Autistic Spectrum Disorder Dr Latha Hackett Consultant in Child and Adolescent Psychiatry latha.hackett@cmft.nhs.uk

1. Autistic Spectrum Disorder Dr Latha HackettConsultant in Child and Adolescent Psychiatrylatha.hackett@cmft.nhs.uk Central Manchester and Manchester Children’s Hospital NHS Trust

2. Aims and Objectives • To gain a basic understanding of autism • To think about how people with autism behave and see the world • To consider tips for working with people with autism • To know who to contact for advice • To be aware of what further training is available Central Manchester and Manchester Children’s Hospital NHS Trust

3. What is Autism? ‘Autism is a lifelong developmental disability that affects the way a person communicates and relates to people around them’ National Autistic Society Central Manchester and Manchester Children’s Hospital NHS Trust

4. : Other related terms include: • Autistic Spectrum Disorder (ASD) • Pervasive Developmental Disorder (PDD) • Autism • Asperger’s Syndrome • High functioning autism • ICD 10 , DSM IV and other classificatory system Central Manchester and Manchester Children’s Hospital NHS Trust

5. You might see a child who has … • Difficulties with social interactions • Difficulties communicating • Difficulties with imagination and flexible thinking Central Manchester and Manchester Children’s Hospital NHS Trust

6. Triad of Impairments Social Interaction Communication Imagination and Flexible thinking Central Manchester and Manchester Children’s Hospital NHS Trust

7. What does it mean to have difficulties with social interaction? Children with social difficulties: • Cannot guess what others are feeling • Cannot guess what others are thinking • Find it hard to pick up on cues around them • Do not make/makes odd eye contact • May isolate themselves, play on their own Central Manchester and Manchester Children’s Hospital NHS Trust

8. And………………. • May find it hard to take turns • May be on the edge of a group - look like he/she wants to join in but does not know how • May not know when to listen • May not know who to listen to • May find it hard to tell or show you how they feel Central Manchester and Manchester Children’s Hospital NHS Trust

9. What does it mean to have difficulty communicating? • May be delayed in communication • May have difficulties understanding the rules of language • May take other people to what they need rather than ask for it • May speak in monotone and/or with odd pitch Central Manchester and Manchester Children’s Hospital NHS Trust

10. And……………….. • May be a good mimic • May not understand what you need to know - give too much or too little information • May take things literally e.g. pull your socks up Central Manchester and Manchester Children’s Hospital NHS Trust

11. What does it mean to have difficulties with imagination and flexible thinking? • May find it hard to play at all • Might only be interested in a few things • These interests may seem very odd • Might be obsessive about the special interest • Might find it hard to predict what’s going to happen next Central Manchester and Manchester Children’s Hospital NHS Trust

12. And…………………. • May find it hard to switch to new activities • Might be overwhelmed by too much choice • Is likely to find concrete ideas easier to understand Central Manchester and Manchester Children’s Hospital NHS Trust

13. In addition ….children with autism may • Have a love of routines • Be extra / super sensitive to - noise, touch, sight, taste and smell • Be less sensitive to - noise, touch, sight, taste, smell and pain • May have associated behaviour problems e.g. with sleeping, eating and toileting Central Manchester and Manchester Children’s Hospital NHS Trust

14. And………………….. • May have a learning disability • May engage in repetitive movements e.g. rocking and twirling • Have difficulties with co-ordination and motor movement • Have difficulties transferring skills Central Manchester and Manchester Children’s Hospital NHS Trust

15. The Autistic Spectrum Everyone with autism: • will have problems with social interaction, communication and imagination / flexible thinking But: • not everyone with autism looks the same or behaves the same e.g. some people with autism will be able to make eye contact better than others Central Manchester and Manchester Children’s Hospital NHS Trust

16. What is the “Spectrum” of Autistic Spectrum Disorder. ID No ID No Lang delay Childhood Autism Asperger’s Syndr Atypical Autism PDD NOS/U Autistic Spectrum disorder

17. Childhood Autism • Diagnosed in Childhood • Have the triad of impairment • Significant learning difficulty • Usually recognised by the age of three and diagnosed preschool • Atypical Autism – age or not all features of the triad but has significant learning difficulties

18. Asperger’s Syndrome • Asperger’s syndrome is a form of autism, a condition that affects the way a person communicates and relates to others. • People with Asperger’s syndrome may find difficulty in social relationships and in communicating, and limitations in social imagination and creative play. • There is usually no significant delay in language ( single words by two yrs and communicative phrases by 3 yrs) • No significant learning difficulty • May have coordination difficulties • 8/9:1 Boy:Girl

19. Asperger’s Syndrome • No language delay, IQ in the average range or above • Pedantic style of speech • Precocious vocabulary development • Narrow interests e.g flags of the world, weather maps, history of the railway etc • Preference for adult company rather than peers • Bossy and controlling • Social oddities that might appear as social withdrawal or as social intrusiveness • A desire for things to be done in the same way over and over again • An excellent attention to and memory for detail

20. What is PDD? • Pervasive developmental disorder is the umbrella term for all autistic and autistic like conditions. • There is some confusion over the use of the diagnostic term PDD-NOS. This should only apply where all other diagnostic terms have been discarded already. • Debates as to what is the best diagnostic term to use are likely to continue

21. Has my Child got a mild form of Autism or how severe is his Autism? • A child is diagnosed as having ASD - if he has all the criteria for ASD – the triad of impairment +age of onset. • There is no mild or severe autism • A child either has ASD or not. • ASD – Childhood Autism, Asperger’s syndrome, PDDu (PDD NOS) • Impairment – Learning difficulties, behaviour problem, has insight into his difficulties, temperament etc.

22. A Typical 10 Minutes……….. It was Saturday morning and I was feeling quite tired as Beth had woken twice during the night and luckily I had managed to get her back to sleep without disturbing Carly. Had Carly been disturbed she would have been very cross and would have started shouting. There is always a lot of noise in our house but not with the children talking or interacting with each other. Carly is in her bedroom listening to her STEPS CD and singing along to it, as this gives her great pleasure. Craig is watching SKY Sports but is disturbed by Beth who wants to watch the Disney Central Manchester and Manchester Children’s Hospital NHS Trust

23. ……………………………….. Channel. Beth is walking round in her pyjamas with her tape recorder to her ear playing the same two seconds of music over and over again. Craig obliges Beth although he is biting his finger in frustration. Beth watches two minutes of Disney, then goes to her room where she watches two or three seconds of video over and over again. This pattern will continue. Beth attempts to go into Carly’s room and Carly angrily chases her away and slams the door. Central Manchester and Manchester Children’s Hospital NHS Trust

24. A for Autism Video

25. Experiences of ASD ‘it is like seeing the world through a kaleidoscope and trying to listen to a radio station that is jammed with static at the same time. Add to that a broken volume control, which causes the volume to jump erratically from a loud boom to inaudible’ ‘rocking and spinning were . . ways to shut out the world when I became overloaded with too much noise’ (Temple Grandin, 1992)

26. ASD - Strengths • Feeling that you are on the wrong planet • Unable to understand why people behave as they do • Temple Grandin • Good rote memory • Special interest can be beneficial • Persistent – carry on where others may give up • May have high energy levels • Can be perfectionists – useful in scientific matters • Slow physical ageing (Chris Gillberg) – look young when old though looked old when young

27. What Causes Autism? • The exact cause or causes of autism is/are still not known. • But research shows that genetic factors are important. • It is also evident from research that autism may be associated with a variety of conditions affecting brain development which occur before, during, or very soon after birth.

28. What causes Autism? 10-15% are associated with medical disorders • Epilepsy • Fragile X Syndrome - 4% higher than general population • Tuberous sclerosis – 50% of TS have Autism, small % of Autism have TS • Gilles de la Tourette Syndrome 10% with Autism have vocal or motor tics • Rubella embryopathy • Smith-Lemli-Opitz Syndrome – Gen dis defect in cholestrol synthesis. 75% have Autism • Duchenne Muscular Dystrophy – X linked recessive degenerative NM disorder. Sometimes ass with Autism

29. Psychiatric conditions, Developmental difficulties • Depression: 50% of AS • Anxiety – social anxiety • Obsessive compulsive disorder • Anorexia – AS girls • Psychosis & Schizophrenia – rare • ADHD, • Learning difficulties

30. And…. • Mild prenatal, perinatal and neonatal factors associated with autism • Mild obstetric difficulties sometimes associated with autism - are considered a consequence of abnormal fetal development or genetic risk for autism rather than the cause

31. Fetal testosterone and autistic traits (2009 press release) • Cambridge group claiming that if there is raised testosterone in the amniotic fluid correlated to high scores on CAST & AQ- Child. • Prenatal androgen exposure is related to children exhibited more autistic traits • 1996-2001, n=248 • Mothers who had amniocentesis • age studied 6-10 • Autistic traits studied with CAST & AQ-child • This is a small study, population who have had amniocentesis so skewed group and needs replication

32. How Common is Autism? • Approximately 1 in 100 people are thought to be on the autistic spectrum • More boys than girls (4:1, 9:1) • 39%have childhood Autism and 61% have ASD’s . • In Manchester, recent figures suggest approximately 50-60 children a year are receiving a diagnosis of ASD in each of our three services • Numbers are rising :

33. Increased incidence • Improved recognition & detection • Changes in study methodology • An increase in availability of diagnostic services • Increased awareness among professionals and parents • Growing acceptance of Autism as comorbid with other conditions • Widening of diagnostic criteria

34. Genetics of Autism • About 4-5% recurrence rate amongst siblings (0.2% in general population) • Twin studies -Identical twins higher (60-90%) than non-identical twins (4-5%) • Genetic findings point to multiple interacting genes - complex genetic etiology • Chromosomes 2, 7, 22 and 15 have been implicated in autism

35. MMR & Autism • Definitive study, Japan 2005. Rutter et all. • Japan had stopped MMR in 1988 (Meningitis scare from the strain they used). • Study of 37,426 children, 88-96. • There was a steady increase in ASD diagnosis from 48/10,000 in 1988– 117/10,000 in 1997. • A Study in London 2003 – had concluded the same. • THERE IS NO LINK BETWEEN MMR & AUTISM

36. Psychological Theories • Try to explain how the individual with Autism thinks and behaves the way they do • 2 Main current psychological models • Theory of mind (Simon Baron-Cohen 1995) • Central Coherence Deficit (Frith 1989) • Executive dysfunction theory

37. Lack of Theory Of Mind (TOM) (‘Mindblindness’) • Inability to put your self in someone else’s shoes • can’t read/understand other’s behaviour and use this to predict their intentions/motives • Sally Anne test • Other people are unpredictable - solitary • lack of empathy – understanding other’s feelings as can’t imagine what it is like to be them/feel that way • Reduces the desire to please others – can’t understand their pleasure • Can’t judge what others need to know

38. Central Coherence Deficit • Inability to draw information together into a coherent whole and filter out the irrelevant • Lost in the detail – causes sensory overload • Desire for sameness/routine reduces sensory onslaught • Difficulties problem solving • Unusual focuses of attention • Avoid new situations/people/things • Difficulties choosing • Difficulties with connections, learning & generalising skills • Islets of abilities, sensory sensitivities (implications)

39. Executive Dysfunction Theory • EF – Ability to control action: Motor, attention & thoughts • Creating plans, executing plans, staying on topic and shifting attention • Core dysfunction: Inability to plan actions & shift attention, repetitive beh – inability to multi-task

40. How is Autism Diagnosed? • There is no one test for autism – a range of information has to be gathered to make a diagnosis: • Medical history; behaviour in different settings; developmental history • Other medical condition that may present with similar characteristics have to be excluded • Diagnosis is usually made by specialists working within Child and Adolescent Mental Health Services (CAMHS) • In Manchester there are now 3 Multi-agency teams -Social Communication Assessment and Intervention Teams (SCAIT), set up to carry out the assessment and diagnosis of autism • The teams consist of: • child psychiatrist, clinical psychologist, educational psychologist, mental health practitioner, specialist speech and language therapist, community paediatrician, Out reach teachers from Rodney house and Specialist school – Birches, Melland & Grange, & Preschool Autism workers.

41. Magnetic Resonance Imaging- Assisted diagnosis of ASD • August 11th 2010 J. Neurosciences • Study based in London • Gray Matter anatomy in adults with ASD • 5 morphological parameters were used • 20 adults with ASD through clini research programme • 20 controls via adverts • 20-68 years range • ASD diagnosed by Adult ASD team ICD 10 criteria – 85% by ADI R, 15% by ADOS – memory of parents for ADI the older the participant. Only 2 had ADI+ADOS scores • 16 ASD did not have delay in language – AS • Weakness: adults, MRI is still in its infancy for such assessments, very small numbers

42. Treatment for Autism • Education and Management of behaviours • Various therapies tried –No evidence that it works • No single approaches have been found useful

43. Treatments offered In Manchester • Psycho-education for parents and school • Behavioural intervention/Cognitive behavioural therapy • Riding the rapids – parent training • Communication workshops for parents/school – visual time tables, picture exchange communication etc • Social understanding group/Skills groups • Transition groups • Medication in a few- associated difficulties such as sleep and Attention Deficit hyperactivity disorder etc

44. Prognosis for Autism • Autism is not curable but is treatable. The following children with Autism do manage better: • Children who achieve language by the age of 5 • Children who are cognitively able • Children diagnosed early • Right educational intervention • Parents/Carers who understand their child’s needs

45. FAQ’s – Facts and Myths • It is not a mental illness • It is not a middle class disorder • It is not due to parental rejection ‘refrigerator mother’ • Autism is not about being a genius • It is not curable

46. FAQ’s – Facts and Myths • Withdrawing from immediate surroundings? • Associated with Epilepsy? • Passed from one generation to another? • Having challenging behaviours? ......... May be

47. FAQ’s – Facts and Myths • A developmental disorder • More likely in boys than girls • Finding it difficult to see things from other’s point of view • Associated with unusual responses to sensory stimuli ........all true

48. Frequently asked Question? • Should I tell my child? • When should I tell my child? • How should I tell? • What should I tell? • Talking together about an autism diagnosis. Rachel Pike NAS

49. Interventions offered • Post diagnostic Autism Workshop (CAP,CP, EP, SLT, NAS, MAP, Com Paeds) x 5 two hour sessions • Behavioural Strategies & Communications workshops for parents • Communication workshops for Preschool children and their parents. (SLT) • Social Understanding groups (CP, SLT) • Post diagnostic school support (EP) • Medication Central Manchester and Manchester Children’s Hospital NHS Trust

50. Who can I contact for advice? Education Health SSD Voluntary Central Manchester and Manchester Children’s Hospital NHS Trust