red flag signs for autism - university of cape town · autism is a behaviourally defined disorder,...
TRANSCRIPT
Departement Sentrum • Department Centre
UNIVERSITEIT VAN DIE VRYSTAAT • UNIVERSITY OF THE FREE STATE • YUNIVESITHI YA FREISTATA
Tel (051) 401 3000 • E-mail: [email protected] • www.ufs.ac.za
Red flag signs for Autism
Paediatric Refresher Course
2011
Vinyard Hotel
Prof. A. Venter
Department of Paediatrics and Child
Health
University of the Free state
In a nutshell
Autism is a behaviourally defined disorder, characterised by qualitative impairments in:
• social communication
• social interaction
• social imagination
• with a restricted range of interests
• often stereotyped repetitive behaviours and mannerisms.
• sensory hyposensitivities or hypersensitivities to the environment are common features
2
How Common are ASDs?
• Estimates suggest that there are 1 in 100 people with an ASD and many of these having a learning disability (LD)
• About four times as many boys as girls have an ASD in the group with LD and there may be ten times as many boys as girls in the high–ability group
Source: Baird, G., Simonoff, E., Pickles, A., et al (2006) ‘Prevalence of disorders of the autistic spectrum in a population cohort of children in South Thames: The Special Needs and Autism Project (SNAP)’, Lancet. 368: 210 –215.
3
ASD DEFIES GENERALIZATION
Measured Intelligence:
Severely Impaired _______________________________________ Gifted
Social Interaction:
Aloof ______________________ Passive ____________________ Active but odd
Communication:
Nonverbal ______________________________________________Verbal
Behaviors:
Intense ________________________________________________ Mild
Sensory:
Hyposensitive ___________________________________________Hypersensitive
Motor:
Uncoordinated ___________________________________________Coordinated
4
NEUROLOGICAL ASPECTS
• CURRENT THEORIES
• Courchesne – Brain overgrowth
• Casanova – Mini Columns
• Rizolatti - Mirror Neurons
• Cerebellar dysfunction
• Amygdala
5
PSYCHOLOGICAL THEORIES
• Theory of mind
• Hyper-systemizing, assortive mating
• Central coherence problem
• Executive dysfunction 6
Introduction
1. In the past the diagnosis of autism could take several years
2. Parents of children with autism spectrum disorders (ASD) are often aware of differences in their child’s development, long before diagnosis is made
3. The notion of early intervention changing the trajectory of development, makes early diagnosis an imperative
Lord & Luyster, 2006
7
Stability of diagnosis at 2 years
(±300 subjects)
• Diagnosis made using versions of ADI and ADOS as well as a clinical impression (last most reliable)
• A non-spectrum comparison group was also recruited.
• 3 Diagnoses made: Autism, PDD-NOS, non-spectrum
• Follow-up at 2.5 and 9 years
Lord, Risi, DiLavore et al, 2006
8
Outcome:
At 9 years:
Nearly all retained diagnosis
Autism diagnosed Small minority now PDD-NOS
at 2 years 1 child now non-spectrum
At 2 years:
± 75% autism
Autism diagnosed ± 25% PDD-NOS
at 9 years 2 children non-spectrum 9
Outcome: At 9 years:
>50% autism
PDD-NOS diagnosed ± 25% PDD-NOS
at age 2 Small minority non-
spectrum
At 2 years:
± 50% autism
PDD-NOS diagnosed ± 30% PDD-NOS
at 9 years ± 25% non-spectrum
10
Lord & Luyster, 2006
Best predictors at 2 years:
1. Repetitive behaviors e.g.:
-hand mannerisms
-repetitive object play
2. Social communication
12
13
Gilles Tréhin: Urville
Stephen Wiltshire: Bath
14
Conclusion:
Autism and ASD can be diagnosed
reliably at age 2 (84%)
Only 1% diagnosed at 2 years ended
with non-spectrum diagnosis
15
Best discriminators at 2 years
[N=30]
• Child’s attention to voice
• Spontaneous direction of other’s
attention
• Understanding words out of context
Lord, 1995
16
Best discriminators at 3 years
• As above plus
• Hand and finger mannerisms
• Using another person’s body as a
tool
17
Characteristics of ASD emerging
between 12-24 months:
• Deficits and delays in emerging joint attention
• Decreased response to name.
• Decreased imitation
• Delays in verbal and non-verbal communication
• Motor-delay
18
Characteristics of ASD emerging
between 12-24 months:
• Elevated frequency of repetitive behaviours
• A typical visuo-motor exploration of objects
• Extremes of temperament
• Decreased flexibility in disengaging visual
attention
Elsabbagh & Johnson, 2009
19
Are ASD symptoms present at birth?
• Probably not
Ozonoff, Iosif, Baguio et al, 2010
• Compared 25 infants later diagnosed with ASD with
25 gender matched low-risk children
• Video at 6, 12,18, 24 and 36 months
• Checked frequencies of
-gaze to faces
-social smiles
-directed vocalizations 20
Outcome:
• No differences at 6 months
• Significant declining trajectories by 12 months
• Refutes the theory of 2 types of autism:
- Stable since birth
- Regressive
21
This has been replicated in other studies Baranek, 1999
Osterling, Dawson 1994
Diagnostic criteria:
Pointing
Showing objects
Looking at others
Orienting to name
22
DIAGNOSIS
23
Dilemma:
1. Unavailability of reliable diagnostic tools
2. Used in literature
i Autism Diagnostic Interview – Revised (ADI-R)
Lord, Rutter, Le Couteur et al,1994
ii Childhood Autism Rating Scale (CARS)
Schopler, Reichler, De Vellis et al, 1980
iii Autism Diagnostic Observation Schedule (ADOS)
Gotham, Risi, Pickles et al, 2006
IV Checklist for Autism in Toddlers (M-CHAT)
Baron-Cohen, Cox, Baird et al, 1996
24
M-CHAT - Scoring sheet – Clinician to complete
1. Does your child enjoy being swung, bounced on your knee, etc.? No
2. Does your child take an interest in other children? No 3. Does your child like climbing on things, such as up stairs? No
4. Does your child enjoy playing peek-a-boo/hide-and-seek? No
5. Does your child ever pretend, for example, to talk on the phone No
or take care of a doll or pretend other things?
6. Does your child ever use his/her index finger to pint, to ask for No
something?
7. Does your child ever use his/her index finger to point, to indicate No
in something?
8. Can your child play properly with small toys (e.g. cars or blocks) No
without just mouthing, fiddling, or dropping them?
9. Does your child ever bring objects to you (parent) to show you something? No 10.Does you child look you in the eye for more than a second or two? No
11. Does your child ever seem oversensitive to noise? (e.g., plugging ears) Yes
12. Does your child smile in response to your face or smile? No
M-CHAT - Scoring sheet – Clinician to complete
13. Does your child imitate you? (e.g., you make a face-will your child No imitate you?
14. Does your child respond to his/her name when you call? No
15. If you point at a toy across the room. Does your child look at it? No 16. Does your child walk? No
17. Does your child look at things you are looking at? No
18. Does your child make unusual finger movements near his/her face? Yes
19. Does your child try to attract your attention to his/her own activity? No
20. Have you ever wondered if your child is deaf? Yes
21. Does your child understand what people say? No
22. Does your child sometimes stare at nothing or wander with no Yes
purpose?
23. Does your child look at your face to check your reaction when No
faced with something unfamiliar?
Tick if parent gives answer indicated above.
Child fails screening test if two or more critical (in bold) items are ticked or if
three or more items ticked in total.
@1999 Diana Robins, Deborah Fein, & Marianne Barton
MANAGEMENT
27
Important:
28
Thorough individual assessment of
strengths and needs to establish an
early intervention programme
INTERVENTION OR EDUCATIONAL
PROGRAMS
• ABA: Applied Behaviour Analysis
• Floortime
• TeacCh: Training and Education of Autistic and Related
Communication Handicapped Children
• Scerts: Social Communication
Emotional Regulation
Transactional Support
• PECS
• Social structures 29
Antecedent, Behavior, Consequence
• The ABC can aid in answering questions such
as
–Are there common patterns?
–Can some stimuli be changed?
–Were there times the behavior did not occur?
–Why?
–Where and with whom did the behavior occur?
–Was the purpose of the behavior
accomplished?
30
MEDICATION
• Mostly for related symptoms/comorbidity
• Inability to focus
• Anxiety
• Seizures
• Depression
31
AFTER THE DIAGNOSIS
• Organize
• Start a video record
• Get support + services: Build a team
• Play with your child
• Sibling time
• Plan something for yourself
• Learn & read
• Internet resources e.g. Autism Speaks
Polyxo.com
Autism Treatment Network
32
Conclusions:
1. Early diagnosis of ASD is possible,
certainly by 12 months of age, definitely
by 2 years
2. The M-CHAT is a good screening tool, the
ADOS perhaps ideal for diagnosis
33
Conclusions:
3. Early red flag signs (12-24 months)
a Repetitive behaviours
b Inattentive to voice
c Absence of shared attention
d Using another person’s body as tool
e Decreased response to name
f Decreased imitation
g Delays in verbal and non-verbal
communication
h Atypical visuo-motor exploration of objects
34
Conclusions:
4. Red flag signs before 12 months
a Absence of pointing
b Showing objects (lack of shared attention)
c Orienting to name
d Gaze at faces absent
e Absence of social smiles
f Absence of directed vocalizations
35
Conclusions:
5. Management should be broad,
multimodal and include the parents
6. The effect of medical interventions on
long term outcome not well researched
yet
36