Download Asperger`s Syndrome talk

ADHD & Autistic Spectrum
Disorders
- in the Dentist’s Chair
Irish Society for Disability
and Oral Health
24th June 2011
Fiona McNicholas
Professor Child & Adolescent Psychiatry,
University College, Dublin
Consultant Lucena Clinic, Tallaght & Our
Lady’s Hospital for Sick Children, Crumlin
Overview of talk
• Signs & Symptoms of ADHD, Dyspraxia
& ASD
• Treatment considerations
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Setting the scene
Autism
Development of Concept
Kanner
Asperger
Creak
Kolvin
1961
1971
"Autistic Disturbances of Affective Contact"
1943
FIRST GENERATION
DESCRIPTIONS
1944
Donald T. was not like other five-year-old
boys.
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Donald's father wrote to Kanner describing his son as “happiest
when he was alone... drawing into a shell and living within
himself... oblivious to everything around him.” Donald had a
mania for spinning toys, liked to shake his head from side to side
and spin himself around in circles, and he had temper tantrums
when his routine was disrupted.
In addition to the symptoms the letter described, Kanner noted
Donald's explosive, seemingly irrelevant use of words. Donald
referred to himself in the third person, repeated words and
phrases spoken to him, and communicated his own desires by
attributing them to others.
Kanner described Donald and ten other children in a 1943 paper
entitled, Autistic Disturbances of Affective Contact
In this initial description of ‘infantile autism, which went on to
become a classic in the field of clinical psychiatry, Kanner
described a distinct syndrome instead of previous depictions of
such children as feeble-minded, retarded, moronic, idiotic or
schizoid.
"Wild Boy of Avalon."
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Jean-Marc-Gaspard Itard
• French Physician born in Provence (17751838)
• Described and treated Victor who showed
several signs of autism and is thought to have
lived his entire childhood alone in the woods
near Saint-Sernin-sur-Rance, France in 1797.
• Itard treated him with a behavioral program
designed to help him form social attachments
and to induce speech via imitation.
Development of concept
Kanner
Asperger
Creak
Kolvin
FIRST GENERATION
DESCRIPTIONS
1979
DSM IV Criteria
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(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)
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(A) Qualitative impairment in social interaction (>2/4)
• 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
• Failure to develop peer relationships appropriate to
developmental level
• 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)
• Lack of social or emotional reciprocity
DSM IV Criteria
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(B) Qualitative impairments in communication (>1/4 )
• 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)
• In individuals with adequate speech, marked impairment in the
ability to initiate or sustain a conversation with others
• Stereotyped and repetitive use of language or idiosyncratic
language
• Lack of varied, spontaneous make-believe play or social
imitative play appropriate to developmental level
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Example of Concrete
use of languagepragmatic difficulties
DSM IV Criteria
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(C) Restricted repetitive and stereotyped patterns of
behavior, interests and activities (>2/4)
• Encompassing preoccupation with one or more stereotyped
and restricted patterns of interest that is abnormal either in
intensity or focus
• Apparently inflexible adherence to specific, nonfunctional
routines or rituals
• Stereotyped and repetitive motor mannerisms (e.g hand or
finger flapping or twisting, or complex whole-body
movements)
• Persistent preoccupation with parts of objects
DSM IV Criteria
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(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 Disorder
Aspergers:
• Absence of delayed language single words
by 2, phrased speech by 3
• Normal IQ
Problems of
Syndrome Definition
Children don’t
often fit into neat
boxes!
“Nature never draws a
line without smudging it”
Lorna Wing
THE GRAPHIC EQUALISER MODEL
OF AUTISM
HIGH FUNCTIONING AUTISM
Normal
Mod. Impaired
Sev. Impaired
IQ
FORMAL
LANGUAGE
COMMUNICATIVE
INTENT
SOCIAL
INTERACTION
THE GRAPHIC EQUALISER MODEL
OF AUTISM
AUTISM AND LEARNING DISABILITY
Normal
Mod. Impaired
Sev. Impaired
IQ
FORMAL
LANGUAGE
COMMUNICATIVE
INTENT
SOCIAL
INTERACTION
Sensory difficulties
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Some children with ASD also have sensory
difficulties.
•
•
•
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Preference for over or under stimulation.
Over sensitive to light, or touch
Higher (or lower) pain threshold
Motor co-ordination problems
Anxiety 65%
Self-injury/aggression 43%
Obsessions and compulsions 40%
Depression 31%
ADHD 30%
Sleep disorder 11%
Tics /Tourettes 8%
Gringras
PREVALENCE
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Apparent increase in prevalence since
early 80’s
•
1 per 1000 Autism
•
>2 per 1000 ASD
Recent studies
•
Cumulative incidence rate to age 7
years of 89/10,000 (Honda et al.
2005)
•
5-16 years 90 /10,000. Male 1.4%
female 0.3% (ONS British Survey of
Child and Adolescent Mental Health
Goodman et al, 2004)
•
80/10,000 Gillberg 2006
Recent increase:
•
•
•
Real or we just got better
diagnosing it?
Broader concept
Redefining LD
Proposed for DSM V
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Just one category: Autistic Spectrum Disorder
Must meet criteria 1, 2, and 3:
1. Clinically significant, persistent deficits in social communication and
interactions, as manifest by all of the following:
•
•
•
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2. Restricted, repetitive patterns of behavior, interests, and activities, as
manifested by at least TWO of the following:
•
•
•
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a. Marked deficits in nonverbal and verbal communication used for social
interaction:
b. Lack of social reciprocity;
c. Failure to develop and maintain peer relationships appropriate to
developmental level
a. Stereotyped motor or verbal behaviors, or unusual sensory behaviors
b. Excessive adherence to routines and ritualized patterns of behavior
c. Restricted, fixated interests
3. Symptoms must be present in early childhood (but may not become
fully manifest until social demands exceed limited capacities)
?? A further increase
Aetiology
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Poorly understood
Neuro-biological disorder
• Genetic
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Highly heritable
MZ>>DZ
In a family with one autistic child, the chance of having
another child with autism is about 5 percent -- or one in 20
-- much higher than in the normal population.
• Functional and structural abnormality with brain
• Occasionally Rubella, Tuberous sclerosis, Encephalitis,
Untreated phenylketonuria (PKU)
• Not due to MMR
• Gene-environment interaction
CHAT Screening Tool
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The following test can be used by a Pediatrician or Family Doctor
during the 18 month developmental check-up.
The CHAT should not be used as a diagnostic instrument, but can
alert the primary health professional to the need for an expert
referral.
During the appointment
•
has the child made eye contact with you
•
Does the child look across to see what your are pointing at?
•
Does the child pretend to pour out tea (juice), drink it, etc?
•
Does the child POINT with his/her index finger at the light
Get the child's attention, then point across the room at an interesting
object and say, "Oh look! There's a (name of toy)!" Watch the child's face.
Get the child's attention, then give child a miniature toy cup and teapot
and say, "Can you make a cup of tea?" (Substitute toy pitcher and glass
and say, "Can you pour a glass of juice?")
Say to the child, "Where's the light?", or "Show me the light.“
Can the child build a tower of bricks (blocks)? (If so how many?) (Number
of bricks....)
Rain Man
ADHD
Inattention
Hyperactivity
Impulsivity
Diagnostic criteria
(ICD/DSM)
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Over activity
Inattention
Impulsivity
Symptoms before
age 7 (6 ICD)
Pervasive across
situation
Cause impairment of
social or educational
functioning.
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Not due to PDD,
Psychotic or other
mental disorder
(anxiety, depression)
Inattention: (6/9)
• Fails to give close attention to details or makes careless
errors in schoolwork, or other activities
• Difficulty sustaining attention in tasks or play activities
• Does not seem to listen when spoken to directly
• Does not follow through on instructions and fails to finish
school work, chores or duties (not due to oppositional
behaviour or failure to understand)
• Difficulty organising tasks/activities
• Avoids, dislikes or reluctant to engage in tasks that require
sustained mental effort
• Loses things necessary for tasks
• Easily distracted by extraneous stimuli
• Forgetful in daily activities
Hyperactivity/Impulsivity (6/9)
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Fidgets with hands or feet or squirms in chair
Leaves seat in classroom or other in which sitting
is expected
Runs about, climbs excessively in situations in
which it is inappropriate (restless)
Difficulty playing in activities quietly
‘On the go’ or ‘driven by a motor’
Talks excessively
Blurts out answers
Difficulty awaiting turn
Interrupts or intrudes on others
Importance of
impulse
inhibition
Associated school problems
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Language impairment 15-75%
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Learning Disability 15-40%
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Low Self esteem
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Poor social skills
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Labeled ‘trouble maker’
Associated Family problems
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Poor relationship
with parents
• often secondary
and improves with
appropriate
intervention
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Family History
ADHD
Prevalence
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ICD 1-2 % or DSM IV 3-5%
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30-50% of children referred to child psychiatry clinics
have ADHD
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Diagnosed in boys 3-4 often than in girls
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Persists in 30-50% of patients into adolescence and
adulthood (symptom profile may change)
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Ireland: Using 5% prevalence rates
 888,310 0-15 year olds (2002 Census)
 44,415 children <15yrs with ADHD
 Increased prevalence in special schools >50%
 How many attend the dentist?
Aetiology
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Abnormal Dopamine signalling in the frontal cortex
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Deficiency of Noradrenaline in the reticular activating system
(RAS)
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the area of the brain responsible for balancing other systems
involved in learning, self-control, inhibition and motivation
Highly heritable
• Multiple interacting genes involved (DRD4, DAT1, DRD5,
DRD1)
• MZ:DZ concordance of 70-80%:30:40%
• Sibling recurrence risks 25%
• Parental ADHD 15%
• Gene-Environment interaction
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Eg maternal smoking/drinking in pregnancy
ADHD and the Brain
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Diminished arousal of the
Nervous System
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Decreased blood flow to
prefrontal cortex and
pathways connecting to
limbic system (caudate
nucleus and striatum)
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PET scan shows decreased
glucose metabolism
throughout brain
Comparison of normal brain (left) and brain
of ADHD patient.
Other symptom patterns coexist
DCD
PDD
Conduct/
oppositional
disorders
Anxiety &
depression
Tourette
ADHD
DCD, Dyspraxia & other names..
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‘Congenital maladroitness‘ (Collier 1st)
Disorder of sensory integration (Ayres,
1972)
‘Clumsy child syndrome'. (1975, Gubbay)
Minimal brain dysfunction
Developmental Coordination Disorder
(DCD)
DSM IV (WHO) Other names include:
• Developmental Dyspraxia
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listed as Specific Developmental Disorder of Motor
Function
Dyspraxia
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There are three steps involved in Praxis.
• Have an idea of what one wants to do
• Organize how to do it, sequence the steps involved
(Motor planning)
• Take action, or execute an unfamiliar motor activity
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Dyspraxia is when you have difficulty in any one
or all of these
The vestibular system important role in
• Balance, coordination, to sensory integration, and
planning and sequencing.
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Planning…
Not everything
goes according
to plan!
Developmental Coordination Disorder (DCD)
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A life-long
condition
Boys>girls
5–6% population
Impact on a wide
number of areas
Whole Body Movement, Coordination,
and Body Image
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Gross motor coordination
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Walking, running, climbing and jumping can be affected.
Poor timing.
Poor balance / Tripping over one's own feet is also common.
Difficulty combining movements into a controlled sequence.
Difficulty remembering the next movement in a sequence.
Problems with spatial awareness, or proprioception.
Difficulty picking up and holding onto simple objects – pencils.
Clumsy - knocking things over and bumping into people accidentally.
Left right confusion, Cross-laterality, ambidexterity
Trouble determining the distance between them and other objects
Some may have general hypotonia
• Fatigue is common because so much extra energy is expended while
trying to execute physical movements correctly
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Fine Motor Control
• Difficulty in handwriting,
speed, grip
• Difficulty using a knife
and fork, fastening
buttons and shoelaces,
cooking, brushing one's
teeth, applying
cosmetics, styling one's
hair, opening jars and
packets, locking and
unlocking doors, shaving
and doing housework.
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Speech and
Language Difficulties
• Difficulty controlling
breathing and phonation.
• Slow language
development.
• Difficulty with feeding.
Cognitive
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Problems with memory, esp STM
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•
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Difficulty remembering instructions
Difficulty organizing one's time
Remembering deadlines
Increased propensity to lose things
Problems carrying out tasks which require
remembering several steps in sequence
• May have excellent long-term memories
despite poor short-term memory
Sensory Integration Dysfunction
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Abnormal oversensitivity or undersensitivity to physical stimuli,
such as touch, light, and sound.
• Inability to tolerate certain textures or touch on skin
• Problems with oral toleration of excessively textured food (commonly
known as picky eating),
• Light oversensitivity
• Auditory oversensitivity
• Temperature oversensitivity.
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Undersensitivity to stimuli may also cause problems.
• Undersensitive to pain may lead to injuries
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Difficulty moderating the amount of sensory information
• Sensory overload, and panic
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Problems with perception of distance, and speed of moving
objects and people
• Problems moving in crowded places and crossing roads
• Learning to drive a car may be extremely difficult or impossible.
Issues for the Dentist
Issues for anyone attending the dentist
 What time is a good time to go?
Issues for anyone attending the dentist
 What time is a good time to go?
Issues for anyone attending the dentist
 When is a good time to go?
 Regular check ups
 Tooth ache
 Children have to go, they are taken by parents
 What time is good?
 If it means missing class, a lot of class..
 When they are not tired, hungry, sick, infectious
 When they are not missing major birthday parties
 When is a good time for the dentist to see a lot of children?
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When they are asleep!!
When they have time, are not stressed, tired, ill
When their receptionist/secretary is there
When the clinic is not over booked
Issues for Children with ASD, Dyspraxia or
ADHD
When do these children come?
 ASD group rarely verbalize complaints re. dental problems, so regular
reviews are necessary, preventative work best but they may come
with a lot of problems
 ASD children may have high pain threshold and have major dental
problems before parent is aware, making first dental appointment very
necessary but traumatic.
 ADHD children often impulsive, and increase in accidental injuries,
broken teeth, lost braces etc
 Diet of either ASD (ritualistic faddy eaters), dyspraxia (eating
problems) or ADHD (high sugar content craved) may lead to dental
carries
 Medications used may be linked with carries!
 Dyspraxic children may also have sensory under-over sensitivity which
will influence when they come
Issues for Children with ASD, Dyspraxia or
ADHD
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Need for sameness and continuity
 Same room, staff, routine, sudden or unanticipated movements may be threatening
 ADHD need for structure and space
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Invasion of personal space
 Dentists invade everyone’s personal space. Close proximity distressing in both ASD and
ADHD
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Invasive nature of oral treatment can lead to problems…
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Self-stimulating behaviour e.g. flapping, rocking, screaming
Obsessive routines
Repetitive behaviours
Unpredictable body movements
Self-injurious behaviour
Hyperactivity, quick frustration
Temper tantrums, head banging
But not all of these are necessarily problems,
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some may be coping mechanisms & best left alone
Prepare others
If you understand that the
screaming is a coping
mechanism, and can put
up with the child’s
screaming, or
mannerisms, it may be
about changing the
attitude of the people
around them
Research on Dental Health & ADHD
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Blomquist wrote a doctoral thesis on ADHD and dental
health.
• Blomqvist M, Augustsson M, Bertlin C, Holmberg K, Fernell E, Dahllöf
G, Ek U. Eur J Oral Sci, 2005
• Department of Pediatric Dentistry, Karolinska Institutet, PO Box 4064,
SE-141 04 Huddinge, Sweden. [email protected]
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Behaviour
Health
Anxiety
How do children with attention deficit
hyperactivity disorder interact in a clinical
dental examination? A video analysis.
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All children born in 1991 (n = 555) in one Swedish municipality.
Screened for ADHD.
• Twenty-two children with ADHD, and 47 controls
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The dental visit was recorded on video and analysed.
Results:
• Compared to the children in the control group, the children with ADHD
made significantly more initiatives, especially initiatives that did not
focus on the examination or the dentist.
• The children with ADHD had fewer verbal responses and more missing
responses.
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The children with ADHD had particular difficulties staying focused
on the examination.
The problems in communication resulted in less two-way
communication between the dentist and the children with ADHD
than controls.
Dietary and dental hygiene habits.
• Less night brushing:
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48% in the ADHD group 82% in the control group.
• Less morning brushing:
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48% and 75%.
• More snacking:
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Children with ADHD were 1.74 times more likely to
eat or drink more than five times a day than children
in the control group.
• Compared to controls
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Children with ADHD had a significantly higher number
of decayed, missing, or filled surfaces (DMFS, 1.0 ±
1.5 vs 2.0 ± 3.0, P = 0.032) and decayed surfaces
(DS, 0.5 ± 0.9 vs 1.7 ± 3.6, P = 0.016) age 11 (not
age 13!)
Dental anxiety
• Completed the Corah Dental Anxiety Scale (CDAS).
• Cortisol measured by four saliva samples: one before
the dental examination, one after, and two the following
morning.
• The subgroup ADHD with hyperactivity-impulsivity had
significantly lower cortisol levels than controls 30 min
after awakening and had a blunted cortisol reaction.
• The correlation between CDAS scores and cortisol
concentrations before the dental examination was
significant in both the ADHD and the control groups.
• ADHD kids do not exhibit a higher degree of dental
anxiety.
• Conclusions:
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More dental problems all round
More Reputable Research!
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‘Removal of the tonsils and adenoids
has been shown to be much more
effective than medication at
improving symptoms of ADHD. ‘
‘You are doing a disservice to your
readers by not mentioning the No. 1
most effective treatment. Oxygen is
that important!’
Cosmetic dentist writing to Dr Gott
How to Prepare
How you
communicate with
your patient
If a child doesn’t
understand the
subtleties of
communication,
teaching them is
difficult and
challenging.
Later: Techniques and
language to use-like
"Good listening" "quiet
hands"
What can you do
Session on what works
in practice
The
professionals
don’t know
everything!
Advice from some mums!
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Tip #1: Find a Reputable Pediatric
Dentist
Tip #2: Choose the Day and Time of the
Appointment Wisely
Tip #3: Talk About the Experience
Positively
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Tip #4: Read Dentist-Themed Stories
Tip #5: Watch Dentist-Themed Videos
Tip #6: Use Dentist & Teeth Coloring
Pages for Child to Color
Tip #7: Don't Delay the Appointment
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Tip #8: Keep Up with your Child's Dental
Hygiene
Tip #9: Don't Be Nervous
Tip #10: Reward Your Child for Good
Behavior at the Dentist
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Tip #11:Allow Your Child to Chew
Sugarless Gum
Where can you get
more info
Published material and
apps- In OFF WE GO &
Social stories IApps