Assisting Early Identification of Autistic Spectrum Disorders ASD in the Paediatric Audiology Clinic

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Assisting Early Identification of Autistic
Spectrum Disorders (ASD) in the Paediatric
Audiology Clinic

• Donald MacAskill AuD
• Audiological Services Manager
• Forth Valley

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AimsIncrease awareness of (ASDs) in the
Profession of Audiology!

• Highlight some of the symptoms of (ASD) and the
  similarities with childhood deafness
• Explain why Audiologists can help with early
  identification and why this is important!
• Show this with a small blinded study carries out
  in Cambridge.
• What to look for and tips within the clinic and
  what to do

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What I am not suggesting

• Audiologists attempting to diagnose ASDs

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So why the interest?

• Cambridge for 7 years
• universities are a safe haven for science and
  maths students (tonyattwood.com.au).
• The top three universities in the world are
  Harvard, Cambridge, and Oxford in that order
• Evidence for genetic involvement in ASDs

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Some Statistics

• Male to female ratio 4.1(Ehlers, S. Gillberg,
  C. (1993)
• Aspergers Syndrome26-36 in 10,000
• but,
• ALL Autism Spectrum Disorders1 in 100
  (Wing,1996)
• (Scotland quotes 1110 Scotland 46,167 (ssa)
  

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Autism Spectrum Disorder

• Classic Autism
• 
  High-functioning
  Autism
• 
  Autistic disorder
• Kanners Syndrome
• Pervasive Developmental Disorders
• 
  Atypical autism
• Mild autism
• Autism spectrum
  disorder/s
• PDDNOS
• Aspergers
  Syndrome
• 
  Autistic-like
  conditions

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• Cambridgeshire prevalence study (1999)
• (5-11 year olds ASD Aspergers S.)
• Overall prevalence in Cshire 57/10,000 or 5.7
  per 1000
• Previous studies indicated this to be 5 per
  10,000.
• However studies depend on the criteria
  considered.

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Symptoms

• The Triad of Impairments
• difficulties in acquiring any form of
  communication
• difficulties in relating to, or understanding
  other people and social situations
• a lack of imaginative ability, often substituted
  by obsessive, repetitive behaviour and a strong
  resistance to change.
• (early onset lt3yrs)

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I - Language and Communication

• Delayed and/or disordered language (expression
  and comprehension)
• Echolalia and repetitions
• Absence of two way conversation (reciprocity)
• Semantic pragmatic impairment
• Literal/concrete understanding(difficulty with
  jokes, teasing)
• Comments rude, irrelevant or out of context
• Talking at people rather than with people
• Perseverance ceaseless questioning
• Disorders of pitch and intonation

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II - Reciprocal Social Interaction

• Lack of awareness and/or interest in others
• Dislikes and avoids social contact or approaches
  it in unusual and unsuccessful ways
• Absent, poor or flitting eye contact
• Unresponsive to verbal requests or being called
  by name
• Difficulty being directed (prefers to do his own
  thing)
• Difficulty participating in group games,
  turn-taking, sharing.
• Poor mind-reading ability (mind-blindness)
• Inconsiderate, selfish because unaware of other
  peoples emotional needs and feelings
• May be affectionate but on own terms

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IIa - Reciprocal Social Interaction

• Aloof group
• in a world of their own avoid eye gazeno
  interest in people, including their peers or
  treat them as objects do not seek comfort if
  hurt, little reaction to pain.
• Passive group
• Allow others near them or play alongside but
  never initiate contact. When they want something,
  they may just stand close to it waiting for
  someone to guess
• Active but odd group
• No sense of social barriers may approach anyone
  including total strangers may stare long rather
  than avoid eye contact Very forceful in their
  attempts to attract others attention to the
  point of being aggressive and unpleasant.

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III - Imagination

• Limited, repetitive play (lining or grouping
  objects and toys spinning wheels flicking
  switches)
• No symbolic,pretend or make believe play
• Preference for routine, sameness
• Dislike of change and new situations
• Repetitive or stereotyped behaviours
• Preoccupations, unusual interests and obsessions

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Summary the problem areas
Language/ Communication (Failure to use
communication for social purposes)
Social Interaction (Lack of reciprocity impaired
empathy lack of joint attention)
Associated problems Variable degree of mental
ability - 75 Clumsiness Toe walking Abnormal
responses to sensory stimuli Food
fads/restrictive diet Sleep disorder
Imagination/ Restricted interests and behaviours
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Where does the Audiologist fit in ?

• Some of the symptoms of hearing loss are similar
• Because the symptoms are similar, children are
  often referred for hearing assessment before any
  thought of autism
• Behaviourally defined disorder where observation
  is essential
• Early identification is wished by parents and may
  improve long term intervention
• Autism does not meet criteria for screening and
  diagnosis may subsequently be delayed in a
  disorder where diagnosis can in most cases be
  reliably made between 2 and 3 years
• A knowledge of the symptoms will result in more
  appropriate and successful assessment
• This assessment and appropriate correspondence
  may assist with earlier diagnosis

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Why Early identification?

• Lifetime cost for Autism 2.94 million
• High Functioning Autistic 785,000
• Evidence that early identification and management
  has better overall outcomes (sound familiar?)

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AimsIncrease awareness of (ASDs) in the
Profession of Audiology!

• Highlight some of the symptoms of autistic
  spectrum disorders (ASD) and the similarities
  with childhood deafness
• Explain why Audiologists can help with early
  identification and why this is important!
• Show this with a small blinded study carries out
  in Cambridge.
• What to look for and tips within the clinic

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A wee audit

• Six month period of CPAC clinics
• As a result of the assessment, any child thought
  to have ASD indicators (and from information
  available, had not been questioned elsewhere by
  professionals or parents ) were placed within a
  data base between Dec 01 and June 02
• Total number 13 including one 16 month child
• Two years later, child health records revealed
  that 10 of the 13 had been identified with PDD
  including the 16 month old child
• Three had no other information in notes
• One mum on hearing her child had normal binaural
  hearing burst into tears

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What to look for

• Corridor consult
• Responds to name? eye contact? Unusual noises? Is
  it a fight to get into the room?
• In room using experience ask is this normal
  behaviour?
• Will he play with anyone, how does he act, can
  you look in his ears
• What does mum say, is he affectionate, does he
  play with others, what is his SL like, how does
  he let his needs be known?
• If the corridor consult indicates ASD, this will
  dictate what happens next

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Hearing assessment in young children with
suspected ASD

• Calm and relaxed environment with few
  distractions
• Keep interaction with child to a minimum, at
  least initially (allows familiarisation on
  his/her own terms)
• Use as little language as possible and keep it
  simple ( always try to attract childs attention
  before speaking by calling name or gentle
  touching)
• Use visual clues whenever possible
• Take advantage of childs initiatives and
  integrate them in the assessment

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How to test (opinion)

• Only very severely autistic children can not be
  tested at least in free field
• VRA may scare but result in a consistent response
  (difficult due to possible hyperacusis but ends
  justifies means)
• Men in boat is a simple and very structured game
• Individual ear information, tymps/reflexes and
  emissions may be difficult as many have an
  aversion to any ear touching (test battery)

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Summary

• ASD is a behaviourally defined disorder that is
  diagnosed by history and direct observation
  (Baird et al. 2003).
• A child with ASD may initially be referred to
  Audiology as a result of their symptoms.
• The informed Audiologist will often spend time
  interacting, observing and directing a child
  referred to them, as such they can help to
  initiate early identification which can lead to
  early intervention and potentially better
  outcomes.

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Break

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Are children with Autism more likely to have
hearing loss?

• Hearing impairment is much more common in autism
  than in the general population. About 1020 of
  all classic cases have moderatesevere or
  profound hearing deficits. C. Gillberg and, E.
  Billstedt (2000)
• Mild to moderate hearing loss was diagnosed in
  7.9 and unilateral hearing loss in 1.6 of those
  who could be tested appropriately. Pronounced to
  profound bilateral hearing loss or deafness was
  diagnosed in 3.5 of all cases, (rosenthall et
  al. 1999)
• BUT

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Are children with Autism more likely to have
hearing loss?

• Children with autism demonstrated essentially
  equivalent results on a battery of physiological
  auditory tests as those obtained from typically
  developing children. However, on average,
  behavioral responses of children with autism were
  elevated and less reliable relative to those of
  typically developing children. Furthermore,
  approximately half of the children with autism
  demonstrated behavioral pure-tone averages
  outside of the normal hearing range (i.e., gt20 dB
  HL) despite having normal to near-normal hearing
  sensitivity as determined by other audiometric
  measures. Tharpe AM, 2006
• There was no evidence of intrinsic differences in
  the peripheral auditory mechanism of children
  with autism that would account for the auditory
  processing disorders and sound sensitivity that
  are commonly reported in this population. Gravel
  JS (2006

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Thought to have ASD

• Daryl Hannah
• Eamon de Valera (1882-1975, Irish president,
  author of Irelands constitution, professor of
  mathematics)
• Gordon Brown (b. 1951, full name James Gordon
  Brown, prominent UK Labour politician)
• Dan Aykroyd (C.M.) (b. 1952, diagnosed with
  Asperger and Tourette syndromes,
• Lewis Carroll (18321898, see description in
  Writers section)
• Vincent van Gogh (18531890, Dutch
  Post-Impressionist
• Gary Numan (b. 1958, diagnosed with Asperger
  Syndrome, real name Gary Webb, electropop music
  pioneer)
• Satoshi Tajiri (b. 1965, Japanese electronic game
  designer, creator of Pokémon
• Bill Gates (b.1955, real name William Gates III,
  co-founder, chairman and chief software architect
  of Microsoft Corporation, richest person in the
  world, global philanthropist, dropped out of
  Harvard, is reputed to have a very high IQ, L-H)
• George Orwell (19031950, real name Eric Blair,
  author and journalist, wrote 1984 and Animal
  Farm, a democratic socialist critic of various
  forms of totalitarianism)
• Lewis Carroll (18321898, real name Reverend
  Charles L. Dodgson, wrote the childrens book
  Alices Adventures in Wonderland, also a
  mathematician, logician, photographer, academic
  and Anglican clergyman, intellectually gifted as
  a child, a stutterer, parents were first cousins,
  L-H)
• Marie Curie (1867-1934, Polish-French chemist and
  physicist, pioneer of research on radioactivity,
  winner of Nobel Prizes in physics in 1903 and in
  chemistry in 1911, the only woman to date to win
  two Nobel Prizes, eldest daughter won a Nobel
  Prize in chemistry, L-H)
• Sir Isaac Newton (16421726, English physicist,
  mathematician, astronomer, natural philosopher
  and alchemist,
• Albert Einstein (18791955, American theoretical
  physicist with German-Jewish origins, winner of
  Nobel Prize in physics in 1921, his head was
  thought to be disproportionately large as an
  infant, had very delayed speech development, in
  childhood was thought by some to be mentally
  impaired, a narrowly-focused autodidact by nature
  he ignored school subjects that did not interest
  him and was not liked by some teachers, his
  preserved normal-sized brain has been extensively
  studied by scientists, some authorities claim he
  was mixed-handed while other sources list him as
  a left-hander)
• Charles Darwin (1809-1882, English naturalist,
  proposed the theory of natural selection, wrote
  The Origin of Species, R-H)
• Ludwig van Beethoven (17701827, Prussian
  composer and pianist, displayed talent at a very
  young age, may have been a left-hander, L-H)

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Joshua Muggleton Blog

• Star Trek Voyager now I have recently been
  working my way though the seasons yet again. And
  I have noticed how the character in the latter
  seasons Seven Of Nine, reacts to social
  situations. She doesnt ask permission to do
  something - she simply knows is most efficient
  and just does it even if it drains some power
  from another area. She voices her opinion out of
  turn, she spends most of her time in a cargo bay.
  Doesnt this sound like an aspie to you?
• I watched the Da Vinci Code film the other day,
  and something struck me about the main character.
  He was able to solve anagrams in his head. He had
  a knack for symbols and their meanings. He was
  very much into codes, logic, visualising
  accurately something he has only briefly seen
  before, and drawing conclusions from that. He had
  an extensive knowledge of his subject, and was a
  professor at Harvard. In his book Aspergers
  Syndrome A Guide for Parents and Professionals,
  Tony Attwood says that universities are a safe
  haven for science and maths students. And
  apparently the top three universities in the
  world are Harvard, Cambridge, and Oxford in that
  order.

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References

• Ehlers, S. Gillberg, C. (1993) The
  Epidemiology of Asperger syndrome. A total
  population study. Journal of Child Psychology and
  Psychiatry, 34 (8) 1327-1350.
• http//www.autism-in-scotland.org.uk/index.shtml
• Gillberg C, Billstedt e, (2000) Autism and
  Asperger syndrome coexistence with other
  clinical disorders Acta Psychiatrica Scandinavica
  102 (5), 321330.
• Gravel JS (2006) Ear Hearing, Jun 27 (3)
  299-312
• Rosenhall U, Sandstoem M, Nordin V, Gillberg C.
  (1999) Autism and hearing loss. Journalof Autism
  Developmental Disorders, 29 349-357.
• Tharpe AM, (2006) Ear Hearing, Aug 27 (4)
  430-41
• http//jmuggleton.blogspot.com/ accessed
  02.03.2007