour, MSW, LSCSW
For
Kansas Health Solution
Aug 26, 2009
Welcome!
• This presentation is for the purpose of offering
training for Autism Spectrum Disorders
• Your host today is:
▫ Kansas Health Solutions
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Introductions
Speaker/Presenter
Susan Ridenour, MSW, LSCSW
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Objectives
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Overview of History
Assessment
KHS Diagnostic Implications
Co-occurring Disorders
Treatment and Resources
Screening Tools
History of diagnostic terms:
Differentiating Autism vs. Asperger Syndrome
• 1944: Vienna based pediatrician Hans
Asperger
• wrote “Autistic Psychopathies of Childhood”
• Leo Kanner – a contemporary of
Asperger – based in United States
• studied similar population referred to as “Infantile
Autism”
• Lorna Wing, reviewed work in 1981
• Changed diagnosis name to Asperger’s Syndrome (AS)
• Views AS as a type of Autism and part of the Spectrum
History (cont.)
• In 1993 International Classification of Diseases,
10th Edition (ICD-10)
• 1994 DSM-IV-TR legitimized the diagnosis of
Asperger Syndrome and transformed our
understanding of autism.
• The broad diagnostic category in the DSM-IVTR is Pervasive Developmental Disorders
▫ currently referred to as Autism Spectrum
Disorders (ASD).
Pervasive Developmental Disorders
• Symptoms are defined by a certain set of
behaviors that on a continuum can range from
mild to severe.
• The following 5 ASD diagnostic codes are more
common in the pediatric population than
diabetes, spinal bifida, or Down Syndrome.
▫ Autistic Disorder
▫ Asperger’s Disorder (Syndrome)
▫ Pervasive Developmental Disorder Not Otherwise
Specified (including Atypical Autism)
▫ Rett’s Disorder
▫ Childhood Disintegrative Disorder
Pervasive Developmental Disorders
• Comparatively, Asperger Syndrome is considered to be a
milder pervasive developmental disorder, distinguished
by a pattern of symptoms. These symptoms will be
reviewed in later slides.
• Summary of literature review:
▫ Asperger Syndrome appears to result from
developmental factors that affect many or all
functional brain systems, as opposed to localized
effects. Muller RA (2007). “The study of autism as a distributed disorder”. Ment
Retard Dev Disabil Res Rev 13 (1): 85-95. I
 Impairments result from maturation-related changes in various
systems of the brain.
World Health Organization (2006).
Prevalence
• To date, numerous well-designed scientific studies have found the
prevalence of Asperger’s to be 2.5 cases per 1,000. Attwood uses
Gillberg’s criteria – 1 in 280 children (1999)
• The CDC estimated the prevalence of all Autism Spectrum Disorders
among 8 year old children to be 1 in 150 based on the combined data
from studies completed in 2000 and 2002.
• Research reported a prevalence of males to females 4.3:1. Although
sex differences have been observed, the ratio studies have not supported this
claim. (Fombonne & Chakrabarti, 2001; Honda, Shimizu, & Rutter, 2005; Madsen et al., 2002;
Smeeth et al., 2004; Taylor et al., 1999).
• Attwood noted there is a 2:1 ratio of men to women who have AS in
his adult practice.
• Girls more difficult to recognize due to their social imitation coping
skills and camouflaging mechanisms.
Autism Spectrum Disorders Project
• Revision of Attwood’s ASAS-R was for ages 5-18
• Only scale supported by current research (2008) that
differentiates:
▫ children and adolescents with AS from those who did not
have ASD
 ***on every dimension of AS***
▫ children with AS from those with autism
▫ Children were referred to an ASD clinic but who did not
receive a diagnosis.
• Keep abreast of the release date on Tony Attwood’s
website:
www.tonyattwood.com.au
CORE dimensions of Asperger Syndrome
Common Theory
Attwood’s Theory
• Theory of
Mind/“Mindblindness”
• Perspective Taking
(Carlson,
VS
etal. 2004.) (Baron-Cohen & Swettenham 1997)
• Executive Functioning
Difficulties - not exclusive to AS,
also seen in ADHD, OCD and Toruette’s
VS
• Rigid Adherence to
Routine
(Hill & Frith 2003)
• ------------------------
• Weak Central Coherence
(Baron-Cohen & Swettham, 1997) (Hill & Frith, 2003)
• Sensory Sensitivity***
VS
VS
• Fact Oriented
*** Of Interest - All of the core dimensions except one have been discovered to
be the core characteristics in earlier studies
Diagnostic Process with KHS
• KHS reimburses for mental health services when a
Member has either a diagnosis of Asperger Syndrome or
Rett Disorder.
• Other Pervasive Developmental Disorder diagnostic
codes billed to KHS, must also have a psychiatric
diagnosis. (dual diagnosis)
• Service documentation must clearly identify the
treatment plan goals and interventions that relate to the
presenting psychiatric issue(s).
Diagnostic Process with KHS
• Confusion can arise in terms of which program is
responsible to provide the complex web of services
needed by this population.
▫ It is not always easy to differentiate the psychiatric
symptoms from the core issues of the broader
pervasive disability.
• SHCN identification provides opportunity for additional
Care Coordination assistance through KHS.
Diagnostic Process with KHS
• If primary symptomology is due to significant
cognitive impairment or substance abuse, refer
to appropriate program. Although with dual
diagnoses there may be transitions between or
collaboration among programs.
CO-MORBIDITY - Dx Implications
• 1998 study: 65% of individuals with ASD had at least
one other psychiatric disorder. (Ghaziuddin, Weidmer-Mikhail, and
Ghaziuddin)
• All of Asperger’s cases appeared to have co-morbid
behavioral and psychiatric disorders. (Ghaziuddin, 2002)
• In a review of the literature, no environmental factor has
been confirmed by scientific investigation.
• Research studies have made no connection between
Asperger Syndrome and childhood trauma, abuse or
neglect. Rutter M (2005). “Incidence of autism spectrum disorders: changes over time and
their meaning”. Acta Paediatr 94 (1): 2-15
CO-MORBIDITY
• Peer and family environments cannot cause ASD
(Attwood 2008)
• Some issues may result from the various
challenges these individuals struggle with on a
daily basis:
▫ severe social impairments,
▫ lack of meaningful age-appropriate relationships,
▫ increased potential of being victimized by others.
Medical Co-Morbidity
• Epilepsy with classic autism.
• Fragile X syndrome, Phenylketonuria (PKU), and
Tuberous Sclerosis also may be present with Autism.
• Most, if not all, individuals diagnosed with an ASD have
significant differences in motor functioning.
• Catatonia , is seen in a higher frequency in people
diagnosed with ASD than in the general population.
▫ 6% to 17% of those with ASD who are over the age of 15
experience a serious “catatonia like deterioration”
Learning Disabilities w/ Asperger:
(Developmental Considerations)
• Higher than normal rate of specific disability in
math and reading.
• Poor Reading Comprehension – problems
applying concepts in real-life context.
• Non-verbal Learning Disability – significant
discrepancy between verbal reasoning abilities
and visual-spatial reasoning
• Specific Learning Disability in Written
Expression.
Learning Disabilities (cont.)
• Although an Asperger Syndrome diagnosis is
usually given if the person has an IQ within the
average to superior range,
• The profile of abilities on a standardized test of
intelligence tends to be remarkably uneven.
• Clinicians may include some cases with a
borderline intellectual impairment when some
cognitive skills are within the normal range.
(Attwood 2007)
Psychiatric Co-Morbidity
• Mood Disorders: Some indication AS runs in
families, particularly in families with histories of
depression and bipolar disorder. (APA 2000; Kim, Szatman,
Bryson, Streiner, & Wilson, 2000; Ghaziuddin et al. 1998; Green, Gilchrist, Burton, & Cox, 2000;
Rumsey et al. 1985; Wing, 1981)
▫ Presentation: The child shows thought disorder,
irritability, has dangerous special interest(s), tends to
be hypo-manic in the evening
• However, neurological immaturity also helps explain
why the AS child under stress is less able to access the
thinking area of the brain and therefore does not act in
what others perceive to be a logical or rational manner.
(Myles 2005)
Anxiety Disorders
• Some research shows a genetic reason for anxiety and
depression. (Kim et al., 2000)
• Depression and anxiety are more common among higher
functioning individuals with AS. (Kim et al., 2000)
▫ Between 70-85% of children with AS have extreme
sensitivity to specific sounds. (Smith Myles 2000)
▫ Over 50% have olfactory and taste sensitivity. (Bromley et al.
2004; Smith Myles et al. 2000)
▫ 1 in 5 children with AS experience bright sunlight as
almost blinding and specific colors as too intense.
• These “dynamic sensory surges” are experienced as
extremely stressful and aversive ; anticipatory anxiety
can become so severe, an anxiety disorder or phobia can
develop. (Jackson 2002)
Anxiety Disorders
• Common response to anxiety: retreating into
solitude or the enjoyment of a special interest or
self medication with substances.
• The most common types of anxiety disorders for
children and adults with AS are (Ghaziuddin 2005b.):
▫
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OCD,
PTSD,
School Refusal,
Selective Mutism, and
Social Anxiety Disorder.
Additional Co-Morbidity
• ADHD is often the first diagnosis.
• 75% meet the criteria for a clinical diagnosis of
ADHD. (Sturm, Fernell, & Gillberg, 2004)
• Obsessive-Compulsive Disorder (OCD) - 25% of
adults with AS also have the clear clinical signs
of OCD. (Russell et al. 2005)
• PTSD develops typically as a consequence of
experiencing a traumatic event or series of
events. (Atwood; Russell and Sofronoff 2004)
▫ Severe and repeated bullying can precipitate the
clinical signs of PTSD in children with AS.
Additional Co-Morbidity
• Depression – People with AS appear vulnerable
to feeling depressed, 1 in 3 children and adults
have a clinical depression. “I feel I don’t belong”
is a common theme. (Ghaziuddin et al. 1998; Kim et al. 2000; Tantam
1988a; Wing 1981.)
• May be no emotion assigned to this state of
mind or experience.
• Special interest can become morbid and the
person is preoccupied with aspects of death.
Bullying
• BULLYING IS VERY COMMON in this
population.
▫ Minds and Hearts website
www.mindsandhearts.net
• More than 90% of mothers of with AS reported
in a recent survey:
▫ Their children had been the target of some form of
bullying within the previous year. (ages 4 and 17)
ANGER
• Commonality is unknown. (Attwood 2007)
• Appears to be a faulty emotion
regulation/control mechanism for expressing
anger.
• Critical to understand the underlying causes or
antecedents that serve as triggers for anger.
**Anger typically seen in 3 Stages**
Rumbling stage, Rage stage, Recovery stage
each stage is of variable length (Myles et al. 2005)
Anger/Tourette’s
• Confrontational, oppositional and aggressive behavior is
usually not modeled on a member of the family. The
parents who are subjected to threats and acts of violence are often
very meek people who may lack assertiveness in conflict situations.
• Negotiation, compromise and cooperation are strategies
not obvious to kids with AS and they may rely on
immature confrontation strategies.
• Tourette Syndrome: Children with a combination of AS
and Tourette’s are at greater risk of:
▫ Having signs of ADHD,
▫ Developing an anxiety disorder such as Obsessive Compulsive
Disorder.
Research has indicated that between 20 and 60% of
children with AS develop tics.
Five Compensatory & Adjustment
Strategies
1. Pathological Demand Avoidance (Newsom)
2. Reactive Depression (Attwood)
3. Escape into Imagination
4. Denial and Arrogance
5. Imitation
Relationship Issues in Therapy
• The lack of demonstrated empathy has been
noted as possibly the most dysfunctional aspect
of Asperger Syndrome from a social and
relationship aspect.
• Individual with AS may experience aversion to
physical touch due to a problem with sensory
issues rather than a lack of love and
commitment to the relationship.
Relationship Issues in Therapy
• Typical partner may resent the obvious lack of
enjoyment and the rarity of such affectionate
gestures.
• Compensatory & adjustment strategies, in
addition to underlying characteristics of AS,
create ongoing problems in relationships and
present complex challenges for service
providers.
Strategies for Intervention
• The Ziggurat Model A Framework for Designing Comprehensive
Interventions for Individuals with HighFunctioning Autism and Asperger Syndrome
 Winner of the 2008 ASA Award for
Outstanding Book of the Year
Strategies for Intervention
• The Ziggurat model expands the TEACCH
approach created by the Treatment and
Education of Autistic and Communication
Handicapped Children.
• TEACCH emphasizes the importance of
identifying underlying strengths and needs of
the disorder.
Strategies for Intervention
• The Underlying Characteristics Checklist assists
in identification of underlying factors as well as
an analysis of patterns of behavior.
▫ The ABC (antecedent/behavior/ consequence.)
• Also included is the Individual Strengths and
Skills Inventory.
Strategies for Intervention
• The results are used to develop a comprehensive
intervention incorporating each of five levels:
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Sensory and Biological,
Reinforcement,
Structure and Visual/Tactile Supports,
Task Demands, and
Skills to Teach.
Strategies for Intervention
• Additional tools utilized by practitioners
include:
▫ power cards,
social stories and scripts,
narratives,
video modeling
review of hidden social curriculums
• The strategy of the Emotional Toolbox is to
identify different types of “tools” to fix the
problems associated with negative emotions.
Strategies for Intervention
• K-CART (Kansas Center for Autism Research
and Training) suggests:
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Floor-time Therapy (Greenspan),
Speech Therapy,
Occupational Therapy,
PECS (early communication program),
Sensory Integration Therapy,
Relationship Development Intervention, and
Verbal Behavior Intervention as useful interventions.
For more information:
www.autismspeaks.org/
Strategies for Intervention
• Play Therapy and play based activity, role play, etc.
are useful modalities to build relationship and
introduce/practice social cues and skills.
• Published case studies and objective scientific
evidence has shown that CBT significantly reduces
mood disorders in children and adults with AS.
Strategies for Intervention
• Using psychotropic medications is one of the most
common forms of treatment for individuals with
ASD.
▫ One study found that approximately 46% of individuals with ASD
were prescribed one medication while roughly 21% were taking
two or more.
• Other medical, vitamin and homeopathic
remedies as well as special diets eliminating
gluten and casein are popular with many
families – research is not available to support
the effectiveness on a large scale
RESOURCES
• Tiny-K (birth-three) provides services to
children with an area of least 25%
developmental delay.
▫ They routinely coordinate services with other
community based programs that provide a variety of
services to children and families.
• The Early Childhood Special Education
Department in each school district evaluates and
provides services to children ages three to five.
▫ A similar process occurs in elementary and secondary
education/special services. Services can be provided
at no cost to the family if the child is eligible.
RESOURCES
• The Autism Waiver is provided through Kansas
Social Rehabilitation Services for children from
the age of diagnosis through the age of five.
▫ Unfortunately, only a limited number of
applicants can be served, however applications
can be obtained through your local SRS office.
RESOURCES
• Kansas Institute of Positive Behavior Supports at
www.kipbs.org.
▫ Services covered by Medicaid or private pay.
• Early Childhood Autism Project (ECAP) at 785865-5520 ext. 320.
▫ Services covered by Medicaid or private pay.
• Waivers through the mental health system are
also available when a child has a diagnosis of
Asperger Syndrome or co-occurring psychiatric
symptoms are negatively impacting daily
functioning.
RESOURCES
• The Kansas Community Developmental
Disability Organization (CDDO) provides Home
and Community Based services or direct
financial support options if the child is
determined eligible.
▫ The MR/DD waiver waiting list is lengthy, and the child
must be five years or older.
• Resources for organizations that work directly
with schools:
▫ Neurological Disabilities Support Project at
www.ksndsp.org and
▫ Project Stay at www.projectstay.com
RESOURCES
• Children’s Mercy and KUMC specialize in
Autism Spectrum Disorder evaluation.
▫ There are also developmental pediatricians with
expertise in this area.
• The Kansas Center for Autism Research and
Training (K-CART) offers clinical services
through its alliance with the Center for Child
Health and Development (CCHD) at KUMC.
RESOURCES
• K-CART (Kansas Center for Autism Research
and Training) offers training for service
providers and school district personnel for
implementation of social skills for ASD at
http://kcart.ku.edu/autism_training/
• Challenging Behaviors: CCHD Developmental
Disabilities Pediatric Problem Behavior Clinic at
www.kumc.edu/cchd or 913-588-5900 (Social
Skills Groups available)
RESOURCES
• The Autism Alliance of Greater Kansas City has
compiled a resource directory that lists services
by topic.
▫ Go to http://www.kcautismservices.com/
• Keys For Networking
▫ www.keys.org
• Families Together – Parent to Parent support
▫ www.familiestogetherinc.org
Screening Tools
• The Childhood Asperger Syndrome Test (The
CAST):
▫ Preliminary development of a UK screen for
mainstream primary school age children.
• Modified Checklist for Autism in Toddlers (MCHAT):
▫ An initial study investigating the early detection of
autism and pervasive developmental disorders.
• Australian Scale for Asperger’s Syndrome
(ASAS): ** Revised version upcoming. **
Screening Tools
• Autism Spectrum Disorders in Adults Screening
Questionaire (ASDASQ)
• Autism Spectrum Screening Questionnaire
(ASSQ):
▫ Screening questionnaire for AS and other highfunctioning spectrum disorders in school age
children.
• Asperger Syndrome Diagnostic Scale (ASDS)
• Asperger Syndrome Diagnostic Interview (ASDI)
Screening Tools
• Sensory Profile, Checklist Revised
• The Adult Asperger Assessment, or AAA, uses
two screening instruments, the Autism Spectrum
Quotient (ASQ) and the Empathy Quotient (EQ):
▫ the original research was conducted at the
Cambridge Lifespan Asperger Syndrome Service
(CLASS) in the United Kingdom.
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