AUTISM SPECTRUCM DISORDER

 
Clinical Presentation
Autism is a complex developmental disorder that typically appears during the first 3 years of age. It affects the functioning of the developing brain. Children with autism typically have difficulties in communications (verbal or non-verbal), social interaction, and 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 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 but severity of symptoms is different in each child

NO TWO CHILDREN WITH Autism ARE EXACTLY SAME

Prevalence / Incidence
The reported incidence is 1 (One) out of 89 (eighty nine) children in India and 1 in 45 children, ages 3 years- 17 years in America (Based on 2019 Survey).

Identification of Autism / Signs and Symptoms of Autism
Children with Autism will have

• Difficulties / delay in communication or poor speech
• Presence of repetitive behaviors /  stereotype movements
• Difficulties in making and keeping friends
• Less sharing of interests with others; uncommon / strong / limited interests
• Lack of speech,  slow to learn speech,  unusual speech, speech sounds unusual,  difficulty in making conversation, repeating words or phrases in place of normal, responsive language
•  Difficulty with imitation and pretend play
•  Repeating activities or movements, insistence on sameness, resistance to change
• Plays with part of the toys rather than the toys as a whole
• Prefers to be alone, in aloof manner, inappropriate attachments to objects, spins objects, not responsive to verbal cues
• Laughing, crying, showing distress for reasons not apparent to others
• Unresponsiveness to normal teaching methods

Children, who are suspected to be autistic, may have danger signs / red flags such as

•  Atypical babbling
•  Atypical tone of voice, crying
• Delayed or atypical development of gestures
• Poor language comprehension and production
• Regression or loss of speech
• Poor / atypical eye gaze and joint attention
• Poor in sharing of emotion
• Poor reciprocal smiling or social interaction
• Reduced or atypical coordination of different modes of communication
• No response when his / her name is called
• Reduced or atypical imitation of actions
• Poor with imaginative play
• Reduced / excessive or atypical manipulation of toys and other objects
• Repetitive actions with toys and other objects
• 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 fingers

Associated / Co-morbid factors with Autism
Children with Autism may have any or many of the following common health and medical conditions. All of these associated problems can be treated successfully with proper medications and therapies.

• Seizure disorder
•  Tics disorders
•  Poor nutrition
•  Gastrointestinal disorders
•  Sleep problems
•  Mental health disorders (Anxiety, Depression, mood disorders)
•  High rate of injuries, etc

Causes of Autism
Autism can be due to varied reasons. It can be due to malformation of the brain. CT scan / MRI scan of the brain of children with autism have shown enlarged ventricles and hypoplasia of the cerebellar vernius (Parts of the brain).

Children with medical conditions like Fragile X syndrome, Tuberous sclerosis, Congenital rubella syndrome, Untreated PKU, etc have more chances of having autism.

Vaccine in infancy and some harmful substances ingested during pregnancy also have been associated with a risk of autism.
 
Latest researches and recent studies strongly suggest that some people have a genetic link to autism. In families with one autistic child, the risk of having a second child with autism is approximately 5 percent. Autism is four times more common in boys than girls.

Diagnosis Making of Autism
Accurate diagnosis of Autism is made based on observation of the individual's communication, social behavior & developmental levels. There is no specific medical test available which confirm autism. Medical tests are done to rule out other similar Neurodevelopmental disorders. At first glance, some children 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 is available which help in diagnosis making and ascertaining the severity of the condition. Such as Autism Diagnostic Interview- Revised (ADI-R), Gilliam Autism Rating Scale - Second Edition (GARS-2), etc

Under DSM-5, Autism is now diagnosed by symptoms based on both the current functioning and past functioning of an individual. The three level of severity include:
Level-1: Requiring support (Mild to Moderate)
Level-2: Requiring substantial support (Moderate to Severe)
Level-3: Requiring very substantial support (Severe to Profound)

Differential Diagnosis
Differential diagnosis is very important as lot of conditions can look like (mimic) Autism but actual sense they are not. They need different management and treatment. Such as

• Attention Deficit /Hyperactivity Problems
•  Intellectual disability or Cognitive impairment ( Mental Retardation)
•  Psychological or Psychiatric Problems
•  Physical and nutritive problems
•  Epilepsy or seizure disorders
•  Behavioral Problems
•  Learning Disability / Slow Learner
•  Speech and language impairment / Selective Mutism
•  Hearing problems / Impairment
•  Minimum brain damage or dysfunction,
• Syndromes like Fragile X Syndrome, etc

Assessments of Children with Autism
All children with autism should be assessed in all areas of child development before starting any treatments or therapies. Holistic assessments to have baseline information about cognition, speech and communication, social-emotional behaviors, self help skills, fine motors skills and gross motor skills is very important. Proper and accurate assessment is very essentials to formulate an effective treatment / training program.

All children with autism should be assessed to rule out any hearing deficits. Audiometric assessment / hearing test, specifically BERA (an advance hearing test) is advised. Visual evaluation is also advised to rule out any visual disorders.

On the basis of needs and availability, combination of these scales are used to have baseline information and evaluation while under therapy 

• Childhood Autism Rating Scale
•  Autism Behavior Checklist
•  Checklist for Autism in Toddlers
•  Vineland Adaptive Behavior Scales
•  Stanford-Binet Intelligence Scale
•  Behavioral Vignettes Test
•  Parenting Satisfaction Scale
•  The Parental Stress Scale
•  Family Environmental Scale

Management and Treatment 
Autism is a complex medical disorder. It requires multimodal treatments/ therapies. ICD’s multidisciplinary treatment team includes most of the following professionals to get optimal results.

• Developmental pediatrician
• Child psychiatrist
•  Clinical psychologist
• Developmental therapist / Occupational therapist / Rehabilitation therapist
•  Speech therapist
• Special educator
•  Pediatric Neurologist
• ENT Specialist
• Ophthalmologist
• Genetic specialist

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. 

Although, there is no cure for autism, however with appropriate treatment and remedial education many children with autism can learn, grow well and become independent as adult. Early intervention (EI) often does miracle by reducing challenges associated with the disorder. EI helps to have lesser disruptive behaviors & provide appreciable degree of independence. Treatment depends on the individual needs of the child and it is always custom made. There is nothing like readymade treatment program. Therapies without extensive and holistic assessments can produce no improvement / result and ultimately wasting the golden developing years. Parents should emphasize on developing communication skill rather on speech only. Few children with autism can take longer duration to achieve verbal communication. In most cases, combination of treatments is more effective. The combination therapy program should comprise of sensory integration therapy, behavioral therapy (ABA / CBT, etc) and speech therapy. Some children with ASD will require the support of a special educator for concept building as remedial education session.       

Treatment Options

• Occupational Therapy / Sensory Integration Therapy
•  Communication therapy / Speech Therapy / Auditory Training
•  Behavioral Therapy /Behavior Management- Modification Therapy
•  Special Education / Remedial Education
•  Dietary modifications
•  Medications
•  Complementary and Alternative Medicines / Exploratory Therapies

Sensory Integration Therapy / Occupational Therapy
Sensory integration therapy is an integral part of a holistic treatment plan. The aim of sensory integration therapy / treatments is to improve the underlying neurological functioning such as attention span, concentration, motor skills, concept building, etc. Sensory integration therapy requires a specific assessment / sensory profile which are very technical, long and time taking.  Along with sensory integration therapy, fine motor development is also required for children with ASD. The fine motor development not only helps in ADL but also in hand writing enhancement.

Communication therapy / Speech Therapy / Auditory Training
Communication therapy is used to treat autistic children who are unable to communicate verbally or to initiate language development. In young children with the autism, speech therapy may be used to help the child gain the ability to communicate and speak. Children with sensory dysfunction require sensory integration therapy along with speech therapy. Mostly isolated speech therapy makes no sense.   

Behavior modification
Problem behaviors are very challenging and stressful issues faced by parents and teachers in their efforts to provide appropriate educational programs to children with autism. Behaviors problem such as physical aggression, self-injury, and tantrums are major barriers to effective social and educational development. Such behaviors put these young children at risk for exclusion and isolation from social, educational, family, and community activities. In addition, problem behaviors may place extra burden on families. Lots of behavior management or modification techniques are available such as ABA, CBT, etc

Special Education / Remedial Education
Special education is provided to children with autism to cope in regular school set up by designing an individual education program (IEP). Mostly children with autism are intelligent but are unable to communicate with class teachers due to sensory dysfunction or poor speech development. They need remedial education session by special educator especially trained in autism spectrum domain  

Dietary modification
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. 

Medications 
Medication may be used to treat various symptoms of autism
Behaviors and symptoms are successfully treated with medications at ICD are

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

No medicine available anywhere for these behaviors / symptoms such as

• Not following directions
• Refusing behaviors- flapping, running, etc
• Slow Learning
• Not talking, Low communication skills
• Poor social skills
•  

All the above behaviors are treated with habilitation therapies such as occupational therapy, behavior therapy, speech therapy, special education or skill training programs

Exploratory Treatments
More than 100 complimentary / alternative therapies have been explored all over the world. In selected cases, ICD provides these therapies with the standard treatment program

• Acupuncture-Acupressure / Traditional Chinese medicine
• Homeopathy
• Ayurveda
• Unani
• Yoga
• Supplementation of Vitamin B-12 / Immunotherapy
•  Gluten and Casein Free Diets (GFCF)
• Omega-3 Fatty Acids /  Efalex Oil or DHA Oil
• Anti-fungal Treatment /  Detoxification for Heavy Metals
• EEG Bio-feedback /  Craniosacral Therapy
• Music Therapy,  etc

Prognosis and Employment Opportunities
Age at intervention started has a direct impact on outcome--typically, the earlier a child is treated, the better the prognosis will be. 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 to 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.

If you want to know which treatment or therapies is best suited for your child / ward, please contact us and get free technical support

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