Download Assessment for Autistic spectrum disorder

Assessment for Autistic
spectrum disorder
Dr Salma
Consultant paediatrician
Objectives of presentation
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What is autism
Signs and Symptoms of Autism
Assessing for ASD
Aspergers
Management of Autism
Prevalence
• 116.1per 10,000 in Thames region of
London in 2006
• 500,000 people in UK have autism
• No association with social class or
ethnicity
• M:F 4:1
Autism
• Autism affects the
way in which people
understand and react
to the world around
them
Social
interaction
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Repetitive
and
stereotyped
behavior
communicatio
n
Autism History
• Eugene Bleuler in 1912 coined the word
autism
• 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
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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
autism
• Learning difficulties
• Epilepsy
• Psychiatric disorders (depression,mental
health, anxiety)
• ADHD
• 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
life
• The average age of dx in UK not till 6
years
• 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
months)
• 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
studies)
• 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
programmes
• muddling up 'I' and 'you'
• problems with understanding questions,
particularly questions involving 'how' and 'why'
• difficulty following conversations
DSM criteria for diagnoses of
autism
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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, as manifested by at least two of the
following:
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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 )
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(B) qualitative impairments in communication as manifested by at least one of the following:
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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
others
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
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(C) restricted repetitive and stereotyped patterns of behaviour, interests and activities, as
manifested by at least two of the following:
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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
movements)
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
Disorder
New DSM 5 criteria
• Elimination of term pervasive
developmental disorder
• Elimination of term Aspergers
Asperger
• 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
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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
Toddlers)
• can be done by GP
or health visitor
• done at 18 months
check
• not a diagnostic tool
• If a child fails first test
needs to be repeated
after one month
CHAT questions for parents
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A1 Does your child enjoy being swung, bounced on your knee, etc. ?
YES/NO
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A2 Does your child take an interest in other children ?
YES/NO
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A3 Does your child like climbing on things, such as stairs ?
YES/NO
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A4 Does your child enjoy playing peek-a-boo / hide and seek ?
YES/NO
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A5 Does your child ever PRETEND , for example to make a cup of tea using a toy
cup and teapot, or pretend other things ?
YES/NO
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A6 Does your child ever use his/her index finger to point, to ASK for something.?
YES/NO
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A7 Does your child ever use his/her index finger to point, to indicate INTEREST in
something ?
YES/NO
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A8 Can your child play properly with small toys (e.g. cars or bricks) without just
mouthing, fiddling or dropping them ?
YES/NO
A9 Does your child ever bring things to you (parent) to SHOW you something. ?
YES/NO
CHAT section B to be observed by
GP or HV
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Bi During the appointment has the child made eye contact with you
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YES/NO
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 ?
YES/NO*
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. ?
YES/NO**
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 ?
YES/NO***
Bv Can the child build a tower of bricks ? If so how many. (No of
bricks.........)
YES/NO
Autism Diagnostic Observation
Studies
• Module1: pre
verbal/single words
• Module 2: phrase
speech
• Module 3: fluent
speech
child/adolescent
• Module 4: fluent
speech
Adolescent/adults
ADOS
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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
age.
• Selected module administered for 30-60
minutes
• 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
3DI
• 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
ADI-revised
• Detailed interview about development and
history of the child. General 2-3 hours
Strengths of ADOS:
• Direct observation of child to have a clear
picture
• Standardized procedure currently
available
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
behaviour
• Does not differentiate Aspergers
• Subjective marking
3DI
• 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)
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TOPS (Thomas outreach project)
Early Bird
Auditory integration training
Music
OT
Pharmacological interventions
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Risperidone
Methylphenidate
Melatonin
Fluoxetine
Multidisciplinary involvement
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Parents
Paediatrician
Pschycologist
Speech and language therapist
School
Occupational therapist
Case study
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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
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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
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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
Conclusion
• Awareness about autism is increasing
• Age of dx is decreasing
• Autism is a neurodisability with increased
prevalence
• Early diagnoses is important
• None of the method is diagnostic of autism
• School report is an integral part of assessment
• Dx is multidisciplinary
Questions?
Thanks for listening