PTRS 833 - Autism

What is a diagnosis of autism based off of?

social-communication, repetitive behaviors, intense interests, rigidity, or sensory differences

How to specify an autism diagnosis

- severity level

- with / without intellectual impairment

- with / without language impairment

- known medical or genetic condition

- with catatonia

Social Communication Deficit Categories

Social Reciprocity, Non-Verbal Communication, Relationships and Shared Play

Examples of Social Reciprocity Deficits

- difficulty initiating or maintaining interactions

- reduced sharing and showing

- back and forth conversation, play

- imitation

- response to name

- responding to others perspectives

- joint attention

Examples of Non-Verbal Communication Deficits

- reduced eye contact

- decreased gestures (pointing, nodding, descriptive)

- facial expressions

- reading other nonverbal cues

Examples of Relationships and Shared Play Deficits

- parallel play

- delayed peer interactions

- lack of imaginative play

- personal space

- friendship

- understanding social rules / expectations

Categories of Restricted and Repetitive Behaviors

Repetitive movements, language, play, insistence on sameness, restricted interests, sensory differences

How many categories have to be present of deficits in social communication for autism diagnosis?

all three

How many categories have to be present of restrictive and repetitive play for an autism diagnosis?

at least 2 of 4

Examples of repetitive movements, language, and play

- flapping, spinning, pacing, toe-walking, posturing

- echoing, scripting, unusual vocal tone / intonation (atypical prosody), repetitive questions, jargon, formal language, pronoun reversal, idiosyncratic phrasing

- lining up toys, spinning wheels on cars, re-enacting movies in play, repeating an action, focusing on small parts of toys

Examples of insistence on sameness

- difficulty with transitions, change in routine

- rigid thinking pattern, rigid application of rules, difficulty understanding nonliteral language

- rituals (eg rigid bedtime routine, inconsistence on same foods or brands each day)

Examples of restricted interests

- obsession with certain toys, characters, topics

- carrying around objects (eg hangers, wrappers)

- may be age appropriate topic or unusual topic

Examples of sensory differences

- sensory seeking, avoiding, or underreaction

- touch: pain tolerance, grooming, clothing sensitivity

- sensitive to lights, noise, smell, taste, texture

- mouthing, licking, smelling non-food items, rubbing toys on face

- visual inspection of objects / toys

how many kids have ASD?

1 in 36 (2.8%)

what gender is ASD more common in?

boys

Potential causes of ASD

- genetics

- twins

- sibling history

- increased paternal age

- possibly increased maternal age

- prematurity and associated events at birth (trauma, ischemia, hypoxia)

Autism is NOT caused by...

vaccines

Core and defining symptom of autism

social impairment

pyschosocial development milestones at 4 months

smiles spontaneously

initiates social interactions

pyschosocial development milestones at 6 months

recognizes familiar and unfamiliar faces, strangers

sustains interactions

joint attention

pyschosocial development milestones at 9 months

stranger danger

seeks parents for play, comfort, assistance

interactive games

waves goodbye

responds to name

pyschosocial development milestones at 12 months

pointing, using gestures to meet needs

gives items to others to play

pyschosocial development milestones at 15 months

pointing, using gestures to share interests

imitates

tries to help around house

listens to stories

pyschosocial development milestones at 18 months

temperament more apparent

separate from parent but want them nearby

affectionate

laughs in response to others

ASD red flags

- no babbling by age 1

- no single words by 16 months or 2-word phrases by age 2

- no gestures by 12 months (pointing, waving, clapping)

- poor eye contact or poor use of eye gaze

- excessive lining up of toys or objects

- lack of smiling or social responsiveness, lack of shared enjoyment

- lack of joint attention

- limited interaction

- lack of gestures to compensate for communication difficulties

- no response to name

- "sticky" attention

- loss of language or social skills or "regression"

Associated features of ASD

- seizures ~25%

- picky eating

- constipation

- sleep problems

- cognitive delays (35% have IDD)

- meltdowns and tantrums (53% have aggression) - can be associated with sleep problems, self-injury, sensory differences, and younger age

When are children typically diagnosed with ASD?

4.5-5.5 years

- but for 51-91% of children with an ASD, development concerns had been recorded before 3 years

Assessment / Screening of ASD

- screening at pediatric office (18 and 24 months)

- MCHAT-R

- Assessment tool (ADOS-2 or ADI-R)

- no biological tests

- development history

- assessment of co-occuring symptoms (language, cognition)

- ideally interdisciplinary, but not necessary

Gross motor delays in school-aged children and adults with ASDs

poor upper limb and lower limb coordination, including bilateral coordination and visuomotor coordination

Delays in infants at risk for ASD and in toddlers and preschoolers with ASD

- gross motor delays in supine, prone, sitting skills are present in the first year of life

- delayed onset of walking may be present in the second year of life

- gross motor delays are also present in preschoolers recently diagnosed with ASD

Fine motor delays in school age children and adults with ASD

poor fine motor coordination such as in performance on manual dexterity tasks

fine motor delays in infants or toddlers / preschooler with ASD

reaching and grasping appear to be delayed in infants at risk for ASDs

- persist in second and third years of life

Posture delays in school age children and adults with ASD

feedforward and feedback control of posture are affected in children and adults with ASDs

- overall, deficient postural control persists in adults

Postural delays in infants or toddlers / preschooler with ASD

delays are evident in posture such as rolling and sitting

- there are suggestions of unusual postures held for brief to long periods in infants who later developed ASDs

Imitation and Praxis in school age children and adults with ASD

imitation impairments are present during postural, gestural and oral imitation

performance of complex movement sequences is poor during imitation, on verbal command, and during tool use, suggesting generalized dyspraxia not specific to imitation

Are Motor Stereotypy common or uncommon in school age children and adults with ASD

common

Motor stereotypy in infants at risk for ASD and toddlers / preschoolers

repetitive banging of objects or unusual sensory exploration may appear in the first year of life, but most often emerge in the second year of life

What are motor stereotypies?

rhythmic, repetitive, fixed predicable but "purposeless" movements

most common = hand and finger movements

- hand flapping or finger flicking

- whole body movements: rocking, spinning, pacing, seeking various types of movement

Rhett Syndrome

genetic disorder present in girls

- associated with ASD

- hand stereotypy, hand to touch mouth movements

Intervention Considerations for ASD

- person centered care

- communication

- routines

- visual supports

- rewards

- incorporate special interests

Considerations for treatment planning

- social-reciprocity, possible language delays

- use of eye-contact, understanding of gestures

- understanding of social expectations, anxiety around new people

- repetitive body movements

- intense interests

- difficulty with transitions, changes, flexibility of thinking

- sensory sensitivities, sensitivity to touch

Associated delays impacts with treatment

- emotional dysregulation

- language, developmental delays

- poor motor planning

Person-centered care for treatment

- presume competence

- tailor your approach to the individual and consider developmental level

- take your cue from family member

- address the individual

- person-first or disability-first language

Communication strategies for treatment

- avoid use of figurative, nonliteral language

- use clear, direct commands

- accept alternate forms of communication (AAC device, signing)

- use gestures in combination with words

Routines and Transitions Strategies for Treatment

- use a consistent routine for treatment sessions

- provide a transition warning (2 more minutes until we will walk back), use timers

- increase predictability - explain what will happen, ask permission / give warning before touching

Visual Support Strategies for Treatments

- visual schedules - pictures showing each thing that will happen, could be helpful for practicing at home or organizing therapy sessions

- video modeling: videos showing children appropriately completing a task - an either be the patient or a "model", edit out errors, review for repetition at home

Repetition and Reward strategies for treatments

- applied behavior analysis - type of therapy based on operant conditioning, behaviorism, learning theory

- break tasks into small pieces

- teach one step at a time, accept approximations

- use frequent and meaningful rewards

What percentage of school aged children with ASD have motor impairments

86.9%

- 22x greater in children with ASD

motor impairments with ASD

balance, gait, imitation, praxis, coordination, postural control

Motor Intervention Treatment Examples

- land-based, exercise, motor physical activity

- sports-based, active recreation

- movement-based mind-body

- equine, therapeutic horseback riding

- active video games / VR and augmented reality

- aquatic therapy / swimming

Sensory Processing

a complex set of actions that enable the brain to understand what is going on both inside your own body and in the world around you

Sensory Conditions

tactile/touch

oral

visual

smell

auditory/sounds/noise