Download Attention Deficit Hyperactivity Disorder/ Oppositional

Pervasive Developmental
Disorders
Nursing 864
September 24, 2009
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Autism Spectrum Disorders
 Autism
 Asperger’s
 PDD,
Syndrome
NOS
Rett’s disorder
 Childhood Disintegrative Disorder
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Autism Spectrum Disorders
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Prevalence
 Approximately
1/150 children
 4.3 : 1 ratio males to females
 Increase in prevalence
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Causes
Better assessment and diagnostic tools
 Improved recognition by health care providers
 Increased public awareness
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Etiology
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Genetic
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Multiple genes involved
Rate of occurrence in siblings 2-8%
Monozygotic twins – 60%
Syndromes and Related Health Problems
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Occurs in less than 10%
Fragile X
Epilepsy
Tuberous sclerosis
Fetal alcohol syndrome
Mental retardation occurs in approximately 70% of children
Increased rate of perinatal complications in the mother
Autism
Diagnosis – DSM- IV-TR criteria
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Qualitative impairment in social interaction (at least 2)
 Impaired nonverbal behaviors
 Failure to develop peer relationships as same age level
 Lack of seeking to enjoy interests or achievement
Qualitative impairment in communication (at least one)
 Delay or lack of spoken language
 Impaired ability to initiate or sustain conversation
 Stereotyped and repetitive use of language
 Lack of varied or spontaneous play
Restricted repetitive and stereotyped patterns of behavior, interests
and activities (at least one)
 Preoccupied with one or more stereotyped or restricted interest
 Inflexible to nonfunctional routines or rituals
 Stereotyped or repetitive movements
Impaired Social Interaction
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Low rates or no initiation of social interaction
Little interest in other children
Trouble sustaining social interactions
Little shared interest
No joint attention
Does not imitate
Does not enjoy social games
No social smile
Little shared interest
Poor eye contact and rarely looks for reaction
Communication Deficits
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Delay in language development – principal criteria for
diagnosis
Difficulty putting meaningful sentences together
Nonverbal communication impaired
 Inappropriate gestures
No response to name called (seems deaf)
Difficulty perceiving themes or intent
Does not point to request (proto-imperative)
Does not point to interest (proto-declarative)
Echolalia
Confused pronouns
Very literal and concrete
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Restricted Range of Interests/Stereotyped
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Preoccupation with topics or intense interest
Preoccupation with sensory experiences
Repetitive movements
Manipulate toys in ritualistic manner
Monotonous play
Spin, bang, line up toys
Rocking motions
Spinning body
Flap hands
Taste or smell unusual objects
Rigid with rules and resistant to transitions
Asperger’s syndrome
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Asperger’s syndrome
 Qualitative
impairment in social interaction (at least
two)
 Restricted repetitive and stereotyped pattern of
behavior, interests and activities (at least one)
 No clinically significant language delay
 No clinically significant delay in cognitive
development, self-help skills or adaptive behavior
(other than social interaction)
PDD, NOS
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Severe impairment in the development of
reciprocal social interaction
 Impaired
verbal or nonverbal communication skills
 Presence of stereotyped behavior, interests, and
activities
 Criteria are not met for other PDD
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Late Onset
Atypical symptomatology
Subthreshold symptomatology
Childhood Disintegrative Disorder
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Rare disorder
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Occurs after at least two years of normal development
Generally is diagnosed around 4-5 years of age.
Occurs more frequently in males
Along with regression in social skills and communication,
there is regression in motor skills
Etiology
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Occurs in less than 5/10,000
Predisposition to genetic and environmental influences
Prognosis guarded
Rett’s Syndrome
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Almost exclusively in females
Typically neurogenerative arrest
Etiology - Gene MECP2 located on the X chromosomes
Early clinical features
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Deceleration of head growth
Period of developmental stagnation is followed by a period of
regression
Loss of purposeful hand skills and oral language
Development of hand stereotypies and gait dyspraxia
Prognosis – 70% 35 year survival rate
Theory of Mind
 The
ability to understand the thoughts and
intentions of others (mental states)
 Perspective taking of others
 It can determine how an individual acts and
react
 Lack of ability or reduced ability in Asperger’s
and Autistic disorder
Sally-Anne test (Theory of Mind)
(Wimmer and Perner, 1983)
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In the presence of the child, the experimenter uses two
dolls, "Sally" and "Anne". Sally has a basket; Anne has a
box.
The experimenters show a skit:
 Sally puts a marble in her basket and then leaves the
scene.
 While Sally is away and cannot watch, Anne takes the
marble out of Sally's basket and puts it into her box.
 Sally then returns.
The children are asked where they think she will look for
her marble.
Children are said to "pass" the test if they understand
that Sally will most likely look inside her basket before
realizing that her marble isn't there.
Pathophysiology
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Neuroanatomical Factors
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Enlargement of gray and white matter cerebral volumes
 Increased rate of head circumference emerges at about 12
months of age
 Increased volumes in the temporal, parietal and occipital
region
 No differences in size in frontal lobe or cerebellum
Possible mechanisms
 Increased neurogenesis
 Decreased neuronal death
 Increased production of nonneuronal brain tissue
Pathophysiology
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Neurotransmitters
 Increased
brain-derived neurotrophic factor
and other neurotrophins
 Age –related serotonin synthesis capacity
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These may contribute to abnormal brain growth
and organization
Screening and Diagnosis
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Group of symptoms
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Behavioral
No medical tests
Screening and diagnosis involved clinical judgment
Diagnosis requires presence of severe and pervasive
impairment across domains
Not every socially awkward or eccentric child has ASD, but
never wait and see
Targeted developmental screening – 9,18 & 30 months
Autism specific screening – 18 and 24 months
Screening Tools
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Level 1
 Modified
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Checklist for Autism in Toddler (M-CHAT)
Screen as young as 18 months
Critical items
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Peer interest
Pointing
Joint attention
Shared interest
Imitation
Responds to Name
Screening Tools
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Level 2
 Child
Autism Rating Scale (CARS)
 Gilliam Autism Rating Scale (GARS)
 Gilliam Asperger’s Disorder Scale (GADS)
 Social Communication Questionnaire (SCQ)
Diagnostic Tools
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Level 3
 Autism
Diagnostic Observation Scale (ADOS)
 Autism Diagnostic Interview – Revised (ADIR)
 Preschool Language Scales (IV) – by SLP
 Adaptive Ratings (i.e., Vineland)
 Cognitive Testing
Diagnostic Evaluation
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Multidisciplinary Team
 Developmental
Pediatrics, Psychology, Speech,
Genetics, and Education
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Medical/Developmental/Behavioral History
Structured Interview
Behavior Ratings Scales
Structured Direct Observation
Direct Interaction/Teaching
Functional Assessment
Standardized Testing (Speech, Genetics, Psychology)
Other Diagnostic Tests
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Used primarily for children with cognitive
impairment
– with MR
 High-resolution chromosomes
 MRI
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Analysis of the number and structure of the chromosomes
 Fragile
X
 DNA Microarray
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Investigates the expression levels of thousands of genes
simultaneously.
Empirically Supported Treatments
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Early Intensive Behavioral Intervention
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Based on Applied Behavior Analysis
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Systematic modifications of the environment based on
principles of behavior identified through experimental
analysis
 Focuses
on the purpose or the function of the
behavior
 Involves changing antecedents and consequences to
change behavior
 Uses principals of operant conditioning
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Incidental Teaching
 To
help improve or elaborate language skills
 Teaching occurs when child initiates
communication
 Must create communication temptations
 Prompts help the child be successful
 Involves labeling and describing that occurs in
the adult-child interaction
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Picture Exchange Communication System
(PECS)
 Augmentative
communication
 Picture exchange for teaching communication
skills
 Emphasizes teaching functional language
 No evidence of children losing established
speech
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Discrete Trial Training
 Precise
teaching interactions that emphasize
potent and frequent reinforcing consequences
 Each skill is taught separately
 Prompting helps insure responding and
success
 Emphasis on high rate of teaching
interactions
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Naturalistic Teaching Procedures
 Teaching
procedures that are embedded in
their natural activities
 Enhances the spontaneity and generalization
of language, social and play skills
 Demonstrated to be beneficial for children
who are developmentally delayed or
disadvantaged
Guidelines for Treatment
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Combination of ABA procedures
 Best
outcome between ages 2-5
 Best outcome for 25 hours or more per week
 Best outcome when functional communication
is established by age 5
Comorbid Conditions
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Behavioral
 ADHD
 Sleep
disturbance
 Disruptive behaviors
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Temper tantrums
Aggression
Self-injury
 Anxiety
 Generalized, intense worries
 Obsessions and compulsions
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Neurologic
– 20-35%
 Hypotonia
 Gait Abnormalities
 Microcephaly – associated with co-existing structural
brain malformations
 Macrocephaly
 Seizures
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Orthopedic
 Toe
walking
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Nutrition
 Restricted
food choices
 Rituals
 Poor
motor skills
 No evidence of dietary restrictions helpful in
treatment (gluten or casein)
 Pica
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Monitor lead levels
Medication Management
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Atypical Antipsychotics - Aggression
– Only FDA approved medication for
children with autism
 Abilify
 Risperdal
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Stimulants- ADHD
Alpha-adrenergic antagonists –
 Clonidine
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& Tenex – impulsivity and sleep
SSRI’s - anxiety
Parent Counseling
Safety
 Nutrition
 Advocacy in the School System – IEP
 Bullying
 Parenting Stress
 Siblings
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Resources
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Autism Action Partnership
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PTI Nebraska
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www.firstsigns.org
National Autism Association
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www.pti-nebraska.org
First Signs
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www.autismaction.org
http://www.nationalautismassociation.org/
Munroe-Meyer Institute
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Center for Autism Spectrum Disorders
559-2441