Autistic Disorder

26 September 2014

Dr. Ronnie Gundelfinger Zentrum für Kinder- und Jugendpsychiatrie Universität

Zürich

Definition of the Autistic Disorder by Leo Kanner 1943

Autistic Disturbances of Affective Contact

•  Inabilty to make social connections •  Inability to use language for the purpose of

communication •  Compulsive desire to keep sameness •  Fascination for objects •  Onset of symptoms before the age of 2 ½ J

•  (normal cognitive abilities)

Hans Asperger

•  “ The nature of these children is revealed most clearly in their behaviour towards other people. Indeed, their behaviour in the social group is the clearest sign of their disorder and the source of conflicts from earliest childhood.”

The autistic spectrum

severe mild

Severity of the autistic symptoms

autistic atypical Asperger disorder autism Syndrome

Definition of autism spectrum disorders

•  Qualitative impairment in reciprocal social interaction •  Qualitative impairment in verbal and nonverbal communikation •  Restricted interest and repetitive patterns of behaviour •  Onset before age 3 years

•  (unusual sensory interests)

Epidemiology

Meta-Analysis 2012

•  autismus spectrum disorders ASD 0, 7 % or 1 : 140

•  Autistic disorder AD ca. 1/4 •  Atypical autism PDD-NOS ca. 1/2 •  Asperger Syndrome AS ca. 1/4

55 % of the cildren with ASD have a normal IQ 30 % of the children with AD have a normal IQ

•  Sex ratio •  Mental retardation •  Epilepsy •  Multi-case families •  ASD with neurological disorders like Tuberous sclerosis,

Fra-X syndrome,

•  extreme prematurity •  Age of parents •  Medication during pregnancy •  Infection during pregnancy, eg rubella •  Effect of folic acid

Is there a biological reason for autistic disorders ?

Diagnosis

Categorial diagnosis <-> Dimensional diagnosis

Psychiatric diagnosis

•  No measurable changes (lab tests, EEG, MRI ……) •  no biomarkers •  only behavioural symptoms

Suspicious symptoms during the 1st year of life

•  Difficulties in the Parent- Child Interaction –  Acoustic:

•  Little reaction to parents‘ voice •  No reaction to name calling •  Very few preverbal sounds

–  Visual: •  Missing or unusual eye contact

–  Tactile • Unusual reaction to touch or body contact

The 1st year – a closer look

•  Studies with siblings of children with ASD

•  Until the age of 6 months –  clinicians can‘t see a difference between the children who later

develop ASD and the children who don‘t.

–  The worries of the parents of the children who later develop ASD and the healthy children don‘t differ.

The 1st year – a closer look

•  Healthy children will show a steady increase in directed social and interactive behavior between 6 and 12 months of age, whereas children with ASD show very little or no increase and in some instances even a loss of these behaviors.

The 1st year – a closer look

•  13 siblings who will later develop ASD

–  At 6 months 1 child with concerns –  At 12 months 5 children with concerns –  At 18 months 3 children with diagnosis, all

others with concerns –  At 24 months 8 children with diagnosis –  At 36 months all children with diagnosis

The 1st year – an even closer look

The search for a biological marker

•  Eye tracking differentiates between children with ASD and controls after 2 months

•  Children with ASD look less at the eyes and more at the mouth or at objects

•  The less children look at eyes and the more they look at the mouth, the more autistic signs they will show at 24 months

The 1st year – an even closer look

•  After birth and during the first weeks there is no difference in eye tracking!!

•  Children with ASD have the same inborn reflex to look at the eyes

•  This behavior stabilizes and increases in normal children, but it decreases in children with ASD

•  Hypothesis: There is a lack in reinforcement

Suspicious symptoms during the 2nd year of life

•  Delay in speech development •  No sharing of the world with others (joint attention)

–  No pointing towards interesting objects –  No bringing of objects in order to show them –  No looking at parents‘ face for social clues –  No joint looking at pictures

•  Lack of imitative play •  Very little or unusual nonverbal Communication •  Loss of verbal or social competencies

Suspicious symptoms after the 2nd year of life

•  Little interest in other children •  Missing or unusual language •  Repetitive and restrictive play behaviour •  Little interest in picture books or stories •  Fascination for rotating or glittering objects •  Unusual hand or body movements •  Hyper- or hyposensitivity to sounds, smells or touch

Diagnostic tools

•  Screening –  CHAT, Checklist for Autism in Toddlers –  M-CHAT, Modified CHAT –  VSK, Questionnaire on Behaviour and Social Communication –  ASSQ, Autism Spectrum Screening Questionnaire

•  Interview –  ADI-R, Autism Diagnostic Interview – Revised –  ASDI, Asperger Syndrome Diagnostic Interview

•  Play observation –  ADOS, Autism Diagnostic Observation Scale –  CARS, Childhood Autism Rating Scale

Diagnostic problems

•  autism or mental retardation (intellectual disability)

•  autism or developmental language disorder

•  autism or severe deprivation (Roumanian orphans)

Incidence of ASD in children and adolescents with mental retardation

N= 825 56 % mild MR, 44 % severe MR

•  ADI-R: mild MR 11.3 % AD severe MR 21.5 % AD

•  ADOS-G: mild MR 5.8 % AD 4.4.% AA

severe MR 25.6 % AD 6.6 % AA

•  DSM-IV: mild MR 3.0 % AD

6.3 % AA severe MR 16.1 % AD 9.9 % AA

Autism from 2 to 9 Years of Age

•  192 children (2-3 years) were evaluated for possible autism –  49 % were diagnosed with autism –  28 % were diagnosed with atypical autism –  25 % were not diagnosed with a autism-spectrum disorder

•  At age 9 –  58 % were diagnosed with autism –  20 % were diagnosed with atypical autism –  22% were not diagnosed with a autism-spectrum disorder

Only 1 of 84 children diagnosed with autism and 10 % of the children diagnosed with atypical autism at age 2 did not receive an autism-spectrum diagnosis at age 9 !

The Modified Checklist for Autism in Toddlers (M-CHAT)

Robins et al. 2001

23 questions, 6 or more positive answers are indicative of a high risk for autistic disorder

6 critical items, 2 or more positive answers are

indicative of a high risk for autistic disorder

•  Does your child ever use his/her index finger to point, to indicate interest in something?

•  Does your child respond to his/her name when you call? •  Does your child take an interest in other children? •  Does your child ever bring objects over to you to show you

something? •  If you point at a toy across the room, does your child look at it? •  Does your child imitate you (e.g. When you make a face)?

Early intensive intervention

•  Behavioural models:

–  Applied Behavioral Analysis (ABA) – UCLA – Modell (Lovaas) –  Verbal Behavior (Carbone) –  Early Start Denver Model (Rogers und Dawson)

•  Others: – Mifne (Alonim) –  FIAS (KJPD Basel) –  Floor Time (Greenspan und Wieder) –  PLAY (Solomon) – Option (Kaufmann) – RDI (Gutstein)

Early intensive behavioural intervention – the Zurich model

1:1 home treatment 25-35 hours per week 2-3 years Based on Ivar Lovaas‘ work Individual program for every child and family

The Transporters

medication

•  Pharmakotherapy has been disappointing •  There are no autism – specific drugs

•  Situation concerning neurotransmitters is complex •  no good animal model

medication

For comorbid symptoms or disorders •  hyperactivity and attention problems

–  stimulants, eg Ritalin, Concerta –  Strattera

•  aggressive, self injurious or extremely hyperactive behaviour –  antipsychotics, eg. Risperdal, Abilify, Dipiperon

•  depression, anxiety or compulsive symptomes –  SSRI, eg. Fluctine, Zoloft

•  Sleep disorders –  Melatonin

films

•  Temple Grandin

•  Mozart and the whale

•  Snow cake

•  Adam

•  Rain Man

•  Extremely loud and incredibly close

Internet

www.autismus.ch

www.tonyattwood.com

Youtube Beiträge zu Temple Grandin Peter Schmidt Nicole Schuster Daniel Tammet

TED