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AUTISM: Explaining The Enigma

AUTISM: Explaining The Enigma. H HSTTI, RAJSHAHI Principal & Subject based Training Courses. Dr. Mamun Hussain MBBS M.Phil PhD FCPS DEPT. OF PSYCHIATRY, RMCH. AUTISM. “The Child is Father of The Man” (WORDS WORTH: My heart leaps up) “The Childhood Shows the Man as Morning Shows the Day”

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AUTISM: Explaining The Enigma

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  1. AUTISM: Explaining The Enigma HHSTTI, RAJSHAHI Principal & Subject based Training Courses Dr. Mamun Hussain MBBS M.Phil PhD FCPS DEPT. OF PSYCHIATRY, RMCH

  2. AUTISM “The Child is Father of The Man” (WORDS WORTH: My heart leaps up) “The Childhood Shows the Man as Morning Shows the Day” (John Milton: Paradise Regained IV) AUTISM: A pervasive developmental disorder Child Development: Normal & Abnormal/Deviant

  3. Mile STONE OF MOTOR DEVELOPMENT 1.5 – 4 month: Raise head to 45 2.5 – 5 month: Roll over 4.5 – 8 month: Sit without support 05 – 10 month: Starts holding on 07 – 12 month: Crawl & creep 7.5 – 13 month: Walk holding on to furniture 9.5 – 14 month: Stand alone 11.5 – 14.5 month: Walk without assistance In first 02 years: Rapid physical & motor development By age 2: Brain 75% of adult size develops

  4. COGNITIVE DEVELOPMENT (Jean Piaget) • SENSORIMOTOR (Birth – 02 yrs): Physical Exploration of Object (Push, Poke, Mouth, Bang), Imitate, Speak & Understand simple words • PREOPERATIONAL (02 – 07 yrs): Reason intuitively, Concept of “Conservation” Not developed, e.g. 01 Sandwich -> 04 pieces or more, Taller glass -> more water. • CONCRETE OPERATION (07 – 11 yrs): Logical reasoning, Conservation of number/length/weight. • FORMAL OPERATIONAL PERIOD (11 – Adulthood): Ability to think abstractly, To reason hypothetically e.g. “KI solution” in a dish – BRIGHT YELLOW; To make yellow solution -> 04 beakers with colorless fluid.

  5. Conservation Tasks VolumeNumber LengthWeight

  6. Stage of moral development: (Kohlberg) e.g. Stealing Drug 1. Premoral – Age 07 yrs Stage 1: Obedience to rule to avoid punishment • For -> wife die, if you don’t spend money • Against -> you’d be in Jail Stage 2: Obedience for reward / favors • For -> if caught, give money ( decrease Jail sentence) • Against -> wife dies before you get out from Jail 2. Morality of conventional role conformity – Age 13 yrs Stage 3: Approval of others – ‘Good boy morality’ • For -> you’re inhuman, if you don’t steal • Against -> a dishonor to family

  7. Cont.. Stage 4: Conforming to norms to avoid censure by authority figure • For -> guilty at wife’s death ( duty was not done) • Against -> guilty for dishonesty & law breaking (while in Jail) 3. Morality of self accepted moral principle Stage 5: Obedience to law & contracts • For -> you’d lose self respect (respect of others if you don’t steal) • Against -> you’d lose respect in community. Stage 6: Morality of individual conscience • For -> you’d condemn yourself always. • Against -> you’d condemn, for not living up to your own standards of honesty.

  8. ERIKSON’S STAGE OF LIFE Social & personality development Relationship/crisis or conflict/outcome – • Birth to 1 year: With mother, Trust vs. Mistrust. • 02 year: With parents, Autonomy vs. Shame and Doubt, Self control/Self doubt/Fearfulness. • 3-5 year: With family, Initiative vs. Guilt, Purpose or direction/loss of self-esteem. • 6-11 year: With neighbor hood & school, Industry vs. Inferiority, Competence/failure to thrive.

  9. Cont.. • Adolescence: With peer groups, Identity vs. Role Confusion, ‘Who one is’/uncertainly about one’s role • Early adulthood: With partners (friendship, sex, competition, co-operation), Intimacy vs. Isolation, Deep relationship/failure to love others. • Middle age: Divided labor & shared household, Generativity vs. Stagnation, Expansion of interest/caring/with own problem only. • Old age: ‘Mankind’ ‘My kind’, Integrity vs. Despair, Satisfaction/disappointment/sense of un fulfillment/fear of death.

  10. LANGUAGE (Criteria of a language) 1. Meaning – words & sentences 2. Generativity – Rules to produce infinite statements, e.g. – The boy hit the ball (the ball were hit by the boy/ the boy didn’t hit the boy/what the boy hit?) 3. Displacement – Referring past & future events.

  11. Spoken Language 1. Phonology: a. Sound combined for words/sentence. b. Phoneme: smallest unit of sound (t/k) c. Morpheme: Smallest meaningful elements, e.g. – Pictures: Picture/s; suffix (ing); prefix(anti) 2. Syntax: Rule of combining morpheme, e.g. The boy eat (Boy the eat) 3. Semantics: (How meaning is expressed) • Concrete objects – Ball / Horse • Abstract qualities – Love / Beauty • Connotative – (Emotional meaning) e.g.- Home • Denotative – (Literal meaning) e.g.- House

  12. Development of language • Babblings: Mixture of adult – phonemes by 5-6 month • Single words: By 1st Birthday, pronounection is erratic e.g. ‘shoe’ – soo, Talk about objects which has “dynamic” quality. • Word combination: By 1-2 yrs • Sentence & complex constructions: By 2-3 yrs, Embedded sentence, ‘I see what you made’ (mother was baking cake), Tag question, ‘Dad is here, isn’t he?’

  13. THEORIES • Acquired through imitation (Leonard, Chapma 1983) • Language is innate (CHOMSKY, 1975) Have LAD (Language Acquisition Device), biologically prepared, Further development PPT (Principle & Parameter Theory or Government & Binding Theory. • Language is dependent upon cognition – Language is a tool through which children express their basic understanding of the world.

  14. IS AUTISM A NEW DISORDER? Autism throughout histories The “Blessed fools” – (UtaFrith 1989) Folk Tales – Stories of native/simple individuals • Sheikh Chilli: Love with girl Asked mother: “What’s to be done?” Answer: Throw pebble, while she comes for drawing water. Sheikh threw big stone, broke her head. (Folktale of India, Kang & kang 1988) • Gahan’s mother went to church, “pull the door behind you, if you come church. Gahan started dragging/pulling (Australia’s children oh the world, Smith 1979)

  15. History 1747: Earliest Document-Brother petitioned in court to annul Blair’s marriage/ Inheritance. 1798: The Wild Boy of Averyun-A feral child caught-“Signs of autism”. 1867 Henry Maudsley: A category of “psychoses”. 1910: Bleuler-To define symptoms of Schizophrenia. 1938: Hans Asperger-“Lecture on autistis psychopath.

  16. Cont.. 1943 Leo Kanner: “Infantile Autism”-“He wandered about smiling, making stereotyped movement with his fingers crossing them about in the air. He shook his head from side to side. Whispering or humming the same three-note tune. He spun with great pleasure anything he could seize upon to spin… when taken into a room, he completely disregarded the people and instantly went for objects, preferably those that could be spun… He angrily shoved away the hand that was in this way, or the foot that stepped on one of his blocks…” (Description of DONALD (5 yr) by Kanner, 1938) Until 1960: Maternal deprivation-“Refrigerator mothers”. Late 1960: Separated “MR” from schizophrenia. After 1980: Autism.

  17. Autism spectrum disorder • Autism • Asperger’s syndrome: language development normal up to 3 yrs, impairment later • Rett’s syndrome: in girl - head circumference decrease, loss of previously learned hand skill between 5-30 month • Childhood disintegrative disorder - normal development up to 1-2 yrs, loss of previous skill before 10 yrs e.g. language, social skill, adaptive behavior, play, motor skill, Bowel – Bladder control. • Pervasive development disorder, NOS (Atypical Autism)

  18. Epidemiology • Prevalence: 1-2/1000 (world wide) • Sex: 4-5 times in boys Etiology & Pathogenesis A. Genetic factors • 50-200 times increase in Siblings • Siblings are at risk – Communication disorder, Social skill disorder • Linkage analysis – Ch-7, 2, 4, 15, 19 • Concordance rate: MZ twin –> 36-96%, DZ twin –> 0-27%. • 1% has fragile X syndrome • 2% has Tub. Sclerosis

  19. Autistic individuals tend to use different areas of the brain (yellow) for a movement task compared to a control group (blue). Autism affects the amygdala, cerebellum, and many other parts of the brain

  20. Cont… B. Biological factors • Supports biological basis – Increase Seizure rate & MR • 70% has MR: 1/3 mild to moderate & near ½ profound • 4 – 32% grand mol Seizure • CT scan: increase ventricle • EEG abnormalities: 10 – 83% • MRI: Polymicrogyria, Hypoplasia of Cerebellar Lobules (suggests cell migration in 1st 06 month of gestation) • Also associated with Congenital Rubella, PKU, TS C. Immunological Factors: • Lymphocytes of fetus react with maternal antibodies • Damages – Embryonic neural/Extra-embryonic tissues.

  21. Cont.. D. Perinatal Factors: • Increase perinatal complication (Bleeding after 1st trimester, meconium in amniotic fluid • Increase respiratory distress syndrome in neonatal period • Increase neonatal anemia E. Neuroanatomical Factors: • At 2yr – Increase gray & white matter, Cerebral vol.( but not Cerebellar volume.) • Decrease Cerebellar Purkinje’s cell – causes abnormalities of attention/arousal/Sensory processes. F. Biological Factors: 1/3rd patient has increase plasma serotonin. G. Environmental Factors (Not confirmed): Heavy metals, pesticides, alcohol, phenols, vaccines, smoking, diesel exhaust, certain foods.

  22. CLINICAL FEATURES • PHSICAL CHARACTERISTICS – No physical signs at first glance, some has Ear abnormalities/abnormal fingerprints. • BEHAVIORAL CHARACTERISTICS • Qualitative impairments in social interaction: • Lack social smile • No reciprocal social skill • Poor eye contact • Cant acknowledge persons (parents/teachers/siblings) • High anxiety, when usual routine is disrupted • Can’t play with peers • Can’t make friends • Increase skill: visual – spatial tasks • Decrease skill: verbal reasoning • Cant infer others feeling • Can’t develop empathy

  23. Lack “Theory of mind”

  24. Repetitively stacking or lining up objects is a behavior sometimes associated with individuals with autism. A young boy with autism who has arranged his toys in row

  25. Cont.. B. Disturbances of communication & language: • Difficulty in language development & using language • Language delay • In 1st yr: decrease babbling • Emit noises in stereotyped fashion • “Word” used once( Not used for wks/months/yrs) • Echolalia • Pronoun reversals: “you want toy.” (I/you) • Decrease Articulation (some use peculiar voice) • 50% never useful speech • Particular fascination with letters/numbers • Some – HYPERLEXIA (But no comprehension)

  26. Cont.. C. Stereotyped Behavior: “Children’s playing are not sports and should be deemed as their most serious action.” (Montaigne: Essays I) • No imitative play • Often spin, bang and line up object • Attachment to inanimate object • Mannerism/grimacing • Reversal of routine: Evoke panic/fear/temper tantrum (e.g. New house, furniture change, breakfast before bath) • Palm towards face while saying ‘good-bye’ • Holding ‘object’ close to eyes • Holding photo/picture/books ‘inversely’ while showing other • While going to market/school: found bird/newspaper – (Say: ‘Bird came/ paper given’)

  27. Cont.. D. Instability of mood & affect • Laughing/crying • Sudden mood change E. Response to sensory stimuli • Over respond – sound of wristwatch • Under respond – sound/pain/normal Speaking voice • Some enjoy music(hum/commercial jingle) • Pain threshold varies also. F. Associated behavioral symptoms • Hyper kinesis, aggression, temper tantrum • Self injurious behav. – head banging/biting/hair pulling • Short attention span • Insomnia • Feeding & eating problem • Enuresis

  28. Cont.. G. Associated physical illness – RTI, GI symptoms, Febrile seizure 3) Intellectual functioning • 70-75% MR – 30% mild to moderate & 45-50% severe to profound. • 1/5th : normal nonverbal intelligent. • Unusual/precocious cognitive abilities (Splinter functions/Islets of precocity) : Prodigious rote memories, calculating abilities, hyperlexia, musical abilities.

  29. D/D & Screening DIFERENTIAL DIAGNOSIS • Other pervasive development disorder – Asperger’, Rett’s disorder • MR • Language disorder • Congenital deafness • Psychological deprivation

  30. SCREENING (When you should suspect?) • No babbling by 12 month • No gesturing (pointing, waving etc) by 12 month • No single words by 16 month • No 2- word phrases by 24 month • Any loss of any language or social skills at any age.

  31. DSM – IV CRITERIA (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)(A) Qualitative impairment in social interaction – 1. Lack of nonverbal behavior 2. Lack of peer relationship 3. Lack of sharing enjoyment 4. Lack of social or emotional reciprocity (B) Qualitative impairments in communication – 1. Delay in, or total lack of, the development of spoken language 2. 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 play or social imitative play.

  32. Cont.. (C) Restricted repetitive and stereotyped patterns of behavior, interests and activities: 1. Increase stereotyped and restricted patterns of interest 2. Inflexible adherence to specific, nonfunctional routines or rituals 3. Mannerisms (e.g. hand or finger flapping or twisting, or complex whole-body movements) (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.

  33. COURSE & PROGNOSIS • A lifelong disorder • Best prognosis: If IQ >70%; communication language by 5 - 7 yrs. • 2/3 rd Autis. adult: Handicapped (severely). • 01 - 02% normal, independent status. • 05 - 20% borderline normal status. • 04 - 32% grandmal Seizure.

  34. GOALS OF TREATMENT • To target behaviors that will improve their abilities to integrate into schools • To develop meaningful peer relationship • To increase likelihood of maintaining independent living as adults • To increase socially acceptable behavior • To decrease odd behavior symptoms • To develop verbal & nonverbal communication • To reduce disruptive behavior • To encourage self – care skills • To support & counsel the parents • Structured classroom training.

  35. MANAGEMENT 1. Management of abnormal behavior 2. Education & social services- • Special care • Residential schooling • Vocational training 3. Help for family- • To cope with distress • Genetic counseling (3% risk of further autistic child) 4. Others- • Behavior problem • Self injury • Anxiety/Depression • Hyperactivity • Epilepsy

  36. CAN WE CHANGE ?How to Accommodate the Pains & Sufferings?“If there is anything we wish to change in the child, we should first examine it & see whether it is not something that could better be changed in ourselves.” (Carl Gustov Jung 1875-1961) A. Information for parents “I here & I forget. I See & I remember. I do & I understand.”[CONFUCIUS] 1. Parental attitude- • Don’t Say:” My son is autistic.” • Say: “He has autism.” • Not handicapped, but ‘disable.” LIVING WITH AUTISM

  37. Cont.. 2. Deficiency of sensory perception • Sensory perception not harmonized in all children. • Vestibular sense – Feet should touch the floor (Otherwise nausea, fear, ear buzzing): e.g. Being on the chair while taking meal/cutting hair. • Proprioceptive sense - Walking, jumping, Holding pen, pencil, scissors, spoons, Washing hand, fixing button. • Clipping nails: ? When • Hair cutting - Not to say “Cutting”.

  38. Cont.. 3. Inability Vs Reluctanay • ‘Cannot do’ - means he is not disobedient • Use card: ‘Help / Wait’ / Picture of hand • Ask baby to show “Card” 4. Literal meaning Vs pragmatic meaning-  • To avoid Rhetorics/proverbs • Example - Not to say-“So clumsy, get it Removed”, • Say – ‘Keep your clothes away; Keep the books in right order’. • Not to say- ‘this is dog’. • Say- ‘A picture of dog’.

  39. Cont.. 5. Limitation of usage of ward- • Learned from TV: ”I won’t listen”; Then he had water • Baby, when “thirsty” says - “I won’t listen.” • Say: ‘We are hungry, so we would have meal’. 6. Picture Vs Word • “Keeping your toys aside clean hand, have meal and go for reading.” • Not understood • Say -Keep toys in the box, Wash your hand, Have meal, Start reading • More comprehensible if “picture” used.

  40. Cont.. 7. Ability Vs Limitation- • FOCUS, What he can • IGNORE, What he can’t. 8. Helping in making social relation • Ask other babies to call him in the game • Spend some time with them • Read out a story book • Say:”He likes this story”/”He has a red ball”. 9. Helping to make social interaction • Tell everybody:”How are you? What you had today”. • WHAT/WHO/WHY/HOW?

  41. Cont. 10. Knowing the cause of irritability/Aggressions. • Increase Stress • Physical cause - Food intolerance/allergy, Sleep problem, GI - symptom, Under nutrition, Illness/Trauma, Biochemical deficiencies • Psychological cause – Depression, Victim of child abuse • Unreasoning word from adults. • If sleeping problem - Sound of watch, Allergen from clothes/quilts/bed sheets, Odor from toiletries/powder/insecticides, Breathing difficulties/acidity, ‘As if going down’ (Keep pillow to raise the border/use mosquitoes).

  42. Cont.. 11. Development of gross & fine motor movements • To stand on one feet • Hop-step & jump • “Roll” on floor/carpet/grass • Give cylindrical pencil to hold by three fingers. • Make “PLAY-DOUGH”: Can make object. 12. Need to have tolerance 13. Give unconditioned love.

  43. Cont.. B. Make Visible Schedule with pictures • Putting clothes • Uses of toilets • Self care • Rules of desirable behavior (silence/questions/hallo/seeking help). • Rules of undesirable behavior • Different positions (House, school, perk, shop). • Everybody activities

  44. B. Make Visible Schedule

  45. Cont..

  46. Cont..

  47. Cont..

  48. Cont..

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