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AUTISM DISORDER -TINU TOMY-PSYCHOPATHOLOGY

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Title: AUTISM DISORDER -TINU TOMY-PSYCHOPATHOLOGY


1
AUTISTIC DISORDER
Presented by Tinu Tomy MSc.Psychology
2
PERVASIVE DEVELOPMENTAL DISORDERS
  • Pervasive developmental disorders include several
    that are characterized by impaired reciprocal
    social interactions, aberrant language
    development, and restricted behavioral
    repertoire. Pervasive developmental disorders
    typically emerge in young children before the age
    of 3 years, and parents often become concerned
    about a child by 18 months as language
    development does not occur as expected.

3
The DSM-IV-TR includes five pervasive
developmental disorders
  1. Autistic disorder,
  2. Rett's disorder,
  3. Childhood disintegrative disorder,
  4. Asperger's disorder,
  5. Pervasive developmental disorder not otherwise
    specified

4
HISTORY
  • As early as 1867, Henry Maudsley, a psychiatrist,
    noted a group of very young children with severe
    mental disorders who had marked deviation, delay,
    and distortion in development. In that era, most
    serious disturbance in young children was
    believed to fall within the category of
    psychoses.

5
  • Leo Kanner, in his classic paper Autistic
    Disturbances of Affective Contact, coined the
    term infantile autism and provided a clear,
    comprehensive account of the early childhood
    syndrome..

6
AUTISTIC DISORDER (historically called early
infantile autism, childhood autism, or Kanner's
autism)
  • Autistic disorder is characterized by symptoms
    from each of the following three categories
  • Qualitative impairment in social interaction,
  • Impairment in communication,
  • Restricted repetitive and stereotyped patterns of
    behavior or interests.

7
Epidemiology
  • Prevalence
  • 8 cases per 10,000 children
  • Sex Distribution
  • more frequent in boys than in girls.
  • . Socioeconomic Status
  • Over the past 25 years, no epidemiological
    studies have demonstrated an association between
    autistic disorder and any socioeconomic status.

8
Etiology and Pathogenesis
Genetic Factors Biological Factors Perinatal
Factors Neuroanatomical Factors Biochemical
Factors Psychosocial and Family Factors
9
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10
DSM-IV-TR Diagnostic Criteria for Autistic
Disorder
  • A total of six (or more) items from (1), (2), and
    (3), with at least two from (1), and one each
    from (2) and (3)
  • 1.qualitative impairment in social interaction,
    as manifested by at least two of the following
  • marked impairment in the use of multiple
    nonverbal behaviors such as eye-to-eye gaze,
    facial expression, body postures, and gestures to
    regulate social interaction

11
  • failure to develop peer relationships appropriate
    to developmental level
  • a lack of spontaneous seeking to share enjoyment,
    interests, or achievements with other people
    (e.g., by a lack of showing, bringing, or
    pointing out objects of interest)
  • lack of social or emotional reciprocity

12
  • 2.qualitative impairments in communication as
    manifested by at least one of the following
  • delay in, or total lack of, the development of
    spoken language (not accompanied by an attempt to
    compensate through alternative modes of
    communication such as gesture or mime)
  • in individuals with adequate speech, marked
    impairment in the ability to initiate or sustain
    a conversation with others
  • stereotyped and repetitive use of language or
    idiosyncratic language
  • lack of varied, spontaneous make-believe play or
    social imitative play appropriate to
    developmental level

13
  • 3.restricted repetitive and stereotyped patterns
    of behavior, interests, and activities, as
    manifested by at least one of the following
  • -encompassing preoccupation with one or
    more stereotyped and restricted patterns of
    interest that is abnormal either in intensity
    or focus
  • apparently inflexible adherence to specific,
    nonfunctional routines or rituals
  • stereotyped and repetitive motor mannerisms
    (e.g., hand or finger flapping or twisting, or
    complex whole-body movements)
  • persistent preoccupation with parts of objects

14
  • Delays or abnormal functioning in at least one of
    the following areas, with onset prior to age 3
    years (1) social interaction, (2) language as
    used in social communication, or (3) symbolic or
    imaginative play.
  • The disturbance is not better accounted for by
    Rett's disorder or childhood disintegrative
    disorder.

15
ICD-10 Diagnostic Criteria for Pervasive
Developmental Disorders
  • Childhood autism
  • Abnormal or impaired development is evident
    before the age of 3 years in at least one of the
    following areas
  • receptive or expressive language as used in
    social communication
  • the development of selective social attachments
    or of reciprocal social interaction
  • functional or symbolic play.

16
  • B. A total of at least six symptoms from (1),
    (2), and (3) must be present, with at least two
    from (1) and at least one from each of (2) and
    (3)
  • 1.Qualitative abnormalities in reciprocal social
    interaction are manifest in at least two of the
    following areas
  • failure adequately to use eye-to-eye gaze, facial
    expression, body posture, and gesture to regulate
    social interaction

17
  • lack of socioemotional reciprocity as shown by an
    impaired or deviant response to other people's
    emotions or lack of modulation of behavior
    according to social context or a weak
    integration of social, emotional, and
    communicative behaviors
  • failure to develop (in a manner appropriate to
    mental age, and despite ample opportunities) peer
    relationships that involve a mutual sharing of
    interests, activities, and emotions
  • lack of spontaneous seeking to share
    enjoyment, interests, or achievements with
    other people (e.g., a lack of showing, bringing,
    or pointing out to other people objects of
    interest to the individual)

18
  • 2.Qualitative abnormalities in communication are
    manifest in at least one of the following areas
  • a delay in, or total lack of, development of
    spoken language that is not accompanied by an
    attempt to compensate through the use of gesture
    or mime as an alternative mode of communication
    (babbling)
  • relative failure to initiate or sustain
    conversational interchange (at whatever level of
    language skills is present), in which there is
    reciprocal responsiveness to the communications
    of the other person
  • stereotyped and repetitive use of language or
    idiosyncratic use of words or phrases
  • lack of varied spontaneous make-believe or (when
    young) social imitative play.

19
  • 3.Restricted, repetitive, and stereotyped
    patterns of behavior, interests, and activities
    are manifest in at least one of the following
    areas
  • an encompassing preoccupation with one or more
    stereotyped and restricted patterns of interest
    that are abnormal in content or focus or one or
    more interests that are abnormal in their
    intensity and circumscribed nature though not in
    their content or focus
  • apparently compulsive adherence to specific,
    nonfunctional routines or rituals

20
  • stereotyped and repetitive motor mannerisms that
    involve either hand or finger flapping or
    twisting, or complex whole body movements
  • preoccupations with part-objects or nonfunctional
    elements of play materials (such as their odor,
    the feel of their surface, or the noise or
    vibration that they generate).
  • C.The clinical picture is not attributable to the
    other varieties of pervasive developmental
    disorder specific developmental disorder of
    receptive language with secondary socioemotional
    problems reactive attachment disorder or
    disinhibited attachment disorder, mental
    retardation with some associated emotional or
    behavioral disorder schizophrenia of unusually
    early onset and Rett's syndrome.

21
Atypical autism
  • Abnormal or impaired development is evident at or
    after the age of 3 years (criteria as for autism
    except for age of manifestation).
  • There are qualitative abnormalities in reciprocal
    social interaction or in communication, or
    restricted, repetitive, and stereotyped patterns
    of behavior, interests, and activities. (Criteria
    as for autism except that it is unnecessary to
    meet the criteria for number of areas of
    abnormality.)
  • The disorder does not meet the diagnostic
    criteria for autism. Autism may be atypical in
    either age of onset or symptomatology the two
    types are differentiated with a fifth character
    for research purposes. Syndromes that are
    atypical in both respects should be coded.
    Atypicality in both ages of onset and
    symptomatology

22
Atypicality in age of onset
  • The disorder does not meet Criterion A for
    autism that is, abnormal or impaired development
    is evident only at or after the age of 3 years.
  • The disorder meets Criteria B and C for autism.

23
Atypicality in symptomatology
  • The disorder meets Criterion A for autism that
    is, abnormal or impaired development is evident
    before the age of 3 years.
  • There are qualitative abnormalities in reciprocal
    social interactions or in communication, or
    restricted, repetitive, and stereotyped patterns
    of behavior, interests, and activities. (Criteria
    as for autism except that it is unnecessary to
    meet the criteria for number of areas of
    abnormality.)
  • The disorder meets Criterion C for autism.
  • The disorder does not fully meet Criterion B for
    autism.

24
Atypicality in both age of onset and
symptomatology
  • The disorder does not meet Criterion A for
    autism that is, abnormal or impaired development
    is evident only at or after the age of 3 years.
  • There are qualitative abnormalities in reciprocal
    social interactions or in communication, or
    restricted, repetitive, and stereotyped patterns
    of behavior, interests, and activities. (Criteria
    as for autism except that it is unnecessary to
    meet the criteria for number of areas of
    abnormality.)
  • The disorder meets Criterion C for autism.
  • The disorder does not fully meet Criterion B for
    autism.

25
BEHAVIORAL CHARACTERISTICS
  • Qualitative impairment in social interaction
  • Disturbance in language and communication
  • Stereotyped behavior
  • Instability of mood and affect
  • Response to sensory stimuli
  • Associated behavioral symptoms and physical
    symptoms
  • Intellectual functioning

26
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27
High functioning autism
  • About 20 of the PDD
  • Above average IQ
  • Superior vocabulary skills
  • Learning disability
  • Motor deficit
  • Less impaired on TOM test
  • Speech less commonly delayed

28
SOME TOOLS
  • CHAT(Check list for autism in toddler)
  • CARS(Childhood autism rating scale)
  • ADOS(Autism diagnosis observation schedule)
  • TOM(Theory of mind)

29
Procedure for Differential Diagnosis on a
Multiaxial System
  • Determine intellectual level
  • Determine level of language development
  • Consider whether child's behavior is appropriate
    for
  • chronological age
  • mental age
  • language age

30
  • If not appropriate, consider differential
    diagnosis of psychiatric disorder according to
  • pattern of social interaction
  • pattern of language
  • pattern of play
  • other behaviors
  • Identify any relevant medical conditions
  • Consider whether there are any relevant
    psychosocial factors

31
Autistic Disorder versus Schizophrenia with
Childhood Onset

Criteria Autistic Disorder Schizophrenia (with Onset before Puberty)
Age of onset Before 38 months Not under 5 years of age
Incidence 2 to 5 in 10,000 Unknown, possibly same or even rarer
Sex ratio (MF) 3 to 41 1.671 (nearly equal, or slight preponderance of males)
Family history of schizophrenia Not raised or probably not raised Raised
Socioeconomic status (SES) Overrepresentation of upper SES groups (artifact) More common in lower SES groups
Prenatal and perinatal complications and cerebral dysfunction More common in autistic disorder Less common in schizophrenia
Behavioral characteristics Failure to develop relatedness absence of speech or echolalia stereotyped phrases language comprehension absent or poor insistence on sameness and stereotypies Hallucinations and delusions thought disorder
Adaptive functioning Usually always impaired Deterioration in functioning
Level of intelligence In most cases subnormal, frequently severely impaired (70) Usually within normal range, mostly dull normal (15 to 70)
Pattern of IQ Marked unevenness More even
Grand mal seizures 4 to 32 Absent or lower incidence
(Courtesy of Magda Campbell, M.D., and Wayne Green, M.D.) (Courtesy of Magda Campbell, M.D., and Wayne Green, M.D.) (Courtesy of Magda Campbell, M.D., and Wayne Green, M.D.)
32
Autistic Disorder versus Mixed Receptive-Expressiv
e Language Disorder
Criteria Autistic Disorder Mixed Receptive-Expressive Language Disorder
Incidence 2 to 5 of 10,000 5 of 10,000
Sex ratio (MF) 3 to 41 Equal or almost equal sex ratio
Family history of speech delay or language problems Present in about 25 of cases Present in about 25 of cases
Associated deafness Very infrequent Not infrequent
Nonverbal communication (e.g., gestures.) Absent or rudimentary Present
Language abnormalities (e.g., echolalia, stereotyped phrases out of context) More common Less common
Articulatory problems Less frequent More frequent
Level of intelligence Often severely impaired Although may be impaired, less frequently severe
Patterns of intelligence quotient (IQ) tests Uneven, lower on verbal scores than dysphasic patients, lower on comprehension subtest than dysphasic patients More even, although verbal IQ lower than performance IQ
Autistic behaviors, impaired social life, stereotypies, and ritualistic activities More common and more severe Absent or, if present, less severe
Imaginative play Absent or rudimentary Usually present
33
Prognosis
  • Research shows that 50 of children diagnosed
    with autism will remain mute throughout their
    lives.
  • Approximately 10 of autistic individuals have
    savant abilities

34
Intervention
35
INTERVENTION
  • Early intervention
  • combined developmental educational
    behavioral approach
  • Pharmacological intervention

36
  • Behavioral Interventions research suggests that
    early, intensive behavioral interventions may
    improve outcomes for children with autism and
    help the children achieve their maximum
    potential.
  • Sensory Integration integration and
    interpretation of sensory stimulation from the
    environment enhances cognition.

37
  • Diet people with autism are more susceptible to
    allergies and food sensitivities than the average
    person. The most common food sensitivity in
    children with autism is to gluten and casein.
  • Vitamin Therapy parents have reported that they
    have tried B6/magnesium often with good or even
    spectacular results.

38
Some factors associated with treatment
  • Childs inability to seek assistance
  • The need to recognize special vulnerabilities
    that children youth might experience that place
    them at great risk for developing emotional
    problems
  • The need for treatment for parents as well as
    child
  • The possibility of using parents as change agent
  • The problem of placing the child outside the
    family
  • Importance of early intervention before the
    problem becomes acute

39
MOST BENEFICIAL
  • Between 2-4 yrs
  • Intensive 15-40 or more hours per week
  • Need a schedule through out the day
  • Intervention should be continued over 1-2 yrs or
    more

40
WHAT TO TEACH
  • Attending skills
  • Communication skill
  • Imitation skills
  • Self help skills
  • Parent as co-therapist

41
Teaching Tips for Children with Autism
  • Use visuals
  • Avoid long strings of verbal instruction
  • Encourage development of childs special talents
  • Use childs fixations to motivate school work
  • Use concrete, visual methods to teach number
    concepts
  • Let child use a typewriter instead of writing
  • Protect child from sounds that hurt his/her ears

42
  • Place child near a window and avoid using
    fluorescent lights
  • Interact with child while he/she is swinging or
    rolled in a mat
  • Dont ask child to look and listen at the same
    time
  • Teach with tactile learning materials (e.g.,
    sandpaper alphabet)
  • Use printed words and pictures on a flashcard
  • Generalize teaching

43
Parenting a Child with a Disability
  • Seek the assistance of other parents
  • Rely on positive resources in your life (e.g.,
    church, counselors)
  • Learn the terminology
  • Seek information (e.g., internet, support
    groups)
  • Maintain a positive outlook

44
  • Find programs for your child
  • Take care of yourself
  • Decide how to deal with others
  • Keep daily routines as normal as possible
  • Know that you are not alone
  • Most importantly, keep your sense of humor

45
OUTCOME
  • Influenced by
  • Severity
  • Degree of retardation
  • Verbal ability
  • Comorbid seizures

46
PREVENTIVE INTERVENTION
  • Routine developmental surveillance
  • Good parenting skills
  • lots of interaction
  • play
  • restrict TV

47
Thank You
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