AUTISM SPECTRUCM DISORDER


Definition
Autism is a complex developmental disability / disorder that typically appear during the first 3 years of life. It affects the functioning of brain. Children & adults with autism typically have difficulties in verbal & non-verbal communication, Social interaction, and leisure or play activities. Children, who have autism often have delayed language development, prefer to spend time alone & show less interest in making friends. Mostly children with ASD are intelligent but a few of them may have poor cognition or intellectual disability while all children with ASD have difficulties with communication, social interaction and repetitive behaviors, appearance and severity of symptoms is different in each child

Please remember- NO TWO CHILDREN WITH ASD ARE EXACTLY SAME

Prevalence
The estimated prevalence is 1 out of 89 in India.
New Government survey of parents in USA suggests that 1 in 45 children, ages 3 through 17, have been diagnosed with autism spectrum disorder (ASD). This is notably higher than the official governmin making and keeping friends

  • Less sharing of interests with others
  • Lack of speech
  • Slow to learn speech
  • Unusual speech, speech sounds unusual
  • Difficulty in making conversation
  • Difficulty with imitation and pretend play
  • Repeating activities or movements
  • Uncommon, strong, limited interests
  • Plays with par of the toys rather than the toys as a whole   
  • Insistence on sameness, resistance to change
  • Repeating words or phrases in place of normal, responsive language.
  • Prefers to be alone, in aloof manner
  • Laughing, crying, showing distress for reasons not apparent to others
  • Unresponsiveness to normal teaching methods
  • Inappropriate attachments to objects
  • Spins objects, not responsive to verbal uses

  • Difference between DSM-5 and DSM-IV
    The latest edition of the DSM DSM-5 made significant changes to the diagnostic criteria for autism and related disorders. In DSM-IV, five separate diagnosis were classified under the heading “Pervasive Developmental Disorders”. Autistic disorder, Asperger syndrome, Pervasive Developmental Disorder not otherwise specified (PDD-NOS), Rett syndrome, and Childhood disintegrative disorder. The Pervasive Developmental Disorder category no longer appears in DSM-5, and Autistic disorder, Asperger syndrome and PDD-NOS have now been combined into one label that is Autism Spectrum Disorder (ASD).

    Under DSM-5, ASD is now diagnosed by symptoms based on both the current functioning and past functioning of an individual.

    In addition to the changes in criteria for the ASD diagnosis, the new DSM-5 has also added a severity rating. The three level of severity include:
    Level-1: Requiring support
    Level-2: Requiring substantial support
    Level-3: Requiring very substantial support

    Associated / Co-morbid factors with ASD

    • ASD can have any or many of the following common health and medical problems
    • Seizure disorder
    • Tics disorders
    • Poor nutrition
    • Gastrointestinal disorders
    • Sleep problems
    • Mental health disorders (Anxiety, Depression, mood disorders)
    • High rate of injuries

    Differential Diagnosis

    • A number of conditions can mimic ASD, a few of them are:
    • Attention Hyperactivity Problems
    • Intellectual disability or Cognitive impairment
    • Psychological or Psychiatric Problems
    • Physical r nutritive problems
    • Epilepsy or seizure disorders
    • Behavioral Problems
    • Learning Disability
    • Speech and language impairment
    • Hearing problems
    • Minimum brain damage or dysfunction

    Etiology / Causes
    There is no known single cause for autism. Current theory classifies autism as a neuro-biological disorder & the focus is on changes in the neuro-anatomy & neurochemistry of the brain. CT scans have isolated a subgroup of autistic children with enlarged ventricles and MRI has identified a subgroup of autistic adults with hypoplasia of the cerebellar vernius.

    Autism tends to occur more frequently than expected among individuals who have certain medical conditions including--

    • Fragile X syndrome
    • Tuberous sclerosis
    • Congenital rubella syndrome
    • Untreated PKU

     
    Vaccine in infancy and some harmful substances ingested during pregnancy also have been associated with a risk of autism. 

    Genetic Link
    Latest Researches and Recent studies strongly suggest that some people have a genetic predisposition to autism. In families with one autistic child, the risk of having a second child with the disorder is approximately 5 percent. This is greater thanent estimate of 1 in 68 American children with autism, by the Centers for Disease Control and Prevention (CDC).

     Autism is four times more common in boys than girls.

    Features / Symptoms /Red Flags for Autism
    Social communication

    • Reduced or atypical eye gaze and joint attention
    • Reduced or atypical sharing of emotion
    • Reduced or atypical reciprocal smiling or social interaction
    • Reduced or atypical social interest or shared enjoyment
    • Reduced or atypical coordination of different modes of communication
    • Reduced or no response when his / her name is called
    • Regression or loss of social emotional skills

    Language

    • Delayed or atypical babbling, particularly back and forth social babbling
    • Delayed or atypical development of gestures
    • Delayed or atypical language comprehension and production
    • Delayed or atypical tone of voice, crying
    • Regression or loss of communication skills

    Play

    • Reduced or atypical imitation of actions
    • Reduced or atypical functional and imaginative play
    • Reduced / excessive or atypical manipulation of toys and other objects
    • Repetitive actions with toys and other objects

    Visual or other sensory and motor skills

    • Atypical visual tracking, visual fixation
    • Under or over reaction to sounds or other forms of sensory stimulation
    • Delayed or atypical fine motor and gross motor skills
    • Repetitive motor behavior
    • Atypical posturing of limbs or digits

    Core Symptoms of ASD

    • Less eye contact, use of gestures or facial expressions
    • Difficulty understanding the emotions, feelings of others
    • Difficulty playing with same age children
    • Problems the risk for the general population. Researchers are looking for clues about which genes contribute to this increased susceptibility. In some cases, parents and other relatives of an autistic child show mild impairments in social and communicative skills or engage in repetitive behaviors. Evidence also suggests that some emotional disorders, such as manic depression, occur more frequently than average in the families of people with autism. 

      Screening Tools / Diagnostic Tests
      There are no medical tests for diagnosing autism. An accurate diagnosis must be based on observation of the individual's communication, behavior & developmental levels. Parental & other caregivers input & developmental history are very important components of making an accurate diagnosis. At first glance, some persons with autism may appear to have mental retardation, a behavior disorder, and problems with hearing or even odd and eccentric behavior.

      Lot of Screening tools available which helps in diagnosing making. Such as
      Autism Diagnostic Interview, Revised (ADI-R)
      Autism Rating Scale - Second Edition (GARS-2)V

      Assessment Techniques
      When you are going to start habilitation of a child with ASD, the child should be assessed in all areas of development.
      Cognition development
      Speech and Communication development
      Social-emotional development
      Self help development
      Fine motors and Gross motor development.

      Mostly children with ASD walk on toes for a period of time. Sometimes parents and professional feel it as the consequence of heel cord tightness but it is due to sensory dysfunction rather than tightness or weakness of any specific muscles. Yes, children with ASD can have problems with balance, joint integrity, proprioception, etc.

      The following assessments are more common

      • Sensory Dysfunction Assessment
      • Speech and Communication Assessment
      • <
      • Mental Level or Cognition Assessment
      • Assessment of Social and emotional Skills

      There is a long list of assessment tools available that are used by educators, clinicians, and researchers to assess children suspected of, or previously diagnosed with ASD.

      • Audiometric assessment
      • Childhood Autism Rating Scale
      • Autism Behavior Checklist
      • Checklist for Autism in Toddlers
      • Vineland Adaptive Behavior Scales
      • Stanford-Binet Intelligence Scale (4th ed.)
      • Behavioral Vignettes Test
      • Parenting Satisfaction Scale
      • The Parental Stress Scale
      • Family Environmental Scale

      Professionals Team 
      Child's pediatrician is the first to suspect autism; child will need to be referred to someone who specializes in diagnosing autism spectrum disorders. This may be a developmental pediatrician, a psychiatrist or psychologist or other professional with specialized training and experience. . This multidisciplinary assessment team may include some or all of the following professionals. They may also be involved in treatment programs.

      • Developmental pediatrician
      • Child psychiatrist
      • Clinical psychologist
      • Developmental therapist / Occupational therapist / Physiotherapist
      • Speech therapist
      • Social worker
      • Special educator

      It is important that parents and professionals work together for the child's benefit. Once a treatment program is in place, communication between parents and professionals is essential to monitor the child's progress. 

      Managements / Treatments / Training
      There is no cure for autism, however with appropriate treatment and education many children with the disorder can learn & develop. Early intervention often can reduce challenges associated with the disorder, lesser disruptive behavior & provide some degree of independence.
      Treatment depends on the individual needs of the child. In most cases, combination of treatment method is more effective.

      Treatment Approaches

      • Occupational Therapy / Sensory Integration Therapy (www.icddelhi.org/ occupational therapy)
      • Communication therapy / Speech Therapy / Auditory Training
      • Behavior Management or Modification Therapy
      • Special Education / Remedial Education
      • Dietary modifications
      • Medications

      Sensory Integration Therapy / Occupational Therapy
      The aim of sensory integration therapy / treatments is to improve the underlying neurological functioning. This treatment includes individual treatment, a balance of structure and freedom, emphasis on the inner drive of the person and therapy involving a special setting and special equipments such as ramps, scooter boards and platform swings etc.
      A separate session for fine motor development is required for children with ASD. The fine motor development not only helps in ADL but Hand writing enhancement 

      Communication therapy / Speech Therapy / Auditory Training
      This therapy is used to treat autistic children who are unable to communicate verbally or to initiate language development. In young children with the disorder, speech therapy may be used to help the child gain the ability to speak. 

      Behavior modification

      • Positive reinforcement to teach self care skills
      • Speech therapy (also sign language teaching)
      • Structured class room training (to learn new material & maintain the acquired learning, ''special schooling'').
      • Development of regular routine with minimum or no changes
      • Behavioral techniques to encourage social & interpersonal interaction

      Special Education / Remedial Education
      Special education is a specialized service provided to children with identified special needs such as ASD by designing an individual education program (IEP). It is an individually designed instructional program that meets the unique learning needs
      Of the child with ASD

      Dietary modification
      Autism is not caused by diet & the use of dietary modifications & supplements to treat the disorder is controversial. Changing the diet or adding vitamin supplements may improve digestion and eliminate food intolerances or allergies which may contribute to behavioral problems in autistic patients. Vitamin B, magnesium & cod liver oil supplements (contain A&D) may improve behavior, eye contact, attention span & learning in autistic patients. Vitamin C improves depression. 

      Medication 
      Medication may be used to treat various symptoms of autism
      Behaviors and Symptoms that might get better with medicines

      • Hyperactivity
      • Impulsivity
      • Short attention span
      • Irritability
      • Aggression
      • Hurts himself or herself
      • Repeating thoughts
      • Repeating behaviors
      • Sleep problems
      • Tics
      • Anxiety
      • Depression

      Behaviors and Symptoms that might not get better with medicines
      Does not follow directions
      Refusing behaviors eg: flapping, running
      Slow Learning
      Not talking, Low communication skills
      Poor social skills

      Exploratory Treatments

      • Nutritional Therapies
        • Vitamin B-12
        • Gluten and Casein Free Diets
        • Pancreatic Enzymes
        • Super Nu Thera
        • Omega-3 Fatty Acids
        • Efalex Oil or DHA Oil
      • Hyperbaric Oxygen Therapy ( HBOT)
      • Secretin Therapy
      •  Stem Cell Therapy
      • Anti-fungal Treatment
      • Detoxification for Heavy Metals
      • EEG Bio-feedback
      • Craniosacral Therapy
      • Traditional Chinese medicine
      • Music Therapy
      • Immunotherapy
      • Homeopathy etc

      Prognosis -Our Experience -Our Concept

      • Age at intervention started has a direct impact on outcome--typically, the earlier a child is treated, the better the prognosis will be. Due to good awareness, lot of infants with suspected ASD visiting us for therapeutic services.  
      • With good therapeutic program with educational services , early intervention show exemplary improvements in selected cases.
      • In recent years, there has been a marked increase in the percentage of children who can attend school in a typical classroom and go on to live semi-independently or fully independently in community settings.
      • However, still the majority of autistic persons remain impaired to some degree in their ability to communicate and socialize.
      • About 20-40% autistic children begin to improve between 4 to 6 years of age and eventually attend an ordinary school and obtain work.
      • 20-50% can live at home but need to attend a special school or training centre and cannot work.
      • 40% improve little and unable to lead an independent life, most needing long term residential care.
      • Those who improve may continue to show language problems, emotional coldness and behavior.

     

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