Assessment for Autistic spectrum disorder

1. Assessment for Autistic spectrum disorder Dr Salma Consultant paediatrician

2. Objectives of presentation • What is autism • Signs and Symptoms of Autism • Assessing for ASD • Aspergers • Management of Autism

3. 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

4. Autism affects the way in which people understand and react to the world around them Autism

6. Social interaction communication Autism Repetitive and stereotyped behavior

7. 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

8. Theories about autism • Pruning theory • Opioid excess theory • Environment • Genetic • Hypersystemisizing theory and empathising theory

9. Incomplete absorption of casein and wheat produces exorphins Opioid excess theory

10. Co morbidities associated with autism • Learning difficulties • Epilepsy • Psychiatric disorders (depression,mental health, anxiety) • ADHD • Coordination problems • Sleep problems • Tics

11. Screening for ASD (Journal of Autism and Developmental disorders)Pauline A Fillipek 1999Age 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

12. 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

13. 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

14. 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

15. DSM criteria for diagnoses of autism • 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, as manifested by at least two of the following: • 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 interaction2. failure to develop peer relationships appropriate to developmental level3. 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 ) • (B) qualitative impairments in communication as manifested by at least one of the following: • 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 others3. stereotyped and repetitive use of language or idiosyncratic language4. lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level • (C) restricted repetitive and stereotyped patterns of behaviour, interests and activities, as manifested by at least two of the following: • 1. encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus2. apparently inflexible adherence to specific, non-functional routines or rituals3. 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

16. 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 forby Rett's Disorder or Childhood Disintegrative Disorder

17. New DSM 5 criteria • Elimination of term pervasive developmental disorder • Elimination of term Aspergers

18. Asperger • No language delay • Normal intellect

19. 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

20. Autism symptoms checklist • Lack of eye contact • Failure to respond • Scripting • Strange behaviour • Resistance to change • Inexplicable actions • Poor motor skills • Perfect symmetry

23. 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 (checklist for autism in Toddlers)

24. CHAT questions for parents • A1 Does your child enjoy being swung, bounced on your knee, etc. ?YES/NO • A2 Does your child take an interest in other children ?YES/NO • A3 Does your child like climbing on things, such as stairs ?YES/NO • A4 Does your child enjoy playing peek-a-boo / hide and seek ?YES/NO • 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 • A6 Does your child ever use his/her index finger to point, to ASK for something.?YES/NO • A7 Does your child ever use his/her index finger to point, to indicate INTEREST in something ?YES/NO • A8 Can your child play properly with small toys (e.g. cars or bricks) without just mouthing, fiddling or dropping them ?YES/NO • A9Does your child ever bring things to you (parent) to SHOW you something. ?YES/NO

25. CHAT section B to be observed by GP or HV • Bi During the appointment has the child made eye contact with you ?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

26. Module1: pre verbal/single words Module 2: phrase speech Module 3: fluent speech child/adolescent Module 4: fluent speech Adolescent/adults Autism Diagnostic Observation Studies

27. ADOS • Scoring on communication • Scoring on Reciprocal social interaction • Observation on play • Observation on stereotyped behaviours and restricted interests

28. 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

29. Marking for ADOSModule 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

30. 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

31. ADI-revised • Detailed interview about development and history of the child. General 2-3 hours

32. Strengths of ADOS: • Direct observation of child to have a clear picture • Standardized procedure currently available

33. 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

34. 3DI • Computer based programme • Reporting by parents

35. Interventions in Autism • PECS (picture exchange communicationssystem) • TEACHH (treatment and education of autistic and communication relatedhandicapped children) • TOPS (Thomas outreach project) • Early Bird • Auditory integration training • Music • OT

36. Pharmacological interventions • Risperidone • Methylphenidate • Melatonin • Fluoxetine

37. Multidisciplinary involvement • Parents • Paediatrician • Pschycologist • Speech and language therapist • School • Occupational therapist

38. Case study • 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

39. Case study • 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

40. Case study • 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

41. 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

42. Questions? Thanks for listening