Monday, 10 June 2013

Autism and Aspergers




Autism and Aspergers

Autism



•Etiology- unknown but there are associations with physical disorders (i.e. Rubella, MMR) suggesting organic pathology

•Definition- abnormal development of language and social relationships with ritualistic and obsessional behaviours (Kanner 1943)


Characteristics

•Failure to comprehend others feelings, lack of interest in imitative or social play, and inability to seek friendships or comfort from others

•Impairments in verbal and non-verbal communication and avoidance of eye contact

•Resistance to change and limited interests


Prevalence

•Difficulties in diagnosis- especially for pre-school age children

•Prevalence rates influenced by the complex classification systems for autism and conditions along the autistic spectrum

•Increased prevalence rates due to improved diagnosis

•Estimated at 7-17 per 10,000 children


Presentation

•Onset at birth but unrecognized until 2/3 years

•Usually a delay between parent concerns and diagnosis

•The disorder occurs in boys 3/4 times more often than in girls

•First sign is lack of sociability

•By 3 years of age parents/health staff report language delay and lack of peer relationships

•Lack of empathy or capacity to reflect on social situations leads to isolation- reinforcing preference for solitary repetitive play

•Half of autistic individuals never speak- those that can show unusual use of language (i.e. intonation, stress, monotone)

•A significant proportion of autistic children have behavioural and emotional problems expressed in hyperactivity, short attention span, aggression, self-harm, anxiety/depression

•Autistic features are often present where there is a generalized learning disability

•Autism is on a spectrum of severity and is highly disabling. It is one of the least prevalent conditions seen in child mental health services, but because of the impact on family and social relationships it demands considerable resources.

•The outcome of autism is poor. There is deterioration in 50% of adolescents- some of which attributable to onset of epileptic seizures. In 30% there is some improvement in behaviour and functioning- usually when onset is later, where IQ is over 60 and speech developed by 5 years of age. This suggests early intervention is crucial.

Assessment


•Multidisciplinary assessment should include:

•Neonatal history, Early development, Parental descriptions of behaviour, Observation with parent and siblings, Physical examination for tuberous sclerosis

•Information from GP, Health Visitor, Midwife, Nursery staff, Social worker

Treatment


•Promotion of normal development- focus on cognitive, language and social skills

•Reduction of rigidity/stereotypy- gradual adjustment rather than total resolution

•Elimination of nonspecific maladaptive behaviours- (i.e. overactivity, aggression, sleep disturbance)

•Alleviation of family distress- practical support and learning problem-solving skills

•Special education provision
•Home based treatment- including family support, behavioural management, and drug treatment


Specific interventions


•Physical therapies- usually prescribed following attempts to rectify problems with behavioural approaches

•Megavitamin therapy- B6 is reported to offer a small nonspecific benefit

•Medication- Haloperidol, Naltrexone, Tricyclic Antidepressants, and psychostimulants report success but with side effects

•Auditory integration training- focuses on reducing the hypersensitivity to sound which distresses 40% of individuals

•Secretin- a hormone treatment thought to improve behaviour

Behavioural therapies

•There is no cure for autism however intensive, structured behavioural programmes have had beneficial effects

•Howlin & Rutter (1987) describe positive results from a home-based intervention consisting of behaviour modification, encouraging language and skill development, and psychological family support


Parent education/training-

•Rutter (1985) emphasises the importance of enlisting parents as co-therapists in behavioural treatments. Helping them learn problem-solving skills is important in their on-going management of current and future behavioural problems


Sibling training

•Several case studies (Celiberti & Harris 1993) describe success in helping siblings learn how to prompt and interact with their autistic sibling enabling them to elicit play and speech


Social skills training

•Despite a variety of approaches there is little evidence for benefit

•Groupwork appears to help with symbolic play and language development- in one study these gains were generalized outside the group (Kohler et al 1995)


Counselling

•Parent support is critical in helping families develop problem-solving skills

•Parent support groups organised by statutory or voluntary agencies

•Multi-agency support must be applied- respite care, financial support, etc, to offer holistic care


Educational approaches


•Benefit occurs when the child is offered a well-structured learning environment

•Individual needs must be addressed

•Special or mainstream school?- depends on the individual child and the individual school

•Parent/school collaboration crucial


Asperger’s syndrome


•Definition- still confusion between Autism and Asperger’s in DSMiv and ICD10

•Asperger’s have better cognitive and communication skills but still poor social interaction and stereotyped interests

• Prevalence- estimated higher than for Autism, but little good evidence


Presentation

•Normal intelligence but problems with social interaction

•More prevalent in boys
•Notable clumsiness

•Pedantic monotonous speech pattern

•Anxiety, low self-esteem and depression in adolescence


Treatment

•No controlled studies for treatment to date (Szatmari 1991)

•Assessment needs to highlight strengths of child

•Parent education and support to help them understand and cope

•Early identification required to intervene with social & language skills