Working with Children and Young People with Autistic Spectrum Disorders

1. Working with Children and Young People with Autistic Spectrum Disorders London Oct 20th 2008 Uttom Chowdhury Bedfordshire and Luton NHS Trust University of Bedfordshire Great Ormond Street Hospital uttom.chowdhury@blpt.nhs.uk

2. History • Leo Kanner (1943) • Hans Asperger 1906-1980 ‘autistic psychopathy’ (1944) • Lorna Wing (1981)

3. The nature of the problem DSM/ICD Deficits in reciprocal social interaction skills Deficits in the onset of language and use of language for social communication Unusual patterns of stereotyped behavior, sensory sensitivities, and restricted interests

4. Autism Spectrum Disorders

5. ICD 10 Diagnostic Criteria:Asperger’s Syndrome • no delay in language • single words by 2 years • communicative phrases by 3 years • self-help skills/adaptive behaviour during the first 3 years • motor milestones/clumsiness? • isolated special skills?

6. ICD 10 (cont) Abnormalities in at least 2 of the following: • eye to eye gaze, facial expression, body posture and social gesture • peer relationships-inability to share • response to other peoples emotions/ behaviour • spontaneous seeking to share enjoyment/ interests

7. ICD 10 (cont) Intense pattern of behaviour in at least one of the following: • Stereotyped and restricted pattern of interest • compulsive adherence to routines/rituals • repetitive motor mannerisms • preoccupation with part-objects or non-functional elements of play

8. Prevalence issues

9. Epidemiology • Autism 7-16 per 10,000 • 3.6-7.1 per 1000 children (7-16 years)- Ehlers and Gilberg 1993

10. Trends for diagnosis of autism in California Data from http://adventuresinautism.blogspot.com/2006/01/california-autism-numbers-4th-quarter.html

11. The autism ‘epidemic’ • Over the past decade - a dramatic increase in recognised cases, and controversy over the explanation • A recent study in Brick Township, New Jersey (Bertrand et al, JAMA, 2001) found up to 1% of boys with an ‘Autistic Spectrum Disorder’ • – the majority of these ‘newly discovered’ cases have normal-range IQ

12. Some myths about autism • rare • associated with demonstrable and unique brain pathology • strongly associated with mental retardation • strongly associated with regression in skills • ruled out clinically by good language skills and normal eye contact • likely to have a simple genetic substrate

13. More myths about autism • People with the diagnosis are liable to be unemployable, unmarried and often incapable of living independently • “The average child with autism will require $8 million in lifetime supervision and care” • possible meaningfully to distinguish autism from Asperger syndrome • Diagnostic classification rules are logically coherent in ICD-10 • Autism is the ‘extreme of the male brain’

14. Aetiology • Brain-size, amygdala,fusiform etc • Cognition/ Theories • Genetics-2,7,15 • ?Environment

15. Theories • Theory of Mind • Central Coherence Deficit • Executive Function Deficit

16. Motor ‘clumsiness’ • awkward in movements-soft signs • poor co-ordination • hard to write/shoelaces/knife and fork

17. Sensitivity • sound • tactile • taste • visual • smell • pain • temperature

18. Rating Scales • Autism Diagnostic Interview (Le Coueter et al 1989) • Childhood Autism Rating Scale (Schopler et al 1980) • High Functioning Autism Spectrum Screening Questionnaire (Ehlers et al 1993) • Autism Screening Questionnaire (Berument et al 1999) • Checklist for Autism in Toddlers (Simon Baron-Cohen et al 2000) • 3DI (Skuse et al, 2004)

19. % answering sometimes or often Whole sample SCDC: Response to individual SCDC questions response options: no sometimes often

20. Proposed comorbidity between dimensions of autistic behavioural phenotype ADHD SLI/PLI Conduct disorders Language & social skill impairments autism Stereotyped behaviours & restricted interests OCD Tourette syndrome Eating disorders

21. Reciprocal social interaction plotted against use of language (ADI-R algorithm) R2 = 0.61 N=816

22. Social interaction/ communication plotted against repetitive and stereotyped behaviour R2=0.37 N=816

23. The gender ratio in autism In low IQ samples it is c. 2.5:1 In autism as a whole it is c. 4:1 In higher-functioning autism and Asperger syndrome it is as high as 10:1

24. Discussion In what way were males and females different? Repetitive Behaviour. Females scored significantly lower than males on both 3Di and ADOS. Large store of factual information Preoccupation with subject of passing interest to other children Unusual interest in things that spin

25. Hypothesis One Underlying impairment (genes – brain – cognition) Emotional, social, functional, economic consequences Behavioural triad of impairments Females have the autism underlying impairment less often than males

26. Hypothesis Two Female behavioural phenotype Emotional, social, functional, economic consequences Underlying impairment (genes – brain – cognition) Male behavioural phenotype Emotional, social, functional, economic consequences

27. INTERVENTIONS

28. Intervention • Sensory and Play (holding/osteopathy/eye tracking etc) • Communication (PACT/TEACCH/PECS/RPMT) • Social Skills (TOM) • Behavioural (Functional Analysis/EIBI/ABA) • Behaviour Management (Joint Attention)

29. Intervention 1 • Sensory and Play • Holding • Cranial osteopathy • Eye tracking • Options • Auditory Integration • Etc etc etc

30. Intervention 2 • Communication • Pre School Autism Communication Treatment (PACT) • Responsive Education & Pre-Linguistic Milieu Teaching (RPMT) • Teaching and Education for Autistic and Communication Disordered Children(TEACCH) • Picture Exchange Communication System (PECS)

31. Intervention 3 • Social Skills • Social Skills • Theory of Mind

32. Intervention 4 • Behavioural • Functional Analysis • Early Intensive Behavioural Intervention (EIBI) • Applied Behaviour Analysis (ABA)

33. Intervention 5 • Behavioural Management • Parent Child Interaction • Joint Attention

34. SERVICES • Health • Social Services • Local Education Authority • Voluntary Sector

35. Health • Speech and Language • Occupational Therapy • Physiotherapy • Community Child Clinics • CAMHS • CLD

36. Social Services • Local facilities • Benefits • Specialist Child Care • Respite services • Therapy services

37. Education • Special Educational Needs • Mainstream and support • Special Schools

38. Voluntary Sector • Support Groups • Contact a Family • National Autistic Society

39. Mental Health • Psychology • Psychotherapy/Family • Speech Therapy • Classroom • Occupational Therapy • Group • Volunteer

40. Mental Health • Psychosis • Depression • Obsessive Compulsive Disorder • Anxiety • ADHD/Tics • Eating Disorder

41. Psychology • IQ • Memory • Attention • Executive Function • Behaviour Management • Anger Management • CBT (video clip)

42. Anger management • Acceptable • Biology • Costs of anger • Tips: relax, count to 10, drink water,move away, listen to music, self-talk—make list and keep in pocket

43. Tips for Parents • Don’t place child in stressful environments • Avoid surprises • Visual and concrete messages help • Be specific with praise • Role play situations • Identify feelings which your child cannot verbalize, and talk these through once the crisis has settled • Look after yourself

44. Counselling/Psychotherapy/Family • Not a cure • Treat personal issues • Better understanding of differences • Siblings

45. Classroom 1 Internal Organizational Difficulties • Make connections with previous learning explicit • Allow child time to process questions and info • Encourage active listening • Cue a child that you are going to ask question next • Visual cues, pre-recorded questions or prompt sheets • Check lists • Diaries and notebooks

46. Classroom 2 Sensory Integration • Ensure child knows what to expect in different rooms • Position in classroom/dining room • Serve food-don’t let them touch! • Non-slip mat/tray etc

47. Classroom 3 Handwriting Chairs correct height Plant feet on floor Develop upper muscle strength Graph paper Word processors/dictaphones Separate marks for content/presentation

48. Classroom 4 Attention and Impulse Control • Minimize distractions • Avoid heaters/projectors • Structured lessons with defined tasks and expectations • Break tasks into chunks • Reward good behaviour • Stressball • Highlight key words

49. Classroom 5 Motivation • Focus on strengths • Negotiate manageable targets • Make it safe to risk failure • Welcome mistakes as a way of learning • Reduce fear of criticism and any fears of looking stupid

50. Classroom 6 Homework • Lunchtime/homework club • Homework diary • Clear labelling/coding • Clear and succinct instructions • Written reminder to hand in homework