ASD

DSM- V diagnostic Criteria for Autism

Autism Spectrum Disorder" -Includes autistic disorder, Asperger's disorder, pervasive developmental disorder not otherwise specified •ICD-10 Codes still Differentiate between these disorders •The DSM V does NOT include Rett Syndrome* chidhood disintegrative disorder obsorbed into spectrum one disorder with different levels of severity

Criterion C

C.Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).

ASD: Complications and Precautions

Complications -Gap in intellectual ability and adaptive functioning (bullying, being taking advantage of) •Social difficulties •Motor deficits (postural control, FM/GM) •Self injury (sensory seeking and anxiety) •Disruptive or challenging behaviors •Sleep disturbances •Seizures •Depression especially with ID- elopement- running away from sensory experience they dont like -drowning b/c of elopement and fascination with water

Criterion D & E

D.Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. E.These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay.

ASD: Comorbidities

Intellectual Disability (ID) -~33%with intellectual disability (IQ less than or equal to 70) -Girls @ 40%, boys @ 32% Learning Disability (LD) Fragile X and other genetic disorders Epilepsy Tic disorder, up to 9% Sleep disorders (50-70%) ADHD Psychiatric disorders (e.g., mood, anxiety)

ASD Etiology

No clear and predictive understanding of the etiology of ASD Evidence suggests -Genetics -Environment -combo of 2 things leading to Brain differences

Genetics

No clear and predictive understanding of the etiology of ASD Twin studies indicate ASD appears to be heritable (have a genetic component) -Copy number variation studies have identified genomic regions associated with increased risk for autism (and other neurodevelopmental disabilities) -Copy number variations are things such as deletions, duplications, translocations

prior to 2013, DSM4 Common impairments

Social Interaction Communication Unusual Behavior 5 basic distinct diagnoses Autistic disroder childhooddisintegrative disorder PDD-NDS aspergers syndrome rett syndrome DSM 4 included 5 pervasive developmental disorders- those listed-

Criterion A summary

Specify severity: Level 1, 2 or 3 (i.e., pertains to degree of support required due to social communication deficits) All 3 items in Criterion A - social-emotional reciprocity, nonverbal communicative behaviors, and relationship deficits - are REQUIRED for a diagnosis of ASD

Diagnosis of ASD

msot done through observation and interveiw to see 5 criteria Tests are used to support clinical diagnosis (DSM V) •Screening checklists Standardized tests -Childhood Autism Rating Scale (CARS-2) -Autism Diagnostic Interview -Autism Diagnostic Observation Schedule (gold standard) -Social Communication Scale -Social Responsiveness Scale ages and stages questionaire at 18 monthes always given in peds office that asks milestones- first screening chekclsit to raise red flag to dig deeper eeee Lab testing and neuroimaging •Presence of ID (DNA analysis recommended for Fragile X, Rett) •Presence of seizure (routine EEG)

fMRI Studies (Task-based studies)

•what causes Differences in social cognition -Facial perception •TDC - focused on eyes & holistic approach •ASD - focused on mouth & each individual feature-based approach Activation in areas of the brain with regard to facial perception •ASD Little to no activation in Fusiform Face area •ASD Increased activation in object-related brain regions

prevalence

-4.3x m>f -similar across race -Early identification and intervention can significantly improve the quality of life for individuals with ASD and their families/caregivers 12 -48 months)

ASD is Characterized by

-Social and communication deficits that interfere with participation in daily life -Presence of restricted, repetitive patterns of behaviors -Sensory behaviors

Disorders Associated with Autism

-fragile X (can be a cause of ASD)

diagnosis of ASD

-not through gene test, blood study, MRI -behaviorally diagnosed

Team Members for intervention

-parents/caregivers -Neurodevelopmental or developmental-behavioral pediatrician -Child neurologist, psychologist, or psychiatrist -Speech language pathologist -Occupational therapist -Physical therapist -Educators

Diagnostic Criteria- A

A.Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the ALL of the following, currently or by history: 1.Deficits in social-emotional reciprocity (ability to engage and share thoughts/feelings with others) 2.Deficits in nonverbal communicative behaviors used for social interaction 3.Deficits in developing, maintaining, and understanding relationships.

Criterion A-2: Indicators of Deficits in Nonverbal and Verbal Communication

Delayed language development -No babbling (by age 1); No single words (by age 16 mo.); No 2 word phrases (by age 2) -Some may develop language typically until 18-24 mo (slows down/not making improvements, not losing it like child disentigrative disorder) Impaired Joint Attention -Young children will demonstrate a •Lack of pointing (by age 1), showing or bringing objects to share interest with others •Failure to follow someone's pointing or eye gaze •Poor eye contact (i.e., will often look at mouth rather than eyes of person talking) -May be relatively subtle in adults •Poor integration of eye contact, gesture, body posture, facial expression, and prosody (rhythm/sound. monotone) just looks clumsy, intense eye contact (looking at nose is happy medium)

risk factors

Genetic link (est. range from 37-90%) -Parents of child with ASD have greater likelihood of having another child with ASD Problems in intrauterine environment -Increased rates when prenatally exposed to certain medications (e.g., valproic acid) Relationship between low birth weight, pre-term birth, & small for gestational age. Relationship between ASD and advancing maternal age (35+) and advancing paternal age (40+) Certain medical conditions (e.g., congenital rubella; Fragile X, Angelman's, Prader-Willi)

ASD: Prognosis

Largely depends on the presence or absence of ID or language impairment. -Functional language by age 5 is good sign. -More than ½ of ASD acquire language Early intervention associated with good outcomes -One study showed that up to 1/3 of children were no longer considered to meet diagnosis criteria by school age per parent report -Improved cognition, language, adaptive behavior, daily living skills, social behavior (better OP) -but median age of diagnosis is 51 mo after early intervention window has closed •Some adults with ASD live/work independently -Often have superior language & intellectual abilities -Find a niche that matches special interests/skills •Most persons with lower levels of impairment: -May remain socially naive and vulnerable, -May have difficulties organizing practical demands -May use compensation strategies and coping mechanisms to mask their difficulties in public. -Are prone to anxiety and depression. Little is known about old age in ASD.

OT eval- Areas of Assessment and Tips

OTPF- how is ASD impacting OP •Self care skills •Communication skills •School and work readiness and skills •Social participation •Performance skills -Motor (e.g., tone, gross/fine motor skills, postural control, praxis) -Sensory (e.g., sensory modulation, discrimination) -Cognitive (e.g., perceptual skills, attention, problem solving, judgment) -Psychosocial (e.g., emotional behavior, social skills) •reaching Developmental milestones •using Multiple contexts to help with generalization (e.g., attributes of context, behavior in various contexts)

Criterion B

Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (adults may mask sx): 1.Stereotyped or repetitive motor movements, use of objects, or speech (finger/hand flapping. lining up toys, flipping objects, echolalia, ideosynchratic phrases- like vocal tic, repetitive and. stereotyped movements) 2.Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (distress with changes, transition to. tasks, consistent greeting rituals, eating same food, dressing same way) 3.Highly restricted, fixated interests that are abnormal in intensity or focus (strong attachment to unusual objects like hand sanitizer, or loving turtles and only think/talk/read about turtles) 4.Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (like spd, with. hypo/hyper sensitive. covering ears, averse responses to textures, lots of smelling, fascination with lights) Specify severity: Level 1, 2 or 3 (i.e., pertains to degree of support required due the behaviors' interfering with functioning). -Need 2 of Criterion B

Sound Therapies (e.g., Therapeutic Listening)

Uses electronically modified music to: -trigger attention and activate body movement. -trigger the self-organizing capacities of the nervous system. -AOTA says insufficient evidence

Childhood Disintegrative Disorder

Very rare genetic neurodevelopmental disorder -More prevalent in males Seems to be more global delays and more severe -Seizures are more frequent than in ASD -More severe cognitive deficits -Worse prognosis

Criterion A-1: Indicators of Deficits in Social-Emotional Reciprocity

Young children will demonstrate -Little to no initiation of social interaction (responding to name) -Lack of emotional sharing •No smiling or social responsiveness (e.g., no response to name) -Lack of imitation -Difficulty understanding other's point of view or intent (i.e., Theory of Mind) Often adolescents and adults (w/o ID) will have problems with social cues -Difficulty joining into conversation -Knowing what to say and what not to say -Difficulty with understanding perspectives of others

Criterion A-3: Indicators of Deficits in Relationships

Young children will demonstrate a -Difficulty with social play and pretend play -Rigidity with rules -Impaired ability to make friends with peers Often adolescents and adults -Desire for friendships but struggle with complete understanding of what friendship entails (e.g., one-sided friendship; friendship based solely on special interest)

Pragmatic Language and Social Skills Training

•Pragmatic language -Refers to the integration of gesture, expression, proximity, and inflection of language to enhance interpersonal understanding of communication -Emphasis is on language skills used in conversation •Approaches: -Peer models -Social skills training -Social stories

What is Autism Spectrum Disorder?

•A lifelong condition •Appears in late infancy/early childhood

Brain Research and Language

•Activation of different areas of the brain suggest difference between persons with ASD and TDC. -Increased propensity to process the meaning of individual words rather than integrate them into a coherent conceptual structure. -Reliance on visualization for language processing (picture. cues/visual calendars)

DIR Approach (Greenspan)

•Aim: To build social communication (e.g., joint attention, communication) that is learned through relationships with consistent and responsive adults -Adult uses child-directed play to open and close circles of communication -"Floor-time"

Applied Behavioral Analysis (ABA)

•Aim: To use of discrete trial training, prompting, and reinforcement to develop skills (e.g., language, social) and decrease behaviors of concern -Particularly useful in ASD with ID

Other Approaches

•Behavioral Approach - Antecedent manipulation and self management - strong evidence -To reduce restricted & repetitive behaviors •Physical activity (e.g.,Kata training and exercises) - limited evidence -To reduce restricted & repetitive behaviors

Types of Intervention

•Developmental-Individual Difference- Relationship (DIR) Model (Greenspan) (meeting child where theyre at, mimicking their behavior to try to enter their world) •Pragmatic and Social Skills Training •Medication (for comorbidities, e.g., ADHD) •Complementary and Alternative therapies (e.g., diet) there is no cure

Childhood Disintegrative Disorder

•Distinct disorder in DSM IV but not DSM V •comes on later than ASD. Marked regression in multiple areas of functioning after at least 2 years of apparently normal development...but before age 10 Significant loss for most previously acquired skills: •Expressive or receptive language •Social skills •Bowel and bladder control •Play skills •Motor skills lower functioning than ASD usually.

Types of Intervention

•Education approaches -Early intervention and coaching -IDEA has special category for ASD for children 3-21 years TEACCH (Treatment and Education of Autistic and Handicapped Children) Applied Behavioral Analysis (ABA) (skill dev.)

Occupational Therapists Can Help To... (AOTA)

•Facilitate play activities that instruct as well as aid a child in interacting and communicating with others. •Devise strategies to help the individual transition from one setting to another, from one person to another, and from one life phase to another. •Collaborate with the individual and family to identify safe methods of community mobility. •Identify, develop, or adapt work or engagement in meaningful activities that enhance the individual's quality of life.

Environmental Exposure

•Gene-environment interactions •Oxidative stress and inflammation may play a role -prenatal Air pollution (really high maternal exposure) vaccindes do NOT cause ASD

Brain Growth in Early Childhood

•Head circumference is normal at birth •Macrocephaly in approx. 60% of males beginning at 4-12 months of age (big heads) •Accelerated total brain volume growth in children with ASD around 2 to 4 years (heads/brains biggert han typically developing children) overgrwoth of ASD brains includes frontal lobe and temporal cortices, parietal lobes, occiptal lobes, maybe even cerebellum

Notes

•If an individual has a DSM-4 diagnosis of autistic disorder, Asperger's disorder, or PDD-NOS, they should be given the "updated" DSM-5 diagnosis of autism spectrum disorder Coding notes: The diagnosis should include if the individual also has -Intellectual impairment -Language impairment -Medical/Genetic condition -Another neurodevelopmental, mental, or behavioral disorder

fMRI Studies (Mirror neuron studies)

•Mirror neurons (MNS) - brain cells that respond equally when we perform an action and when we witness someone else perform the same action. •Mirror neuron activation during the imitation and observation of emotional facial expressions -Children with ASD had no MNS activity in inferior frontal gyrus as compared to TDC. diff with social interaction and. relationships, brainsa rent wired the same as tdc

Criterion B: Indicators of Restricted, Repetitive Behaviors

•Motor stereotypies (e.g., hand flapping, finger flicking) •Repetitive use of objects (e.g., spinning or lining up objects) •Repetitive speech (e.g., echolalia, parroting of words heard; stereotyped use of phrases) •Strict adherence to routines or rituals •Preoccupation with objects or subjects; Highly fixated interests •Many adults w/o ID learn to suppress repetitive behavior in public (masking)

Communication Development Approaches

•Picture Exchange Communication System -Use of visual language system (e.g., pictures, signs) to scaffold spoken language •Use of augmentative and alternative communication (AAC) devices (respond well to screens)

Rett's Syndrome

•Rare genetic neurodevelopmental disorder -KNOWN Mutation in MECP2 gene •on X chromosome Occurs in females, males dont survive birht Features similar to autism -Mood fluctuations, anxiety, inconsolable crying -Indifference to others -Sleep abnormalities -wringing of unoccupied hand (removed from DSM because these severe sx only present in narrow life window. meets criteria for ASD at some times but not at others. known cause, not behavioral finding) if child meets 5 ASD they have ASD with qualifier/associated of rett's syndrome

OT Sensory-Based Intervention Tips

•Recommendations for children with autism, who may experience hypersensitivity to sensory input: -Lower lighting -Reduce clutter -Signal the beginning and end to an undertaking -Implement "first/then" cards (first we'll do this..., then we'll do this...) -Pictures for communication (less words) -Visual schedules -Develop a sensory diet

TEACCH: "Culture of Autism"

•Relative strength in and preference for processing visual information •Frequent attention to details but difficulty understanding the meaning of how those details fit together •Difficulty combining or organizing ideas, materials, & activities •Difficulties with attention (e.g., distractible, difficulty shifting attention especially when transitioning) •Difficulty with concepts of time •Communication problems, including "pragmatics" •Tendency to become attached to routines, •Very strong interests and impulses in engaging in favored activities •Marked sensory preferences and dislikes

ASD: Etiology

•Research suggests brain differences -Abnormal brain growth •Gray and white matter -Abnormal activation and connectivity •Various regions of the brain (e.g., facial recognition)

Relevant Theoretical and Treatment Approaches

•Sensory Models -Non-ASI Sensory-Based Interventions •Some evidence for related interventions (sensory diet) (refer to AOTA CAT) •Multi-sensory activities -Moderate evidence that "frequent, active participation in multi-sensory experiences can help improve autism symptoms, cognitive functions, motor performance, sensory integration function, and focus" (Fazlioglu & Baran, 2008; Thompson, 2011; Woo & Leon, 2013; Wuang et al., 2010) -There is no evidence to support the use of non-customized sensory diets (Devlin et al., 2009) or brushing (Davis et al., 2011).

Relevant Theoretical and Treatment Approaches

•Sensory Models - To help a child appropriately respond to information coming through the senses -Ayres' Sensory Integration model •Growing evidence (refer to AOTA CAT- members only) •"Overall, the results of the reviewed studies provide moderate evidence indicating that the use of ASI for children with ASD can improve performance in daily life activities and childhood occupations."

stage 1Rett's Syndrome

•Stage I (16-18 months) may be overlooked -Less eye contact; reduced interest in toys; delays in gross motor skills; hand-wringing may occur (squeezing, cappling, rubbing) •Stage II (1-4 yrs) may last weeks or months -Rapid or gradual loss of purposeful hand skills and spoken language; hand stereotypies present when awake; walking may be unsteady; slowed head growth

4 Stages of Rett's Syndrome (cont'd)

•Stage III (2-10 yrs) many remain in this "plateau stage", others improve in social function -Apraxia, motor problems, seizures are prominent -May show more interest, alertness, attn span, & comm skills •Stage IV "late motor deterioration stage" -Reduced mobility, scoliosis, muscle weakness, rigidity/spasticity, abnormal posturing; repetitive hand movts may decrease; eye gaze usually improves

Intervention Guidelines

•Successful treatment of children under 3 years of age involves: -parental participation, -early intervention, -increased intensity and duration of treatment, - individualized treatment •Generalization to other context will not occur so must be specifically taught

TEACCH Approach

•Understanding the "culture of autism" (see next slide) •Develop an individualized person- and family-centered plan for each client or student, rather than using a standard curriculum •Structure the physical environment •Use visual supports to make the sequence of daily activities predictable and understandable

Social Stories

•Written by parents or professionals to help a child with a difficult and/or confusing situation •Useful for introducing new routines and rules, and defining desired social skills •Critical to incorporate perspective of the child helpful for transitions and new routines